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Psychoeducational Interventions in Children and Adolescents with Type-1

Diabetes: A Systematic Review

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DOI: 10.5093/clysa2022a4

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 Clínica y Salud (2022) 33(1) 35-43

Clínica y Salud
h t t p s : / / j o u r n a l s. c o p m a d r i d. o r g / c l y s a

Psychoeducational Interventions in Children and Adolescents with Type-1

Diabetes: A Systematic Review
Bárbara Luquea,b, Joaquín Villaécijaa,b, Rosario Castillo-Mayéna,b, Esther Cuadradoa,b, Sebastián Rubioa,b, and Carmen
Tabernerob,c,d
a
University of Córdoba, Spain; bMaimonides Biomedical Research Institute of Córdoba (IMIBIC), Spain; cSocial Psychology Department, University of Salamanca, Spain;
d
Institute of Neurosciences of Castilla y León (INCYL), University of Salamanca, Spain

ARTICLE INFO A B S T R A C T

Article history: The effectiveness of psychoeducational interventions in children and adolescents with type 1 diabetes is unclear. A
Received 8 June 2021 systematic review was developed in accordance with PRISMA. Relevant databases (Pubmed, Cochrane, PsycINFO, and
Accepted 23 November 2021 PsyARTICLES) were analyzed. Articles of the last decade with type 1 diabetes population between 6 and 18 years participating
in psychoeducational interventions were the inclusion criteria. Twenty studies were reviewed, and improvements were
found in glycosylated hemoglobin, diabetes knowledge, and psychosocial variables. The results support the positive
Keywords:
effect of these interventions. The characteristics that seem to be behind the success of these interventions are the design
Diabetes mellitus type 1
appropriate to the characteristics of the population, the participation of psychologist and educators, the continuity of
Education
Psychoeducation the program over time, and the use of digital tools and interaction strategies. Further studies need to be carried out and
Interventions replicated in different groups of children and adolescents.
Children
Adolescents
Patient education Las intervenciones psicoeducativas en los menores y adolescentes con diabetes
Systematic review
tipo 1: una revisión sistemática

R E S U M E N

Palabras clave:
Hay dudas acerca de la efectividad de las intervenciones psicoeducativas en menores y adolescentes con diabetes tipo 1,
Diabetes tipo 1
Educación motivo por el cual se realizó una revisión sistemática de acuerdo con el protocolo PRISMA. Se analizaron distintas bases de
Psicoeducación datos (Pubmed, Cochrane, PsycINFO y PsyARTICLES) con los siguientes criterios de inclusión: artículos de los últimos diez
Intervenciones años, con población con diabetes tipo 1 de edades comprendidas entre los 6 y 18 años que hubieran participado en cualquier
Niños intervención psicoeducativa. Se revisaron 20 estudios y los resultados mostraron una mejora en la hemoglobina glicosilada,
Adolescentes en el conocimiento de la enfermedad y en algunas variables psicosociales tras estas intervenciones. Las características que
Educación del paciente parecen estar detrás del éxito de estas intervenciones psicoeducativas son el diseño adecuado a las características de la
Revisión sistemática
población, la participación de profesionales de la psicología y de la educación, la continuidad del programa en el tiempo y el
uso de herramientas digitales y otras estrategias de interacción. Se destaca la necesidad de realizar más estudios y que sean
replicados en diferentes grupos de menores y adolescentes.

Chronic diseases are considered as noncommunicable diseases mostly in adulthood. Although the body can produce insulin, it does
(NCDs) and cause many deaths each year. Specifically, 41 million not manage it correctly, and its origin is related to a deficit of physical
people die each year from these diseases (71% of the deaths that occur activity and overweight. Gestational diabetes is a temporary condition
worldwide in a year). Diabetes is included in this group of NCDs, during pregnancy that could complicate it, produced by an increase
along with cardiovascular diseases, cancer, and chronic respiratory in blood glucose levels during this period (WHO, 2021). Finally, T1D,
diseases (World Health Organization [WHO, 2020]). the focus of this study, normally appears at an early age, where the
The main diseases are type 1 diabetes (T1D), type 2 diabetes (T2D), beta cells of the pancreas are attacked, losing its ability to produce
and gestational diabetes. T2D is the predominant type and occurs insulin, the regulatory hormone of blood glucose levels (Spanish

Cite this article as: Luque, B., Villaécija, J., Castillo-Mayén, R., Cuadrado, E., Rubio, S., & Tabernero, C. (2022). Psychoeducational interventions in children and adolescents with type-1
diabetes: A systematic review. Clínica y Salud, 33(1), 35-43. https://doi.org/10.5093/clysa2022a4

Funding: This study was supported by the Spanish Ministry of Science, Innovation and University via a doctoral FPU grant to the second author (FPU18/04504), and was developed
while a project was financially supported by the same public organization (PID2019-107304RB-I00), in which the main researchers are co-authors of the paper.
Correspondence: bluque@uco.es (B. Luque); carmen.tabernero@usal.es (C. Tabernero).

ISSN:1130-5274/© 2022 Colegio Oficial de la Psicología de Madrid. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
36 B. Luque et al. / Clínica y Salud (2022) 33(1) 35-43

Diabetes Federation [FED, 2020]). Comorbidities of T1D include skin the scarce scientific literature on the characteristics of educational
complications, neuropathy, foot problems, eye complications, DKA and psychoeducational interventions in this population and the lack
(ketoacidosis) and ketones, kidney disease, high blood pressure, and of an effective consolidated model, make it necessary to undertake
stroke (American Diabetes Association [ADA, 2020]). this review to optimize the use of these interventions in children and
It is estimated that currently 1.1 million children under 19 years adolescents with T1D in order to begin adaptation to the disease as
of age have T1D worldwide, with 128,900 new cases diagnosed in soon as possible, since 90% of new diagnoses occur at this age (SSPE,
children each year (International Diabetes Federation [IDF, 2019]). 2019).
The prevalence differs between countries, although its frequency is With this approach, the main aim of this study was to carry out an
increasing, especially in children under 5 years of age. Spain is the exploration on the approach of educational and psychoeducational
country with the highest incidence in southern Europe, with between interventions in children and adolescents (age range 6-18 years)
1,200 and 1,500 new cases diagnosed each year (Spanish Society of with T1D, with two specific objectives: 1) to identify scientific
Pediatric Endocrinology [SSPE, 2019]). evidence on the effectiveness of these interventions in this
The worrying data of this disease forces us to explore the scope population and 2) to consider the methodological and educational
of action that we have from education and psychology. The WHO has strategies used in previous research to extract successful guidelines
developed the Global Action Plan for the Prevention and Control of for designing future interventions.
NCDs 2013-2020, where the education and empowerment of these
patients has a fundamental role (WHO, 2013). In this sense, an
Method
educational intervention on diabetes, or diabetes self-management
education (DSME), is a teaching-learning process about knowledge, Study Design
tools, and practices for diabetes self-care that address the needs
of the patient, to promote better health (Beck et al., 2017). These Published scientific articles have been used to prepare the
conventional educational programs are sometimes supplemented systematic review; therefore, ethical committee approval has not
by psychosocial elements such as problem-solving, motivation, been necessary.
coping skills, stress management, counselling, communication skills, The study design was prepared in accordance with preferred
and behavioral therapy (Charalampopoulos et al., 2017; Murphy et reporting items for systematic reviews and meta-analyses
al., 2006). These are known as psychoeducational interventions. In (PRISMA) guidelines (Moher et al., 2009), as well as the instructions
practice, both interventions are usually combined (Murphy et al., suggested by Cajal et al. (2020). To check the effectiveness of the
2006). interventions, we collected the psychosocial variables studied and,
However, the studies published on the effectiveness of educational the HbA1c level as a biomedical indicator.
or psychoeducational interventions in T1D show contradictory
results. On the one hand, there is not enough evidence to justify that
these programs are effective by themselves in children and young Inclusion Criteria
people with T1D, although there is evidence of their effectiveness
when accompanied by other programs (Charalampopoulos et Scientific articles published in English or Spanish were searched,
al., 2017; Murphy et al., 2006). On the other hand, positive results given that English is the language of scientific communication and
such as psychological, and educational benefits are found (Armour Spanish is researchers’ native language. To focus on current science
et al., 2005; Winkley et al., 2006), achieving better control of the and the latest educational trends, such as the use of technology
disease and, consequently, a better quality of life for these patients. and the rise of mHealth tools for self-care, only papers published
In addition, we cannot forget signs such as the benefit of the during the last ten years (2010-2019) were used. Articles that did
participation of psychologists, the rapid implementation in newly not allow access to the full text were eliminated. The country where
diagnosed children and the innovative strategies aimed at promoting the intervention was carried out was not considered as a reason for
patient participation (Charalampopoulos et al., 2017). Also, education exclusion.
appears to be most effective when integrated into routine care, when We defined the technical inclusion criteria by answering the
it encourages parental involvement and when adolescent self-efficacy PICO (acronym for patient, intervention, comparison and outcome)
(understood as the beliefs in one’s own capabilities to achieve a goal question, as shown in Table 1. Studies that did not differentiate be-
in each situation) is promoted (Murphy et al., 2006; Wood & Bandura, tween type 1 and type 2 diabetes mellitus populations have been
1989). Early interdisciplinary healthcare enhances the efficiency excluded.
of disease management, and therefore, the quality of life of these
patients (Urzeal et al., 2020). In adult population, which could serve Search Strategy and Eligibility Criteria
as a background for another population group, one of the highlights
is the use of mobile device App that could strengthen the perception The initial search was performed between October 2019 and
of self-care by contributing to an increase in the information available February 2020. Four databases were used: Medline (PubMed),
about health education in diabetes, helping patients to control their Cochrane Register of Controlled Trials (CENTRAL), PsycINFO, and
glycated hemoglobin (HbA1c) (Bonoto et al., 2017). PsyARTICLES. A search was also carried out in May 2020, before the
The poor adaptation to the disease in the pediatric population final writing of the paper, to incorporate new studies published in
(Bilbao-Cercós et al., 2014), understood as the degree of psychosocial this period.
adequacy of the subject’s behavior, emotional state, and appraisal in The study population ranged between 6 and 18 years old. Studies
relation to the disease (Portilla del Cañal & Jo, 1995), together with were included if the mean age did not exceed 18 years old.

Table 1. PICO Strategy

Population Children and adolescents (age range 6 to 18 years) with type 1 diabetes
Intervention Educational or psychoeducational intervention
Control or comparator Comparator that allows us to distinguish the effects (traditional control group, a pre-post design or an alternative intervention)
The main outcome considered is the HbA1c level. Secondary outcomes: psychosocial variables (quality of life, diabetes knowledge, self-efficacy, and self-
Outcome
management).
 Psychoeducational Interventions in Young People with T1D 37

Table 2. Search Strategies used in Databases

(((“type 1 diabetes”[Title/Abstract] OR t1d[Title/Abstract] OR “juvenile diabetes”[Title/Abstract] OR “insulin-dependent diabetes”[Title/Abstract] OR “type 1

Medline (Pubmed) diabetics”[Title/Abstract])) AND (education*[Title/Abstract] OR psychoeducation*[Title/Abstract] OR psycho-education*[Title/Abstract])) AND (children[Title/
Abstract] OR adolescent*[Title/Abstract] OR youth[Title/Abstract] OR child[Title/Abstract] OR teenager*[Title/Abstract] OR “young people”[Title/Abstract])

“type 1 diabetes” OR t1d OR “juvenile diabetes” OR “insulin-dependent diabetes” OR “type 1 diabetics” in Title Abstract Keyword AND education OR psychoeducation
Cochrane OR psycho-education OR educational OR psychoeducational OR psycho-educational in Title Abstract Keyword AND children OR adolescent OR youth OR child OR
teenager OR “young people” OR adolescents OR teenagers in Title Abstract Keyword
PsycINFO ab(“type 1 diabetes” OR t1d OR “juvenile diabetes” OR “insulin-dependent diabetes” OR “type 1 diabetics”) AND ab(education* OR psychoeducation* OR psycho-
PsyARTICLES education*) AND ab(children OR adolescent* OR youth OR child OR teenager* OR “young people”)

Based on our PICO question, a combination of MESH terms (me- title and 51 after the reading of abstract due to not meeting the
dical subject headings) was used: 1) “type 1 diabetes mellitus”, “ju- inclusion criteria. In this way, 62 studies were selected to be read
venile diabetes”, “insulin-dependent diabetes”, “type 1 diabetics”; in full, of which only 20 were analyzed. The rest were discarded for
2) “education*”, “psychoeducation*”, “psycho-education*”; and 3) the following justified reasons: other outcomes or type of study
“children”, “adolescent*”, “youth”, “child”, “teenager*”, “young peo- (n = 12), only the protocol was published (n = 11), pilot study (n
ple”. These terms and their respective variants are used to search in = 8), invalid for inclusion criteria (n = 5), studies duplicated or
title, abstract or keywords with the Boolean operators OR and AND, intermediate balance (n = 2), no full text found (n = 2), or abstract
as shown in the detailed search in Table 2. of Congress type (n = 2). All the selected studies met the quality
criteria evaluated using the Effective Public Health Practice Project
Strategies for the Selection of Studies and Analysis of the (EPHPP) Quality Assesstment Tool (Thomas et al., 2004). Figure
Results 1 shows the flow diagram designed by PRISMA to analyze the
different stages of study selection.
The selection of articles was made independently by two
researchers, and a third resolved any disagreements. Firstly, all Characteristics of Selected Studies
publications found within the search criteria were transferred to
the free version of the EndNote Clarivate Analytics platform and all Papers are summarized in Table 3. All studies included were
the repeat publications were removed. A manual review was then published over the last decade (2010-2019), although some of them
necessary because some references did not match. The selection were developed in the years prior to the date of their publication;
was first made by reading the title, then by reading the abstracts, 75% of the studies were clinical trials. There were also cohort studies
and finally by selecting the studies to read in full. (10%), quasi-experimental studies (10%), and other not clearly
specified (5%).
Studies from many locations resulted: Europe (n = 9), America
Publications identified by
(n = 7), Asia (n = 2), Africa (n = 1), and Oceania (n = 1). All studies se-
search in the databases lected involved a children or adolescents population with T1D. The
N = 1,040 sum of all studies results in 3,743 participants (53.52% females), of
which 2,115 belonged to experimental groups with some type of
educational or psychoeducational intervention. Study participants
Publications duplicates removed = 171 range from 24 to 675, and the mean of participants 187.2. The mean
age groups ranged from 12.1 ± 1.1 years to 17.4 ± 2.4 years. Thirteen
Publications excluded
trials recruited adolescents (only over 11 years), while seven stu-
Publications selected (n = 807) dies combined the child-youth population. HbA1c levels at baseline
n = 869 After ding of title: 756 ranged from 7.8 ± 1.1% to 10.9 ± 0.4%. For both age and HbA1c levels,
After reading of abstract: 51 we always prioritized having the mean at baseline, differentiating
the group that performed the intervention and the control group,
Full-text articles exluded when this data is available. Other data are specified in the general
Full-text articles for n = 42 characteristics Table 3.
evaluation Outcomes or type of study: 12
n = 62 Only protocol: 11
Pilot study: 8 Outcomes Found to Check the Effectiveness of the
Inclusion criteria: 5
Intervention
Duplicate or intermediate
Studies included balance: 2
n = 20 No full text: 2 The HbA1c level is the most used outcome to evaluate the impact
Abstract to Congress: 2 of the educational or psychoeducational intervention; overall, 18 of
the 20 selected studies used this variable, which was measured at
Figure 1. Flow Diagram of Study Selection. baseline and at different times during and/or after the intervention.
Among the psychosocial variables, the most studied was quality of
life or health-related quality of life, which appeared in 12 studies,
Results
followed by self-management (n = 5), knowledge of diabetes (n =
Study Selection 4), and self-efficacy (n = 4).

A total of 1,040 potential scientific publications resulted from Effectiveness of Interventions and Instruments Used
the designed search strategy: Medline (n = 598), Cochrane (n
= 329), PsycINFO (n = 107), and PsyARTICLES (n = 6), although Of the 18 studies that measured HbA1c levels in their research,
there were 869 final documents when duplicates were removed. 11 provided significant improvements in this glycemic control
Of these publications, 756 were excluded after the reading of variable. This improvement did not occur with the same analyses
38 B. Luque et al. / Clínica y Salud (2022) 33(1) 35-43

Table 3. Characteristics of Included Trials

Mean (SD)
First author (year) Mean (SD) age
Inclusion criteria Intervention Participants % HbA1c at Control group Follow-up Outcomes
Country (years)
baseline
Abolfotouh et al. Educational program. Four 120-minutes
Age 12-20 years with IG: 121 14.61 10.51 At baseline and 6
(2011) sessions, 1 per month in groups of 15 Usual care QoL; HbA1c
T1D CG: 122 (2.2) (1.9) months
Egypt adolescents
Group interaction (4-5 participants) in four
Usual care Self-Esteem; Social
Altundang et al. (2016) Age 12-14 years with T1D 35-45-minutes sessions. Education Guide, IG: 18 10.2 At baseline and 3,
- and Education support; Diabetes
Turkey for at least 1 year and a consultation stage with family and peer CG: 20 (2.4) 6 and 9 months
Guide knowledge
interactions stages later
HbA1c; Self-
Age 12-18 years with GSD-Y, an empowerment-based, and person- perceived health;
Brorsson et al. (2018) IG: 37 At baseline and 6
T1D > 12 months, HbA1c centered reflection (2-hours each in 7 group 14.8 8.4 Standard care HRQoL; Family
Sweden CG: 32 and 12 months
> 7.9% sessions for 5 months) conflicts; Self-
efficacy
HbA1c; QoL (Self-
management;
Age 8-16 years with CASCADE. 4 module structured education IG:
At baseline Intervention
Christie et al. (2016) T1D and a mean which uses solution focused, and 135/182 Standard
13.1 (2.1) 9.9 (1.5) and 12 and 24 compliance;
UK 12-month HbA1c motivational approaches. Groups of 3-4 CG: care
months Emotional and
of 8.5% families. 1 session/month for 4 months 149/183
behavioral
adjustment)
Self-
At baseline
Emiliana et al. (2019) Age 6-18 years with PRISMA. Educational tool with animated Pre and Post management;
IG: 31 - - and the end of
Indonesia T1D videos type Level of
intervention
compliance
Diabetes SME. Educational activities HbA1c; Diabetes
At baseline
García-Pérez et al. (interactive seminars and games to knowledge;
Age 11-18 years with IG: 34 and at least 3
(2010) promote a healthier attitude) followed the 13.8 (2.2) 8.6 (1.7) Usual care Anxiety;
T1D CG: 23 months after
Spain recommendations of the ADA. In groups Psychological
the camp
and individually. 8 days in a summer camp adaptation
TeenCope vs Managing Diabetes.
Two Internet-based psycho-educational HbA1c; QoL;
programs. One 30 minutes session/week and secondary
TeenCope
for 5 weeks. TeenCope, a program based At baseline (Coping, Self-
Grey et al. (2013) Age 11-14 years with IG: 167 12.31 8.51 vs.
on social cognitive theory, used a graphic and 3, 6, 12 efficacy; Social
USA T1D at least 6 months CG: 153 (1.1) (1.4) Managing
novel video format to model problematic and 18 months competence; Self-
Diabetes
social situations, and different coping skills management;
to solve problems. Managing Diabetes was Family conflict)
the CG
To be less than 18
years with T1D
T1Y1 program, a structured diabetes
and for at least one Standard At baseline
Hawkes et al. (2019) education. 10 hours throughout the year IG: 391
diabetes autoantibody 11.3 Diabetes and 6, 12, 18 HbA1c
USA and families met with a nutritionist at 3 CG: 284 -
(we analyzed only Care and 24 months
and 9 months after diagnosis
5-12 years and 12-18
years age groups)
At baseline
Age 14-18 years with
STePS study. Distress and depression and 4.5
T1D for at least 1 Resilience DD; Diabetes self-
Hood et al. (2018) prevention program vs diabetes education IG: 131 (the end of
year and daily insulin 15.71 (1.1) 9.1 (2.0) vs. management;
USA program. Nine biweekly sessions lasting CG: 133 intervention),
dosing of at least 0.5 education and HbA1c
90-120 minutes for 4.5 months 8, 12 and 16
units/kg/day
months
A chat line intervention. Once a week
(90-minutes) for at least 2 years
consecutively. The topic of each session At baseline
Iafusco et al. (2011) Age 10-18 years with IG: 193 Non-chat
was vote by all participants at the 13.6 (2.7) 7.8 (1.1) and 1 and 2 QoL; HbA1c
Italy T1D CG: 203 group
beginning and concern about diabetes years
management, anxiety about future and
social relationships
EDU (educational materials in mail every
2 weeks for 8 weeks with three-page
Age 13-17 years with
packets and information about T1D) vs PA At baseline
Jaser et al. (2019) T1D for at least 6 EDU: 60 Adherence;
intervention. PA received the intervention 14.81 (1.4) 9.21 (0.9) EDU vs. PA and 3 and 6
USA months and HbA1c PA: 60 HbA1c; QoL
reminders and the same materials that months
levels 8-12%
educational group, as well as components
intended to induce PA
SC, CA+ (monthly outreach by the Care
Ambassador via phone or email) and SC: 51
Age 8-16 years with At baseline
Katz et al. (2014) CA+Ultra (psychoeducational intervention CA+: 52 SC, CA+ and
T1D for at least 6 12.91 8.41 and 1 and 2 HbA1c; QoL
USA that provided realistic expectations and CA+Ultra: CA+Ultra
months years
problem-solving strategies). 50
 Psychoeducational Interventions in Young People with T1D 39

Table 3. Characteristics of Included Trials (continued)

Mean (SD)
First author (year) Mean (SD) age
Inclusion criteria Intervention Participants % HbA1c at Control group Follow-up Outcomes
Country (years)
baseline
PED. 12-month structured project
At baseline
(educational workshops every three HbA1c; Diabetes
(three-month
Mauri et al. (2017) Age 6-16 years with months based on active participation Pre and Post knowledge; Self-
IG: 24 12.1 (1.5) 8.8 (1.0) before the
Italy T1D through play, and direct experiences) type management;
project) and
followed by an educational summer camp. Wellbeing
1 year
Interdisciplinary team participation
At baseline
HbA1c; QoL;
FACTS. Six sessions (90 minutes monthly) and 6 and
Murphy et al. (2012) Adolescents with T1D IG: 158 Well-being;
incorporating skills training and family 13.1* (1.9) 9.3* (1.9) Usual care 18 months.
Australia for at least 1 year CG: 147 Family
teamwork in 4-6 families/group HbA1c every 3
responsibility
months
Internet intervention for 3 years using
Age 14-23 years with At baseline
Facebook and CareLink software.
T1D treated with an and every 3
Petrovski et al. (2017) Intervention is the same as traditional but IG: 33 Standard
insulin pump and 17.4 (2.4) 7.8 (1.8) months during HbA1c
Macedonia written reports and chats in Facebook. All CG: 34 care
sensor for at least 6 the study for a
patients received a standardized protocol of
months 3-year-period
education about correct diabetes control
Age 11-16 years with KICk-OFF. An intensive education program. At baseline HbA1c; QoL;
Price et al. (2015) IG: 199 13.7
T1D for at least one 5-day group education with interactive and 9.3 (1.7) Usual care and 6, 12 and Diabetes Self-
UK CG: 197 (1.4)
year practical activities 24 months efficacy
Santiprabhob et al. DSME and psychosocial support group (6-8 At baseline HbA1c; Diabetes
Patients older than 12 15.6 Pre and Post
(2012) patients) sessions with problem-solving IG: 27 8.3 (1.8) and 3, 6, 9 and knowledge; QoL;
years with T1D (2.1) type
Thailand scenarios. 5-day camp 12 months Self-care behavior
Age 11-17 years with Psychoeducational program. 3 sessions (1.5 At baseline
Verbeek et al. (2011) Pre and Post
T1D and level HbA1c hours each) for patients and 1 for parents IG: 25 14.3 (1.7) 10.0 (0.7) and 3 and 9 HbA1c
Netherlands type
> 9.0% during a 3-month period months
Age 12-18 years with Motivational interviewing-based education MI: 15.3 MI: 10.9
At baseline HbA1c;
Wang et al. (2010) T1D for > 1 year and (MI) vs structured diabetes education MI: 21 (1.4) (0.4)
MI vs SDE and 3, 6 and 9 Depression; QoL;
USA HbA1c ≥ than 9% on (SDE). Educators of MI were trained at a SDE: 23 SDE: 15.6 SDE: 11.1
months Self-care
two consecutive visits 2-day workshop (1.7) (0.3)
HbA1c; QoL;
Internet Psychoeducational Program
Self-care;
Whittemore et al. Age 11-14 years with (Teens.Connect). Two components, Planet At baseline
IG: 64 Self-efficacy;
(2016) T1D for at least 6 TEENCOPE (5 interactive sessions) and 12.11 (1.1) 8.21 (1.4) D (Open and 3 and 6
CG: 60 Perceived stress;
USA months Managing Diabetes (5 internet-based access) months
Depressive
problem-solving lessons)
symptoms

Note. ADA = American Diabetes Association; CA = Care Ambassador; CA+ = Care Ambassador Plus; CA+Ultra = Care Ambassador Ultra; CASCADE = Child and Adolescent Structured Competencies Approach to Diabetes
Education; CG = control group; DD = diabetes distress; DSME = Diabetes Self-Management Education; EDU = Education; FACTS = Families and Adolescents Communication and Teamwork Study diabetes education program;
GSD-Y = Guided Self-Determination-Young; HbA1c = glycosylated hemoglobin; HRQoL = health-related quality of life; IG = intervention group; KICk-OFF = Kids in Control of Food; MI = Motivational Interviewing-based
education; PA = positive affect; QoL = quality of life; PED = Pediatric Education for Diabetes; SC = Standard Care; SDE = Structured Diabetes Education; SE = Structured Education; SME = Self-Management Education; STePS
= Supporting Teens Problem Solving; T1D = type 1 diabetes; T1Y1 = Type 1 Year 1 program.
1
Undifferentiated data between groups.

but can be classified into three groups: produced after comparison et al., 2003); and in the Generic Quality of Life (PedsQL-G) (Price et
with the levels of the experimental group itself prior to the study al., 2016), Cronbach alpha was .88 in the original (Varni et al., 2001).
(n = 3), due to a comparison between the experimental group and For diabetes knowledge, a test was created by the researchers in
the control group (n = 5), or some other improvement due to the one study (Altundag & Bayat, 2016); a questionnaire based on a
interaction of another biomedical or psychosocial variable (n = 3). Spanish adult population was adapted for children and adolescents
Regarding psychosocial variables, positive effects were also found: (García-Pérez et al., 2010), with a Cronbach alpha of .63, and .87 in
the quality of life measure showed improvements in 5 studies, the original (DISK) (Bueno et al., 1993); some questions were used
diabetes knowledge showed improvement in all trials in which it from the Diabetes Knowledge Questionnaire [Questionario sulla
is used (n = 4), self-efficacy in 2 studies, and self-management in 1. conoscenza del diabetes] from the Italian Diabetes Education Study
In addition, other less-used variables also showed improvements, Group (GISED), with a Cronbach alpha of .60; and another non-
such as self-esteem, social support, distress diseases, or perceived specific instrument (Santiprabhob et al., 2012). For self-efficacy,
stress. For the measurement of psychosocial variables included in a diabetes-specific subscale of self-efficacy for the Diabetes Scale
our study, where improvements were found, the instruments used was used, and Cronbach alpha was .88 in the studied sample (Grey
are described. For the quality of life, the Diabetes Quality of Life for et al., 2013). A questionnaire was designed (Abolfotouh et al., 2011),
Youth Inventory (DQOLY) (Iafusco et al., 2011), with a Cronbach alpha similar to the design by McCaul et al. (1987). For self-management,
for its three factors of .85 in life satisfaction, .83 in disease impact, a self-management questionnaire was used with a reliability test of
and .82 in disease-related worries in the original questionnaire .91 (Emiliana et al, 2019).
(Ingersoll & Marrero, 1991). In the Arabic version of DQOLY
(Abolfotouh et al., 2011), Cronbach alpha was .83; in the Pediatric General Features of the Intervention
Quality of Life Inventory (PedsQL) (Grey et al., 2013), Cronbach
alpha was .87 in the studied sample; in the Pediatric Quality of Life All the studies selected according to the inclusion criteria had a
Inventory Type 1 Diabetes Module (PedsQL-D) (Jaser et al., 2019; methodological design that allowed to measure the effects of the
Price et al., 2016), Cronbach alpha was .71 in the original scale (Varni educational or psychoeducational intervention. Three methods were
40 B. Luque et al. / Clínica y Salud (2022) 33(1) 35-43

found: intervention group versus control group (n = 13), pre- and did not make use of digital resources: 4 of the 5 studies that rely on
post-type (n = 4), and comparison between different interventions digital resources to carry out their interventions showed significant
(n = 3); 85% of the studies included psychosocial variables to control improvements in HbA1c levels. Various psychoeducational strategies
the effectiveness of the interventions, while the rest (15%) took the were explicitly found: empowerment-based (Brorsson et al., 2019),
biomedical variable HbA1c as the only outcome. motivational approaches (Christie et al., 2016; Wang et al., 2010),
The educational perspective shows a heterogeneous distress program (Hood et al., 2018), positive affect (PA) (Jaser et al.,
implementation of multiple strategies and resources for the 2019), role-playing (Grey et a., 2013; Katz et al., 2014; Mauri et al.,
development of these interventions. Programs range from a more 2017; Price et al., 2016; Santiprabhob et al., 2012; Whittmore et al.,
traditional model of diabetes education to more innovative models 2016). Six studies were found in which psychologists participated in
that work on psychosocial variables. The involvement of information different ways: in the intervention (García-Pérez et al., 2010; Iafusco
and communication technologies should be noted: chat line (Iafusco et al., 2011; Mauri et al., 2017; Santiprabhob et al., 2012), in a pilot
et al., 2011), Facebook (Petrovski & Zivkovic, 2017), animated videos study before intervention (Christie et al., 2016), and training diabetes
(Emiliana et al., 2019), or other forms of Internet intervention (Grey et educator (Wang et al., 2010).
al., 2013; Whittemore et al., 2016). Even so, most interventions (75%) All the details of the methods are described in the Intervention-

Table 4. Main Contributions of the Studies Analyzed: Conclusions and Outcomes

Study Main contribution
C: Educational intervention may protect QoL and glycemic control from worsening over time.
Abolfotouh et al. (2011)
O: Deterioration QoL in IG was significantly less severe than in the CG; knowledge, adherence, self-efficacy and HbA1c improved (p < .001).
C: Training and peer interaction were found to be effective in adapting to the disease.
Altundang et al. (2016) O: There was a decrease in HbA1c levels and an increase in self-esteem (p < .001) and social support (p < .05), and significant increase in knowledge levels (p < .001) in
IG. No changes in CG.
C: An intervention with GSD-Y may have an effect on glycemic control. The content may serve as a model for person-centered care.
Brorsson et al. (2018)
O: HbA1c with an analysis between boys and girls separately and adjusted for family conflicts, boys after 12 months improved (p = .019).
C: Significant challenges in the delivery of a SE intervention using psychological techniques to enhance engagement and behavior change.
Christie et al. (2016)
O: HbA1c levels did not improve in children and adolescents with poor control.
C: The use of animated videos in SME could improve self-management and children’s compliance in the management of diet, physical act, treatment, stress management
Emiliana et al. (2019) and blood glucose control.
O: PRISMA education had significant effects on self-management and level of compliance (p < .05).
C; O: No relevant changes in diabetes knowledge, anxiety or psychological adaptation were found after the psychoeducational intervention in the summer camp. The
García-Pérez et al. (2010)
adaptation to the school environment was the only significantly improvement.
C: Internet interventions improved results. Combining both diabetes management education and behavioral interventions is more effective than only one.
Grey et al. (2013) O: Alter 18 months who completed both interventions had lower HbA1c (p = .04) and higher QoL (p = .02) and self-efficacy (p = .03), among others, compared with who
did only one.
C: SE and support in the first year after diagnosis can improve short-term outcomes, although the effect did not persist after training.
Hawkes et al. (2019)
O: HbA1 was significantly lower in the T1Y1 group at 6 (p < .001), 12 (p < .001) and 18 (p < .01) months. No effect at 24 months.
C: Intervention before your psychological symptoms begin can prevent DD. STePS represents a promising prevention program.
Hood et al. (2018) O: Intervention was associated with reduction in DD between groups (p < .05) and stable glycemic control, resilience characteristics and depressive symptoms in the 1
year post-treatment.
C: A chat line is an effective tool to the diabetes team that could help to improve diabetes compliance.
Iafusco et al. (2011) O: QoL improved in the intervention group (p = .001). Decreased HbA1c levels in the intervention group (p < .001) although no difference was observed between groups
(p = .056).
O: A positive psychology intervention had initial significant positive effects on coping and quality of life. A more intensive or longer-lasting intervention may be needed
to sustain these effects and to improve adherence and glycemic control.
Jaser et al. (2019)
O: No significant effects were found for glycemic control. PA intervention group improved quality of life (p = .022) and disengagement coping at 3 months (p = .018), but
not at 6 months.
C: The psychoeducational intervention was effective in maintaining or improving HbA1c.
Katz et al. (2014) O: There were no differences in HbA1c across treatment groups although more youth in the psychoeducation group with suboptimal baseline HbA1c ≥ 8% maintained or
improved their HbA1c.
C: A model where a pediatric diabetologist cooperates with an adult diabetologist seems be a solution to the transitional gap.
Mauri et al. (2017) O: HbA1c improved significantly (p < .05), knowledge of self-monitoring of blood glucose and the diabetes adapted nutrition (p < .001) and the presence of adequate
behaviors (p < .001).
C: Attendance at group education sessions in clinics was very poor. More personalized educational approaches may be required.
Murphy et al. (2012)
O: No significant difference in HbA1c at 18 months.
C: Social networks like Facebook can help improve glycemic control using insulin pump therapy.
Petrovski et al. (2017)
O: Both groups improved HbA1c levels. Significant improvement (p < .05) was found in favor of the Internet group.
Price et al. (2015) C; O: HbA1c levels showed no significant improvement. Improvements in QoL score levels at 6 months.
C: The effect of diabetes camp on glycemic control is controversial.
Santiprabhob et al. (2012)
O: HbA1c levels and the QoL did not improve statistically significant post-camp. Knowledge 12 months post-camp improved (p < .001).
C: A psychoeducational program can be beneficial to improve HbA1c levels.
Verbeek et al. (2011)
O: HbA1c levels decreased after 9 months (p = .08). In a subgroup of 15 patients showed a significant reduction at 9 months follow-up.
C: SDE is found to be effective in improving metabolic control.
Wang et al. (2010)
O: Over the follow-up, the SDE group had a lower adjusted mean HbA1c than MI group (p = .03). There were not differences in psychosocial measures.
C: Teens need frequent reminders to increase their participation in psychoeducational programs.
Whittemore et al. (2016) O: After 6 months there were no significant differences in HbA1c, QoL or other outcomes between groups. Teen. Connect group had lower perceived stress over time
(p < .01).
Note. C = conclusions; CG = control group; DD = diabetes distress; GSD-Y = Guided Self-Determination-Young; HbA1c = glycosylated hemoglobin; IG = intervention group; MI = Motivational Interviewing-based education;
O = outcomes; PA = positive affect; QoL = quality of life; SDE = Structured Diabetes Education; SE = Structured Education; SME = Self-Management Education; STePS = Supporting Teens Problem Solving; T1Y1 = Type 1
Year program.
 Psychoeducational Interventions in Young People with T1D 41

column of Table 3, where specific characteristics of the programs use of video games is also recommended as a potential tool for
are outlined. Regarding the main contributions made by each study educational interventions, it needs to be specifically designed for
and their most outstanding results, they are presented in Table 4. that age group and framed within the theoretical foundations of
health psychology (DeShazo et al., 2010). In this sense, the use of
Discussion these tools could facilitate an intervention based on behavioral
models to promote the development of self-efficacy judgements in
The aim of this systematic review was to carry out an exploration this population, according to the social cognitive theory formulated
to find scientific evidence of the positive impact of educational or by Bandura (1997).
psychoeducational interventions, and the strategies used for its On the other hand, peer interaction is a strategy that can benefit
development to improve disease control in children and adolescents the achievement of objectives in an educational setting. Specifically,
with T1D. HbA1c levels were the most common outcome measure. training and peer interaction could be effective in adapting to the
Although the improvement of HbA1c level is important, from disease (Altundag & Bayat, 2016). Peer-based interventions show
an education and psychology viewpoint other motivational and some promise, although there are not many studies (Kazemi et al.,
psychosocial variables that allow us to achieve greater control of 2016). For the transition stage, the cooperation of an adolescent and
the disease are also relevant. Perhaps, the most important is self- an adult, both with diabetes disease, can be an effective option for a
management, the goal of any educational intervention on diabetes. progressive transition of care (Mauri et al., 2017).
The continuity over time of the interventions also seems to be
a key factor in their success. Positive effects have been found with
Contrasting Positions on the Effectiveness of Educational or
a positive psychology intervention (Jaser et al., 2019), or with a
Psychoeducational Interventions
structured education program (Hawkes et al., 2019), but the effects
did not continue after training. A more intensive or longer-lasting
There is insufficient evidence to recommend the use of specific
intervention may be needed to sustain these effects (Jaser et al.,
psychoeducational interventions for children and adolescents with
T1D, based on a review of UK trials (Charalampopoulos et al, 2017). 2019). Families who re-visited the web portal after one year obtained
Even so, as this same study confesses, meta-analyses in the USA found better glycemic control (Hanberger et al., 2013). It is probable that
that psychoeducational interventions can improve HbA1c levels young people need frequent reminders to increase their participation
by up to half a percentage point, in addition to other psychological in psychoeducational interventions (Whittemore et al., 2016).
and educational benefits (Armour et al, 2005; Winkley et al., 2006). It is also important to highlight that different methodologies and
Another study argues that although no evidence of significant various approaches achieved positive results with their interventions,
improvements in HbA1c levels was found in their meta-analysis e.g., self-management courses (Johnson et al., 2019), structured
for the adolescent population after structured education, there was diabetes education (Wang et al., 2010), psychoeducational programs
evidence for the adult population (Liu et al., 2020), though a reduction (Katz et al., 2014; Verbeek et al., 2011), and positive psychology
in vascular complications was found in the adult population with T1D interventions (Jaser et al., 2019), among others. The heterogeneity of
(Menezes et al., 2016). the methods used, and their effectiveness, leads us to believe that
The need to continue studying theoretical approaches and adaptation to the specific context in which it will be applied is what
methods that can be applied, including the strategies of these is truly important (Charalampopoulos et al., 2017), rather than a
programs , remains latent, since education can lead to better particular educational program (Murphy et al., 2006).
control of diabetes (Jenhani et al., 2005; Pals et al., 2020). If one Finally, the implementation of these intervention programs is
method is effective for one population, could it be effective for mostly carried out by medical specialists and nurses in nutrition
another one if it is adapted appropriately? The heterogeneity of the and diabetes care. Even so, the participation of physicians or
interventions makes it impossible for us to adopt a single stance multidisciplinary staff has shown effect (Menezes et al., 2016),
because of diverse implementations. Strategies, methods, and tools and the involvement of psychologists was one of the differences
have worked to provide indications that could be addressed and with the successful USA programs (Charalampopoulos et al., 2017).
combined in future interventions. We believe that the participation of psychologists is fundamental
for successful psychosocial and motivational variables, and the
participation of experts in education is fundamental for the
Featured Strategies, Methods, and Tools
pedagogical and methodological approach of interventions where
the teaching-learning process has a primary role.
Firstly, the use of digital tools seems to favor the positive effect.
Of the five analyzed studies that are supported by digital resources
and tools, all five present a significant improvement in some of Limitations and Future Approaches
their analyzed variables: HbA1c levels (Grey et al., 2013; Iafusco et
al., 2011; Petrovski & Zivkovic, 2017), self-management (Emiliana In accordance with the main aim initially stated, we consider that
et al., 2019), self-efficacy (Grey et al., 2013), and quality of life (Grey the development of the research has been correct and has allowed an
et al., 2013; Iafusco et al., 2011). Specifically, animated videos could exploration of the educational and psychoeducational interventions
improve self-management of the disease (Emiliana et al., 2019); developed in children and adolescents with T1D. In relation to the first
internet interventions combining diabetes management education specific objective, some of the limitations encountered do not allow
and behavioral interventions (Grey et al, 2013); a chat line (Iafusco us to affirm the effectiveness of these interventions with absolute
et al., 2011); and the use of social networks as a platform to deliver certainty, although there are indications of their usefulness. In
these interventions to improve glycemic control using insulin pump relation to the second aim, techniques and methods have been found
therapy (Petrovski & Zivkovic, 2017). The use of information and that appear to be effective in the development of these interventions.
communication technology (ICT) creates expectations, yet to be It is possible that some very specific studies have been left out of
discovered, with great potential for the treatment of chronic diseases the selection due to not being included under these criteria. In this
such as diabetes (Rhee et al., 2020). way, this study could be extended to other databases, languages,
This strengthens the idea that using applications could help and other criteria to enrich its results. The wide age range chosen
improve HbA1c control and strengthen the perception of self-care could also be a limitation, although due to the limited scientific
and safety in diabetic patients (Bonoto et al., 2017). Although the literature on this topic, we have decided not to adjust it further. In
42 B. Luque et al. / Clínica y Salud (2022) 33(1) 35-43

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