Linda Siminerio

Background: School-partnered interventions may improve health outcomes for children with type 1 diabetes, though there is limited evidence to support their effectiveness and sustainability. Family, school, or health system factors may interfere with intervention usability and implementation. Objective: To identify and address potential implementation barriers during intervention development, we combined methods in user-centered design and implementation science to adapt an evidence-based psychosocial intervention, the collaborative care model, to a virtual school-partnered collaborative care (SPACE) model for type 1 diabetes between schools and diabetes medical teams. Methods: We recruited patient, family, school, and health system partners (n=20) to cocreate SPACE through iterative, web-based design sessions using a digital whiteboard (phase 1). User-centered design methods included independent and group activities for idea generation, visual voting, and structured critique of the evolving SPACE prototype. In phase 2, the prototype was evaluated with the usability evaluation for evidence-based psychosocial interventions methods. School nurses reviewed the prototype and tasks in cognitive walkthroughs and completed the Intervention Usability Scale (IUS). Two members of the research team independently identified and prioritized (1-3 rating) discrete usability concerns. We evaluated the relationship between prioritization and the percentage of nurses reporting each usability issue with Spearman correlation. Differences in IUS scores by school nurse characteristics were assessed with ANOVA. Results: In the design phase, the partners generated over 90 unique ideas for SPACE, prioritizing elements pertaining to intervention adaptability, team-based communication, and multidimensional outcome tracking. Following three iterations of prototype development, cognitive walkthroughs were completed with 10 school nurses (n=10, 100% female; mean age 48.5, SD 9.5 years) representing different districts and years of experience. Nurses identified 16 discrete usability issues (each reported by 10%-60% of participants). Two issues receiving the highest priority (3.0): ability to access a virtual platform (n=3, 30% of participants) and data-sharing mechanisms between nurses and providers (n=6, 60% of participants). There was a moderate correlation between priority rating and the percentage of nurses reporting each issue (ρ=0.63; P=.01). Average IUS ratings (77.8, SD 11.1; 100-point scale) indicated appropriate usability. There was no difference in IUS ratings by school nurse experience (P=.54), student caseload (P=.12), number of schools covered (P=.90), or prior experience with type 1 diabetes (P=.83), suggesting that other factors may influence usability. The design team recommended strategies for SPACE implementation to overcome high-priority issues, including training users on videoconferencing applications, establishing secure forms for school data reporting, and sharing glucose data in real-time during SPACE meetings. Conclusions: Cross-sector interventions are complex, and perceived usability is a potential barrier to implementation. Using web-based cocreation methods with community partners promoted high-quality intervention design that is aligned with end-user priorities. Quantitative and qualitative assessments indicated appropriate degree of usability to move forward with pilot-testing.

Behavioural scientists and educators began efforts for the study of behaviour, psychosocial themes and health systems research and advanced the field of

BACKGROUND School-partnered interventions may improve health outcomes for children with type 1 diabetes, though there is limited evidence to support their effectiveness and sustainability. Family, school, or health system factors may interfere with intervention usability and implementation. OBJECTIVE To identify and address potential implementation barriers during intervention development, we combined methods in user-centered design and implementation science to adapt an evidence-based psychosocial intervention, the collaborative care model, to a virtual school-partnered collaborative care (SPACE) model for type 1 diabetes between schools and diabetes medical teams. METHODS We recruited patient, family, school, and health system partners (n=20) to cocreate SPACE through iterative, web-based design sessions using a digital whiteboard (phase 1). User-centered design methods included independent and group activities for idea generation, visual voting, and structured critique of the evolving SPACE prototype. In phase 2, the prototype was evaluated with the usability evaluation for evidence-based psychosocial interventions methods. School nurses reviewed the prototype and tasks in cognitive walkthroughs and completed the Intervention Usability Scale (IUS). Two members of the research team independently identified and prioritized (1-3 rating) discrete usability concerns. We evaluated the relationship between prioritization and the percentage of nurses reporting each usability issue with Spearman correlation. Differences in IUS scores by school nurse characteristics were assessed with ANOVA. RESULTS In the design phase, the partners generated over 90 unique ideas for SPACE, prioritizing elements pertaining to intervention adaptability, team-based communication, and multidimensional outcome tracking. Following three iterations of prototype development, cognitive walkthroughs were completed with 10 school nurses (n=10, 100% female; mean age 48.5, SD 9.5 years) representing different districts and years of experience. Nurses identified 16 discrete usability issues (each reported by 10%-60% of participants). Two issues receiving the highest priority (3.0): ability to access a virtual platform (n=3, 30% of participants) and data-sharing mechanisms between nurses and providers (n=6, 60% of participants). There was a moderate correlation between priority rating and the percentage of nurses reporting each issue (ρ=0.63; P=.01). Average IUS ratings (77.8, SD 11.1; 100-point scale) indicated appropriate usability. There was no difference in IUS ratings by school nurse experience (P=.54), student caseload (P=.12), number of schools covered (P=.90), or prior experience with type 1 diabetes (P=.83), suggesting that other factors may influence usability. The design team recommended strategies for SPACE implementation to overcome high-priority issues, including training users on videoconferencing applications, establishing secure forms for school data reporting, and sharing glucose data in real-time during SPACE meetings. CONCLUSIONS Cross-sector interventions are complex, and perceived usability is a potential barrier to implementation. Using web-based cocreation methods with community partners promoted high-quality intervention design that is aligned with end-user priorities. Quantitative and qualitative assessments indicated appropriate degree of usability to move forward with pilot-testing.

Despite the increasing body of knowledge of treatment strategies for diabetes, many patients with type 2 diabetes mellitus (T2DM) are still in a persistent

Background: Ongoing support is critical to diabetes self-management education and support (DSMES) effectiveness, but difficult to realize, particularly in areas with limited resources. The objective of this feasibility study was to assess the impact of a virtual support model on diabetes outcomes and acceptability with high-risk patients with type 2 diabetes in a rural community. Methods: In a 12-month nonrandomized trial in federally qualified health centers (FQHCs), patients with hemoglobin A1c (HbA1c) >9% were referred to the Telemedicine for Reach, Education, Access, Treatment, and Ongoing Support (TREAT-ON) program where a Diabetes Care and Education Specialist provided DSMES through videoconferencing. HbA1c change was compared in 30 patients in the intervention group (IG) to a propensity score-matched retrospective control group (CG) of patients who received in-person DSMES delivered by a DCES. Changes in HbA1c, diabetes distress, empowerment, self-care and acceptability were assessed within the intervention group (IG) between those who did and did not meet self-management goals. Results: The IG experienced similar significant reductions in HbA1c as the CG. Most (64%) IG participants achieved their self-management goal. Goal attainers had a significant HbA1c decrease of 0.21% every 3 months as well as significant reduction in diabetes distress and improvement in general dietary intake. Regardless of goal attainment, IG participants reported high levels of acceptability with TREAT-ON. Conclusions: This feasibility study suggests that TREAT-ON was well-received and as effective as traditional in-person DSMES. While findings augment ample evidence regarding DSMES benefits, the TREAT-ON model offers additional advantages and provides validation for telehealth to inform future practice in reaching and supporting self-management for high-risk patients in underserved areas. Trial Registration: Clinicaltrials.gov, # NCT04107935.

Objectives. To understand the practices, attitudes, and beliefs of type 1 diabetes (T1D) providers towards school-based diabetes care (SBDC), including counseling families and communicating with schools, and explore the barriers and facilitators which affect their support of SBDC. Research Design and Methods. We conducted a national survey of pediatric T1D providers about their perceived support of SBDC, including family counseling and school communication. We used descriptive statistics to analyze results and explored differences by practice size (Results. A total of 149 providers completed the survey. Nearly, all (95) indicated SBDC was very important. Though most (63) reported counseling families about SBDC multiple times per year, few (19) spoke with school staff routinely, reporting that was a shared responsibility among different providers. Close to 90 agreed school feedback on T1D management plans would be helpful, yet only 31 routinely requested this input. Moderate to extremely significant barriers to SBDC communication included internal factors, such as staff resources (67) and time (82), and external factors, such as school nurse education needs (62) and differing school district policies (70). Individuals from large or academic practices reported more barriers in their knowledge of SBDC, including federal/state laws. Desired facilitators for SBDC included a designated school liaison (84), electronic transmission for school forms (90), and accessible school staff education (95). Conclusions. Though providers universally agree that SBDC is important, there are multilevel internal (practice) and external (policy) barriers to facilitating a bidirectional relationship between schools and health teams.

Objective. Using continuous glucose monitoring (CGM), we examined patterns in glycemia during school hours for children with type 1 diabetes, exploring differences between school and nonschool time. Methods. We conducted a retrospective analysis of CGM metrics in children 7–12 years (n = 217, diabetes duration 3.5 ± 2.5 years, hemoglobin A1c 7.5 ± 0.8%). Metrics were obtained for weekday school hours (8 AM to 3 PM) during four weeks in fall 2019. Two comparison settings included weekend (fall 2019) and weekday (spring 2020) data when children had transitioned to virtual school due to COVID-19. We used multilevel mixed models to examine factors associated with time in range (TIR) and compare glycemia between in-school, weekends, and virtual school. Results. Though CGM metrics were clinically similar across settings, TIR was statistically higher, and time above range (TAR), mean glucose, and standard deviation (SD) were lower, for weekends and virtual school ( ). Hour and setting exhibited a significant interaction for several metrics ( ). TIR in-school improved from a mean of 40.9% at the start of the school day to 58.0% later in school, with a corresponding decrease in TAR. TIR decreased on weekends (60.8 to 50.7%) and virtual school (62.2 to 47.8%) during the same interval. Mean glucose exhibited a similar pattern, though there was little change in SD. Younger age ( ), lower hemoglobin A1c ( ), and insulin pump use ( ) were associated with higher TIR in-school. Conclusion. Although TIR was higher for weekends and virtual school, glycemic metrics improve while in-school, possibly related to beneficial school day routines. Keywords: type 1 diabetes, school health, continuous glucose monitoring, time in range, glycemic control.

Objective. The diabetes device confidence scale (DDCS) is a new scale designed to evaluate school nurse confidence with diabetes devices. We hypothesized that the DDCS score would be associated with related constructs of school nurse diabetes knowledge, experience, and training. Research Design and Methods. In a cross-sectional study, we coadministered the DDCS and diabetes knowledge test 2 (DKT2) questionnaires to school nurses in Pennsylvania. We summarized DDCS scores (range 1–5) descriptively. We evaluated the relationship between the DKT2 percent score and DDCS mean score with the Spearman correlation coefficient. Simple linear regression examined school nurse characteristics as predictors of DDCS score. Results. A total of 271 completed surveys were received. The mean DDCS score was 3.16 ± 0.94, indicating moderate confidence with devices overall. School nurses frequently reported low confidence in items representing specific skills, including suspending insulin delivery (40%), giving a manual bolus (42%), knowing when to calibrate a continuous glucose monitor (48%), changing an insulin pump site (54%), and setting a temporary basal rate (58%). The mean DKT2 score was 89.5 ± 0.1%, which was weakly but not significantly correlated with the DDCS score (r = 0.12, ). Formal device training ( ), assisting ≥5 students with diabetes devices in the past 5 years ( ), and a student caseload between 1000 and 1500 students ( ) were associated with higher mean DDCS score. Conclusions. DDCS score is related to prior training and experience, providing evidence for the scale’s convergent validity. The DDCS may be a useful tool for assessing school nurse readiness to use devices and identify areas to enhance knowledge and practical skills.

Purpose: The purpose of this qualitative study was to explore the effectiveness of Glucose to Goal (G2G), a diabetes self-management education and support (DSMES) model for primary care (PC). Methods: PC providers and staff were recruited from 5 PC practices participating in the 18-month intervention to participate in focus groups and interviews, which were used to gain insights about their perspectives on DSMES and how G2G was implemented across the intervention. Data were collected by qualitative researchers at baseline, midpoint, and study completion. Results: At baseline, PC participants held a favorable view of DSMES and welcomed having a diabetes educator (DE) in their practice. Most participants suggested DEs would be helpful in meeting patients’ nutrition needs but should give therapeutic advice only with a doctor’s oversight. Participants anticipated that having a DE onsite would mitigate transportation, scheduling, communication, and cost barriers. Participant viewpoints about G2G remained unchanged from midpoint to study end, while barriers regarding location and transportation were perceived as being reduced by having a DE in the practice. Despite referral rates remaining low in some practices, many concerns stated at earlier timepoints appeared to have been attenuated by G2G components (eg, bringing the DE onsite, preidentifying patients, and DE ability to communicate and make diabetes management recommendations). Conclusions: This study demonstrates that G2G, providing DSMES in PC, appeared to be a welcome service where acceptance of and enthusiasm for the model grew over the course of the intervention.