Effect of a Structured Educational Intervention Through Mobile App on Hemoglobin A1c (HbA1c), Self-Efficacy and Self- Care in Adolescent With Type 1 Diabetes (T1DM)

Type 1 diabetes mellitus (T1DM) is a chronic illness that affects children and adolescents worldwide. It affects approximately 1.52 million individuals under the age of 20 years worldwide. The incidence increased from 7.78 per 100,000 population to 11.07 per 100,000 population from 1990 to 2019. In Pakistan, 7,927 individuals aged 20 years or younger have been diagnosed with T1DM however, this number is most likely underreported.

T1DM is a challenging illness to manage because it requires adherence to strict self-management regimes involving frequent glucose monitoring, insulin administration, balancing physical activity, diet control, and the prevention and management of acute complications. Its management becomes more challenging in adolescents (10-19 years), which is a transitional period from childhood to adulthood. During this phase, significant hormonal and physiological changes occur, which can increase insulin resistance and thus deteriorate glucose metabolism. Furthermore, individuals in their adolescence strive for independence but also tend to socialize more with their agemates, which transforms their eating habits and physical activity patterns. This makes it difficult for adolescents to embrace the responsibility of managing their diabetes. The literature suggests that adolescents with diabetes lack sufficient knowledge and skills to effectively manage their illness. These challenges can result in inadequate glycemic control, as evidenced by higher glycated hemoglobin (HbA1c) levels in adolescents than in children and adults with T1DM. The World Health Organization emphasizes the role of self-efficacy and self-care behaviors in adolescents to improve glycemic control and prevent diabetes-related complications. A recent study in Capital Territory of Pakistan reported that 49.2% of the adolescents with T1DM have inadequate self-care. This study also reported a negative correlation between self-care and HbA1c levels. These findings suggest that self-care practices are the key to achieving better glycemic control.

The literature indicates that structured educational interventions (SEI) can significantly improve healthy lifestyle practices among adolescents with T1DM and enhance their self-efficacy. Diabetes-related education has been shown to reduce the frequency of hypoglycemic episodes and improve glycemic control. Structural intervention programs are the recommended approach for the optimal maintenance of self-care behaviors.

Compared with the conventional approach to education, the use of smartphones by adolescents offers an excellent medium for improving health literacy regarding various health problems, including diabetes. Various mobile health applications (apps) have been developed and are being used to improve health literacy and promote self-management practices in patients with diabetes in various age groups, including adolescents. Some experimental studies have also demonstrated the effectiveness of SEI delivered via mobile health apps in improving self-efficacy and modestly reducing HbA1c in adolescents with T1DM.

Problem Statement Limited interventional research has been conducted on adolescents with T1DM in Pakistan, with the exception of one study. Existing research has primarily focused on the assessment of knowledge, complications, and self-care behaviors. Using a longitudinal design, which evaluated the effectiveness of diabetes care for T1DM patients across various age groups (0 to > 19 years). Patients and their parents provided information on various aspects of T1DM through community-based camps. However, the details of the intervention regarding the duration and mode of delivery have not been reported. Furthermore, this approach may be inappropriate for adolescents. A qualitative study of adolescents with T1DM in Pakistan highlighted several significant challenges regarding the inability of adolescents to independently manage their disease, including complications, psychological stress, and social stigmatization associated with the disease. The participants in this study reported a lack of comprehensive training and formal education in diabetes management. Moreover, Insufficient support from healthcare professionals leads to reliance on informal information sources .

Concomitant with the above findings, I observed my 14-year-old daughter with T1DM relying heavily on Internet sources to seek information regarding her condition. Although a wealth of information is available online, it is crucial to find authentic, age-appropriate, and culture-specific content for adolescents. Globally, several apps are available for the education of adolescents with T1DM. However, existing international apps may not be suitable for the Pakistani context. Details about the international app are provided in Appendix A. The locally available apps are not comprehensive, as they focus on a single aspect of self-care, such as glucose tracking or diet. Moreover, the existing apps only serve as a source of information, but they do not provide an opportunity for the active involvement of adolescents in managing their disease. Given the increasing prevalence, uncontrolled glycemic levels, inadequate self-care in T1DM and unavailability of the age-appropriate apps, it is imperative to design and test a comprehensive structured educational intervention that is feasible and engaging in teaching adolescents about self-care. The literature suggests that adolescents learn more efficiently through mobile apps. Hence, the structured educational intervention will be delivered through a mobile app to improve HbA1c levels, self-efficacy, and self-care practices.

Purpose of the study This study will assess the feasibility of a pilot RCT and evaluate the effectiveness of a structured educational intervention delivered through a mobile app on HbA1c levels, self-efficacy, and self-care among adolescents with T1DM.