The Science of Diabetes Self-Management and Care2023, Vol. 49(1) 55 –64© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/26350106221145323journals.sagepub.com/home/tde
Abstract
Purpose: The purpose of the study was to describe differences in non-Hispanic Black (NHB) and non-Hispanic White (NHW) parents’ perceptions of factors that influence the use of diabetes technology.
Methods: Focus groups were conducted with parents of NHB and NHW children at a pediatric diabetes center in the Northeast United States. Kilbourne’s health disparities framework informed the focus group guide and a priori coding for directed content analysis. Further analysis allowed subcategories to emerge inductively.
Results: Twenty-one parents participated. Five subcategories emerged, describing differences in NHB and NHW parent decisions regarding diabetes technology: (1) child’s choice, (2) shame versus pride, (3) pros and cons of technology, (4) time frame, and (5) blood glucose indications of readiness. NHB parents feared technology malfunction, worried that visible devices could worsen experienced stigma of diabetes diagnosis, and described the diabetes team as gatekeepers, who changed eligibility criteria for diabetes technology use for their research purposes. In contrast, NHW parents reported diabetes team expectation of diabetes technology use and did not report provider-related barriers. Conclusion: This study adds to existing literature advancing our understanding of the patient and provider mechanisms underlying racial disparities in diabetes technology use. This understanding may guide development of interventions focused on patients, providers, and structural factors to improve equity in use of diabetes technology by youth with type 1 diabetes.
Marked racial disparities in diabetes outcomes have been shown in children with type 1 diabetes (T1D). In large multicenter trials, non-Hispanic Black (NHB) children had significantly higher glycosylated hemoglobin A1C levels than non-Hispanic White (NHW) children.1-4 Stemming from downstream effects of structural racism, racial minorities experience disproportionate burdens of health disparities.5 For children with T1D, Black race has been associated with higher A1C. When controlling for household incomes in low (<$50 000) and high (>$100 000) household income, NHB children have 1% higher A1C levels than children from NHW families.4 Although NHB children with T1D have slightly higher A1C levels than NHW children with similar average glucose concentrations, the magnitude of reported differences in A1C levels far exceeds this physiological difference.6 Compared to NHW youth, early disparities have been observed in NHB children who had significantly higher A1C levels at 1-year postdiagnosis, indicating a pressing need to intervene early to decrease disparities.7 Factors that have been posited to explain higher A1C in NHB children included fear of hypoglycemia, lower residual beta cell function at diagnosis with short or no honeymoon period, fewer diabetes visits and less contact with the diabetes team, disproportionately disadvantaged social determinants of health, and perceived racism that decreased shared decision making and adherence to provider input.8
NHB children experience more acute and chronic complications of diabetes. They are significantly more likely to experience severe hypoglycemia9 and diabetic ketoacidosis4,9 (DKA) compared to NHW children, leading to significantly higher rates of emergency department visits and hospitalization.3 In the longer term, there is a higher incidence of end-stage renal disease4 and retinopathy10 among NHB patients with T1D. The rate of diabetesrelated deaths in NHB children under 19 years of age is 2.3 times higher than that of NHW patients.11
The prevalence of diabetes technology use, such as insulin pumps and continuous glucose monitors (CGMs), by youth with diabetes has risen dramatically in recent years.2,12 Youth who manage their diabetes using an insulin pump experience significantly improved A1C levels,1,2,13,14 fewer DKA episodes,12 and lower rates of diabetic retinopathy.13 Similarly, youth who use a CGM have lower A1C2 and less fear of severe hypoglycemia.13
Growing evidence demonstrates that although diabetes technology is advancing, NHB youth have significantly lower rates of device use than NHW youth.3,15,16 Several studies have demonstrated that disparity in technology use remains even after controlling for household income and insurance status.4,13,17,18 Similarly, rates of CGM use in NHB compared to NHW is significantly lower, regardless of government or commercial insurance.19 This racial disparity in use of insulin pumps and CGMs emerges early in T1D care and has been demonstrated within the first year following diagnosis of T1D.17 As novel diabetes technologies have continued to emerge, they have appeared to widen disparities. For example, Lipman et al18 reported that NHW were 2 times more likely in 2005 and 2.5 times more likely in 2019 to use an insulin pump compared to NHB youth, revealing a widening disparity over time.
The racial disparities seen in the treatment of T1D in children are concerning, and root causes must be determined and addressed. These disparities have revealed institutional racism present in pediatric diabetes care, defined as practices or behaviors within an organization that create unequal outcomes between groups based on their race.20,21 To guide health disparity research, Kilbourne et al22 created a 3-phase approach framework: to detect, understand, and intervene to reduce or eliminate disparities. Increasing phase 1 research has been conducted to detect and measure health disparities in T1D health outcomes and technology use in youth.4,17 Recent phase 2 disparities research has focused on understanding the potential determinants of diabetes technology disparities. For example, Mencher et al,23 in a qualitative study exploring factors that influenced decision making, reported that NHB adolescents and parents made decisions to not use diabetes technology because of worries of stigmatization and mistrust of the medical community. In another qualitative study, young adults with T1D reported that providers acted as gatekeepers for information about and prescription access for diabetes technology, that there was little shared decision making, and that their concerns about diabetes technology were not addressed.24 Understanding the perspective of parents of children with T1D is critical to the design of effective interventions that will address these disparities.3 To confirm and extend our understanding of disparities in the use of diabetes technology, the purpose of this study was to (1) identify parents’ perspectives on the patient and provider factors influencing decision making on the use of diabetes technology for management of their child’s diabetes and (2) explore how these factors differed by race.
This qualitative exploratory study was reviewed and approved by the hospital Institutional Review Board. The COREQ checklist for qualitative research reporting was used in the preparation of this report.
The Diabetes Center at The Children’s Hospital of Philadelphia provides diabetes care and education to 2700 children and adolescents at a large urban main hospital and at 8 regional satellites. Inclusion criteria were NHB and NHW parents of children with T1D who were under 18 years of age and had been diagnosed for at least 1 year to ensure that they had several interactions with both the inpatient and outpatient diabetes team. Parents who were non-English speaking were excluded. Although racial disparities have been reported for other racial and ethnic groups, disparities have been greatest for NHB youth,2 thereby delimiting the scope of this study for feasibility and to hear from this most marginalized group.
A convenience sample of parents were recruited for 4 different groups, organized by race and whether the child was using or not using diabetes technology (insulin pumps and/or CGM): 2 NHB groups with technology, 2 NHB without technology, 1 NHW group with technology, and 1 NHW without technology. The research team purposively overrecruited NHB parents to ensure the nuanced perspectives of NHB parents whose views have been historically underrepresented in the literature. Although the research team had planned for in-person recruitment in clinic, this was not possible with the move to telehealth visits due to COVID-19 restrictions. Focus groups were also moved from in person to a virtual platform. Eligible parents were called by phone and invited to attend a virtual focus group. The project manager placed reminder phone calls/texts to parents 1 to 2 days before the scheduled focus group. Based on previous study recruitment in this diabetes center, we anticipated that study recruitment would take 2 months. Phone recruitment, in comparison to recruiting during scheduled clinical appointments, proved difficult. Recruitment was concluded after 15 months of attempts.
The research team included a nursing faculty and nursing postdoctoral fellow with expertise in qualitative methods (CJH and JM), pediatric endocrinology physicians and nurse faculty experienced in pediatric diabetes health disparities research (JM, THL, CPH), and clinicians with pediatric diabetes clinical expertise (CJH, THL, CPH).
Parent gender, age, marital/partner status, race, education level, and household income was collected via survey at the time of enrollment.
JM, an experienced focus group facilitator who was not part of the diabetes clinical team, conducted the virtual focus groups. A semistructured focus group guide (Table 1), informed by Kilbourne’s framework, was used to explore patient and provider factors that influenced decision making for diabetes technology.
Descriptive statistical analyses were used to describe the study sample of parents and their children. Focus groups were audio-recorded, transcribed verbatim, and uploaded to Dedoose, a web-based qualitative analysis software platform.25 Qualitative analysis was performed simultaneously with ongoing data collection so that earlier findings informed later focus groups, allowing the researchers to pursue observations and patterns emerging in the data. Using a directed content analysis approach,26 the research team used the constructs of patient factors and provider factors from Kilbourne’s Health Disparities Framework22 as a priori categories for initial coding and data reduction. CJH and JM independently coded 2 focus groups using this coding structure, followed by a discussion of the coding rules and exemplar quotes to reach consensus over any discrepancies. All 7 focus groups were then collectively coded, followed by weekly discussions to ensure continued agreement on the coding rules (CJH and JM). Each category was further explored inductively, allowing subcategories to emerge from the data. Through weekly discussion, the subcategories were merged, reduced, or eliminated to create succinct, nonredundant final subcategories that highlighted racial differences (Figure 1).
Trustworthiness was enhanced by having 2 independent investigators (CJH, JM) complete the initial coding, analysis, and interpretation of the data; each read and reread the focus group transcripts to become familiar with the data. Weekly meetings were held to compare and discuss interpretations to reach consensus on the meaning of the data and the definitions of categories and subcategories. The remainder of the research team verified the analysis (CPH, THL). An audit trail captured the evolving interpretations to ensure dependability and confirmability of the analysis. The reader is encouraged to consider the transferability of the findings to their patient population and clinical context.27
A total of 47 parents initially consented and enrolled; 21 (13 NHB/8 NHW) parents participated in 1 of 7 one-hour virtual focus groups from September 2020 to January 2022. Participants had a mean age 44.8 years (SD 7.1, range 34-55 years), were highly educated (38% graduate or professional degree, 33% college degree, 24% some or 2-year college, 1% vocational training), affluent (43% high >$106 000, 43% middle $40 000-100 000, 14% low income < $30 000), and most participants were mothers (n = 16, 76%). Parents who dropped out before participating in a focus group had lower education and income levels than those who attended a focus group.
Patient factors. Patient factors were defined as the parents’ beliefs and preferences regarding their child’s use of technology to help manage their diabetes. Three emerging subcategories included supporting child’s choice, shame versus pride, and the pros and cons of technology.
Supporting child’s choice. Most parents of children who did not use technology, regardless of race, described supporting their child’s choice to not use an insulin pump even if they, themselves, would prefer that their child used a pump. Because they were managing their child’s diabetes well enough with blood glucose monitoring and insulin injections, they did not believe that an insulin pump was an absolute need, “She’s the kid that follows all the rules . . . we had such a tight program, she’s used to that schedule.” All parents, regardless of race, were unwilling to force their child to wear a pump, believing that the child had to have control over the decision and their body. Parents of children not using technology shared that their child refused to wear a medical device on their body and especially did not want 2 attached devices (pump and CGM), “they do not want to be a cyborg.” Some parents thought that their child’s preference for technology may change when the option of closed loop systems was readily available.
Shame versus pride. For parents of children not using technology, the reasons behind supporting their child to not use an insulin pump or CGM differed by race. NHB parents spoke about not wanting their child to appear different by wearing technology. As one NHB parent noted, “For people of color, we already have a lot of things already against us, so if I [her son] can keep this covered up, I never wanted anyone to treat him any different.” Another NHB parent described their child’s attempt and subsequent refusal to wear a CGM because of the alarms sounding in public, “People were asking him questions and bullying him about it.” In contrast, no NHW parents of children not using technology mentioned any concerns that their child would appear different. Instead, the NHW parents reasoned that they did not want to antagonize their child by insisting that they use an insulin pump. As one NHW parent described, “It’s the only control that she has, that she can say what’s happening to her body as opposed to me saying you have to wear a pump and her hating it and then hating her diabetes more.”
Not wanting to appear different seemed rooted in the NHB parents’ attitude of shame versus pride related to the diabetes diagnosis. NHB parents described a deep “shame that goes along with the diagnosis in our [Black] communities,” which was not raised among NHW parents. As one NHB mother reported,
I got legitimately [sic] shamed, thinking that him having diabetes was neglect, I got “I know the way your family is going to change your diet,” everybody’s assumption was I was giving him Skittles for breakfast.
These NHB parents explained that their family, friends, and community believed that they were well versed with the causes of diabetes. As one NHB parent reported,
When my son was diagnosed, the medical community was doing a really good job of pushing the dangers of type 2 diabetes for children and telling people to stop drinking soda, no sugary cereal.
Additionally, NHB parents described feeling defensive against this community judgment, driving them to educate their community about T1D, a diagnosis that was not preventable and was a sign of neither poor parenting nor poor decisions in eating behavior. Although NHW parents also spoke of the need to educate their family and community about T1D, they did not attach a feeling of judgment or shame to their child’s diagnosis. In contrast, one NHW parent reported her daughter’s advocacy with pride,
She’s given presentations to her Girl Scouts, her tennis team, people who are going to be in her class and going to be watching out for her . . . one year she did a science fair project on diabetes and the history of it and the future of it and where the technology’s going, she actually won too.
Pros and Cons of Insulin Pumps. Parents’ perceptions of the pros and cons of insulin pumps seemed to differ by race. NHB parents, although they reported some positives with insulin pump use, they seemed more aware of the dangers. Specifically, NHB parents whose children did not use technology identified dangers as a barrier to pump use. As one NHB mother noted, “It’s a hazard of having the tubing in there, she’s a kid, she played, I didn’t want other children to pull it out.” Another NHB parent said, “They will want to be children, they don’t want to stop, you know, you go swimming and now it’s wet and fell out.” These NHB parents worried about disruptions in their day should the parent need to go to the child to reinsert the pump, “I have to leave and go from work and come to put the pump back in, I can’t do that.” In contrast, no NHW parents described dangers with insulin pump use, instead framing pump site dislodgement or tubing occlusion as a hassle that could easily be managed. Instead, NHW parents described positives of insulin pumps, such as “no more frequent injections,” “how the pump would give more precise dosages” for tighter management of blood glucose, and the “convenience” to give insulin boluses for meals and snacks, especially in public.
Provider factors. Provider factors were defined as parents’ perceptions of the diabetes team’s knowledge and attitude when speaking to them about their child’s options for diabetes technology. Most parents reported positive communication with the diabetes team, finding them responsive to their child’s needs and to their questions. However, some NHB parents found the team to be rude and condescending, that they did not know how to speak to them and made them feel like an outsider. No NHW parents reported negative communication with the diabetes team. Overall, parents related their perception about the diabetes team communication about diabetes technology, including the time frame for initiation of pump therapy and blood glucose indications of device readiness.
Time frame. Parents reported that the time frame for when the initial discussion and expectations of timing to initiate device use varied, ranging from early discussions during the inpatient hospitalization at diagnosis, at the first clinic visit, or at 1 year after diagnosis. Although some NHW and NHB families reported being told to wait 1 year to give them time to “learn the math, get familiar with the manual process, and to develop a routine,” the idea of a requisite year time frame was heard more often from NHB than NHW parents. One NHB mother noted,
It just seemed like they had a plan. Like this is what they do with all the patients with diabetes. This what they do the first year and then they bump you to using the pens and then they bump you using the CGM, it felt like they were trying to make it seem it was happening in steps.
Some NHB parents spoke of being forceful about wanting technology and insisting that they did not want to wait a year. One NHB parent who identified herself as a nurse said, “I knew that pump was the route I wanted to go, at the first appointment that was what I wanted.” She reflected that she was met with resistance and described her interactions as, “My assigned educator can be very rude, condescending, I have to remind her that I am a nurse and that I do understand what she is saying.” Furthermore, some NHB parents identified a CGM study that was conducted in the Diabetes Center several years prior to this current study as their introduction and access to diabetes technology. As one NHB parent described,
I really wanted the CGM and they were telling me no, you need to wait for the year and you have to do these classes first, and we kept having issues with scheduling classes. And then one of the doctors was doing a study and so we got into the study maybe at 6 months postdiagnosis.
After this initial access to diabetes technology, the NHB parent reflected, “We showed that we could do it, so the team just had to write a script.” NHB parents seemed aware of this access point, “If I had never gotten into the study, I would have had to wait a year.” Another NHB parent provided insight into the motivations of the diabetes team, “With the CGM, it was obvious they were very supportive because it went with participation in their research [laughs].”
In contrast, most NHW parents reported that the diabetes team communicated an expectation of early technology use. As one NHW parent said, “Even if they’re saying you have a choice, they are pushy, I think it came up so much, like here’s an expected calendar, that she could end up being on the pump by December.” Some NHW parents complained that the conversation about technology came up frequently during clinic visits despite their earlier refusal. As one NHW parent stated, “During a virtual visit, I really had to say stop, you’re not listening to me right now, no she does not want it.” No NHW parents mentioned participation in the CGM study as their path to diabetes technology for their children.
Blood glucose indications of readiness. There appeared to be differences by race in the diabetes team’s consideration of blood glucose indications of readiness to initiate pump therapy. NHB parents described their understanding that the diabetes team evaluated their child’s blood glucose and A1C levels to determine their child’s readiness to use an insulin pump. These NHB parents reported that they were told to wait until the child’s blood sugars were in control and more stable, “We couldn’t do it because they said her blood sugar wasn’t steady at all, I think it has to stay in a normal steady, not too high for her to get it.” At clinic visits, these same NHB parents noted there was an assessment of the child’s blood glucose trends, “Every time we went to the office, they would ask how his sugars were, and say, okay, I think we should wait before we try something else.” In contrast, no NHW parents reported blood glucose levels as criteria that influenced the decision to use insulin pumps.
In this study, we have shown that both patient beliefs and preferences and the diabetes teams’ attitudes toward decisions related to insulin pump use differed by race. Consistent with previous findings,23 NHB parents in this study supported their child’s choice to not use diabetes devices that made their diabetes diagnosis visible, which could possibly exacerbate their child’s experience of diabetes-related stigma. Although CGM alarm features brought a feeling of safety, the NHB parents reported their children became self-conscious, confirming earlier reports that CGM alarms were perceived as embarrassing.28 This protective stance by NHB parents in this study confirmed previous data demonstrating that 78% of minority youth reported diabetes stigma, including being treated differently and feeling blamed and shamed.29 This suggests that diabetes teams should provide anticipatory guidance to parents to handle diabetes-related stigma and to equip them to educate their family and communities about the differences between T1D and type 2 diabetes.
Although NHW parents in this study described the advantages of insulin pump therapy and considered pump malfunction or tubing dislodgement as an annoyance, NHB parents described the disadvantages of insulin pumps with its risks and danger. In this study, NHB parents’ concerns related to pump malfunction supported previous data reporting NHB fear and distrust of insulin pumps and the medical community in general.30
Although the same information about diabetes technology may have been provided to all parents and children, it may have been delivered in different ways, with different emphasis, or perceived in different ways, as is suggested by the differences in NHB and NHW parental perceptions reflected in this study. The reports from parents in this study suggest that diabetes teams need to increase their awareness of how they frame the use of insulin pumps as either dangerous or safe and whether messages are delivered in different ways due to unconscious racial bias. For instance, Puckett et al30 explored differences in approach to determine pump readiness in 2 pediatric endocrinology clinics, one with low, inequitable use of insulin pump therapy across their patients and the other with high, equitable use. In the low use clinic, providers considered insulin pumps complex and risky, using a long list of eligibility criteria (eg, at least 4 blood glucose checks per day, carbohydrate counting, no recent DKA admission, acceptable A1C). This team insisted that families wait a year because administering long-acting basal insulin by injection was safer. In contrast, the high use clinic was in favor of insulin pump therapy for all children, believing that the improved quality of life with pump use outweighed the risk of DKA. These findings suggest that diabetes teams should consider how they present diabetes technology and how this influences decision making. More specifically, further research, including direct observations of clinical interactions, is needed to understand how messages regarding diabetes technology are not only communicated but also how they are received. This information will help shape effective changes in clinical interactions that address racial disparities in use of diabetes technology.
In the current study, NHB parents of children using technology expressed not feeling supported in their desire to use technology and experienced provider-driven barriers to access technology. Parents described their perception of the diabetes team as gatekeepers who determined eligibility criteria for insulin pump therapy, confirming previous findings.24 Findings suggested that providers perceived that the family could “earn” an insulin pump after 1 year if they proved their competence with diabetes management and demonstrated that the child’s blood glucose was in an acceptable range. The American Diabetes Association’s (ADA) 2022 guidelines call for the introduction of diabetes technology early in treatment, even at diagnosis, of automated insulin delivery (hybrid closed looping) or insulin pump therapy in appropriate individuals, who are capable of using the device safely.31 These guidelines, however, do not explain how a diabetes team determines who is “appropriate and capable.” In a recent survey of members of the Pediatric Endocrine Society on their prescribing practices for diabetes devices, most reported using personal guidelines for patient selection rather than any objective eligibility criteria.32 Although the ADA 2022 technology guidelines suggested that to decrease known disparities in technology use providers should use objective, consistent criteria to determine readiness,31 there seems to be little guidance on how diabetes teams assess readiness for insulin pump use. It is unknown to what extent this lack of consistent readiness guidance contributes to racial disparities in technology use. There is a pressing call to action for expert recommendations to develop consensus guidelines on readiness and eligibility for diabetes device use.
Without clear and consistent clinical guidelines, diabetes teams may act as gatekeepers, unintentionally changing their approach based on race or personal bias rather than on objective guidelines to determine readiness. Unfortunately, due to the unconscious nature of bias, diabetes teams may be unaware of their racial bias in recommending and prescribing diabetes devices, which may contribute to racial disparities observed in diabetes technology use. In a recent study, pediatric diabetes providers were presented 1 of 2 cases that differed by public versus private insurance and were asked to rank-order the factors that influenced their decision to recommend insulin pump therapy.33 Respondents ranked the type of insurance as very high importance and race/ethnicity as the least important, revealing a possible lack of awareness of the role structural racism plays in driving disparities in care. In our current study, the differences in the NHB parents’ perceptions compared to the NHW parents’ perceptions suggest there is a difference in the way and timing of when the technology information is either delivered or how it is perceived. In this way, it is equally possible that there is a lack of diabetes team awareness of racial bias in presenting and prescribing diabetes technology. Some NHB parents reported their initial access to diabetes technology was their participation in a CGM study in the diabetes center. No NHW parents mentioned this study. NHB parents seemed aware of the paradox of being told they must wait a year to be prescribed CGM yet then having the timeline accelerated when providers needed research participants for CGM studies. For the NHB parents in this study, the eligibility criteria seemingly shifted, driven by self-interest of the clinical researchers rather than patient preference and readiness to use technology. Professional education is needed to increase awareness of racial bias and the need for objective readiness criteria for diabetes technology use.
This study, conducted during the COVID-19 pandemic, has several limitations. Parents who participated in the virtual focus groups needed computer and internet access, resulting in possible sample bias. However, offering virtual rather than in-person groups may have increased accessibility for some parents. Because this study was conducted at a single pediatric diabetes center with a small sample, the readers must determine the transferability of our findings to their patient population and clinical context. The data were obtained by parents’ descriptions during focus groups, relying on their memory and accuracy of reporting, and may be subject to recall bias. The perspective of the diabetes team was beyond the scope of this study and did not allow us to differentiate between clinician messages versus parent interpretations. Despite these limitations, these findings reveal an evolving picture of parents’ perspectives of the patient and provider factors that may be root causes to observed racial disparities in diabetes technology use.
Overall, this study extends Kilbourne’s phase 2 research to understand health disparities in pediatric diabetes device use. The findings suggest that there are differences in patient beliefs and culture that drives their preferences for technology. In addition, NHB and NHW parents reported different experiences of the diabetes team related to diabetes technology communication and expectations. Many of the most promising efforts to improve diabetes management are likely to widen disparities because the most advantaged social groups are likely to extract the greatest benefit. Some argue that children who are resistant to technology use may become more motivated to try with closed looped systems, incorporating insulin pump and CGM together, which are demonstrating significant improvements in A1C and time in range.34 Although the hope was that racial disparities in A1C would disappear with the advent of advanced technologies, recent data of youth using advanced hybrid closed looped systems found a significant reduction in A1C for NHW but not for NHB youth.35 These data suggest that the root causes of disparities are complex, involving both patient and provider factors. The health of children with diabetes experiencing the greatest disparities must be improved more rapidly than that of the rest of the population so that gaps can be narrowed.21,36 Future studies should continue to extend and expand our understanding of racial disparities to inform interventions.
As greater understanding comes to light, future research must also turn toward Kilbourne’s phase 3 intervention research. For example, the Type 1 Diabetes Exchange has established a Health Equity Advancement Lab (HEAL) Advisory Committee and accompanying quality improvement program to specifically explore and develop interventions to reduce inequities.37 Instead of blaming patients for disparities, diabetes teams must examine their own biases38 and are challenged to adopt and test structures and processes to promote equitable access to diabetes technology. A useful direction would be for diabetes teams to develop guidelines to intentionally promote patient and family readiness for diabetes technology use and to ease access.
Thank you to the parents who shared their experience and thoughts about the use of diabetes technology for their children living with diabetes.
No authors report a financial conflict of interest with this study.
This study was supported by a Pediatric Endocrinology Nursing Society Research Grant.
Carol Howe https://orcid.org/0000-0003-3022-8316
From Harris College of Nursing and Health Sciences, Texas Christian University, Fort Worth, Texas (Dr Howe); School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania (Dr Morone, Dr Lipman); Diabetes Center for Children, Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia (Dr Hawkes); and Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia (Dr Lipman).
*Jennifer Morone is also affiliated to Yale University, National Clinician Scholars Program, School of Medicine, New Haven, CT.
*Colin P. Hawkes is also affiliated to Yale University, Department of Paediatrics and Child Health, University College Cork, Ireland; INFANT Research Centre, University College Cork, Ireland; Diabetes Center for Children, Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia.
Corresponding Author:Carol J. Howe, PhD, RN, CDCES, Harris College of Nursing and Health Sciences, Texas Christian University, TCU Box 298620, Fort Worth, Texas 76129, USA.Email: carol.howe@tcu.edu
