Biomarker Predictors of Clinical Efficacy of the Anti-IgE Biologic Omalizumab in Severe Asthma in Adults: Results of the SoMOSA Study.

Background: The anti-IgE monoclonal antibody omalizumab is widely used for severe asthma. This study aimed to identify biomarkers that predict clinical improvement during 1 year of omalizumab treatment. Methods: One-year open-label Study of Mechanisms of action of Omalizumab in Severe Asthma (SoMOSA) involving 216 patients with severe (Global Initiative for Asthma step 4/5) uncontrolled atopic asthma (at least two severe exacerbations in the previous year) taking high-dose inhaled corticosteroids and long-acting ß-agonists with or without maintenance oral corticosteroids. It had two phases: 0-16 weeks, to assess early clinical improvement by Global Evaluation of Therapeutic Effectiveness (GETE); and 16-52 weeks, to assess late responses based on ⩾50% reduction in exacerbations or mOCS dose. All participants provided samples (exhaled breath, blood, sputum, urine) before and after 16 weeks of omalizumab treatment. Measurements and Main Results: A total of 191 patients completed phase 1; 63% had early improvement. Of 173 who completed phase 2, 69% had reduced exacerbations by ⩾50% and 57% (37 of 65) taking mOCSs had reduced their dose by ⩾50%. The primary outcomes 2,3-dinor-11-ß-PGF2α, GETE score, and standard clinical biomarkers (blood and sputum eosinophils, exhaled nitric oxide, serum IgE) did not predict either clinical response. Five volatile organic compounds and five plasma lipid biomarkers strongly predicted the ⩾50% reduction in exacerbations (receiver operating characteristic areas under the curve of 0.780 and 0.922, respectively) and early responses (areas under the curve of 0.835 and 0.949, respectively). In an independent cohort, gas chromatography/mass spectrometry biomarkers differentiated between severe and mild asthma. Conclusions: This is the first discovery of omics biomarkers that predict improvement in asthma with biologic agent treatment. Prospective validation and development for clinical use is justified.

Evaluating barriers and facilitators to healthcare providers' use of an emergency department electronic referral portal for high-risk children with asthma using the Theoretical Domains Framework.

OBJECTIVE: Urban children with asthma are at risk for frequent emergency department (ED) visits and suboptimal asthma management. ED visits provide an opportunity for referrals to community-based asthma management services. Electronic medical record-based referral portals have been shown to improve quality of care but use of these portals by healthcare providers (HCPs) is variable. The purpose of the study was to investigate facilitators, barriers, and recommendations to improve the use of an electronic referral portal to connect children presenting with asthma exacerbations in an urban pediatric ED to community-based education and case management services. METHODS: The study was grounded in the Theoretical Domains Framework, an implementation provided the theoretical basis of the study. All ED HCPs were invited to complete qualitative interviews; twenty-three HCPs participated. Interviews were coded using directed content analysis. RESULTS: Facilitators to portal use included its relative ease of use and HCP beliefs regarding the importance of such referrals for preventive asthma care. Barriers included insufficient time to make referrals, lack of information regarding the community agency and challenges communicating the value of the referral to patients and/or their caregivers. CONCLUSIONS: Successfully engaging HCPs working in ED settings to use electronic portals to refer children with asthma to community agencies for health services may involve helping providers increase their comfort and knowledge of the external provider agency, ensuring organizational leaders support the need for preventive asthma care and provision of feedback to HCPs on the success of such referrals in meeting the needs of those families served.

Utilization of electronic portal referrals to a community agency for children presenting with an asthma exacerbation to a pediatric emergency department.

PURPOSE: To evaluate referral rates and factors associated with referrals to a community agency for children evaluated for an asthma exacerbation at a pediatric emergency department (PED) and compare PED visits for asthma the following year between those referred and not referred. METHODS: We reviewed electronic health records of children 2-18 years evaluated in our PED from 01/01/2019 to 12/31/2019 with an ICD-10 diagnostic code for asthma (J45x) following the introduction of a portal where clinicians could refer children to a community agency focused on improving health outcomes for asthma. We abstracted data on demographics, PED visits, and hospitalizations and used multivariate logistic regression to evaluate factors associated with referrals. RESULTS: Of the 2262 charts analyzed, the majority of patients were male (61%), Black (76%), and held public insurance (71%). Only a minority of patients (n = 140, 6%) were referred. Age [6-12 years (AOR: 1.93, 95% CI: 1.21-3.08, p = .006), 13-18 years (AOR: 10.61, 95% CI: 6.53-17.24, p = .001)] and lifetime number of PED asthma visits [≥3 visits (AOR: 1.91, 95% CI, 1.01-3.62, p = .05)] were associated with referral. There was no significant difference in the mean number of PED visits in one year [referred: 0.59 (SD1.2) vs. not referred: 0.79 (SD1.3), t = 1.70, p = .09] between the two groups. CONCLUSION: The referral rate to community agency from PED for asthma is low. There was no difference in short-term PED utilization for asthma between those referred and not referred.

Diabetes distress in urban Black youth with type 1 diabetes and their caregivers: associations with glycemic control, depression, and health behaviors.

OBJECTIVES: Adolescents with type 1 diabetes (T1D) and their caregivers endorse high diabetes distress (DD). Limited studies have documented the impact of DD on Black youth. The aims of the present study were to (1) describe DD among a sample of Black adolescents with T1D and their caregivers, (2) compare their DD levels with published normative samples, and (3) determine how DD relates to glycemic outcomes, diabetes self-management, parental monitoring of diabetes, and youth depressive symptoms. METHODS: Baseline data from a multicenter clinical trial were used. Participants (N = 155) were recruited from 7 Midwestern pediatric diabetes clinics. Hemoglobin A1c (HbA1c) and measures of DD, parental monitoring of diabetes care, youth depression and diabetes management behaviors were obtained. The sample was split into (1) adolescents (ages 13-14; N = 95) and (2) preadolescents (ages 10-12; N = 60). Analyses utilized Cohen's d effect sizes, Pearson correlations, t-tests, and multiple regression. RESULTS: DD levels in youth and caregivers were high, with 45%-58% exceeding either clinical cutoff scores or validation study sample means. Higher DD in youth and caregivers was associated with higher HbA1c, lower diabetes self-management, and elevated depressive symptoms, but not with parental monitoring of diabetes management. CONCLUSIONS: Screening for DD in Black youth with T1D and caregivers is recommended, as are culturally informed interventions that can reduce distress levels and lead to improved health outcomes. More research is needed on how systemic inequities contribute to higher DD in Black youth and the strategies/policy changes needed to reduce these inequities.

The moderating role of diabetes distress on the effect of a randomized eHealth intervention on glycemic control in Black adolescents with type 1 diabetes.

OBJECTIVE: Due to systemic inequities, Black adolescents with type 1 diabetes are more likely to have suboptimal glycemic control and high rates of diabetes distress, but tailored interventions for this population are lacking. In primary outcomes of a randomized clinical trial, a family-based eHealth intervention improved glycemic control in Black adolescents with type 1 diabetes and elevated depressive symptoms. The present study is a secondary analysis of these clinical trial data examining the moderating effect of diabetes distress on the efficacy of the intervention. METHODS: Using secondary data from a multicenter randomized clinical trial (Clinicaltrials.gov [NCT03168867]), caregiver-adolescent dyads were randomly assigned to either up to three sessions of an eHealth parenting intervention (n = 75) or a standard medical care control group (n = 74). Black adolescents (10 years, 0 months to 14 years, 11 months old) with type 1 diabetes and a caregiver willing to participate were eligible. Adolescents reported their diabetes distress at baseline, and hemoglobin A1c (HbA1c) data were collected at baseline, 6-, 13-, and 18-month follow-up. RESULTS: No between-group contrasts emerged in a linear mixed-effects regression (p's > .09). Within-group contrasts emerged such that adolescents assigned to the intervention who reported high diabetes distress had lower HbA1c at the 18-month follow-up relative to baseline (p = .004); the 18-month decrease in HbA1c was -1.03%. CONCLUSIONS: Black adolescents with type 1 diabetes and high levels of diabetes distress showed significant decreases in HbA1c following a family-based eHealth intervention, suggesting diabetes distress may be a key moderator of intervention efficacy within this population.

The Language We Use: Providers' Perceptions About Families.

Implicitly-held unconscious associations and attitudes may not align with the beliefs we hold outwardly or explicitly but can affect our professional perceptions, decisions, and actions. In a phenomenological study identifying strategies used to support families in vulnerable circumstances, we conducted nine focus groups to examine how early interventionists (EIs) described families and children, the language they used, and how they used it. Thematic qualitative analysis revealed three themes about families: perceptions of parenting, perceptions of capability, and perceptions of priorities. How EIs characterized families and their interactions with families were both reflective of and counter to family-centeredness and, at times, indicative of implicit bias. This study addresses a critical gap in the field, given the lack of empirical research available about implicit bias in early childhood intervention professionals. Implications for personnel preparation and practice change are discussed to begin the necessary work of moving the field toward more culturally sustaining practices.

Effects of family and neighborhood risks on glycemic control among young black adolescents with type 1 diabetes: Findings from a multi-center study.

While individual and family risk factors that contribute to health disparities in children with type 1 diabetes have been identified, studies on the effects of neighborhood risk factors on glycemic control are limited, particularly in minority samples. This cross-sectional study tested associations between family conflict, neighborhood adversity and glycemic outcomes (HbA1c) in a sample of urban, young Black adolescents with type 1 diabetes(mean age = 13.4 ± 1.7), as well as whether neighborhood adversity moderated the relationship between family conflict and HbA1c. Participants (N = 128) were recruited from five pediatric diabetes clinics in two major metropolitan US cities. Diabetes-related family conflict was measured via self-report questionnaire (Diabetes Family Conflict Scale; DFCS). Neighborhood adversity was calculated at the census block group level based on US census data. Indictors of adversity were used to calculate a neighborhood adversity index (NAI) for each participant. Median family income was $25,000, suggesting a low SES sample. In multiple regression analyses, DFCS and NAI both had significant, independent effects on glycemic control (ß = 0.174, P = 0.034 and ß = 0.226 P = 0.013, respectively) after controlling for child age, family socioeconomic status and insulin management regimen. Tests of effects of the NAI and DFCS interaction on HbA1c found no significant moderating effects of neighborhood adversity. Even within contexts of significant socioeconomic disadvantage, variability in degree of neighborhood adversity predicts diabetes-related health outcomes in young Black adolescents with type 1 diabetes. Providers should assess social determinants of health such as neighborhood resources that may impact adolescents' ability to maintain optimal glycemic control.

Optimizing Recruitment of Black Adolescents into Behavioral Research: A Multi-Center Study.

OBJECTIVES: Adolescents of color are underrepresented in behavioral health research. Study aims were to quantify the amount and types of outreach effort needed to recruit young Black adolescents with type 1 diabetes and their primary caregiver into a clinical trial evaluating a parenting intervention and to determine if degree of recruitment difficulty was related to demographic, diabetes-related, or family characteristics. METHODS: Data were drawn from a multi-center clinical trial. Participants (N = 155) were recruited from seven pediatric diabetes clinics. Contact log data were used to quantify both number/type of contacts prior to study enrollment as well as length of time to enrollment. Families were coded as having expedited recruitment (ER) or prolonged recruitment (PR). Baseline study data were used to compare ER and PR families on sociodemographic factors, adolescent diabetes management and health status and family characteristics such as household organization and family conflict. RESULTS: Mean length of time to recruit was 6.6 months and mean number of recruitment contacts was 10.3. Thirty-nine percent of the sample were characterized as PR. These families required even higher levels of effort (mean of 9.9 months to recruit and 15.4 contacts). There were no significant between-group differences on any baseline variable for ER and PR families, with the exception of family income. CONCLUSIONS: Researchers need to make persistent efforts in order to successfully enroll adolescents of color and their caregivers into clinical trials. Social determinants of health such as family resources may differentiate families with prolonged recruitment within such samples.

Toward the Development of a Culturally Humble Intervention to Improve Glycemic Control and Quality of Life among Adolescents with Type-1 Diabetes and Their Families.

Type-1 Diabetes (T1D) is a prevalent and costly disorder associated with substantial morbidity that differentially impacts low-income and/or minority adolescents and their families. The primary study objective was to develop a guiding model to inform culturally humble interventions for Mid-southern youth with T1D presenting with multiple correlates of suboptimal glycemic control and their families. In order to develop a clinic specific guiding model, conceptualizations of health, the need/type of intervention thought to be most helpful, the optimal structure, and strategies to improve the cultural/regional fit was ascertained from (A) youth with T1D (n = 13) and caregivers (n = 11) via qualitative interviews and, (B) pediatric endocrinologists and nurse practitioners (n = 6), and (C) nurses, diabetes educators, dietitians, and social workers (n = 9) via focus groups. Qualitative themes were synthesized to guide the treatment development model whereby Quality of Life and Glycemic Control would be directly enhanced by interventions to promote Coping, Support, Education, and Improved Psychosocial Functioning and indirectly through improved Adherence and T1D Autonomy delivered in a culturally humble way that affirms youths' T1D identify. These finding suggest that existing evidence-based treatments may provide a great fit for low-income, and/or minority youth with T1D and their families living in the mid-south, provided these interventions are delivered in culturally humble manner.

Outcomes From a Sequential Multiple Assignment Randomized Trial of Weight Loss Strategies for African American Adolescents With Obesity.

BACKGROUND: Minority adolescents are at highest risk for obesity and extreme obesity; yet, there are few clinical trials targeting African American adolescents with obesity. PURPOSE: The purpose of the study was to develop an adaptive family-based behavioral obesity treatment for African American adolescents using a sequential multiple assignment randomized trial (SMART) design. METHODS: Fit Families was a SMART where 181 African American adolescents (67% female) aged 12-17 were first randomized to office-based versus home-based behavioral skills treatment delivered from a Motivational Interviewing foundation. After 3 months, nonresponders to first phase treatment were rerandomized to continued home-based behavioral skills treatment or contingency management with voucher-based reinforcement for adolescent weight loss and for caregiver adherence to the program. All interventions were delivered by community health workers. The primary outcome was treatment retention and percent overweight. RESULTS: All adolescents reduced percent overweight by -3.20%; there were no significant differences in percent overweight based on treatment sequence. Adolescents receiving home-based delivery in Phase 1 and contingency management in Phase 2 completed significantly more sessions than those receiving office-based treatment and continued skills without CM (M = 8.03, SD = 3.24 and M = 6.62, SD = 2.95, respectively). The effect of contingency management was strongest among older and those with lower baseline confidence. Younger adolescents experienced greater weight reductions when receiving continued skills (-4.90% compared with -.02%). CONCLUSIONS: Behavioral skills training can be successfully delivered to African American adolescents with obesity and their caregivers by community health workers when using a home-based service model with incentives. More potent interventions are needed to increase reductions in percent overweight and may need to be developmentally tailored for younger and older adolescents.

Efficacy of mindfulness-based stress reduction in emerging adults with poorly controlled, type 1 diabetes: A pilot randomized controlled trial.

BACKGROUND/OBJECTIVE: The negative effects of stress on persons with type 1 diabetes (T1D) are well-established, but effective interventions to reduce stress among emerging adults with T1D are limited. The study objective was to conduct a pilot randomized controlled trial (RCT) to obtain preliminary data on the efficacy of mindfulness-based stress reduction (MBSR) to reduce stress and improve diabetes health outcomes in a population of high-risk, urban emerging adults with poorly controlled diabetes. METHODS: Forty-eight participants aged 16 to 20 years of age with T1D (mean duration = 8 years) were randomly assigned to one of three conditions: MSBR, cognitive-behavioral stress management (CBSM), or a diabetes support group. Data were collected at baseline, end of treatment, and 3 months after treatment completion. Measures of self-reported stress and depressive symptoms, diabetes management, and glycemic control were obtained. RESULTS: MBSR was found to reduce self-reported stress at end of treatment (P = 0.03, d = -0.49) and 3-month follow-up (P = 0.01, d = -0.67), but no effects on diabetes management or glycemic control were found. Diabetes support group participants had improved glycemic control at the end of treatment (P = 0.01, d = -0.62) as well as reduced depressive symptoms at 3-month follow-up (P = 0.01, d = -0.71). CONCLUSIONS: Results provide preliminary support for the efficacy of MBSR to improve psychosocial adjustment in emerging adults with poorly controlled T1D but require replication in adequately powered studies. Findings also support the value of peer support in improving health outcomes in this age group.

Adaptation of an Evidence-Based Diabetes Management Intervention for Delivery in Community Settings: Findings From a Pilot Randomized Effectiveness Trial.

Objective: To adapt an evidence-based intervention targeting diabetes management in adolescents with poorly controlled type 1 diabetes for use in a community setting by community health workers (CHWs) and to conduct pilot testing of the new intervention, REACH for Control (RFC). The study was conducted as a collaboration between university researchers and a federally qualified health center. Methods In a pilot effectiveness trial, feasibility and acceptability of RFC were evaluated based on participant enrollment, treatment dose, and consumer satisfaction. RFC effects on adolescent adherence, health outcomes, and quality of life were also assessed. The trial used a parallel group design. Families were randomized to 6 months of RFC plus standard medical care (n = 26) or standard care (SC) only (n = 24). Data were collected at baseline and 7-month posttest. A mixed-methods approach was used to analyze data. Results: Qualitative analyses suggested that caregivers viewed RFC and delivery of a home-based intervention by CHWs positively. Furthermore, adolescents who received RFC had statistically significant (p = .05) and clinically meaningful improvements in hemoglobin A1c (HbA1c) (0.7%) and reported significant improvements in quality of life from baseline to follow-up (p = .001). No significant changes were found for adolescents in standard medical care. However, while dose of primary intervention session delivered was acceptable, dose of follow-up sessions used for skills practice was low. Conclusions: Results provide preliminary support for RFC's acceptability and effectiveness to improve health status and quality of life when used in community settings serving high-risk, low-income families. Additional testing in a full-scale effectiveness trial appears warranted.

Promoting resilience through neurocognitive functioning in youth living with HIV.

Using a phased model of intervention development, we developed an intervention to promote resilience in youth living with HIV via improved neurocognitive resources. First, youth completed a naturalistic prospective memory (PM) task and were randomized into a visualization condition or control condition. Next, 47 of these participants completed another naturalistic PM task and were randomized into Calendaring condition, an Alarm condition, a Combined condition, or a Control condition. Youth with low PM demonstrated observable gains from the visualization technique. Youth in the Combined Calendaring and Alarm condition demonstrated significantly better performance than participants in the Control and Calendaring conditions. In a Proof-of-Concept study with 16 youth, the previous findings were translated into a single session in-person intervention followed by tailored text messaging to improve adherence and viral load via improved neurocognitive resources. The resulting intervention showed a signal of effect with viral load reductions in youth with available data. Targeting compensatory strategies to enhance neurocognitive functioning may promote resilience and health outcomes. A randomized pilot study with a control condition is the next step.

Improving Diabetes-Related Parent-Adolescent Communication With Individualized Feedback.

Objective: To pilot a brief individualized feedback intervention to improve the communication skills of parents with an adolescent with type 1 diabetes. Methods: Parent-adolescent dyads (N = 79) discussed a diabetes-related problem, while an interventionist rated the parent's communication skills to give feedback to the parents. Parents were then randomized to a brief feedback session to target person-centered communication skills or an educational session. Dyads discussed another diabetes care problem to assess for change in communication skills. Independent raters coded parent communication skills from video recordings to rate behaviors in the service of examining possible changes in communication skills. Dyads completed ratings of perceived closeness and empathy after each conversation. Results: Controlling for overall positive communication at baseline, parents who received feedback showed more improvement in specific person-centered communication skills than parents in the control group. Adolescents in the feedback group reported greater increases in parental empathy and intimacy from pre- to postmanipulation than the control. Conclusions: The feedback intervention showed preliminary efficacy for increasing person-centered communication skills and perceived empathy and intimacy.

Brief Computer-Delivered Intervention to Increase Parental Monitoring in Families of African American Adolescents with Type 1 Diabetes: A Randomized Controlled Trial.

BACKGROUND: African American adolescents with type 1 diabetes (T1D) are at elevated risk for poor diabetes management and metabolic control. Parental supervision and monitoring of adolescent diabetes management have been shown to promote better diabetes management among adolescents, but parents typically decrease their oversight during the transition to independent diabetes care. INTRODUCTION: The purpose of the study was to conduct a randomized clinical trial to test the feasibility and efficacy of a three-session, computer-delivered motivational intervention (The 3Ms) to promote increased parental monitoring among primary caregivers of young African American adolescents with T1D. The intervention was brief and optimized for delivery during routine diabetes clinic visits. MATERIALS AND METHODS: Sixty-seven adolescents with T1D aged 11-14 and their primary caregiver were randomly assigned to one of three arms: adolescent and parent motivational intervention (Arm 1), adolescent control and parent motivational intervention (Arm 2), or adolescent and parent control (Arm 3). Intervention effects were assessed 1 month after intervention completion. RESULTS: Parents in Arm 1 and Arm 2 had significant increases in knowledge of the importance of monitoring adolescents' diabetes care. Parents in Arm 2 also had trend to significant increases in direct observation and monitoring of adolescent diabetes care, and adolescents in Arm 2 had significant improvements in glycemic control. DISCUSSION AND CONCLUSIONS: Findings from the present study provide preliminary support for the efficacy of a brief, computer-delivered parenting intervention for improving family management practices and adolescent health outcomes among African American adolescents with T1D and their caregivers.

Mediators of Treatment Effects in a Randomized Clinical Trial of Multisystemic Therapy-Health Care in Adolescents With Poorly Controlled Asthma: Disease Knowledge and Device Use Skills.

OBJECTIVE: Determine whether Multisystemic Therapy-Health Care (MST-HC) improved asthma knowledge and controller device use skills among African-American youth with poorly controlled asthma and whether any improvements mediated changes in illness management. METHODS: A randomized controlled trial was conducted with 170 adolescents with moderate to severe asthma. Families were randomized to MST-HC or attention control. Data were collected at baseline and 6 and 12 months after intervention completion. RESULTS: In linear mixed models, adolescents in the MST-HC group had increases in asthma knowledge; asthma knowledge was unchanged for attention control. Controller device use skills increased for adolescents in the MST-HC group, while skills declined for attention control. Both knowledge and skills mediated the relationship between intervention condition and changes in illness management. CONCLUSIONS: Tailored, home-based interventions that include knowledge and skills building components are one means by which illness management in African-American youth with poorly controlled asthma can be improved.

Sequential Multiple Assignment Randomized Trial (SMART) to Construct Weight Loss Interventions for African American Adolescents.

The purpose of this study was to develop an adaptive behavioral treatment for African American adolescents with obesity. In a sequential multiple assignment randomized trial, 181 youth ages 12-16 years with primary obesity and their caregiver were first randomized to 3 months of home-based versus office-based delivery of motivational interviewing plus skills building. After 3 months, nonresponders to first phase treatment were rerandomized to continued home-based skills or contingency management. Primary outcome was percent overweight and hypothesized moderators were adolescent executive functioning and depression. There were no significant differences in primary outcome between home-based or office-based delivery or between continued home-based skills or contingency management for nonresponders to first-phase treatment. However, families receiving home-based treatment initially attended significantly more sessions in both phases of the trial, and families receiving contingency management attended more sessions in the second phase. Overall, participants demonstrated decreases in percent overweight over the course of the trial (3%), and adolescent executive functioning moderated this effect such that those with higher functioning lost more weight. More potent behavioral treatments to address the obesity epidemic are necessary, targeting new areas such as executive functioning. Delivering treatment in the home with contingency management may increase session attendance for this population.

Recruitment strategies and the retention of obese urban racial/ethnic minority adolescents in clinical trials: the FIT families project, Michigan, 2010-2014.

INTRODUCTION: The successful recruitment and retention of participants is integral to the translation of research findings. We examined the recruitment and retention rates of racial/ethnic minority adolescents at a center involved in the National Institutes of Health Obesity Research for Behavioral Intervention Trials (ORBIT) initiative by the 3 recruitment strategies used: clinic, informatics, and community. METHODS: During the 9-month study, 186 family dyads, each composed of an obese African American adolescent and a caregiver, enrolled in a 6-month weight-loss intervention, a sequential multiple assignment randomized trial. We compared recruitment and retention rates by recruitment strategy and examined whether recruitment strategy was related to dyad baseline characteristics. RESULTS: Of the 186 enrolled families, 110 (59.1%) were recruited through clinics, 53 (28.5%) through informatics, and 23 (12.4%) through community. Of those recruited through community, 40.4% enrolled in the study, compared with 32.7% through clinics and 8.2% through informatics. Active refusal rate was 3%. Of the 1,036 families identified for the study, 402 passively refused to participate: 290 (45.1%) identified through informatics, 17 (29.8%) through community, and 95 (28.3%) through clinics. Recruitment strategy was not related to the age of the adolescent, adolescent comorbidities, body mass index of the adolescent or caregiver, income or education of the caregiver, or retention rates at 3 months, 7 months, or 9 months. Study retention rate was 87.8%. CONCLUSION: Using multiple recruitment strategies is beneficial when working with racial/ethnic minority adolescents, and each strategy can yield good retention. Research affiliated with health care systems would benefit from the continued specification, refinement, and dissemination of these strategies.

Multisystemic Therapy Improves the Patient-Provider Relationship in Families of Adolescents with Poorly Controlled Insulin Dependent Diabetes.

The purpose of this study was to determine if multisystemic therapy (MST), an intensive, home and community-based family treatment, significantly improved patient-provider relationships in families where youth had chronic poor glycemic control. One hundred forty-six adolescents with type 1 or 2 diabetes in chronic poor glycemic control (HbA1c ≥8 %) and their primary caregivers were randomly assigned to MST or a telephone support condition. Caregiver perceptions of their relationship with the diabetes multidisciplinary medical team were assessed at baseline and treatment termination with the Measure of Process of Care-20. At treatment termination, MST families reported significant improvement on the Coordinated and Comprehensive Care scale and marginally significant improvement on the Respectful and Supportive Care scale. Improvements on the Enabling and Partnership and Providing Specific Information scales were not significant. Results suggest MST improves the ability of the families and the diabetes treatment providers to work together.

Meeting the Needs of Emerging Adults With Type 1 Diabetes Living in a Rural Area With Mobile Health Interventions: Focus Group Study.

BACKGROUND: Emerging adults (EAs; age 18-30 years) with type 1 diabetes (T1D) have more challenges with diabetes management and glycemic control than other age groups. Living in a rural community introduces additional unique diabetes care challenges due to limited access to specialty care and ancillary support services. Yet, few interventions have been developed to improve diabetes management in rural-dwelling EAs with T1D. OBJECTIVE: This study aimed to understand the diabetes management experiences of older adolescents and EAs (age 16-25 years) with T1D living in a rural area and to assess their perceptions of the acceptability of 4 fully automated mobile health (mHealth) interventions to support diabetes management. METHODS: EAs were identified by clinical staff through convenience sampling. In total, 8 EAs participated in 1 focus group and 1 EA completed an individual interview; all data were collected over Zoom. Facilitators explored EAs' experiences living in a rural community with T1D and discussed EAs' impressions of, feedback on, and recommendations for improving 4 mHealth interventions to meet the specific needs of EAs with T1D living in rural communities. Discussions were transcribed and analyzed using conventional content analysis. RESULTS: In total, 9 EAs (aged 18.8, SD 2.7 years; 5, 56% men; 8, 89% White) with a duration of diabetes of 8.6 (SD 4.3) years participated. They described experiences with diabetes stigma (attributing diabetes to poor lifestyle choices) and feelings of self-consciousness (hyperawareness) in their rural communities. They attributed these experiences to the small size of their communities ("everyone knows") and community members' lack of knowledge about diabetes (unable to differentiate between type 1 and type 2 diabetes). In contrast, EAs reported high levels of social support for diabetes and diabetes care from family, friends, and other community members, but low support for medical needs. The location of their diabetes care providers and the limited accessibility of diabetes-specific and general medical care services in their local community created a challenging medical care context. Overall, EAs found mHealth interventions appealing due to their digital delivery and highlighted features that increased accessibility (voiceovers and simple, jargon-free language), individualization (ability to tailor intervention content and delivery), and applicability to their own lives and other EAs with T1D (relatability of vignettes and other content). EAs suggestions for improving the interventions included more opportunities to tailor the interventions to their preferences (greater frequency and duration, ability to adapt content to emerging needs), increasing opportunities for peer support within the interventions (friend and significant other as identified support person, connecting with peers beyond their local community), and making the tone of intervention components more casual and engaging. CONCLUSIONS: mHealth interventions aligned with EAs' needs and preferences are a promising strategy to support EAs in communities where social support and resources might be limited. TRIAL REGISTRATION: N/A, not a clinical trial.