Role of theories in school-based diabetes care interventions: A critical review

Table 2 Theories and main findings of the studies included in the review

Study ID	Theories	The role of theories	Operationalization and measurement	Main findings
1	Social cognitive theory	(1) Intervention design: Improving student self-efficacy in self-diabetes management through interactive activities and model learning. (2) Effectiveness evaluation: Behavioral and perceptual measures of students’ self-efficacy and coping skills	(1) Self-efficacy was measured by the Self-Efficacy for Diabetes (SED) (Grossman et al, 1987). (2) Diabetes-related experiences with schools and parental satisfaction were measured by surveying parent perceptions. (3) Diabetes knowledge and competence in student self-management of diabetes were measured by surveying care-provider perceptions. (4) Behavioral outcomes were assessed by clinical diabetes indicators such as HbA1c level.	(1) No statistically significant differences were found between pre-and post-intervention mean scores of the SED. (2) No statistically significant differences were found between pre- and post-intervention in terms of self-care practices, parent satisfaction with school care, HbA1c, family knowledge and competence in diabetes management, and frequency of hospitalization. (3) The frequency of blood glucose monitoring at home increased. (4) The frequency of insulin administrations at school doubled. (5) Diabetes care visits in school were feasible and not disruptive to the student educational program. (6) School personnel felt less fearful about acute situations (hypoglycemia or hyperglycemia) and were more aware of students’ blood glucose trends, and were more comfortable reporting these trends to make changes in insulin dose
2	Theory of the diffusion of innovations	Evaluation of intervention effectiveness	Measurement metric included: (1) Whether school nurses found the online education program equal to or better than the education methods they currently used. (2) Whether the online education program met the needs of school nurses. (3) Whether the online education program helped school nurses learn diabetes management quickly and easily. (4) Whether the online education program was available for school nurses who were unable to attend the face-to-face workshop. (5) Whether school nurses perceived improvement in the ability to implement diabetes management for students	(1) School nurses learned more about the effects of oral-medications and over-the-counter medications on blood glucose control. (2) School nurses learned more about the process of developing a meal plan. (3) Most (91%) participants rated the online education program as useful. (4) The theory premise that innovations should be equal to or better than the current practice was inconclusive since some of the school nurses appreciated the convenience of the online program, whereas others felt it did not help them learn
3	Social cognitive theory	Evaluation of intervention effectiveness	(1) Diabetes care knowledge was measured by a set of multiple-choice survey questions such as “How many grams of carbohydrates are equal to 1 serving of carbohydrate?” (2) Self-efficacy was measured by Likert-scale questions (1 = “Strongly Disagree”; 7 = “Strongly Agree”) asking how confident the school nurses were in their abilities to perform different diabetes care tasks	(1) Correct answers to all but one knowledge-related question improved from the pre to post-test assessment. (2) School personnel who had family members with diabetes had greater pretest confidence in their understanding of diabetes (P = 0.043), the ability to measure blood glucose (P = 0.001), and knowledge of the effects of diabetes on children (P = 0.046). (3) A significant difference in overall knowledge was found between the pre- and post-test assessment (P < 0.001). Correct answers to six questions on the knowledge test showed significant improvement (P < 0.05). (4) Stuff members who had prior diabetes education had greater pretest knowledge of diabetes (P = 0.012). (5) Stuff members who had prior diabetes education were more likely to correctly answer the question about the desired range of blood glucose (P = 0.008) and the question about the effect of high blood glucose on thinking (P = 0.023). (6) Stuff members who had prior diabetes education were more likely to correctly answer the question “After treating hypoglycemia correctly, how long should you wait before re-checking the blood glucose?” on the post-test (P = 0.037). (7) All confidence items in caring for students with diabetes improved significantly between the pre- and post-test assessment (P < 0.001). (8) Confidence for all items on the pretest and post-test were significantly higher for those with prior diabetes education (P < 0.01)
4	Social cognitive theory		(1) Diabetes care knowledge was measured by 30 questions assessing different aspects of diabetes care. (2) Self-efficacy was measured by Likert scale questions (1 = “Not at all confident”; 7 = “Extremely confident”) assessing abilities to perform different diabetes care tasks	(1) There was a significant difference in the average pretest (M = 49.75, SD = 16.25) and post-test (M = 90.04, SD = 6.66) knowledge scores for nonmedical personnel [t(80) = -23.12, P = 0.000]. (2) There was a significant difference in the average pertest (M = 69.58, SD = 14.90) and post-test (M = 94.25, SD = 5.89) knowledge scores for school nurses [t(50) = -13.92, P = 0.000]. (3) There was a significant difference in the average pretest (M = 3.46, SD = 1.87) and post-test (M = 6.30, SD = 1.17) confidence scores for nonmedical personnel [t(80) = -15.45, P = 0.000]. (4) There was a significant difference in the average pretest (M = 5.80, SD = 1.34) and post-test (M = 5.80, SD = 1.34) confidence scores for school nurses [t(50) = -6.50, P = 0.000]. (5) There was a significant difference in the scores of confidence change between nonmedical personnel (M = 2.84, SD = 1.65) and school nurses [(M = 1.14, SD = 1.25), t(130) = 6.30, P = 0.000]. (6) There was no significant correlation between the participants’ rating of the usefulness of the program and the change in knowledge (r = −0.092) or confidence (r = 0.017). (7) There was a significant positive relationship between the change in knowledge scores and change in confidence scores [r = 0.442, P (one-tailed) < 0.01]