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

Table 1 Basic characteristics of the studies included in the review

Study ID	Ref.	Study design	Participants: Sample size	School characteristics	Intervention aims	Intervention components
1	Faro et al[21], 2005	Single group pre-post	Students: 27 (15 boys, 12 girls)	K-12 schools in a large urban district in New York	(1) Increase school nurse knowledge and confidence in performing diabetes care. (2) Strengthen collaboration between school health personnel and diabetes specialists. (3) Improve student self-efficacy and self-management skills	(1) Regular school visits by pediatric nurse practitioners (PNP), engaging students with diabetes, school nurses, teachers, and other school personnel. (2) Blood glucose management at home and school, diabetes knowledge and coping skills, healthy eating, carbohydrate counting, insulin dose adjustment, and hypoglycemia and hyperglycemia management
2	Bachman et al[24], 2008	One-shot case	School nurses: 12	Schools in Missouri	Evaluate an online continuing education program providing school nurses with updated practice principles and knowledge	Education on blood glucose management, diabetes knowledge, meal plan development, oral medications, hypoglycemia and hyperglycemia, insulin adjustment, insulin injection vs pump therapy, individual responsibilities of insulin pump management, diabetes management plan development, implementation of individual health plan, and emergency action plan, laws and regulations related to child diabetes care
3	Smith et al[23], 2012	Single group pre-post	School nurses: 44; Health aids: 37	Elementary, middle, and high schools, and one vocational school in New Albany-Floyd County, Indiana	Evaluate an education program for school health personnel to improve diabetes care-related knowledge and confidence	(1) The basic program was a 60-min educational session with the following components: diabetes knowledge, diabetes pathology, hypoglycemia and hyperglycemia, dietary management, exercise, blood glucose management. (2) The expanded program was a 180-min educational session that included carbohydrate counting, insulin administering, blood glucose meter, and written diabetes care plans
4	Gutierrez et al[22], 2019	Single group pre-post	School personnel: 132	Schools in rural districts of South Central Texas	Evaluate an online educational program for medical and nonmedical school personnel to improve diabetes-care related knowledge and confidence	Education on blood glucose monitoring, hypoglycemia and hyperglycemia, insulin and insulin regimens, insulin delivery services, dietary management, exercise management, and emergency management

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]

Table 3 Main constructs of theories applied in school diabetes care interventions

Theory	Main constructs	Applications to school diabetes care interventions (n = number of studies)
Social cognitive theory	Self-efficacy	Students’ self-efficacy in self diabetes management at school (n = 1); School nurses’ self-efficacy in diabetes management (n = 3); Nonmedical school personnel’s self-efficacy in diabetes management (n = 2)
	Behavioral capability (knowledge and experience)	Students’ knowledge in self-diabetes management at school (n = 1); School nurses’ knowledge in diabetes management (n = 3); Nonmedical school personnel’s knowledge in diabetes management (n = 2)
	Observational learning	Intervention component in improving students’ self-diabetes management skills and confidence (n = 1)
	Reinforcements (social support)	Support for students with diabetes regarding self-diabetes management at school (n = 1)
Theory of the diffusion of innovations	Relative advantage; Compatibility; Complexity; Trialability; Observability	To evaluate the successfulness of an online education program for school nurses in the rural area to improve diabetes management skills (n = 1)

Table 4 Assessment of the roles of theories in guiding the interventions

Criterion/study ID	1	2	3	4
(1) Theory was used to predict study participants’ behavior	Yes	No	Yes	Yes
(2) Theory was used to select participants for the intervention	No	No	No	No
(3) Theory was used to select or develop the intervention and relevant measures	Yes	Yes	Yes	No
(4) Theory was used to tailor/customize the intervention to study participants	Yes	Yes	No	No
(5) Theory-relevant constructs were evaluated in the study	Yes	Yes	Yes	Yes
(6) Results were discussed in the context of the theory	Yes	Yes	No	No