title: An ongoing struggle: a mixed-method systematic review of interventions, barriers and facilitators to achieving optimal self-care by children and young people with type 1 diabetes in educational settings.
abstract: BACKGROUND
  Type 1 diabetes occurs more frequently in younger children who are often pre-school age and enter the education system with diabetes-related support needs that evolve over time. It is important that children are supported to optimally manage their diet, exercise, blood glucose monitoring and insulin regime at school. Young people self-manage at college/university.
  
  
  METHODS
  Theory-informed mixed-method systematic review to determine intervention effectiveness and synthesise child/parent/professional views of barriers and facilitators to achieving optimal diabetes self-care and management for children and young people age 3-25 years in educational settings.
  
  
  RESULTS
  Eleven intervention and 55 views studies were included. Meta-analysis was not possible. Study foci broadly matched school diabetes guidance. Intervention studies were limited to specific contexts with mostly high risk of bias. Views studies were mostly moderate quality with common transferrable findings.Health plans, and school nurse support (various types) were effective. Telemedicine in school was effective for individual case management. Most educational interventions to increase knowledge and confidence of children or school staff had significant short-term effects but longer follow-up is required. Children, parents and staff said they struggled with many common structural, organisational, educational and attitudinal school barriers. Aspects of school guidance had not been generally implemented (e.g. individual health plans). Children recognized and appreciated school staff who were trained and confident in supporting diabetes management.Research with college/university students was lacking. Campus-based college/university student support significantly improved knowledge, attitudes and diabetes self-care. Self-management was easier for students who juggled diabetes-management with student lifestyle, such as adopting strategies to manage alcohol consumption.
  
  
  CONCLUSIONS
  This novel mixed-method systematic review is the first to integrate intervention effectiveness with views of children/parents/professionals mapped against school diabetes guidelines. Diabetes management could be generally improved by fully implementing and auditing guideline impact. Evidence is limited by quality and there are gaps in knowledge of what works. Telemedicine between healthcare providers and schools, and school nurse support for children is effective in specific contexts, but not all education systems employ onsite nurses. More innovative and sustainable solutions and robust evaluations are required. Comprehensive lifestyle approaches for college/university students warrant further development and evaluation.
authors.forename: Deborah
authors.initials: D
authors.lastname: Edwards
authors.affiliation: School of Social Sciences, Bangor University, Bangor LL57 2EF, UK. jane.noyes@bangor.ac.uk.
authors.forename: Jane
authors.initials: J
authors.lastname: Noyes
authors.forename: Lesley
authors.initials: L
authors.lastname: Lowes
authors.forename: Llinos
authors.initials: L
authors.lastname: Haf Spencer
authors.forename: John W
authors.initials: JW
authors.lastname: Gregory
mesh_terms: D000293:Adolescent; D015190:Blood Glucose Self-Monitoring; D002648:Child; D003922:Diabetes Mellitus, Type 1 / Q000628:therapy*; D019468:Disease Management; D005247:Feeding Behavior; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007003:Hypoglycemia / Q000517:prevention & control; D007004:Hypoglycemic Agents / Q000008:administration & dosage; D007328:Insulin / Q000008:administration & dosage; D008019:Life Style; D010353:Patient Education as Topic; D012572:School Health Services; D012648:Self Care; D013334:Students; D017216:Telemedicine; D055815:Young Adult
chemical_list: D007004:Hypoglycemic Agents; D007328:Insulin