“I’m Staring at the Screen all the Time”: Technology Use and Mindfulness in Adolescents with Type 1 Diabetes

Abstract

Type 1 diabetes (T1D) is a chronic, complex medical condition associated with higher rates of anxiety in adolescents. Higher rates of anxiety are associated with poorer glycemic control. Although technological advancements have been made to improve self-management of glycemia, few technological interventions aim to mitigate anxiety symptoms. Adolescents frequently use technology every day for school and socialization in addition to management of glycemia. Technology has not yet been leveraged to provide evidence-based interventions, such as mindfulness, for anxiety symptoms and other psychosocial comorbidity in adolescents with T1D. We aimed to examine technology preferences in adolescents with type 1 diabetes, their experiences with mindfulness practices, and their perceived acceptability of a mobile health application delivering mindfulness training. Twenty participants aged 14 to 17 years old with T1D participated in this qualitative descriptive study. Interview transcripts were organized using the ATLAS.ti software version 8 and coded using an in vivo approach and thematic analysis. Descriptive statistics regarding participant demographics and hemoglobin A1c levels were analyzed using SAS statistical software version 9.2. Findings supported heavy technology use, limited experience with mindfulness, and positive receptivity regarding an app that delivered a mindfulness training program specifically for adolescents with T1D. Thus, a mobile health application may be a feasible and acceptable way to deliver an evidence-based psychosocial intervention to this vulnerable population.

Approximately 304,000 children and adolescents in the United States are currently living with type 1 diabetes (T1D) (Centers for Disease Control and Prevention [CDC], 2023). T1D is a chronic, complex disease that requires self-management of a burdensome treatment plan to maintain safe blood glucose levels. The intensive daily commitment required to maintain the treatment plan often leads to increased stress and anxiety symptoms in adolescents living with T1D (Iturralde et al., 2019). Approximately 20% of adolescents living with T1D experience clinically significant anxiety symptoms (Akbarizadeh et al., 2022). Chronic stress and anxiety symptoms are associated with suboptimal diabetes self-management and out-of-range glycemic control (Rechenberg et al., 2019; Reinauer et al., 2023).

Technology intended to improve self-management of T1D is rapidly evolving (Zahid et al., 2023). Current technologies most frequently used to manage diabetes include insulin pumps, continuous glucose monitors (CGM), and mobile health applications that integrate communication between pump and/or CGM (Reddy et al., 2023). In addition to insulin dosing, diabetes self-management requires record-keeping of carbohydrate intake, medication adherence, and exercise tracking, which can be streamlined with the use of mobile health applications (Doupis et al., 2020). While technology has been harnessed to create cutting edge physiological treatment strategies for T1D, its potential to improve psychosocial comorbidities such as stress and anxiety symptoms has not yet been fully leveraged.

Adolescents are a key demographic who understand and frequently integrate technology into their daily lives. Adolescents voraciously consume technology; approximately 95% of adolescents have their own smart phone (Pew Research Center, 2023). On average, adolescents spend approximately 8.5 hours a day in front of a screen, including television, phone, and computer (Rideout et al., 2022). Interventions that are delivered on a technological platform are therefore highly accessible, intuitive, and acceptable to this demographic (d’Halluin et al., 2023).

Technology has the potential to not only improve disease management, but also to improve psychosocial outcomes in adolescents with chronic conditions (Radovic & Badawy, 2020). For instance, psychosocial interventions delivered on mobile health applications are most often utilized by adolescents as these interventions provide easy access to mental health care and reduce barriers such as mental health stigma (d’Halluin et al., 2023). Mindfulness, a type of meditation, has been shown to decrease stress and anxiety symptoms in adolescents with T1D (Iina et al., 2021; Nagel et al., 2020). However, mindfulness interventions are traditionally delievered in synchronous group settings, which is a developmental and accessibility barrier to adolescents. A more feasible delivery method of mindfulness is likely through technology, to accommodate the busy schedule and technology savvy lifestyles of adolescents (Koerner & Rechenberg, 2022).

Given the frequent technology utilization paired with the high incidence of psychosocial comorbidities in adolescents with T1D, mobile health applications featuring psychosocial interventions have the potential alleviate the psychosocial symptoms associated with living with a treatment intensive chronic condition. However, any new or adapted intervention must take into account the needs and preferences of the population for which it is intended. As such, we aimed to 1) understand technology preferences in adolescents with T1D; 2) describe adolescent experiences with mindfulness practices; and 3) examine the acceptability of a mindfulness mobile health application in adolescents with T1D.

Methods

Design

We used a qualitative descriptive approach (Sandelowski, 2010) to describe the experience of engaging with technology and participation in mindfulness practices in 20 adolescents ages 14 to 17 living with T1D. We used an in-depth, semi-structured telephone interview as telephone interviews have been established as a reliable and valid way of collecting qualitative data (Novick, 2008). The interview consisted of 10 open-ended questions. The average interview duration was 35 minutes.

Sample and Setting

Adolescents were approached via online advertisements posted on social media web sites and distributed through diabetes support organizations. Interested participants contacted the study team via email or phone to discuss the study and determine eligibility. Participants eligible for the study were: (1) 14 to 17 years of age; (2) diagnosed with T1D for at least 6 months; (3) without other chronic medical conditions requiring intensive daily management; (4) not currently participating in other studies; and (5) able to read and speak English fluently. We selected adolescents 14 to 17 years of age to capture the transition from early and middle adolescence to late adolescence, as this age span coincides with the period when self-management and glycemic control rapidly and significantly decline. We continued sampling until data saturation was achieved.

Procedures

The University of South Florida Institutional Review Board approved this study (Approval number: STUDY004827). Informed consent was obtained at the time of recruitment from the parent or legal guardian and informed assent was obtained from the adolescent. We then collected demographic data, including participant age, race/ethnicity, biological sex, household income, disease duration, treatment type, and hemoglobin A1c using a HIPAA compliant Internet-based questionnaire, which was distributed prior to the interview. Then, the qualitative interview was conducted by phone at a time deemed convenient to the adolescent and parent or legal guardian. Participants received a $20 gift card as compensation.

Data Management

Interviews were audio-recorded using a HIPAA compliant digital recorder. Interviews were transcribed verbatim by a professional transcriptionist and de-identified prior to analysis. We used ATLAS.ti version 8 (ATLAS.ti Scientific Software Development, Berlin, Germany) to facilitate qualitative data analysis.

Analysis

All interview transcripts were organized within the software program ATLAS.ti. A detailed audit trail was maintained throughout the study by all coders. Descriptive statistics regarding participant demographic characteristics and hemoglobin A1c levels were computed using SAS statistical software version 9.2 (SAS Institute, Inc., Cary, NC).

We used the six-phase approach to qualitative data analysis as described by Braun and Clarke (2006). We used an inductive approach which began during the data collection phase, leading to continuous evolution of the interview guide, and ultimately to more focused probes as our understanding of the data evolved. Sampling continued until data redundancy was agreed upon by the interviewers (RK, KR) and all coders (KR, CG).

Interviews were coded by two experienced coders using an in vivo approach (Saldana, 2015). A conceptual coding method was employed by two coders (KR, CG). We developed the final coding structure using an iterative process by synthesizing and collapsing the preliminary in vivo codes through the process of discussion until consensus was achieved. The final coding structure included 40 codes. Using the final codebook, the interviews were then coded again by two coders (KR, CG) concurrently until 80% coding agreement was achieved. Once all interviews were co-coded, we collapsed the codes into categories, and the categories into themes. We underwent a process of member checking, sharing findings with participants to cross-check findings. We also used conceptual mapping, field notes, and detailed memos to refine themes and further bolster reliability and trustworthiness of findings. The criteria for achieving validity in qualitative research as described by Whittemore, Chase, and Mandle (2001) guided our design and approach from data collection through analysis.

Results

Participants’ demographic characteristics and hemoglobin A1c levels are presented in Table 1. In our sample of 20 adolescents, the mean age was 15 years, 85% identified as non-Hispanic white, and 75% identified as female. To manage their diabetes 75% utilized insulin pumps, and mean hemoglobin A1c was 7.6%.

Table 1.

Participant Demographics

Characteristic	N (%) or M
Gender
Female	15 (75%)
Male	5 (25%)
Age
Age (years)	15.1
Race/Ethnicity
White, Non-Hispanic	15 (75%)
White, Hispanic	2 (10%)
Asian, Non-Hispanic	2 (10%)
Other, Hispanic	1 (.05%)
School Year
9th Grade	6 (30%)
10th Grade	8 (40%)
11th Grade	5 (25%)
12th Grade	1 (.05%)
Household Incomea
$35,000-45,999	2 (10%)
$50,000-74,999	-
$75,000-99,999	6 (30%)
>$100,000	9 (45%)
Diabetes Characteristics
Age Diagnosed	8.9
Hemoglobin A1c Level	7.6
Diabetes Managementb
Pump	15 (75%)
Injection	4 (20%)

Note. Missing data due to participants’ non-response

The findings for this paper are organized into three themes and six sub-themes. Theme one (1) describes heavy use of technology among teens with T1D, theme two (2) explores participant understandings and experiences of mindfulness practice, and theme three (3) reports feedback for developing a mindfulness intervention mobile health application for teens with T1D. Representative quotes are provided in Table 2.

Table 2.

Qualitative Interview Data

Master Theme	Subtheme	Supporting Quotes
Current technology use	Heavy use of technology	COVID-19 increased use. Well, like I was saying you can’t see people so that’s going back to just constantly being on a screen…We are not in-person currently. Every single day is pretty much the same. You just go on your laptop, do your work. When school’s over you just go on your phone. It’s constant just digital screens.(10) Education. I’m on my computer a lot during the week ‘cause I have school. I’m just staring at the computer from 8 to 2… I’m staring at the screen all the time. (2) Entertainment. Weekends, [hours spent on a device] goes up because [you] can’t hang out with friends. We can’t see anybody. You’re all alone in your house. Usually my dad’s doing stuff with work on weekends. My mom’s just doing other things. I’ll just be on TikTok for hours and hours and hours ‘cause you can’t hangout with anyone. You can’t see anybody. (10)
	Social media use	Social media helps stay connected to friends and family. For social media, I like to stay in touch with my family, especially since we’re divided. Half of my family’s in California, and half is in Oklahoma. I tend to stay in touch and see their lives out there through that. Then with friends on social media, I just talk to them, and like to see their posts, and give them compliments and stuff. (16) COVID-19 increased social media use. I think that is a big aspect because, obviously, you're not supposed to be seeing many people right now. Maybe you're seeing family and close friends, but you're really not being with groups of people. Social media and things like Zoom are really bringing you together with people. When you don't talk to people is when you feel lost… I love talking to people and going back and forth with them and seeing how their life is and telling them about how my life is going. I know for the first two weeks of school, it was a challenge figuring out how to talk to my friends and still stay social distancing and stuff and like that. Once I was finally able to talk with them through FaceTime and just Instagram DM's and Facebook, you feel happier. (1) Social media can support school activities. On my computer there's another social media app that I have called Discord. It's like you can talk to a lot of your friends and there's this one main thing that's called a server, and a bunch of people can be in the server and you can all talk to each other. You can text or voice chat with each other whenever you really want…That I find is easier because when you're doing homework on it, you can also share your screen to show them what you're working on or help them with questions or get help with questions, so it helps things like—it's just overall easier 'cause it helps both people. (6) Social media can be a distraction. I don’t really use them because I just never really found the need to. I was never really the super popular kid, you could say. I never really found the need to get Instagram because—I don’t know. I honestly don’t know because there’s no reason to get it. I know it’s just gonna make me distracted even more. It’s not like my friends are begging me. (13)
	Use of technology to support health.	Diabetes Management. I like [the Dexcon app]. It’s good ‘cause I’m not really—when I’m not wearing my Dexcom, I’m not really good at testing my blood sugar, at pricking my finger. I just kind of forget. It’s good to know, just to be constantly monitored…When you open it, it tells me my blood sugar. (9) Limitations of Non-T1D Nutritional Support. I have used [the app] for tracking carbs, but I forget about it every once in a while, and then I stop. Then it’s kind of wishy washy…I don’t love the calorie tracker on it, just ‘cause then I feel kind of—I feel almost pressured to eat less. I don’t love that, since I know I’m—if I know I’m being healthy, that I’m being healthy. I don’t know. I think just that. I don’t love the community on that app either. That’s why I think I just go on it every once in a while or just try to find the carbs through that… A lot of the people on that app are kind of—I won’t say random, but they’re more there for weight loss, and I’m not really there for weight loss. I don’t know them. I don’t know them very much. It’s not very useful to me. (16) Exercise Support. Yeah, I use my Apple watch all the time for exercising…There's an activity section and a working out section, so activity tracks your whole day, even including the exercise section, so it tells you how many flights of stairs, how many steps, calories burned, et cetera, and how many active minutes you had, and then exercise you can click on it to start it, or you can click on the specific one you want. It gives you options like outdoor run, indoor run, outdoor bike, core exercises, like anything you can really think of, even sports it includes, you can set it to that and then it tracks like how many minutes, how many calories burned, and all of that stuff, and then that goes into activity and adds up for your daily total, so it's nice. (6)
Understandings and experiences of mindfulness practice.	Mindfulness practices are beneficial to well-being.	The words that come to mind are probably just calm and serenity because that’s what I think of just taking a moment for yourself and relaxing yourself. I think it’s self-care honestly. (16)
	Limited exposure, interest in mindfulness practice.	I’ve heard about the meditation, that it’s really good for the body, and it’s very calming, and it’s a very good stress reliever, but I haven’t tried it yet. I’m planning to, I just don’t know when. (15)
	Positive experiences with mindfulness	Actually, I had a mindfulness coach that I went to for a few months back in 2019. We talked a lot about meditation and being grounded and stuff. That actually really helped me take a moment and step back and breathe, because having sometimes your mind—everyone—gets really stressed and frustrated sometimes. When you feel like that on top of having a high glucose level, it drives you crazy. People can’t live like that. I was taught for a few months just to step back and breathe. We practiced breathing exercises and meditation and reading. A lot of reading. Just a lot of peaceful areas. Just relax and stuff. That actually did help me. She was a mindfulness coach. I did that for a few months. That seemed to help. (10)
	Limited experience with mindfulness app use.	Positive experiences with mindfulness app use. I got [the] Calm [app] when quarantine started, because it was just a lot to take in, the fact that we’re in the global pandemic, so I got the Calm app to help with my anxiety over that, and then I’ve grown to really like the Calm app. At first, I didn’t really want to get it ‘cause I didn’t think it would do anything for me, but once I got it, it made a really big difference. I would play it at night before I went to bed if I was feeling anxious that day, and it would help me calm down and be able to get some rest. When I would meditate in the morning before school started, I remember I would get up and I would get my Calm app and I would start listening it on my way out to the backyard. That way, when I was already out there, I was already kind of in that, I guess, state of mind of listening to that music… Then I remember getting the Calm app, and it just significantly helped me, because there’d be times where I just really needed a deep breath. I just needed to go outside and meditate or something like that, and I remember I would go outside, get my phone, and use the Calm app and then all of a sudden everything would just feel better. Then I would go on with my day as I would any other day and find things to do with myself. I was listening to that, I would be able to practice, call my friends, things like that, just to make it feel more of a sense of normality, and I thought that all started because of the Calm app because, in reality, the first thing we did in the morning’s probably the most important because they say breakfast is the most important meal of the day. Well, so it what you do with your mind and with your body. (14) I feel a bit better about that day. If that day was bad for me, then it kinda reassures me that it's okay to have that bad day, that not all days are going to be great, I guess, especially for my blood sugars, especially if I did experience [audio cuts out 17:33] blood sugars that day, then that [unintelligible 17:36] of high blood sugars are okay to have. It's normal. Just try again the next day… Oh, yeah, sometimes it—I think a popular thing it does is imagining that you're at a beach or somewhere peaceful, or a forest, per se, that's very calming and doesn't have many distractions, and it tells you to imagine yourself walking through that forest and noticing the things in that forest. (20)
	Barriers to mindfulness app use.	Lack of interest. I had one that I liked, but I got bored of it, since it really wasn’t helping. I don’t remember what it’s called. I think it was just called Self Care, but I use the Motivation app every day. (16) Busy schedules. It's not really the app itself. I'm so busy that I don't even know if I would have time to use it. I feel like that kind of thing. I also have to be in the right headspace too 'cause I get bored very easy, so I don't think it's the app itself. I think it's me… Yeah, I feel like when the pandemic started I started meditating, but then I became busy again, and so I stopped. (18) Cost. Maybe it’ll say, “one month for free,” but then after the month, it’s really expensive, you know? (12) Limited phone storage. Mainly, I don't get them because my phone storage is really bad, so I don't really know—I don't even have room for them. (7)
Feedback on Mindfulness App for Teens with T1D	Receptivity of T1D Mindfulness App	Oh, I was gonna say because diabetes comes with stress in itself. Even if a kid doesn’t already have depression or anxiety when they get diagnosed with diabetes, it is a life changing thing. With that comes a lot of stress. I feel like having even just a simple app, I feel like that could help kids with stress with diabetes. (10) Potential Resistance. I feel like if there was a managing stress app for diabetics, I feel like teens wouldn’t really totally be open ‘cause when you’re a teen, and you have diabetes, a lot of your life is just trying not to feel different from everyone else. If you have a specific app for diabetes stress, if you’re a teen, sometimes that’ll sound cheesy. A lot of people won’t do it because they don’t wanna feel different, which I totally understand. I would probably do the same. I wouldn’t really take any stress things specifically for diabetes…I don’t wanna feel like I’m in need of some specific help or I am super unique, even though unique is a good thing. I don’t wanna feel unique in the way of, I don’t know, diabetes. (13)
	Suggested features for a T1D mindfulness app.	Simplicity and usability. I also like apps that have simple layouts that don't have a lotta buttons to them. Whenever something's really complex, I tend to not get it. (7) What makes it nice is that when you first get an app, it tells you how to do stuff, how to set it up. It's not just showing you the home screen and making you figure it out yourself, so it gives you the steps in order to set it up and everything. (6) Visual appeal. I like colors, so not a dull app. If the app is just black and white and gray, that’s boring to me. It’s not appealing to my eyes.
	Suggestions on stress management methods to include	Personal Journaling. Just someplace to put all your thoughts into because I think stress is just a bunch of stuff in your head at once when you don’t need all that stuff in your head…All that stuff in your head at once. I think if it’s just someplace to just put all this stuff that you’re thinking about. Just having something like that would be really nice. That’s at least an app like you said. Just a place to put all your, I don’t know, ideas, all your work, all your stress, all of your ideas, all your thoughts, and all that kind of stuff…I think it should be something that is probably private because I think a lot of teens have their own private lives, you could say. They don’t want anyone else knowing about it. They just want to not just keep it to themselves. I think even just writing it down on an app will help. I think that would be nice. (13) Music. I really like the music aspect, and I also like—I guess they’re called nighttime stories, I think it is. I like the music because I can listen to it whenever I’m studying, if I’m feeling anxious, if I want to meditate, and I can listen to it anytime because it has such a broad range of what you can listen to, and it goes to all areas. I think one of them’s like a focus area or a calming area for the music, and then the nighttime stories. I know that they have people like celebrities, I think, read you stories or tell you stories, and it does make all the difference to have that range of what you can listen to for different activities. (14) Positive affirmations. With my diabetes, it’s always been like people always look at me as less of a person. Then, I always have to encourage myself or pick myself up, so maybe something that encouraging on it, just encouraging words or something would be really cool to me. (8) Nutrition Management. What other things do you feel like would potentially be helpful to have reminders or different things to help manage your diabetes? What would you want to see in an app? Interviewee: Maybe I know there’s that little book for the food base and carbs, but maybe something where you can just type something in or scan something, and it’ll tell you the nutritional info. I think that would be helpful, especially if you’re at a restaurant or at a food place, so there’s no sheet. That would be helpful if over-ballisting or under-ballisting. (16) “SOS” Feature for Acute Distress. I would wanna use that if it could help me feel calm and for—if I go high or low, depending on how high I go and how low I go. I would like to—that’d be good for me because I do get scared and stressed out when I go low. (11)
	Social interaction with other users can support companionship, community, and engagement	Beneficial in relating to others with T1D. As you were saying that I just thought of that. I don’t know how exactly you would do, but if people could post things, or you could add friends on there, that would be really nice. In my school, in my middle school, there was me and two other people that had diabetes. In my high school, there’s probably only a handful. There is times whenever I feel alone in my diabetes, so I think having that community and having that friends, like, “Hey, you’re not alone. I deal with the same exact things you do, and even though I’m not with you, I know what you’re going through, and I know that.” I think that would be really cool. (8) Beneficial in building community. I think it would really help from day to day, and bring the diabetic community closer. It’s something we can find similarities in or find better help or even have our questions answered if we can find those kind of things online. I think it would really be a big help to the community. (16) Engagement through Competition. I feel like I just like the competitive aspect because, personally, I’m a pretty competitive person when it comes to things sometimes, so I feel like it’s really fun when I’m with my friends and we’re like, “Oh, yeah, I’m gonna win,” and I’m like, “No, that’s not gonna happen.” That’s just the fun aspect of [laughter] it because it’s just fun to be able to have those apps and—or games, I should say, and have them be so fun and be able to have a little bit of competitiveness with them. (14)

Heavy Use of Technology

Participants reported high levels of daily use of technology, particularly as the COVID-19 pandemic limited in-person social interaction and increased online learning. As described by one participant, “I’m staring at the screen all the time.” It was common for participants to engage in virtual education, spending up to 7 hours online for classes and homework. Recreational use (e.g., entertainment, music, social media) of online apps per day ranged from 2-10 hours, averaging 4.5 hours. Participants reported using cellular devices most often to text and engage in social media. Some preferred the use of laptops for activities such as schoolwork or streaming television and films.

Games were often accessed through smartphone apps, as well as traditional and handheld game consoles (e.g., Xbox, Nintendo Switch, Nintendo Wii). Some participants enjoyed games that promote physical activity (e.g., dancing, tennis simulation, exercise) and social components. Digital art, music, educational videos, web-based comics, and audio books were other forms of entertainment accessed through apps.

Social Media Use

Nearly all participants reported use of social media apps, with one describing how “it’s crucial to have those things on your phone as a teen” to “be in the loop.” Instagram and Snapchat were the most utilized social media apps, in addition to Facebook, Twitter, Pinterest, TikTok, and Discord. Participants had overall positive views of social media apps, describing them as “entertaining” and offering a method of “seeing updates in people’s lives.”

Sharing photos and direct messaging with friends and family were most valuable. Social media apps were described as particularly useful for staying connected with friends and family during the COVID-19 pandemic. In addition to socializing, other uses of social media apps included gaining inspiration for art and fashion, as well as school-related activities (e.g., homework, projects). Only two participants reported following accounts related to T1D.

While most feedback on social media apps was positive, participants did acknowledge how it can be a distraction and “addictive.” The only participant who did not use social media apps believed “it’s just gonna make me distracted even more.” This participant also reported a lack of interest within their limited peer group.

Use of Technology to Support Health

Many participants reported using technology to manage T1D and overall health. Apps integrated with glucose monitors (e.g., Dexcom, Sugarmate) were commonly used. One participant reported use of a digital insulin pen (e.g., InPen). Ease of ongoing monitoring, alerts, and automatic data sharing with parent caregivers were particularly useful features. However, usefulness is limited by unreliable or unstable internet connection.

While nutrition apps were understood as somewhat beneficial, one participant pointed out how such apps can conflict with T1D management. Despite some value in the ability to track carbohydrates, this participant described how the app’s calorie tracker and user community promotes weight loss and eating less, stating: “I don’t love the community on that app…they’re more there for weight loss…it’s not very useful to me.”

Some participants reported using technology to support exercise habits. In addition to game play described above, participants utilized wearable devices (e.g., Apple Watch) to track time spent exercising, total daily steps, and calories burned. One participant reported use of a workout app (e.g., Nike Training Club) to guide regular physical activity.

Understandings and Experiences of Mindfulness Practice

Mindfulness is Beneficial, but not a Routine Practice

Mindfulness was viewed by participants as helpful for stress and anxiety relief, increased relaxation, and a calmed mental state. Despite this consensus, participants described having little knowledge of and experience participating in mindfulness practice. Meditation and yoga were two methods of mindfulness introduced during school (e.g., Physical Education classes) or through family members.

While most participants had positive perspectives about the benefits of mindfulness, most had little to no exposure to or experience practicing mindfulness, meditation, or yoga. However, participants were largely receptive to trying meditation or yoga if given the opportunity. Those with experience described how reading about mindfulness, deep breathing, meditation, and yoga helped them feel “peaceful” and “stress-free,” offering a way to “have your mind cleared” from a full day. One participant described how mindfulness was particularly helpful for managing stress related to T1D.

Limited Experience with Mindfulness App Usage

Some participants had previously downloaded mindfulness apps to explore meditation practices, provide general relaxation, and improve sleep. Participants who had experience with practicing mindfulness described how use of mindfulness apps resulted in “a really good state of mind” and an improved outlook on daily stressors. Calming music, guided meditations, and positive affirmations were particularly beneficial. While viewed as beneficial, use was not regular amongst our sample and attrition was low. Lack of interest, busy schedules, cost, and limited phone storage were named as barriers to use. Participants with no previous experience described awareness of mindfulness applications but a lack of motivation to try them.

Feedback on a Mindfulness App for Teens with T1D

High Receptivity Towards a T1D Mindfulness App

Overall, a mindfulness and stress management app specifically tailored for teens with T1D was more appealing than mindfulness apps non-specific to T1D. Most participants reported willingness to use such an app and believed it would be beneficial for teens managing stressors related to T1D. Perceived benefits included improved mental health, overall well-being, and management of T1D. One participant commented, “I don’t really know a lot of resources for teens with diabetes,” recognizing this unmet need.

While most participants were very receptive, some participants felt stress management was not necessarily unique to those with T1D, and how a mindfulness app would not need to be specific to T1D. One participant elaborated on their own lack of interest, based on a common desire to fit in: “When you’re a teen, and you have diabetes, a lot of your life is just trying not to feel different from someone else.”

Suggested Features for a T1D Mindfulness App

Simplicity and Usability

Simplicity of design was emphasized as very important for usability, with one participant stating when apps are overly complex, they “tend not to get it.” Initial set up should be straight-forward and self-explanatory. Visual appeal was mentioned as an important factor in overall attraction, with one person suggesting the ability to customize layout.

Stress Management Features and Topics

In addition to guided meditations, participants suggested including features such as personal journaling, calming music, and positive affirmations. Notifications with positive affirmations, motivational quotes, and reminders to practice breathing techniques were described as useful. However, the ability to opt-in and customize notifications was preferred.

Specifically relevant for teens with T1D, participants suggested including nutrition education and monitoring, as well as reminders for checking blood sugar levels. An “SOS feature” with techniques for managing acute distress would be a valuable tool. As described by one participant, “I would wanna use that…because I do get scared and stressed out when I go low.”

Social Engagement

Opportunities for interaction with other users (e.g., chat, message board) were very appealing and participants described the value of social support from other teens with T1D. Sharing personal experiences and relating to others “plays a huge role in the social aspect of connecting with people.” Indeed, most participants regularly used social media apps (e.g., Instagram, Facebook, Snapchat, TikTok, Twitter). Participants were excited to build friendships and share useful information with a community who “know[s] what you’re going through.” Some considerations included grouping users by grade level, as well as methods for reporting or blocking another user.

Many participants described how user engagement can be supported by friendly competition among users. A leaderboard was recommended as a method of encouraging use and increasing enjoyment, which has been employed in other apps.

Discussion

The aim of this qualitative descriptive study was to understand technology preferences in adolescents with T1D, their experiences with mindfulness practices, and examine acceptability of a mindfulness-based stress reduction mobile health application. Adolescents described heavy use of technology throughout the day, with a particular emphasis on both diabetes management mobile health applications and social media use. Participants conveyed limited exposure to mindfulness practices and were receptive towards a mindfulness-based stress reduction mobile health application tailored to their specific needs and preferences.

Incorporation of technology has greatly improved diabetes outcomes, including improved diabetes self-management and thus, improved glycemic control (Sherwood et al., 2020). Participants reported relying on smartphone applications to assist with diabetes self-management, as expected. However, despite reliance on technology to aid in diabetes self-management tasks, we found most adolescents did not use technology to manage psychosocial comorbidities such as stress and anxiety symptoms (Reinauer et al., 2023).

The few participants who had previously used commerically available mindfulness applications reported reduced stress responses in ther day to day lives. These responses aligned with the published literature where mindfulness interventions were associated with improved psychosocial symptoms in adolescents with T1D (Iina et al., 2021; Nagel et al., 2020). Participants reported that regular usage of mindfulness interventions were limited due largely to scheduling and time commitment in synchronous settings, which aligns with the current literature concerning feasibility of mindfulness interventions (Boggiss et al., 2020). Mobile health applications offer a solution to these barriers, providing brief, asynchronous, and developmentally appropriate mindfulness-based practices (Boggiss et al., 2020; Koerner & Rechenberg, 2022). Adolescents with T1D reported an interest in the use of a mobile health application to cultivate a mindfulness practice.

When using mobile health applications, adolescents prefer the intervention be tailored to age group, have social components, such as a discussion, offer customizability of colors and styles, and easy accessibility (Jeminiwa et al., 2019; Kabacińska et al., 2022). Other key factors include having rewards for meeting certain goals within the program or “gamification” (Jeminiwa et al., 2019). Our participants reported similar expectations and expressed the desire to have a tailored app for their preferences. When asked about specific features of a mindfulness intervention, participants indicated that simplicity of design and social engagement were most important. The desire for customization and personalization highlights the importance of creating adaptable tools that meet the diverse needs of adolescents of this demographic.

Strengths and Limitations

The study utilized a qualitative descriptive approach which facilitated a thorough understanding of the experiences of adolescents with T1D in relation to technology use and mindfulness practices. We used the six-phase approach to qualitative data analysis, per the Braun and Clark guidelines (2006), which enhanced the trustworthiness and reliability of the study’s findings. Other tools to ensure methodological trustworthiness were member checking, where findings were shared with participants to verify and validate the accuracy of the interpretations, use of two experienced coders, and maintenance of a detailed audit trail.

In addition to the strengths of the study, there are limitations to consider. Participants were recruited through online methods, potentially introducing sampling bias as individuals without internet access or those not engaged in the online community may be underrepresented. Our findings may not encapsulate the experiences of those with limited access to digital devices as those who participated were more likely to if they had positive views of technology. Finally, the study relied on self-reported data, including technology usage patterns and mindfulness experiences which introduce the potential for recall and social desirability bias.

Implication for Future Research

As technology is already a critical component of diabetes self-management, the development of mobile health applications that target psychosocial comorbidity would be an apt fit for adolescents with diabetes. Adolescents in our study reported positive receptivity and interested in a mindfulness mobile health application. Tailoring these apps to the unique needs of adolescents with T1D could improve their overall well-being and glycemic outcomes.

Conclusion

The study explores the relationship among technology, mindfulness, and the health management experiences of adolescents with T1D. Our findings support the development of targeted mobile health interventions to improve diabetes self-management and psychosocial support for adolescents with T1D. Utilizing technology to reduce the psychosocial burden of living with diabetes may lead to improved outcomes and a better quality of life for adolescents managing this chronic condition.