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. Author manuscript; available in PMC: 2020 Nov 9.
Published in final edited form as: Diabetes Educ. 2019 Jan 25;45(2):194–202. doi: 10.1177/0145721718825342

Experiences of Adolescents and Emerging Adults Living With Type 1 Diabetes

Karishma Datye 1, Kemberlee Bonnet 1, David Schlundt 1, Sarah Jaser 1
PMCID: PMC7650844  NIHMSID: NIHMS1642356  PMID: 30678608

Abstract

Purpose

The purpose of this study was to identify barriers to adherence in type 1 diabetes through adolescent focus groups and to use this information to determine how diabetes educators can have a positive impact on their patients’ diabetes management.

Methods

Two focus groups were conducted with adolescents and young adults (n = 11) ages 17 to 21 with type 1 diabetes. A focus group script, which consisted of 4 open-ended questions about diabetes care and challenges associated with management of diabetes, was used to elicit discussion. The focus group transcripts were coded and analyzed using the inductive-deductive approach.

Results

Participants described unique barriers to and facilitators of self-care behaviors in their management of type 1 diabetes. A conceptual framework was developed to describe adherence to self-management in adolescents with type 1 diabetes. Biological, psychological, and environmental situational influences emerged that influence self-care behaviors. In addition, facilitators of self-care behaviors, including the health system and diabetes education, were identified, and together the interaction between situational influences, facilitators, and self-care behaviors influenced adherence to diabetes treatment.

Conclusions

The conceptual framework based on these focus groups may help diabetes educators assess and address barriers to self-care behaviors in adolescents and young adults with type 1 diabetes.

Type 1 diabetes management during adolescence and the transition to adulthood is particularly difficult given the multiple stressors unique to this time period.1 The worsening glycemic control noted as youth progress through adolescence2 is very concerning given the complications associated with chronic uncontrolled hyperglycemia, including retinopathy and nephropathy.3,4 While diabetes management in this age group is exacerbated by physiologic changes (puberty and associated insulin resistance), several other factors are implicated in the worsening glycemic control of adolescents, notably poor adherence to therapy.5–8 As adherence9 to therapy increases, hemoglobin A1C decreases; thus, to improve glycemic control in adolescence, self-care behaviors should be identified and targeted.7 It is critical, therefore, for the diabetes educator to understand the unique difficulties young people experience during this time period.6,10,11

Diabetes educators play a crucial role in the education and management of youth with type 1 diabetes. With younger children, diabetes educators focus on providing education to the family of the patient, but in the adolescent and young adult age group, educators and other providers must focus primarily on the patient, who may be treating their diabetes relatively independently. This age group is one of marked transition and independence, which has several unique barriers to adherence, including the transition to independent diabetes management, decreased parental involvement, involvement of peers, and psychosocial barriers, such as mood disorders, anxiety, and eating disorders.6,11 By understanding the unique barriers to adherence that adolescent and emerging adult patients may face, educators have increased ability to assess and address the barriers to improve adherence to therapy.

While barriers to adherence in type 1 diabetes have been studied previously,6 and the association between adherence to therapy and improved glycemic control has been shown,7 much of the research in this age group has focused on self-report measures rather than qualitative focus group studies,12,13 which may limit our understanding of challenges and facilitators. While survey instruments and validated assessment tools14,15 are critical to understanding barriers to adherence, they do not allow for discussion about the barriers in question. Some studies have performed focused individual interviews with patients with type 1 diabetes; for example, Pyatak et al8 interviewed young adults with type 1 diabetes to explore psychosocial stressors to diabetes care. This study found their study population reported several psychosocial stressors, and these stressors were associated with worsening glycemic control, but further assessing these barriers in a group setting may shed more light on specific stressors. In addition, while some studies have used focus groups to facilitate discussion among patients with type 1 diabetes, these studies have primary focused on a particular barrier or a particular group of patients. Kennedy et al16 conducted a focus group of newly diagnosed patients with type 1 diabetes to understand barriers to exercise in this population, but this study was focused specifically on exercise and other barriers were not examined. Therefore, the purpose of this study is to identify barriers to adherence in type 1 diabetes through adolescent focus groups, to use this information to increase understanding of these barriers, and to determine how diabetes educators and other providers can have a positive impact on their patients’ diabetes management.

Methods

Research Design

Focus groups were conducted to explore barriers to adherence in youth with type 1 diabetes. Focus groups were chosen to allow for robust discussion between participants and to facilitate more in-depth discussion than may be possible with individual interviews. In addition, this study was primarily designed to understand barriers in youth, and focus groups were used to allow for discussion among peers that may not be possible in other research settings.

Sample/Setting

Participants were recruited from the Vanderbilt Pediatric Diabetes Clinic, a busy urban center that cares for over 2700 youth patients with diabetes (primarily type 1 diabetes). The patient population is approximately half female, with ethnic breakdown as follows: 60% white, 10.4% black or African American, 1.6% Hispanic, 0.5% Asian or Pacific Islander, and 27.5% pediatric patients with unknown ethnic background. A prior study exploring barriers to adherence in type 1 diabetes had previously been conducted by the authors of this study, and participants in that study were asked whether they would like to participate in the current focus group-based study. Those participants who asked to be contacted about this study were informed about the study and invited to participate either over the phone or in the clinic itself, in accordance with the recruitment and consenting protocol approved by the institutional review board (IRB). Additional participants were recruited while being seen in the diabetes clinic for routine care once all previous study participants who were interested in the focus group study had been contacted. The study team followed a recruitment script that had been approved by the IRB, and participants were informed that participation was voluntary. See below for inclusion and exclusion criteria.

Participants and Procedure

Two focus groups were conducted with adolescent patients diagnosed with type 1 diabetes receiving health care at Vanderbilt University Medical Center. Inclusion criteria consisted of (1) pediatric clinic patients ages 17 to 21 who had been diagnosed with type 1 diabetes for greater than 1 year (as defined by an endocrinologist), (2) treatment with basal/bolus insulin, and (3) English speaking. Adolescents with psychiatric comorbidities such as schizophrenia or bipolar disorder were excluded from participation, as these could exist as barriers to adherence to diabetes management that are outside the scope of this study. All participants were recruited following the protocol approved by the IRB.

When participants arrived for the focus group, informed consent was obtained from the parents and assent from participants under 18 years of age. Participants 18 years and older provided informed consent. Demographic data were collected prior to starting the focus group (see Table 1).

Table 1.

Demographic Information of Focus Group Participants (n = 11)

Focus Group 1 Focus Group 2
Number of participants 7 4
Age, y 18.1 (range, 17–20) 17.8 (range, 17–20)
Sex, female, % 71 75
Duration of diabetes, y 10.7 (range, 6–18) 9 (range, 5–14)
MDI/insulin pump 100% insulin pump users 25% insulin pump users
Race 5 white, 1 black, 1 other 4 white
Ethnicity 6 non-Hispanic/Latino, 1 Hispanic/Latino 3 non-Hispanic/Latino, 1 Hispanic/Latino
Mean A1C
 % 8.2 (range, 6.1–9.3) 8.1 (range, 7.1–8.8)
 mmol/mol 66 (range, 43–78) 65 (range, 54–73)
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Abbreviation: MDI, multiple daily injections.

A trained focus group facilitator used a semistructured focus group guide consisting of open-ended questions to conduct the 2 focus groups. Questions were developed with input from a multidisciplinary team, including an endocrinologist, a pediatric psychologist, and experts in qualitative research. Participants were asked 4 primary questions about diabetes care and challenges:

  1. Think about a day when everything went well, and you were able to do everything you need and want to do to take care of your diabetes. What worked that day, what made it possible to do everything you needed to do to take care of your diabetes?

  2. If you could change anything about how your doctor, nurse practitioner, dietician, nurse, etc. interacts (talks with you) and works with you, what would it be?

  3. Talk us through your daily diabetes routine and tell us about what makes certain times of the day more or less challenging/hard to take care of your diabetes? We are hoping to learn what seem to be the most challenging/difficult issues in taking care of your diabetes, and what are the most challenging or hardest times of day for taking care of your diabetes.

  4. We have spent some time talking about type 1 diabetes, and some of the things that may make it easier or harder to manage. Think back to 5 years ago (or middle school), what was different back then? Specifically, were there things that made it easier or harder to manage your diabetes? Are these things the same now, or have things changed?

Specific prompts were developed for each question to facilitate detailed discussion of the 4 questions.

Two different focus groups were conducted; the first had 7 participants, and the second had 4 participants. Focus groups were digitally recorded, and transcription was performed by Rev.com. Focus groups were transcribed within 3 days of focus group completion. The first focus group was 79 minutes, and the second focus group was 68 minutes. Focus groups were led by a psychologist with experience in focus groups and youth with type 1 diabetes.17,18 Participants were compensated with a $20 gift card upon completion.

Analysis

Qualitative data coding and analysis was managed by the Vanderbilt University Qualitative Research Core, led by a PhD-level psychologist. Data coding and analysis was conducted by following the COREQ guidelines,19 an evidence-based qualitative methodology. Experienced qualitative coders first established reliability in using the coding system, then independently coded both transcripts. Coding of each transcript was compared, and any discrepancies were resolved to create a single coded transcript. Each statement was treated as a separate quote and could be assigned up to 5 different codes. Transcripts were combined and sorted by code. Analysis consisted of interpreting the coded quotes and identifying higher-order themes, using an iterative inductive-deductive approach. Deductively, theoretical contributions to the analysis included (1) the AADE7 taxonomy of self-management behaviors (the AADE7 is a framework for understanding the essential elements of diabetes self-management and includes healthy eating, physical activity, monitoring, medication, problem solving, risk reduction, and healthy coping),9 (2) social cognitive theory,20,21 and (3) a biopsychosocial framework.22 Inductively, the codes and themes from the focus groups were used to fill in the details of the conceptual framework.

Results

Conceptual Framework

Using the inductive-deductive approach, we developed a conceptual framework to describe adherence to self-management in adolescents with type 1 diabetes. A hierarchical coding system was developed and refined using the focus group guide and a preliminary review of 1 transcript. Major categories included (1) good/bad days, (2) lifestyle, (3) barriers to diabetes management, (4) interactions with the medical team, (5) self-care/general habits, (6) emotional experiences related to diabetes, (7) social support, (8) other topics, and (9) timing of diabetes challenges. Major categories were further divided from 1 to 9 subcategories, with each subcategory having additional levels of hierarchical divisions. Definitions and rules were written for the use of each category (https://healthbehavior.psy.vanderbilt.edu/datye/DatyeCodingSystem.pdf).

Figure 1 illustrates that biological, psychological, and environmental factors influence self-care behaviors. These situational influences sometimes make it harder to adhere to self-management behaviors and other times serve as motivators to self-management. The center of the framework depicts self-management as a dynamic interaction of all 7 categories of self-care behaviors. Systems-level influences on self-care behaviors are conceptualized as the health system and diabetes education. The situational and systems-level influences can include both challenges and facilitators. The interactions among challenges, facilitators, and self-care behaviors are viewed as influencing adherence to diabetes self-management, thus affecting health outcomes. Health outcomes occur on a continuum from poor control to good control and may vary from time to time and situation to situation. In addition, adherence to self-management behaviors creates feedback. This feedback may affect the biological, psychological, and environmental influences; may change future self-management behaviors; or may change the individual’s receptivity to health care and diabetes education.

Figure 1.

Figure 1.

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Factors that influence adolescent self-care behaviors.

In the following sections, we discuss each element of the conceptual framework. We give a general description and cite specific quotes that illustrate key themes.

Situational Influences

We identified biological, psychological, and environmental factors that function as situational influences on an individual’s diabetes self-care behavior. The dominant themes around biological challenges were centered on hypoglycemic episodes; these related to hunger, cravings, symptoms, time of day, and fatigue. Participants’ discussion of hypoglycemia and fatigue centered on waking up with a low level of glucose, which led to disrupted sleep, thus contributing to fatigue: “You wake up and honestly, I feel like I’m about to die. … Literally, I feel like I’m delirious, so I’m just in there grabbing everything I can get … I don’t like when I wake up in the morning, really early in the morning, because I feel like I’m missing out on sleep.” Participants also discussed episodes of hypoglycemia as related to cravings, expressed as loss of control: “I eat everything when it’s low. When I’m at work and I have my glucose tablets, I’ll just eat that, but if I’m at home I’ll just sit by a cabinet and eat until I can’t eat any more. … Yeah, but it’s like a craving for me.” Hypoglycemic episodes were also discussed in terms of feeling sick, causing inability to eat: “I don’t know if those [sic] goes for anybody but me, but sometimes when I’m low, I guess it’s maybe off a really high and just crashing rapidly, I refuse to eat. I feel like I can’t eat anything or drink anything. It’s almost like if I try just eating it, I’m going to throw it right back up. It’s almost like severe nausea, I guess.”

Psychological challenges included 5 primary elements: knowledge, affect, cognition, motivation, and life goals. Participants also discussed self-deprecating humor, reframing, and setting goals as psychological strategies that facilitate better adherence. Discussions of affect focused primarily on fear of one’s future diabetes health status: “My dad is diabetic too and he has auditory hallucinations, so his stories scare me. I always get like if I’m too low that could happen or if I’m high, one of those days where you just can’t get it down I’m like, I’m going to go blind in a couple of years because of this. Or just thinking am I going to lose a foot, am I going to have all these medical problems—that fear.” Two primary coping strategies were discussed in focus groups, humor and reframing. Humor tended to be self-deprecating: “The other kids, when they joke about it, I’m laughing with them. I’m like, ‘Yeah, I got the beetus.’” Cognitive reframing was a way to turn a challenge into a benefit: “It sucks to have diabetes, but I guess it’s nice to look at the things you can do. I got to talk to my class and I babysit a little girl that has diabetes. … You got to make the best out of it.” Setting one’s life goals is also a challenge: “I think one of the bad things is I can’t do as many jobs. We can’t fly airplanes. My dad was in the military so I was like ‘oh, that sounds cool.’ And then they were like ‘you can’t go in the military.’”

Environmental challenges to diabetes self-management included school, competing priorities, and peer relations. Peer relations in a school setting were seen as challenging, primarily centering on the risk of being bullied or avoiding attention from others when performing diabetes care: “I had a lot of problems in high school with it. I would eat and I wouldn’t take my insulin or I wouldn’t check my blood sugar, just because I didn’t want to draw attention to myself … you don’t want to get bullied about it. I just feel like people target you on anything. I felt like my diabetes was an easy target.” Interacting with teachers also created challenges to self-management: “One time, my blood sugar was low in class and I didn’t feel like it was real low, so I was just going to drink the juice in class. She [teacher] didn’t allow drinks or food or anything. I was like, ‘Can I drink this?’ She freaked out on me.” School, overall, was expressed as a competing priority with diabetes self-management: “When school starts, I guess diabetes takes a backseat, because I’m worried about other things.”

Systems Influences

The health system refers to the type and quality of health care. Adolescents with type 1 diabetes are typically treated by pediatric endocrinologists and also may receive care from dietitians, nurse practitioners, and mental health providers. In addition to the health system, diabetes education is also a facilitator of self-care behavior. Diabetes educators assist patients in acquiring the knowledge and skills they need to manage their diabetes. High-quality diabetes education can have positive influences on self-care behaviors. Participants discussed the planning piece of self-management with their diabetes providers: “It’s a like a game plan. He [diabetes provider] helps map it out, like, okay, if finals are here, it’s probably going to be a little bit higher in here. It’s where you need to just pay a little bit more attention. Not necessarily check it twice as much or anything. Just pay attention how I’m feeling. How I’m acting.” Providers helped participants review self-management strategies that could be improved: “In my [diabetes provider] appointments we go over what I need to do and what I’ve done wrong. If anything needs to change as far as my basal rate or anything. If I don’t change it I need to change myself and what I need to do as far as, like I said, taking medicine, check my blood sugar more often and whatnot.”

Participants discussed the effective delivery of self-management education by diabetes providers: “Yeah, they do a good job at explaining it. I think because this is the pediatric side so they word it so you understand and then you learn it, the longer you have it and they just do a really good job of helping me understand what it is and how it works.” Diabetes providers are also effective in delivering the message to patients that serious consequences can occur from mismanagement: “They [diabetes providers] tell me all the bad things that can happen to me later on and I get that.”

Self-Care Behaviors

Diabetes self-management behaviors included diet, physical activity, monitoring, insulin, problem solving, coping, and reducing risks (based on the AADE7 taxonomy of self-management behaviors9).

Participants discussed positive self-management in terms of steadiness of blood glucose levels without disruption to activities they enjoy and administration of proper insulin dosages: “I think a good day is when I can eat what I want and do what I want, and my blood sugar stays right where it needs to be. I’m giving insulin right when I need to or the exact dosage and all that. I don’t really experience any fluctuation.” Self-management was also discussed in terms of personal responsibility for self: “I think more about diabetes and planning out my day than I did before because I have to be responsible now since I’m an adult.”

Participants discussed planning ahead as a self-management strategy. In terms of hyperglycemia, this was discussed in terms of personal reminders: “I set alarms on my phone. Lantus time or ‘don’t forget to check your sugar’ or reminders on my pump if I need to do a bolus at certain times.” Regarding hypoglycemia, discussed in terms of adequate amounts of carbohydrates to treat hypoglycemia, “I just have to think more about it, what I’m doing and guess how that’s going to affect me in a couple hours and am I at a place, if I’m low is there going to be snacks or should I bring it?”

Negative self-management behaviors were discussed in terms of eating and lack of blood glucose checking as risks for hyperglycemia: “When say I get home from school, I’m so tired that I just don’t even check my blood sugar and I eat something. That’s why in the afternoons my blood sugar’s always higher, because I don’t normally check my blood sugar even though I should” and “The snacks, I usually don’t check my blood sugar before eating it. I do take the insulin, but usually afterwards when I do take my blood sugar, it’s still high because I didn’t check it before eating.”

Feedback

Discussion in this section centered on hyperglycemic situations. Successful adherence to self-management behaviors provides feedback on how to respond to future challenges and reinforces self-efficacy and motivation. On the other hand, poor adherence could lead the patient to “give up” and not try as hard in the future, reducing self-efficacy and lowering motivation: “A month or so ago, I was really high before I was going to bed and I was so tired because I’d already stayed up for two hours trying to get it down and it was three in the morning and I was finally like, ‘I don’t really care.’” There is also a sense of frustration in that he or she can adhere to self-management but not obtain desired results, which could also lead to giving up: “Bad days … I’ll wake up with a high blood sugar and then I’ll eat breakfast. I’ll do what I’m supposed to. Then my lunch. I’ll still have a high blood glucose. That I think will frustrate me just because I’m supposed to be doing what I’m supposed to, but … it’s still not in the range that I need it to be in, so I think that’s what frustrates me.” Adherence to diabetes self-management behaviors improves glycemic control; however, there is not a perfect relationship between adherence and diabetes control. Patients who are adherent to their diabetes care still experience hypoglycemia and hyperglycemia, which can result in feelings of frustration.

Discussion

In this study, adolescents and young adults with type 1 diabetes described barriers to and facilitators of adherence (see Figure 1), classified as situational influences (biologic, psychologic, and environmental influences) and systems influences (including the health system and diabetes education). Several specific areas of concern emerged among youth participants (see below), and addressing these concerns may offer diabetes educators an opportunity to assess and address barriers to adherence in their patients.

Hypoglycemia was noted as a significant challenge (biological situational influence). Several participants mentioned the difficulties in treating hypoglycemia, how their environment made treatment challenging (ie, management in school), and the craving that many experience with low blood glucose. Participants also made several interesting observations about hypoglycemia, specifically stating that they did not want to draw attention to themselves in school when they experienced low blood glucose and that treating hypoglycemia could be difficult because they wanted to eat a large quantity of food. These observations provide an opportunity for diabetes educators to focus on hypoglycemia as a barrier to adherence. For example, understanding that adolescents do not want to call attention to themselves with hypoglycemia in school may be a reason to consider a continuous glucose monitor (and specifically a continuous glucose monitor that does not alarm), a device used less in adolescents than other age groups.23 In addition, diabetes educators can focus on appropriate management of hypoglycemia and practical suggestions, such as carrying appropriately portioned rapid-acting carbohydrates in small individual containers (ie, 4 glucose tabs or approximately 16 g of carbohydrates). Similarly, if patients feel that drinking juice in class may call attention to themselves while in school, diabetes educators may provide patients with a list of other rapid-acting carbohydrates that patients may carry with them.

It is also notable that, while several adolescents and young adults in our sample mentioned their difficulties with hypoglycemia, this is not traditionally thought of as a barrier to adherence. Although questionnaire measures to assess fear of hypoglycemia exist (eg, Hypoglycemia Fear Survey),24 validated measures of adherence, including the PRISM and Barriers to Diabetes Adherence scale, do not have specific questions about hypoglycemia.14,15 In addition, if patients are worried about hypoglycemia, they may keep their blood glucose above their target range, causing hyperglycemia. Specific questions about fear of hypoglycemia and barriers to appropriate treatment of hypoglycemia may help the diabetes educator appropriately address this barrier during clinic visits.

Adolescents described their interactions with their providers during office visits as both positive and negative. For example, 1 participant described always feeling nervous on days of the diabetes appointment while waiting for the A1C result. Participants also noted that the medical team often focuses on what is wrong, what needs to be changed, and how poor diabetes control in the future can lead to bad outcomes. These findings are similar to those reported by Lowes and colleagues,25 in their study of adolescents’ and caregivers’ perceptions of clinical care in diabetes. However, adolescents in our study noted that focusing on the immediate effects of blood glucose levels and management is more important than discussing future outcomes and potential complications. This observation is in line with other pediatric studies that have shown focusing on what matters to the adolescent now is more likely to result in behavioral change.26 Interestingly, recent studies have also found that young adults with type 1 diabetes may want to talk about the difficulties they have in living with and managing their diabetes and that providers should make a point to discuss this at visits.27

These points are key for diabetes educators—goal setting with the patient and working toward the patient’s goals may be an important motivating factor for adolescents. For example, for adolescent athletes, focusing on improving glycemic control to improve weight gain and muscle mass may be more helpful than focusing on long-term complications such as nephropathy and retinopathy. Furthermore, framing the visit in a positive light, providing feedback for patients about improved glycemic control helping to achieve their goals, rather than focusing primarily on negative aspects of diabetes management, may improve attitudes about clinic visits in this population. Health care providers could also acknowledge the frustration of performing self-care behaviors and not seeing results. Clinic visit attendance is notoriously poor during the adolescent and young adult transition period,28 and an increased focus on what matters to the patient, with joint goal setting and discussion of how the transition process works, may increase attendance.29 Some clinics have also considered group visits as a way to allow adolescents who may be struggling with similar issues to focus on their concerns together.30 Given that adolescents and young adults in our sample raised issues that are not typically covered in diabetes education (eg, skipping insulin when with peers, managing diabetes when using alcohol), group visits may be a unique way for diabetes educators to address some of the negative concerns participants have about clinic visits.

The current study contributes to our understanding of situational and health systems barriers to and facilitators of adherence in adolescents and young adults with type 1 diabetes, but limitations should be addressed. While each focus group led to robust discussion of management of type 1 diabetes, there were only 2 focus groups, and each group had a relatively small number of participants. In addition, all participants were treated at the same medical center, and therefore their diabetes education and clinical experience were likely similar (they were all treated by providers from the same clinic). It would be helpful to conduct focus groups with participants treated at different institutions to see if their diabetes education influenced the barriers or facilitators to adherence they noted. However, although participants were all treated at the same clinic, some lived over 2 hours away, demonstrating the broad catchment area of the clinic and the regional diversity of participants in the study.

Implications.

Findings from our study offer novel insights into the challenges in adhering to the recommended treatment regimen in this high-risk population, and this, in turn, has several implications for diabetes educators. Hypoglycemia appears to present a challenge in management of diabetes. Participants voiced fear of hypoglycemia, difficulties in managing hypoglycemia, and how the environment (eg, school) may influence management of hypoglycemia. Diabetes educators should be cognizant of these difficulties and focus on potential areas of concern preemptively. For example, reviewing available technologies such as continuous glucose monitors to aid in detection of hypoglycemia may be helpful to patients trying to minimize hypoglycemia while in school. In addition, practical recommendations can be given such as prepackaging snacks into 15 g of carbohydrates to make treatment of hypoglycemia easier and prevent patients from eating several tabs (or candy) at once, which may cause hyperglycemia. Talking about strategies to avoid drawing attention to them in the middle of class may be very relevant for some patients. As adolescents may be more focused on their current challenges (school, work, sports, etc) as opposed to long-term effects of hyperglycemia, joint goal setting to help adolescents meet their current goals may help engage adolescents more in their diabetes care. Finally, considering options such as group clinic visits may allow adolescents the opportunity to discuss their challenges in a group setting. Given concerns around poor clinic attendance in this age group, finding ways to engage adolescents in their care is crucial. Future studies are needed to understand how diabetes educators can best assess and address these barriers to adherence to help adolescents engage and improve their adherence to diabetes care.

Acknowledgments:

The authors thank Shuodan Zhang for her assistance in enrolling participants for the focus group during her Vanderbilt Medical Student Research Training Program.

Funding: This publication was supported by CTSA award No. UL1 TR002243 from the National Center for Advancing Translational Sciences. Its contents are solely the responsibility of the authors and do not necessarily represent official views of the National Center for Advancing Translational Sciences or the National Institutes of Health. This work was also supported by the Endocrine Fellows Foundation.

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