Diabetes Summer Camp in children and adolescents with type 1 diabetes: Effects on well-being and quality of life

Abstract

Objetive:
The aim of this study was to examine the quality of life, anxiety and affectivity in children and adolescents with type 1 diabetes (T1D) and in their parents after participating in a diabetes summer camp.

Method:
A total of 20 children and adolescents with T1D, aged 8-14, and their parents participated. The study design was quasi-experimental longitudinal with an intra-subject factor with two measurements (pre/post), and an inter-group factor (child/parent).

Results:
After attending camp, a significantly increased quality of life, demonstrated by the emotional well-being and self-esteem scores, was found in the children but not in the parents. Less negative affectivity and an improvement in positive affectivity was seen in the parents, but not in the children. Differences in anxiety were found in both the children and the parents.

Conclusions:
This research presents empirical evidence of the benefits of participation in a diabetes camp in both children and their parents.

Full text

Please
cite
this
article
in
press
as:
Anarte
MT,
et
al.
Diabetes
Summer
Camp
in
children
and
adoles-
cents
with
type
1
diabetes:
Effects
on
well-being
and
quality
of
life.
Endocrinol
Diabetes
Nutr.
2019.
https://doi.org/10.1016/j.endinu.2019.08.002
ARTICLE IN PRESS
+Model
ENDINU-968;
No.
of
Pages
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Endocrinol
Diabetes
Nutr.
2019;xxx(xx):xxx---xxx
www.elsevier.es/endo
Endocrinología,
Diabetes
y
Nutrición
ORIGINAL
ARTICLE
Diabetes
Summer
Camp
in
children
and
adolescents
with
type
1
diabetes:
Effects
on
well-being
and
quality
of
life
María
Teresa
Anartea,b,∗,
Mónica
Carreiraa,b,
Ana
Leiva
Geac,
Esperanza
Varela a,b,
Marta
Mateo-Anarted,
Juan
Pedro
López
Sigueroa,e,
Isabel
Leiva
Geaa,e
aInstituto
de
Investigación
Biomédica
de
Málaga-IBIMA,
Spain
bDepartment
of
Personality,
Assessment
and
Psychological
Treatment,
Faculty
of
Psychology,
University
of
Málaga,
Spain
cUniversity
Hospital
‘‘Virgen
de
la
Victoria’’,
Málaga,
Spain
dATRI-J
Center,
Fundación
La
Esperanza
E.B.S.
Málaga,
Málaga,
Spain
ePediatric
Endocrinology
Service,
Regional
University
Hospital,
‘‘Materno
Infantil’’
Hospital,
Málaga,
Spain
Received
14
April
2019;
accepted
16
August
2019
KEYWORDS
Type
1
diabetes;
Summer
camp;
Quality
of
life;
Anxiety;
Affective
symptoms
Abstract
Objetive:
The
aim
of
this
study
was
to
examine
the
quality
of
life,
anxiety
and
affectivity
in
children
and
adolescents
with
type
1
diabetes
(T1D)
and
in
their
parents
after
participating
in
a
diabetes
summer
camp.
Method:
A
total
of
20
children
and
adolescents
with
T1D,
aged
8---14,
and
their
parents
participated.
The
study
design
was
quasi-experimental
longitudinal
with
an
intra-subject
factor
with
two
measurements
(pre/post),
and
an
inter-group
factor
(child/parent).
Results:
After
attending
camp,
a
significantly
increased
quality
of
life,
demonstrated
by
the
emotional
well-being
and
self-esteem
scores,
was
found
in
the
children
but
not
in
the
parents.
Less
negative
affectivity
and
an
improvement
in
positive
affectivity
was
seen
in
the
parents,
but
not
in
the
children.
Differences
in
anxiety
were
found
in
both
the
children
and
the
parents.
Conclusions:
This
research
presents
empirical
evidence
of
the
benefits
of
participation
in
a
diabetes
camp
in
both
children
and
their
parents.
©
2019
SEEN
y
SED.
Published
by
Elsevier
Espa˜
na,
S.L.U.
All
rights
reserved.
∗Corresponding
author.
E-mail
address:
anarte@uma.es
(M.T.
Anarte).
https://doi.org/10.1016/j.endinu.2019.08.002
2530-0164/©
2019
SEEN
y
SED.
Published
by
Elsevier
Espa˜
na,
S.L.U.
All
rights
reserved.

Please
cite
this
article
in
press
as:
Anarte
MT,
et
al.
Diabetes
Summer
Camp
in
children
and
adoles-
cents
with
type
1
diabetes:
Effects
on
well-being
and
quality
of
life.
Endocrinol
Diabetes
Nutr.
2019.
https://doi.org/10.1016/j.endinu.2019.08.002
ARTICLE IN PRESS
+Model
ENDINU-968;
No.
of
Pages
7
2
M.T.
Anarte
et
al.
PALABRAS
CLAVE
Diabetes
tipo
1;
Campamento
de
verano;
Calidad
de
vida;
Ansiedad;
Síntomas
afectivos
Campamento
de
verano
en
ni˜
nos
y
adolescentes
con
diabetes
tipo
1:
efectos
sobre
el
bienestar
y
la
calidad
de
vida
Resumen
Objetivo:
El
objetivo
de
este
estudio
fue
examinar
la
calidad
de
vida,
la
ansiedad
y
la
afec-
tividad
en
ni˜
nos
y
adolescentes
con
diabetes
mellitus
tipo
1
(DM1),
y
en
sus
padres
después
de
participar
en
un
campamento
de
verano
de
diabetes.
Método:
Participaron
un
total
de
20
ni˜
nos
y
adolescentes
con
DM1
de
8
a
14
a˜
nos,
además
de
sus
padres.
El
dise˜
no
del
estudio
fue
longitudinal
cuasi-experimental
con
un
factor
intra-sujeto
con
2
mediciones
(pre/post),
y
un
factor
intergrupo
(ni˜
no/padre).
Resultados:
Después
de
asistir
al
campamento
se
observa
un
aumento
significativo
en
la
calidad
de
vida,
demostrado
en
las
puntuaciones
de
bienestar
emocional
y
autoestima
en
los
ni˜
nos.
Los
padres
mostraron
menos
afectividad
negativa
y
más
positiva.
Se
encontraron
diferencias
en
ansiedad
en
ni˜
nos
y
sus
padres.
Conclusiones:
Se
muestra
evidencia
empírica
sobre
los
beneficios
de
un
campamento
de
dia-
betes
tanto
en
ni˜
nos
como
en
sus
padres.
©
2019
SEEN
y
SED.
Publicado
por
Elsevier
Espa˜
na,
S.L.U.
Todos
los
derechos
reservados.
Introduction
Type
1
diabetes
(T1D)
is
a
chronic
disease
that
affects
more
than
just
physical
health.
The
impact
of
the
diagnosis,
due
to
changes
imposed
by
treatment,
can
generate
a
high
level
of
stress,
alter
emotions
and
decrease
quality
of
life
(QoL)
in
the
child
and
in
the
family.1Accordingly,
the
relationship
between
the
patient,
the
healthcare
team
and
the
family
is
critical
to
achieving
good
adaptation
to
the
disease.2
The
International
Society
for
Pediatric
and
Adolescent
Diabetes
(ISPAD)
in
its
2018
statement3reports
that
adoles-
cents
with
diabetes
have
a
higher
incidence
of
depression,
anxiety,
psychological
distress
and
eating
disorders
com-
pared
to
their
peers
without
T1D.
Depression
and
anxiety
are
related
to
fewer
glucose
controls
and
poor
glycemic
control.
In
addition,
depression
is
also
associated
with
poor
treat-
ment
adherence
and
poor
QoL.3Improved
QoL
in
adolescents
is
associated
with
increased
self-efficacy,
less
depression
and
better
metabolic
control.4The
entire
family
system
suffers
considerable
stress,
and
some
authors
report
that
the
psychological
adaptation
of
children
to
the
disease
is
governed
by
the
reactions
of
their
parents
to
this
stress,5
which
forces
the
family
to
modify
their
lifestyle6and
affects
their
QoL.
Thus,
48%
of
parents
report
poor
QoL
and
81%
feel
overwhelmed
by
their
child’s
diabetes,
at
times
associating
this
feeling
with
anxiety
and
depression.7
Although
there
are
many
factors
influencing
a
child’s
adherence
to
treatment
regimen
and
glycemic
control,3 --- 8
parental
mood
plays
an
important
role
in
controlling
the
child’s
diabetes.
Mothers
with
a
high
anxiety
level
tend
to
take
greater
responsibility
for
managing
their
child’s
dia-
betes,
perceiving
their
teenagers
as
not
capable
of
doing
so,
while
their
children
perceive
a
high
maternal
control
of
their
diabetes
and
a
high
level
of
overprotection
by
their
parents.
Parental
psychological
well-being
(especially
the
mother),
however,
is
associated
with
the
metabolic
outcomes
of
the
child,1finding
worse
glycemic
control
the
poorer
the
psy-
chological
well-being
of
the
parents.9The
protective
factors
are
higher
QoL
in
children
with
T1D
and
reduced
depressive
symptoms
and
stress
in
their
parents.10
Several
studies
have
examined
the
effect
of
diabetes
camp
participation
on
psychological
variables
without
a
consensus.
There
is
no
agreement
regarding
anxiety11 since,
while
Briery
and
Rabian12 reported
a
significant
decrease
in
anxiety
levels
from
pre-camp
to
post-camp,
Török
et
al.13
found
no
significant
differences
in
these
levels,
nor
did
García-Pérez
et
al.14 Additionally,
no
improvement
was
found
in
QoL,11,15,16 although
there
was
improvement
in
the
Self-perception
subscale.17 Improvement
was
seen,
however,
in
distress,
self-esteem,
self-efficacy
and
atti-
tudes
toward
the
child’s
disease
after
diabetes
camp.12,13,16
Although
the
ISPAD3reports
that
adolescents
with
diabetes
have
a
higher
incidence
of
depression,
no
studies
have
ana-
lyzed
the
emotional
state
of
children
who
have
participated
in
a
diabetes
camp.
Diabetes
camp
has
become
a
common
part
of
dia-
betes
care
worldwide.
Although
a
patient’s
knowledge
and
self-management
of
diabetes
may
improve
after
camp,18
improvements
in
psychological
variables
have
not
been
consistently
demonstrated.
Studies
examining
the
role
of
psychological
variables
in
children
and
adolescents
who
par-
ticipate
in
diabetes
camp
are
scarce
and
even
nonexistent
in
some
of
these
variables.
Consequently,
the
aim
of
this
study
was
to
investigate
both
the
outcome
effectiveness
of
a
diabetes
summer
camp
program
for
children
and
adolescents
with
diabetes,
and
the
expected
changes
in
QoL,
anxiety
and
affectivity
in
both
children
and
their
parents.
Methods
Participants
Informed
consent
was
obtained
from
21
children
with
T1D
who
participated
in
a
summer
camp
and
from
their
parents.
The
final
sample
consisted
of
20
children
with

Please
cite
this
article
in
press
as:
Anarte
MT,
et
al.
Diabetes
Summer
Camp
in
children
and
adoles-
cents
with
type
1
diabetes:
Effects
on
well-being
and
quality
of
life.
Endocrinol
Diabetes
Nutr.
2019.
https://doi.org/10.1016/j.endinu.2019.08.002
ARTICLE IN PRESS
+Model
ENDINU-968;
No.
of
Pages
7
Summer
Camp
and
diabetes:
Empirical
evidence
on
well-being
and
quality
of
life
3
T1D
and
their
parents.
One
child
was
excluded
after
failing
to
complete
the
full
evaluation
(post-test).
Sociodemo-
graphic
characteristics
were:
10
(50%)
boys
and
10
(50%)
girls,
mean
age
10.4
years
(95%
CI:
9.54---11.26)
with
a
standard
deviation
(SD)
1.85
(range:
8---14,
median:
10
years).
All
children
had
completed
primary
school.
The
mean
disease
duration
was
3.03
years
(95%
CI:
1.67---4.40)
with
an
SD
2.92
(range:
0.13---10.05,
median:
1.69
years).
Parental
participation
comprised
18
mothers
(90%)
and
two
fathers
(10%),
with
a
mean
age
of
40.65
(95%
CI:
37.8---43.5)
in
the
29---52
age
range
with
a
median
age
of
41
years.
Once
the
parents
signed
the
informed
consent,
interviews
were
conducted
by
psychologists
with
research
experience.
The
children/adolescents
and
parents
then
completed
the
ques-
tionnaire
independently.
The
psychological
evaluation
was
conducted
two
weeks
before
the
camp
and
one
month
fol-
lowing
its
completion.
The
study
protocol
was
approved
by
the
joint
Ethics
Research
Committee
of
the
Regional
Univer-
sity
Hospital
of
Malaga
(Spain).
Instruments
Quality
of
Life:
(a)
Psychological
screens
in
parents:
Health
Questionnaire
SF-12.19 The
short
version
of
the
SF-36
was
used
to
assess
QoL
in
the
parents
of
children
with
T1D.
The
SF-12
consists
of
12
items,
with
two
measures:
physical
(PCS-12)
and
mental
(MCS-12)
components.
Higher
scores
indicate
higher
QoL.
(b)
Psychological
screens
in
Children:
the
KINDLR20 is
a
general
instrument
that
evaluates
QoL
in
children
and
adolescents,
with
a
version
for
parents.
The
corresponding
version
was
used
for
each
age:
Kid-Kindl:
8---12
years;
Kiddo-KINDL:
13---16
years;
and
the
version
for
parents
of
children
aged
8---16
years.
The
specific
areas
of
evaluation
are:
physical
well-being,
emotional
well-being,
self-esteem,
family,
friends,
and
school
(6
modules,
each
comprising
4
items).
There
is
a
seventh
module
(Hospital
stay)
with
six
items
which
are
only
answered
by
those
who
have
had
a
recent
hospital
admission
or
were
diagnosed
a
long
time
ago.
Typically,
only
the
24
items
corresponding
to
the
first
6
modules
(physical
well-being,
emotional
well-being,
self-
esteem,
family,
friends,
and
school)
are
administered
and
provide
a
total
score
(see
Tables
1
and
2:
TOTAL
score
with-
out
module
7).
However,
when
necessary,
module
7
(Hospital
stay:
6
items)
is
also
administered,
thus
enabling
a
total
score
to
be
obtained
for
all
7
modules
(see
Tables
1
and
2:
TOTAL
score
with
module
7).
The
answers
are
recorded
on
a
five-category
Likert
scale
(1
=
never
and
5
=
always).
The
questions
refer
to
the
week
before
the
interview
and
the
scores
obtained
from
the
means
for
each
dimension
indicate
that
a
higher
score
represents
better
QoL.
Anxiety:
(a)
Psychological
screens
in
parents:
STAI:
State-Trait
Anxiety
Inventory21 consisting
of
two
self-report
scales
measuring
State
Anxiety
(STAI-S)
and
Trait
Anxiety
(STAI-T);
(b)
Psychological
screens
in
children:
STAIC,
self-report
State-Trait
Anxiety
Inventory
for
Children
(between
the
ages
of
9
and
15).
The
direct
scores
on
these
scales
are
transformed
into
percentiles,
with
highers
scores
indicating,
greater
anxiety
(state
or
trait).
Affectivity:
(a)
Psychological
screens
in
parents:
The
PANAS
Positive
and
Negative
Affect
Schedule22 evaluates
positive
(10
items)
and
negative
(10
items)
emotional
states
in
two
ways:
during
the
past
week
and
as
a
general
sta-
tus.
(b)
Psychological
screens
in
children:
PANASN,
version
for
children
and
adolescents.
High
scores
on
the
Posi-
tive
Affect
subscale
indicate
greater
positive
affectivity
(e.g.,
enthusiastic,
energetic,
active,
etc.)
while
high
scores
on
the
Negative
Affect
subscale
indicate
greater
negative
affectivity
(e.g.,
fearful,
nervous,
hostile,
etc.).
Procedure
The
summer
camp
lasted
10
days
and
the
intervention
team
comprised
10
physicians
and
one
diabetes
educator
(nurse).
The
non-medical
personnel
included
the
president
of
the
diabetes
association
of
Málaga,
10
free-time
monitors
with
diabetes,
each
monitor
caring
for
five
children
to
support
glycemic
control
(performing
checks
and
insulin
administration)
and
five
free-time
monitors
without
T1D
in
charge
of
the
leisure
and
sports
activities
for
all
50
chil-
dren
who
attended
the
camp.
To
ensure
that
their
responses
were
not
biased
by
previous
experience,
only
those
who
attended
the
camp
for
the
first
time
were
included
in
this
study
thus
fulfilling
the
principle
of
homogeneity.
Accord-
ingly,
the
differences
found
in
the
post-test
evaluation
could
not
be
attributed
to
the
previous
state
(experi-
ence)
of
the
participants.
The
camp
structure,
contents,
and
educational
program
followed
the
recommendations
of
the
American
Diabetes
Association23 for
summer
camp
organization
and
management.
Education
consisted
of
two
parts:
lecture
and
small
group
discussion
with
10---15
chil-
dren
per
group.
Sessions
lasted
one
hour
each
day
and
were
directed
by
a
pediatric
or
adult
endocrinologist.
Lecture
topics
included
disease
etiology
and
symptoms,
insulin
therapy
and
injection
techniques,
the
importance
of
diabetes
control,
blood
glucose
monitoring,
exercise
and
diabetes.
At
each
meal
(breakfast,
lunch,
snack
and
dinner)
workshops
were
conducted
on
counting
carbohy-
drate
servings,
conveniently
adapted
to
present-day
meals,
and
insulin
dose
was
calculated
in
collaboration
with
the
physician---monitor---child,
analyzing
the
insulin
administered
at
the
same
meal
the
previous
day.
The
rest
of
the
time
the
children
participated
in
sports,
painting,
ceramics,
and
other
activities.
Among
the
special
activities,
one
highlight
was
a
motivational
talk
by
an
astronaut
with
diabetes
who
told
his
life
story.
Data
analysis
The
study
design
was
quasi-experimental
longitudinal
with
an
intra-subject
factor
and
an
inter-group
factor
(child/parent)
with
two
measurements
(pre/post).
Thus,
four
groups
were
statistically
defined:
children
pre-post
intervention
and
parents
pre-post
intervention.
Therefore
we
compared:
-
Inter-group
analysis
before
and
after
the
summer
camp:
children
with
their
parents
at
baseline
(pre-test)
and
post-
test.
-
Intra-group
analysis
before
and
after
the
summer
camp:
children
between
their
baseline
and
post-test
measure-
ments.

Please
cite
this
article
in
press
as:
Anarte
MT,
et
al.
Diabetes
Summer
Camp
in
children
and
adoles-
cents
with
type
1
diabetes:
Effects
on
well-being
and
quality
of
life.
Endocrinol
Diabetes
Nutr.
2019.
https://doi.org/10.1016/j.endinu.2019.08.002
ARTICLE IN PRESS
+Model
ENDINU-968;
No.
of
Pages
7
4
M.T.
Anarte
et
al.
Table
1
Comparative
analysis
inter-group
post-test
KINDL/KINDL
parents’
version.
Children
with
diabetes
Parents
Wilcoxon
test
N
Mean
SD
Median
N
Mean
SD
Median
Z
p
1.
Physical
well-being
15
16.33
3.18
18.00
15
16.00
2.39
15.00
0.67
0.567
2.
Emotional
well-being
15
19.33
1.18
20.00
15
17.80
1.97
18.00
2.62
<0.001
3.
Self-esteem
15
17.93
2.49
18.00
15
17.60
2.50
18.00
0.43
0.726
4.
Family
15
16.13
3.34
15.00
15
17.53
2.96
18.00
1.34
0.190
5.
Friends
15
18.73
2.19
20.00
15
17.60
2.53
19.00
1.61
0.117
6.
School
15
13.73
2.63
13.00
15
16.53
2.17
16.00
2.84
0.003
TOTAL
score
without
module
7
15
102.20
8.74
104.00
15
103.07
8.36
104.00
0.50
0.637
7.
Hospital
stay 2
27.00 4.24
27.00
2
20.50
0.71
20.50
---
---
TOTAL
score
with
module
72
131.50 2.12 131.50
2
123.00
4.24
123.00
---
---
KINDL:
questionnaire
for
evaluating
QoL
in
children
and
adolescents
and
the
KINDL
parents’
version.
The
mean
scores
correspond
to
the
sum
of
the
items
in
each
module
and
the
total
score
(with
or
without
module
7).
Table
2
Comparative
analysis
intra-group
pre-post
children:
KINDL
and
STAIC.
PRE
measurement
POST
measurement
Wilcoxon
test
N
Mean
SD
Median
N
Mean
SD
Median
Z
p
KINDL
1.
Physical
well-being
15
16.35
2.30
17.00
15
16.33
3.18
18.00
0.06
0.485
2.
Emotional
well-being
15
18.10
1.55
18.00
15
19.33
1.18
20.00
2.42
0.008
3.
Self-esteem
15
16.70
2.25
17.00
15
17.93
2.49
18.00
1.91
0.035
4.
Family
15
17.80
2.12
18.00
15
16.13
3.34
15.00
1.34
0.099
5.
Friends
15
17.80
1.91
18.00
15
18.73
2.19
20.00
1.70
0.055
6.
School
15
15.45
3.62
17.00
15
13.73
2.63
13.00
0.98
0.176
TOTAL
score
without
module
7
15
102.20
8.43
105.00
15
102.20
8.74
104.00
0.34
0.376
7.
Hospital
stay 1
27.00
---
27.00
2
27.00
4.24
27.00
---
---
TOTAL
score
with
module
71
127.00
---
127.00
2
131.50
2.12
131.50
---
---
STAIC
State
Anxiety
13
38.63
22.72
40.00
13
21.92
22.98
15.00
2.45
0.005
Trait
Anxiety
15
27.94
19.46
20.00
15
23.31
24.30
15.00
1.85
0.034
KINDL:
questionnaire
for
evaluating
QoL
in
children.
The
mean
scores
correspond
to
the
sum
of
the
items
in
each
module
and
the
total
score
(with
or
without
module
7).
STAIC:
questionnaire
for
evaluating
state/trait
anxiety
in
children.
The
mean
scores
correspond
to
the
direct
scores
transformed
into
percentiles
according
to
age
and
sex
(from
1%
to
99%).
-
Intra-group
analysis
before
and
after
the
summer
camp:
parents
between
their
baseline
(pre-test)
and
post-test
measurements.
Of
the
20
children
initially
evaluated
(pre-test),
15
were
measured
post-test
(six
girls
and
nine
boys)
representing
a
loss
of
25%
(five
cases)
for
the
longitudinal
analyses.
Their
parents
were
also
evaluated
post-test
(15).
For
STAIC
analy-
sis,
three
children
were
removed
due
to
their
age
(8
years)
as
the
STAIC
is
administered
between
the
ages
of
9
and
15
years.
As
shown
in
the
results,
the
N
of
the
analyses
var-
ied
among
variables
because
not
all
parents
could
be
fully
evaluated.
Thus,
when
presenting
the
results
as
pairs,
the
data
from
the
unmatched
case
was
lost.
The
non-parametric
Wilcoxon
test
was
used
to
perform
the
intra-subject
repeated
measures
analysis
for
both
chil-
dren
and
parents.
As
the
cases
were
matched
(parent/child),
the
inter-group
analysis
must
be
considered
a
situation
of
related
samples
and
thus
the
Wilcoxon
test
was
applied.
The
description
was
performed
with
the
mean
and
the
median,
parallel
to
the
comparisons.
All
statistical
analyses
were
carried
out
with
SPSS
Statistics,
version
22.
Results
Quality
of
life
-
Inter-group
analysis
(pre/post-test
children
versus
parents):
The
groups
were
homogeneous
at
baseline,
with
no
statistically
significant
differences
between
the
children
and
their
parents
in
QoL.
Significant
differences
were
found
in
two
of
the
areas
evaluated
by
the
KINDL.
In
emotional
well-being
after
the
summer
camp,
children
scored
higher
than
their
parents.
In
the
school
area,
parents
scored
higher
than
their
children,
tending
to
better
perceive
the
situation
of
their
children
in
school.
In
the
remaining
areas
no
significant
differences
were

Please
cite
this
article
in
press
as:
Anarte
MT,
et
al.
Diabetes
Summer
Camp
in
children
and
adoles-
cents
with
type
1
diabetes:
Effects
on
well-being
and
quality
of
life.
Endocrinol
Diabetes
Nutr.
2019.
https://doi.org/10.1016/j.endinu.2019.08.002
ARTICLE IN PRESS
+Model
ENDINU-968;
No.
of
Pages
7
Summer
Camp
and
diabetes:
Empirical
evidence
on
well-being
and
quality
of
life
5
found.
Nor
were
there
differences
in
the
total
score
(Table
1).
-
Intra-group
analysis
(pre/post-test
children):
Of
the
seven
KINDL
questionnaire
subscales,
significant
differences
were
found
in
two:
self-esteem
(p
=
0.035)
and
emotional
well-being
(p
=
0.008),
with
a
significant
improvement
in
the
emotional
well-being
and
self-esteem
of
children
who
participated
in
the
camp
(Table
2).
However,
in
the
total
score,
no
significance
(p
=
0.376)
was
detected.
-
Intra-group
analysis
(pre/post-test
parents):
No
statisti-
cally
significant
differences
were
found
in
any
of
the
areas
evaluated
with
KINDL
(parent
version).
Nor
did
we
find
significant
differences
in
the
SF-12
(physical
or
mental
component).
Anxiety
-
Inter-group
analysis
(pre/post-test
children
versus
parents):
No
significant
differences
were
seen
in
the
scores
on
state
and
trait
anxiety
between
the
children
and
their
parents
at
baseline
or
after
the
children’s
participation
in
the
camp;
thus,
the
groups
were
homogeneous.
-
Intra-group
analysis
(pre/post-test
children):
Table
2
shows
a
significant
decrease
in
both
state
anxiety
and
trait
anxiety
scores
in
children
post-camp.
-
Intra-group
analysis
(pre/post-test
parents):
Following
the
camp,
a
statistically
significant
decrease
was
seen
in
the
state
anxiety
scores
in
the
parents
of
children
with
T1D.
No
significant
differences
were
seen
in
trait
anxiety
scores
(Table
3).
Positive
and
negative
affectivity
-
Inter-group
analysis
(pre/post-test
children
versus
parents):
At
baseline,
no
significant
differences
were
seen
in
positive
affect
(PA).
However,
in
negative
affect
(NA)
highly
significant
differences
were
found
between
the
scores
of
children
and
those
of
their
parents,
with
the
parents
scoring
higher
in
NA
than
their
children
(Table
4).
-
Following
the
camp
we
found
highly
significant
differences
between
PA
in
children
and
their
parents
(Table
4),
with
parents
scoring
higher.
-
Intra-group
analysis
(pre/post-test
children):
Although
a
slight
decrease
was
observed
in
the
mean
scores
of
the
children
in
both
NA
and
PA
post-camp,
no
significant
dif-
ferences
were
found.
-
Intra-group
analysis
(pre/post-test
parents):
Considering
affectivity
in
the
past
week,
we
found
no
significant
dif-
ferences
in
the
pre-post
scores
of
the
parents.
However,
post-camp,
highly
significant
differences
(p
<
0.01)
were
seen
in
general
affectivity
(trait);
NA
scores
were
lower,
while
PA
scores
were
higher
(Table
3).
Discussion
The
main
goal
of
modern
diabetes
care
in
children
and
ado-
lescents
has
evolved
from
a
purely
medical
approach
to
one
seeking
optimal
glycemic
control,
normal
psychological
development
and
maximum
QoL.24 Camp
researchers
strive
to
provide
empirical
evidence
that
disease
specific
camps
are
beneficial
for
children
with
chronic
diseases.
Some
studies
report
the
effectiveness
of
these
camps
on
QoL,
apart
from
medical
and
physiological
impacts,25 although
others
provide
conflicting
data.
Studies
examining
psy-
chological
variables
in
this
field,
however,
are
rare.
The
literature
yields
no
results
on
affective
symptoms
(such
as
depression)
and
the
results
on
anxiety
are
contradictory.11
Therefore,
we
must
delve
deeper
into
this
topic
to
provide
new
empirical
evidence
in
a
field
little
studied
and
hence
the
motivation
for
this
study.
Concerning
QoL,
after
children
attended
summer
camp
they
had
greater
emotional
well-being
than
their
parents,
while
parents
tended
to
be
more
aware
of
their
child’s
situation
in
school.
This
data
is
in
line
with
the
scientific
literature.
Parents
reported
poorer
QoL
than
their
children
and
this
may
indicate
the
burden
of
diabetes
on
parents.26
Children
had
better
QoL
(emotional
well-being
dimension)
than
their
parents.
However,
the
diabetes
camp
enabled
parents
to
perceive
their
child’s
school
situation
differently,
perhaps
due
to
the
gain
they
observed
in
autonomy
and
overall
management
of
diabetes.
This
is
much
more
evident
in
the
intra-group
compari-
son
of
children,
whose
levels
of
self-esteem
and
emotional
well-being
were
significantly
increased
after
camp
partici-
pation,
which
is
not
observed
in
the
intra-group
analysis
of
the
parents
(with
the
SF-12).
This
improved
QoL
(particularly
emotional
well-being)
supports
data
from
other
authors.11---15
Improvement
in
the
self-esteem
of
children
after
diabetes
camp
has
also
been
reported
previously.12,13
The
findings
on
anxiety
in
children
after
attending
camp
show
significantly
decreased
scores
in
both
state
and
trait
anxiety.
These
results
support
studies
in
which
camps
had
a
positive
impact
on
anxiety
in
the
child.12 Moreover,
consider-
ing
depression
and
anxiety
in
this
population
and
its
impact
on
adherence
and
changes
in
glycemic
control,3a
decrease
in
anxiety
provides
empirical
evidence
of
the
benefit
of
sum-
mer
camps,
and
can
be
considered
a
positive
experience
for
children
with
T1D.
A
significant
decrease
in
anxiety
was
also
found
in
the
parents
following
their
child’s
attendance
at
camp,
although
only
in
state
anxiety.
Nonetheless,
it
should
be
noted
that,
initially,
parents
scored
higher
in
anxiety
(state
and
trait)
than
their
children.
Despite
improvements
in
parental
anxiety
after
camps,
their
scores
were
higher
than
those
of
their
children.
These
results
are
consistent
as
parents
are
the
primary
caregivers
for
their
children
and
although
their
anxiety
decreased,
they
may
still
have
felt
overwhelmed
by
the
demands
of
T1D
experience
by
their
children.7
Although
at
baseline
there
were
no
statistically
signifi-
cant
differences
between
children
and
their
parents
in
PA,
there
were
differences
in
NA,
with
parents
scoring
higher
than
their
children.
However,
there
were
no
significant
intra-group
(pre-post)
differences,
in
the
children
or
their
parents.
Differences
were
seen
in
the
general
affectivity
of
the
parents
after
their
child’s
attendance
at
the
camp,
which
improved
significantly
with
decreasing
NA
scores
(gen-
eral)
and
increasing
PA
scores.
Hence,
this
research
provides
evidence
that
while
the
parents
initially
had
a
higher
neg-
ative
affectivity
than
their
children,
the
child’s
attendance

Please
cite
this
article
in
press
as:
Anarte
MT,
et
al.
Diabetes
Summer
Camp
in
children
and
adoles-
cents
with
type
1
diabetes:
Effects
on
well-being
and
quality
of
life.
Endocrinol
Diabetes
Nutr.
2019.
https://doi.org/10.1016/j.endinu.2019.08.002
ARTICLE IN PRESS
+Model
ENDINU-968;
No.
of
Pages
7
6
M.T.
Anarte
et
al.
Table
3
Comparative
analysis
intra-group
pre-post
parents:
STAI
and
PANAS.
PRE
measurement
POST
measurement
Wilcoxon
test
N
Mean
SD
Median
N
Mean
SD
Median
Z
p
(1
tail)
STAI
State
Anxiety
14
58.05
27.58
55.00
14
39.00
27.61
29.00
2.27
0.011
Trait
Anxiety
14
44.84
32.08
45.00
14
32.00
32.95
16.00
1.38
0.089
PANAS
NA
last
week
15
21.15
9.77
19.50
15
17.67
7.25
16.00
1.15
0.131
PA
last
week
15
29.90
6.59
30.50
15
33.40
5.82
34.00
1.42
0.083
NA
general 15
31.70
5.85
33.00
15
17.73
8.38
13.00
3.01
0.001
PA
general 15
20.70 8.35
19.00
15
33.13
6.27
34.00
2.96
0.001
STAI:
State/Trait
anxiety
questionnaire
(adults).
The
mean
scores
correspond
to
the
direct
scores
transformed
into
percentiles
according
to
age
and
sex
(from
1%
to
99%).
PANAS:
Affectivity
Questionnaire
(adults).
The
mean
scores
correspond
to
the
sum
of
the
items
of
each
of
the
subscales:
NA
or
PA
(from
10
to
50
points).
NA
=
negative
affect;
PA
=
positive
affect.
Table
4
Comparative
analysis
inter-group
pre-test
and
post-test
PANASN/PANAS.
Children---Parents
Children
with
diabetes
Parents
Wilcoxon
Test
N
Mean
SD
Median
N
Mean
SD
Median
Z
p
(2
tails)
Pre-test
NA
children---NA
parents
20
15.20
2.73
15.00
20
31.70
5.85
33.00
3.93
<0.001
PA
children---PA
parents
20
24.00
2.88
25.00
20
20.70
8.35
19.00
1.53
0.126
Post-test
NA---NA
general
15
14.47
2.39
14.00
15
17.73
8.38
13.00
0.94
0.369
PA--- PA
general
15
22.93
3.69
24.00
15
33.13
6.27
34.00
3.07
0.001
PANAS:
Affectivity
Questionnaire.
The
mean
scores
correspond
to
the
sum
of
the
items
of
each
of
the
subscales:
NA
or
PA
(from
10
to
50
points).
PANASN:
Version
for
children
and
adolescents.
NA
=
negative
affect;
PA
=
positive
affect.
at
summer
camp
had
beneficial
effects
on
the
parents
who
then
showed
more
positive
affectivity
(general).
These
data
support
the
literature
that
shows
a
high
percentage
of
par-
ents
are
overwhelmed
by
their
child’s
diabetes,8which
is
related
to
NA
(such
as
depressed
mood)
and
anxiety.6Thus,
the
evidence
presented
indicates
that
camp
attendance
by
the
children
who
participated
in
this
study
was
a
protective
factor
for
the
mood
of
their
parents.6These
results
may
have
a
wider
scope
considering
that
the
well-being
of
parents
is
positively
associated
with
the
metabolic
outcomes
of
their
children.1
Overall,
this
study
provides
empirical
evidence
of
the
benefits
of
participation
in
a
diabetes
camp
not
only
in
chil-
dren
who
have
participated
in
this
study
but
also
in
their
parents.
Improvements
were
seen
in
the
QoL
of
the
children
(mainly
self-esteem
and
emotional
well-being)
and
anxiety
in
the
children
and
parents,
as
well
as
in
the
general
affec-
tivity
of
the
parents.
We
therefore
suggest
summer
camp
as
a
highly
beneficial
option
for
children
with
T1D
that
also
provides
benefits
for
parents.
Nonetheless,
given
the
small
sample
size
(main
limitation
of
this
study),
these
results
can-
not
be
generalized.
More
studies
are
needed27 to
advance
knowledge
and
to
improve
the
methodological
deficiencies
seen
in
previous
studies28---30 to
enable
firm
conclusions
to
be
drawn
regarding
the
psychosocial
impact
of
camps
on
both
children
and
adolescents
with
T1D
and
their
parents.
Future
research
is
recommended
to
identify
the
protective
factors
that
contribute
to
empowerment
in
both
children
and
their
parents
as
well
as
to
analyze
the
effects
on
adherence
and
metabolic
control,
which
could
have
an
impact
on
improved
control
in
children
and
adolescents
attending
these
camps.
Contribution
of
authors
MTA,
ILG,
and
JPLS
contributed
to
the
design
of
the
study.
MC,
EV,
MMA
and
ALG
contributed
to
the
collected
the
data.
MTA
contributed
to
the
analysis
of
data.
MTA,
ILG,
EV,
MC
and
MMA
contributed
to
the
interpretation
of
the
data,
wrote
and
revised
the
manuscript.
All
authors
read
and
approved
the
submitted
final
version
of
the
paper.
Conflict
of
interests
The
authors
declare
that
they
have
no
conflict
of
interests.

Please
cite
this
article
in
press
as:
Anarte
MT,
et
al.
Diabetes
Summer
Camp
in
children
and
adoles-
cents
with
type
1
diabetes:
Effects
on
well-being
and
quality
of
life.
Endocrinol
Diabetes
Nutr.
2019.
https://doi.org/10.1016/j.endinu.2019.08.002
ARTICLE IN PRESS
+Model
ENDINU-968;
No.
of
Pages
7
Summer
Camp
and
diabetes:
Empirical
evidence
on
well-being
and
quality
of
life
7
Acknowledgements
The
English
translation
of
this
study
was
funded
by
the
University
of
Malaga
(Spain).
Project
Ref.:
Proyecto
Puente
(B.5).
Universidad
de
Málaga
(2018---2019).
We
want
to
thank
the
parents
and
children
who
have
collaborated
in
this
study
disinterestedly.
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