JMIR FORMATIVE RESEARCH

Idalski Carcone et al

Original Paper

Meeting the Needs of Emerging Adults With Type 1 Diabetes
Living in a Rural Area With Mobile Health Interventions: Focus
Group Study
April Idalski Carcone1, MSW, PhD; Bree E Holtz2, PhD; Madeleine Reardon1, BA; Dariane Vesey1, BS; Deborah A
Ellis1, PhD; Michael Parks3, RN, BSN, CDCES
1

Department of Family Medicine and Public Health Sciences, School of Medicine, Wayne State University, Detroit, MI, United States

2

Department of Advertising + Public Relations, College of Communication Arts and Sciences, Michigan State University, East Lansing, MI, UnitedStates3

Nutrition and Wellness/Diabetes Education, Upper Peninsula Health System – Marquette, Marquette, MI, United States

Corresponding Author:
April Idalski Carcone, MSW, PhD
Department of Family Medicine and Public Health Sciences
School of Medicine
Wayne State University
3128 Integrative Biosciences Bldg
6135 Woodward
Detroit, MI, 48202
United States
Phone: 1 3135771057
Email: acarcone@med.wayne.edu

Abstract
Background: Emerging adults (EAs; age 18-30 years) with type 1 diabetes (T1D) have more challenges with diabetes management
and glycemic control than other age groups. Living in a rural community introduces additional unique diabetes care challenges
due to limited access to specialty care and ancillary support services. Yet, few interventions have been developed to improvediabetes management in rural-dwelling EAs with T1D.
Objective: This study aimed to understand the diabetes management experiences of older adolescents and EAs (age 16-25
years) with T1D living in a rural area and to assess their perceptions of the acceptability of 4 fully automated mobile health(mHealth) interventions to support diabetes management.
Methods: EAs were identified by clinical staff through convenience sampling. In total, 8 EAs participated in 1 focus group and1 EA completed an individual interview; all data were collected over Zoom. Facilitators explored EAs’ experiences living in arural community with T1D and discussed EAs’ impressions of, feedback on, and recommendations for improving 4 mHealthinterventions to meet the specific needs of EAs with T1D living in rural communities. Discussions were transcribed and analyzed
using conventional content analysis.
Results: In total, 9 EAs (aged 18.8, SD 2.7 years; 5, 56% men; 8, 89% White) with a duration of diabetes of 8.6 (SD 4.3) years
participated. They described experiences with diabetes stigma (attributing diabetes to poor lifestyle choices) and feelings ofself-consciousness (hyperawareness) in their rural communities. They attributed these experiences to the small size of theircommunities (“everyone knows”) and community members’ lack of knowledge about diabetes (unable to differentiate between
type 1 and type 2 diabetes). In contrast, EAs reported high levels of social support for diabetes and diabetes care from family,
friends, and other community members, but low support for medical needs. The location of their diabetes care providers and thelimited accessibility of diabetes-specific and general medical care services in their local community created a challenging medicalcare context. Overall, EAs found mHealth interventions appealing due to their digital delivery and highlighted features that
increased accessibility (voiceovers and simple, jargon-free language), individualization (ability to tailor intervention content anddelivery), and applicability to their own lives and other EAs with T1D (relatability of vignettes and other content). EAs suggestions
for improving the interventions included more opportunities to tailor the interventions to their preferences (greater frequency andduration, ability to adapt content to emerging needs), increasing opportunities for peer support within the interventions (friend

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Idalski Carcone et al

and significant other as identified support person, connecting with peers beyond their local community), and making the tone ofintervention components more casual and engaging.
Conclusions: mHealth interventions aligned with EAs’ needs and preferences are a promising strategy to support EAs incommunities where social support and resources might be limited.
Trial Registration: N/A, not a clinical trial(JMIR Form Res 2024;8:e55650) doi: 10.2196/55650
KEYWORDS
emerging adults; type 1 diabetes; intervention; qualitative; mHealth; mobile phone; smartphone

Introductionof adults aged 18-29 have a smartphone [24]. Thus, cell phonedelivered mHealth interventions are accessible to US EAs.

Type 1 diabetes (T1D) impacts >1.6 million Americans, with
>18,000 children and adolescents (<20 years) diagnosed
annually [1]. Rural areas bear a higher burden of T1D (2.6 cases
per 1000) compared to urban areas (2.2 cases per 1000) [2].
T1D care requires a complex daily regimen of blood glucose
monitoring, tracking dietary intake, and administering insulin,with quarterly follow-up by diabetes specialty care providers[3]. However, <2% of endocrinologists practice in rural areas,
with a third of people with T1D in rural areas without accessto an endocrinologist within 50 miles of their home [4], andnearly two-thirds (62%) of rural counties lack diabetes supportand education programming [5]. Youth with T1D in ruralcommunities are less likely to have behavioral health providers
among their diabetes care team [6] and are more likely to reportpoor patient-provider communication than their urban peers[7,8]. Thus, living in a rural community introduces barriers toan already challenging care regimen, which results in lower
appointment keeping, more frequent hospitalization, and greater
disease burden [9-13].

Our research team previously developed 4 mHealth interventions
to support diabetes management among adolescents and EAs
with T1D living in urban contexts. Each of these used a different
evidence-based approach to improving illness management.
These were (1) increasing the individual’s autonomy andself-efficacy for daily diabetes management [25], (2) providing
reminders to complete diabetes care tasks [26], (3) improving
communication with health care providers [27], and (4)enhancing support from family members to complete diabetes
management tasks [28]. The motivation enhancement system(MES) is a brief counseling intervention to build intrinsic
motivation and self-efficacy for daily diabetes management
using Motivational Interviewing [29] techniques. TXT (SMS
text message reminders) is a 30-day intervention to complete
daily diabetes care tasks [30-32]. The question prompt list (QPL)
facilitates patient-provider communication by helping EAs
prepare a list of questions for diabetes medical appointments.
MyT1DHero facilitates communication between adolescentsand caregivers regarding daily diabetes management througheducation, gamification, and prompting. This study had two
aims: (1) to understand the diabetes management experiences
of EAs with T1D living in a rural area and (2) to assess EAs’
perceptions of the acceptability of these 4 different mHealthapproaches to optimizing diabetes management.

Emerging adulthood, the developmental period spanning thelate teens to late 20s, is marked by increasing independence andautonomy, including transitions into new roles as emerging
adults (EAs) enter college or the workforce [14,15]. Thistransitional period can further exacerbate the challenges of T1D
management, as illustrated by EAs’ poorer diabetes management[16,17] and glycemic control [18] and higher rates of diabetic
ketoacidosis [19]. EAs are less likely to use diabetes
management technologies such as continuous blood glucose
monitors (CGM) [20] and insulin infusion pumps [21]. The
unique context created by the combined challenges of having
T1D, living in a rural community, and being an EA underscores
the need for interventions tailored to this high-risk population.
Studies investigating the specific needs of EAs with T1D inrural communities are limited, as is the availability of
empirically supported interventions to support diabetes
management in this population. Furthermore, existing behavioral
interventions to support T1D management have mostly targetedchildren and younger adolescents; such approaches may lackdevelopmental relevance for EAs [4,14,22]. Mobile health(mHealth) technologies are one strategy to deliver supportive
interventions to improve diabetes management and healthoutcomes for EAs with T1D in rural areas [12-15]. In the US,
nearly all adolescents have a cell phone by age 15 [23] and 96%

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Methods
ParticipantsParticipants were recruited from the pediatric endocrinology
department of a hospital located in Michigan’s Upper Peninsula.
Michigan’s Upper Peninsula is composed of 15 counties, all ofwhich are designated as rural by the US Census Bureau [33,34].
EAs meeting the following criteria were eligible: (1) age 16-25
years, (2) diagnosed with T1D for ≥6 months, (3) no comorbid
medical conditions altering diabetes management, (4) nocomorbid mental health conditions altering cognitive state, and(5) no learning disability precluding participation in study
activities.
In total, 10 EAs were identified and agreed to participate;however, one did not complete the study. Of the 9 participants,
most identified as non-Hispanic White (89%), half were male(56%), and the mean age was 18.8 (SD 2.7) years. In total, 6(67%) were in high school, and 6 worked part-time. All 9 lived
with their parents and rated their relative socioeconomic status
as 5.6 (SD 1.4) out of 10 on the McArthur scale, reflecting a
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lower-than-average socioeconomic status [35]. The mean
duration of diabetes was 8.6 years (SD 4.3) and most managed
diabetes with a CGM (89%, n=8) and an insulin infusion pump
(89%, n=8). On average, EAs traveled 48.2 (SD 58.7) miles toattend a diabetes clinic at the recruitment site.

Idalski Carcone et al
and ended with a second goal-setting and behavioral strategy
component.

Daily Reminders

Study details are summarized in the CONSORT-EHEALTH(Consolidated Standards of Reporting Trials of Electronic andMobile HEalth Applications and onLine TeleHealth) checklist
available in Multimedia Appendix 1.

TXT involved twice daily reminders to complete diabetes caretasks. Participants selected text reminders to complete 1 of 3
diabetes care domains (ie, insulin management, blood glucose
monitoring, or dietary management) or selected a generalreminder to “do their diabetes care.” TXT was further tailored
to deliver reminders at times selected by the participant.

Procedures

Communication With Health Care Providers

Participants were identified by a diabetes clinic nurse who
reviewed their medical chart for inclusion. The nurse contacted
eligible patients by phone to request permission to share theircontact information with the research team. Research staff
followed up with patients to explain study details and enroll
them in the study. Eligible participants completed 2 study visits
via Zoom. In the first, a research assistant obtained informed
consent, after which participants completed a brief Qualtrics
survey to record demographic information (eg, age, race, andgender) and diabetes treatment regimen. The second was thefocus group discussion. One participant completed an individualinterview.

The diabetesQPL was developed to encourage active
participation in diabetes clinic visits. The QPL was a list of
diabetes care questions compiled through a literature search,
web-based resources, and consultation with 3 diabetes medicalcare providers. QPL questions addressed common concerns in
3 diabetes care domains and EA-specific topics. The selected
questions were emailed to the participant before their diabetes
clinic visit.

Focus Groups
In total, 2 focus groups with 3 and 5 participants each were led
by 2 trained research assistants (RAs). One RA took notes andprovided technological support. The second used asemistructured interview guide developed for the study to direct
the discussions through 5 segments over 120-150 minutes. The
first asked participants to describe their experiences living with
T1D in a rural community, including barriers and challenges todiabetes management at the individual, family, peer, health caresetting, and community levels. The next 4 segments introduced
each intervention and solicited EAs’ impressions, feedback,and recommendations. One participant was unable to attend a
focus group but agreed to complete an individual interview.
This participant responded to the same questions from the focus
group semistructured interview guide. The notetaker verified
the Zoom focus group and interview transcriptions for accuracy.

Interventions
Autonomy and Self-Efficacy Enhancement
The MES was 2 motivational interviewing-framed sessions.
Session 1 began with psychoeducation about 3 key components
of diabetes care, that is, glucose monitoring, insulin
administration, and dietary management. Participants thenadvanced through motivation-enhancing exercises designed toincrease intrinsic motivation and self-efficacy for diabetes
management. It ended with setting a goal for daily diabetes care,that is, doing all diabetes care every day, doing more, andcontinuing to think about diabetes care (an autonomy-supportive
option for those not ready to change their diabetes carebehavior); behavioral strategies to support goal attainment, forexample, setting reminders, establishing cues, and enlistingsocial support, were described. Session 2 reviewed progress
toward the daily diabetes care goal, continued to growmotivation using reflection and motivation-enhancing exercises,
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Family Support
MyT1DHero aimed to improve communication and reduce
conflict between adolescents (10-15 years old) with T1D andtheir caregivers. Designed using user-centered principles, theMyT1DHero app had 2 separate interfaces, 1 for adolescentsand 1 for caregivers, which facilitated glucose testing via
scheduling and tips on glycemic management. Adolescents andcaregivers received 2-3 weekly prompts to encouragecommunication. Using the app earned adolescents points to“purchase” items for their superhero avatar, for example, capes,
boots, logos, masks, and hair colors and styles. MyT1DHeroalso linked adolescents to peer video testimonials, sharing theirstories and providing affirming messages. Information about
MyT1DHero development and pilot study results can be foundelsewhere [36-39].

Analytic Plan
Data were hand-coded by 2 coding teams. The first was led by
the lead author (AIC, female), a qualitative expert and developerof the MES, TXT, and QPL interventions, and included 4 coders,a paid RA, and 3 student volunteers. This team analyzed EAs’
feedback on living with T1D in rural communities and the MES,
TXT, and QPL interventions using conventional content analysis[40]. During the initial training period, coders became familiar
with the study aims and background, data collection methods,
and analytic approach. They developed the initial coding
framework based on the content of the interview guide and an
initial review of all transcribed data. Coders independently
coded each transcript, then met to review and discuss theircoding, identifying and resolving coding discrepancies throughdiscussion and collaboratively developing consensus-codedtranscripts. The coding framework was refined andsupplemented with examples throughout this iterative process.
Data saturation was not a goal of this exploratory study. The
secondary team coded feedback on MyT1DHero following asimilar procedure. Coders were 2 RAs with previous experience
with MyT1DHero, led by its principal investigator (BH).

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Ethical Considerations
The primary author’s institutional review board (IRB) approved
all procedures (IRB protocol #071318B3E reviewed by theWayne State University Institutional Review Board B3- Social,
Behavioral, Education Committee [IRB00000327]). All research
participants provided informed consent via an information sheet
as part of the study enrollment process. For participants who
were <18 years old, research staff obtained parental consent
and youth assent. All study data were collected using a coded
identifier to protect participants’ identities; the linkage toparticipants’ identities was stored securely and accessible only
to IRB-approved research staff until the data analysis concluded,
then it was destroyed. Participants received a US $50 gift card
after the second visit.

Results
Diabetes Management in Rural Communities
EAs explained because they live in a small community“everyone already knows” they have diabetes, but people intheir community do not understand the different types ofdiabetes: “It’s really hard to get anyone my age, or anyone ingeneral, to understand the difference between type 1 and type
2. Even my really close friends still relate me to one of their
grandparents that have type 2.” EAs reported that community
members did not understand how they must live and care for
their diabetes. This included voicing concerns about food andsometimes going even further and attempting to limit their eating
behavior: “I deal with it every time there's a birthday or any
sort of snack or something. People are like, can you eat that?
Are you sure you can eat that?“ Because of this knowledge
deficit, EAs reported experiencing diabetes stigma. “People
just assume, ‘Oh, you didn’t take care of yourself, so you got
diagnosed with diabetes.” These experiences contributed tofeelings of self-consciousness. EAs reported feeling hyperawareor “on stage” when in a public context, leading to anxiety andsometimes changes in their diabetes care practices: “I wouldn’t
leave class even though I could feel that my blood sugar was
low because I didn’t want to have to ask.”
In contrast to those moments, EAs also recounted experiencing
diabetes-specific social support. Not unexpectedly, family wasa primary source of support for diabetes. EAs described theirparents providing support in the day-to-day management ofdiabetes: “Sometimes, if I don't feel it [low/high blood glucose]or I don't notice, my dad's connected to mine, so he'll text me
and let me know.” EAs reported that their parents also continued
to play a key role in communicating with their diabetes careprovider and coordinating their diabetes supplies: “My mom
helps with the carb counting and servings, and, actually ordering
the prescriptions and everything that I need.” Friends wereanother source of support, such as prompting EAs to checkblood sugar after noticing a change in behavior or mood: “Ihave one best friend who if I'm mad or I'm upset or I'm going
pale, she’ll be like, ‘what's your blood sugar right now?’”
Finally, some described experiencing support from othermembers of the community. To illustrate, one EA explained,“I'm involved with a martial arts group that helps me take careof my diabetes a lot.”
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Idalski Carcone et al
Rural EAs described medical care challenges, including
continuity of care, location and accessibility of diabetes careproviders, and concerns about the affordability of medical care.
For continuity of care, EAs’ discussed the challenge of trying
to maintain the same team of medical care providers over time:“the hospital cycles through diabetes related personnel, every
couple of years or sometimes even every year there’s newpeople.” EAs reported frequent changes in clinic personnel
affected their relationship with providers: “For the past 5 years,
I've had mostly the same diabetes doctor. But when I first got
diagnosed, I saw all of them like one after the other and it felt
like I was like resetting every single time because I would haveto explain to them all these different things over and over again.
By keeping with the same doctor, we can build upon things
instead of restarting every time.”
Another challenge of clinical care in a rural setting was provider
location and accessibility. EAs explained that they must travel
long distances, which requires extended periods of time toreceive their diabetes medical care: “For the past 14 years, I’ve
had to drive 3 and a half hours for an endocrinologist, 4 times
a year.” EAs reported limited access to diabetes support services
in their local community: “It's a 2-hour drive there and at ourclinic here there's not much diabetes education at all. We used
to have a diabetic educator, but she retired and so there's noone.” EAs found accessing primary health care services was
also a challenge: “I’ve been trying to see a primary care
physician for the past year, just because everyone’s full up
because there’s only so many doctors in the area. I’ve had to
wait a while until the doctor will let me in.” Local providers
were also unfamiliar with T1D: “a lot of people in the clinic,
they know what it [T1D] is, but they don’t really know muchabout it.” EAs also described limited access to emergency
services: “Back in 2020 something was wrong with my bloodand I ended up passing out. I was seizing a little bit and we had
to call the paramedics. Because we’re so far outside of town itprobably took about 25 minutes for them to get to my house. I
was fine but that was a realization for my family, that was pretty
scary for us.” EAs also reported the scarcity of medical care
impacted their transition to adult health care: “They very clearlysaid, we're not kicking you out, but you do have to look. You
have to find someone else because their spots are limited too.”Finally, EAs shared concerns about medical insurance andmaintaining their current coverage: “I'm on Medicaid and every
time I get my run down at the end of the quarter, I got that dread.
There's no reason they should be kicking me off, but it's stillthat worry in the back of my head, giving me some anxiety.”
They also voiced worries about insurance coverage after turning
26 and were no longer eligible for their parents’ insurance:“Having insurance is the biggest worry for all of us
subconsciously. I originally went to school for pharmacy and
now I switched over to education. Trying to focus on a careerthat has health insurance is huge. That’s everybody’s worry
after 25.”

Intervention-Specific Feedback
Building Autonomy and Self-Efficacy (MES)Overall, EAs reported favorable impressions of the MES
intervention. First, EAs found the intervention “user-friendly
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and straightforward” and viewed delivery between diabetes
clinic visits as a strength. EAs appreciated features that enhanced
the intervention’s accessibility to people’s different abilities.
Specifically, EAs noted the avatar’s voiceovers eliminatedbarriers for people with different reading capabilities: “This is
a problem I used to have when I used to play video games andI couldn’t read, or when I could barely read. I didn’t know what
was happening.” They also noted the use of simple language
versus technical jargon made the interventions appropriate forbroad audiences, with several specifically noting those newly
diagnosed with T1D: “There wasn’t a lot of jargon or anything
in the video, so it just seemed simple and straightforward.
Something that a new diabetic in particular would be
comfortable using.” They appreciated the collaborative,
nonjudgmental nature of the intervention: “it seems to not talkdown on you, it’s more like we can work to better yourmanagement.”
EAs found the MES content applicable to their own lives andothers with T1D: “A lot of diabetics can relate to having theirhigh hemoglobin A1c and growing from that and looking backand realizing how many changes you’ve made and how they’vereally helped you.” EAs found the vignettes illustrating
behavioral strategies to support the completion of daily diabetes
care helpful, especially those leveraging features of diabetes
technology. They recommended including more tips, advice,
and education to maximize technology use to support diabetescare, such as calendar alerts programmed into a smart phone
and websites to facilitate carbohydrate counting: “They do soundreally, really helpful. I know that I should start implementing
some strategies to remember more things.” EAs had several
suggestions for improvement, including finding ways to makethe intervention more engaging, including more conversational
peer testimonials [“more like heart-to-heart” or “interview
style”], more charismatic actors, and making the tone of theintervention more casual and engaging: “It just felt reallyprofessional. You were getting a talking to.” Finally, EAs
suggested adding components to address the “mental part” ofliving with diabetes, including coping with feelings associatedwith stigmatization and self-consciousness, and exercise, “thatcan be really scary, if you’re worried about your blood sugar
jumping or going down super low.”Reminders for Diabetes Management (TXT)
Overall, EAs found the TXT intervention acceptable, indicating
the intervention was a good fit for their age and use oftechnology: “I’d definitely use it.” EAs described the reminders
as a “gentle nudge” and the integration of the participant’s nameinto the message as “more personal.” EAs appreciated that TXT
content was individualized to their preferences and diabetes
treatment regimen. EAs liked being able to tailor the timing of
the reminders to times they often forget to complete their careor higher-risk times: “I like that you can choose what time
because I personally have certain times where I know I’m
usually going to be at a higher blood sugar.” They also
appreciated being able to tailor the content of the messages andsuggested more tailoring options: “If you had a checklist ofwhat [diabetes technology] you’re using.” EAs liked thevariation in the wording of the messages: “I really like that it
isn’t the same message over and over. There’s some difference
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Idalski Carcone et alin some of the messages to you’re not just getting the samesentence over and over, and then you start to ignore it.” Whilemost thought the reminders would be useful, some did note theymight be redundant or unnecessary depending on the diabetes
technology an individual might be using: “With my [continuous
glucose monitor], I’m reminded to check my blood sugar as
often as I need and if my blood sugar is high, my pump will
vibrate.” EAs thought TXT might be particularly useful for
those newly diagnosed or undergoing a life transition: “thereminders would be more useful for someone who is gettingback into a routine, like going to college.”
EAs found the intensity of the reminders acceptable but
suggested greater intensity might be welcome. Specifically, 2
texts per day was “a pretty good number, one in the morning,
one in the night, as a general reminder to do important things,”
but EAs suggested 4 [“breakfast, lunch, dinner, and then makesure your blood sugar is on track before you go to bed”] or 5[“morning, because you’ve had breakfast, and then lunch, andI have a snack between lunch and dinner, that would be anothergood time, then dinner and then late at night”] would fit betterwith their needs. EAs cautioned, “more than five would be alot” and “overdoing it.” EAs thought “30 days is a pretty goodamount of time to at least start a habit and get into a routine”
but suggested offering the option to extend the intervention“until you had enough.” EAs also suggested greater flexibility
in tailoring the content and timing of the reminders over time
and to restart the reminders later: “People should have the option
whether they want to continue what they are doing or if theyneed help at a different time. Being able to switch when you
get the reminders would be really helpful.”

Question Prompt List (QPL)
Overall, the QPL intervention was well-received and acceptable.
EAs described it as helpful “because sometimes I forget whatquestions I was going to ask” and a useful prompt for topics“you might not have even considered before.” EAs thought the
QPL might be particularly helpful during times of transition:“I probably would have appreciated [it] a few months ago when
I was in my process of getting my [continuous glucose monitor]
because that was a lot of questions in a short amount of time.”
Finally, EAs thought the scope of the content sufficiently broad:“questions were good for beginners and there were alsoquestions that were a little more in detail, things that I would
ask at appointments.” EAs appreciated the individualization of
the question list to their diabetes treatment regimen and theability to write their own questions: “where you could
personalize your own questions and have them send it to you.”
They also appreciated the component of the intervention dealing
with age-appropriate concerns such as driving: “Once you hit
a certain age, you check [blood glucose] before you drive andstuff like that. So, having those questions on there would benice for kids who maybe might not feel comfortable talking totheir parents about it.” There was one content suggestion, to
include a prompt about prescription renewals.
When it came to delivering the QPL, EAs thought having theirlist of questions sent to them digitally (via email, text, or anapp) was best: “then you can just pull it up” but noted having
the ability to “take notes in the margins would also be helpful.”
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Some thought integration with their patient portal would help
facilitate communication between quarterly clinic visits,
although some topics raised concerns about confidentiality,“You have to make sure that all that information is between
who you want to be between” or justified a more in-depth,
face-to-face conversation: “Questions about correction factors
could probably be over the portal, but if I’m like, ‘how do I do
marijuana while taking care of my blood sugar, that’s probably
a full conversation with the doctor.” EAs also thought it would
be useful to have a copy sent to their diabetes care team.

MyT1DHero
Overall, EAs responded positively to MyT1DHero and thought
it would promote communication and independence in diabetes
management: “It’s hard to transfer over from having a parent
controlling everything to having more control over it yourself.
Having that communication and shared information without
needing to constantly be texting or calling or anything would
be incredibly handy.” EAs suggested that the app could be
improved in 3 ways. First, EAs suggested enhancing social
support features to allow a friend, roommate, or significant otherto be the support person rather than a parent: “You'd want to
add someone else, someone you're living with.” They also
highlighted the potential for the app to provide a broader baseof social support. Noting feelings of isolation and stigmatization
due to a lack of peers with T1D in their community, EAs
believed incorporating a social support component thatconnected them with peers outside of their rural community
would provide a critical source of support: “Knowing there areother people who are having the same problems. It's not likethe world has singled you out for some reason.”Discussion
Principal Results
This study examined the experiences of a high-risk populationof EAs with T1D living in rural communities [14,15]. EAs
reported diabetes challenges in their community and medicalcare. Firstly, EAs felt stigmatized because of their diabetes.
More than half of adolescents [41] and EAs [42] with T1Dreport feeling stigmatized in their communities. Adults withdiabetes living in rural communities also report greater stigma
than those in non-rural settings [43]. The visibility of diabetes
wearable technologies, that is, pumps and CGMs, may contributeto the experience of stigma [43]. Diabetes stigma is associatedwith poor diabetes quality of life [41], poor glycemic control[42], health complications [44], and poor psychosocial
functioning [45], which were also reported by rural EAs in thisstudy. While mental health screening and referral to behavioral
services are standard practices [46,47], the assessment of stigma
and its negative sequelae may be underrecognized. Conversely,
rural EAs also reported perceiving social support related tocaring for their diabetes from family, friends, and other trusted
community members, a protective factor that may offset the
detrimental effects of stigma [48]. Positive role models who
provide health advice can be a critical source of social support
for youth [49], but may be limited in rural communities [49].
EAs described challenges in their diabetes medical care due totraveling long distances to receive medical care and a limited
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Idalski Carcone et al
number of providers in their local community, which impacted
the continuity and quality of their diabetes medical care. These
concerns are consistent with previous reports of reduced accessto health care providers and specialty care providers specifically[4,10,11,49], frequent provider turnover [10], and limited
resources for diabetes education [12] and ancillary services[7,8]. While telehealth may be a useful supplement to in-personcare, EAs in other contexts have stressed the importance ofin-person care for high-quality diabetes care [50]. EAs are also
worried about their pending transition from the pediatric to adult
health care system and their ability to afford medical care. A
T1D Exchange study [51] found financial stress to be asignificant predictor of having an elevated hemoglobin A1camongst EAs with T1D, suggesting a need for supportive
interventions during this transition.
Despite the elevated risk experienced by EAs with T1D living
in rural communities with scarce resources for diabetes
management, few interventions have been designed specificallyto meet the needs of this population. EAs themselves havereported that the transition to adulthood and the assumption of
responsibility for diabetes care are significant challenges [52],reinforcing the need for support during this developmental
period. The EAs in this study viewed the mHealth interventions
examined as user-friendly and acceptable. They identified
strengths and weaknesses of the reviewed interventions that
could be applied to future interventions developed for the EA
population.
As digital natives, EAs are early adopters, savvy users, andinnovators of technology use, having grown up with technology
integrated into their social ecology [53]. Thus, it is unsurprisingthat EAs described technology-delivered interventions as a good
fit for their age group and recommended further integration withtechnology, such as linking intervention components to theelectronic medical record. For EAs living in rural communities,
technology-based interventions may offer critical support in asetting where resources are low and barriers to supportive
services are great [54].
In addition to digital delivery, EAs highlighted aspects of theinterventions’ that increased accessibility, individualization,
and applicability of the intervention content to their own lives
and those of other EAs living with T1D. A recent systematic
overview of 18 systematic reviews and meta-analyses of digitalinterventions for adolescents and young adults with mental
health conditions similarly found design elements that werecredible, engaging and interactive, relatable, and flexible wereassociated with acceptability [54]. In addition to being
acceptable, mHealth interventions demonstrate promise for
improving glycemic control [55,56].
Consistent with their developmental stage, EAs found aspectsof the intervention that supported their independence appealing
and suggested ways to further support their growing
independence. For example, they suggested augmenting the
MyT1DHero intervention’s communication feature to allow forfriends, roommates, or significant others to support their diabetes
care rather than exclusively relying on parental support.
Additionally, EAs recommended that the intervention broaden
its social support component by facilitating connections withJMIR Form Res 2024 | vol. 8 | e55650 | p. 6
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JMIR FORMATIVE RESEARCH
peers beyond their local community. They believed that
expanding their social network in this manner would help
mitigate the feelings of isolation and stigma often associatedwith T1D. Other studies conducted with urban adolescents havesupported the value of peer support beyond one’s local
community [57,58].

Limitations
This study has limitations. First, EAs in this study were all usingstate-of-the-art diabetes care technology (ie, insulin pumps andCGMs) and self-described themselves as well-managed andindependent in their diabetes care, which differs from reportsthat EAs are less likely than other age groups to use diabetes
technologies consistently [20,21] and more likely to experience
suboptimal adherence [16,17], glycemic control [18], and higher
rates of diabetic ketoacidosis [19]. Furthermore, they were allfrom a small rural area of Michigan. Thus, their diabetes careexperiences, needs, and perceptions of the interventions
presented may differ from those of EAs not using the same
diabetes technology, with the same high level of glycemic
control, or living in different rural communities. A
methodological limitation may be the use of video conferencing

Idalski Carcone et al
to conduct the focus groups. While video conferencing enabled
EAs living in geographically distant communities to cometogether for the focus groups, the dynamics of the discussions
may have been attenuated in the digital domain, although others
have found no impact on data quality [59]. Finally, given thelimited sample and small number of focus groups, these results
may not reflect data saturation.

Conclusions
mHealth intervention is a promising strategy to support EAs
with T1D living in rural communities. EAs found a variety of
approaches to optimizing diabetes management acceptable andwell-aligned with their developmental needs for autonomy andindependence. Each approach was seen as offering criticalsupport for diabetes management in communities where social
support and tangible resources were limited. Their feedback
highlights the importance of tailoring supportive interventions
to the specific needs and preferences of EAs in ruralcommunities [60,61]. Next steps could include refining theseintervention approaches based on this feedback and testing theirimpact on diabetes management and glycemic outcomes among
EAs living in rural contexts.

Acknowledgments
The research reported in this paper was supported by the National Institute of Diabetes and Digestive and Kidney Diseases(NIDDK; R01DK116901 and R25DK113659) and the National Institutes of Health Common Fund and Office of Scientific
Workforce Diversity under 3 linked awards (RL5GM118981, TL4GM118983, and 1UL1GM118982) administered by the National
Institute of General Medical Sciences. The content is solely the responsibility of the authors and does not necessarily represent
the official views of the National Institutes of Health.
The authors thank the research staff and trainees, including Nailah Henry (research participant recruitment), Ozichukwu Ukandu(data coder), and Nadia Niha (data coder), for their support of this research project. We also thank the emerging adults who
participated in the study and provided their valuable insights. ChatGPT (OpenAI) was not used for any purpose in this study or
during data analysis.

Data Availability
The data sets generated analyzed during this study are available from the corresponding author after the execution of a data use
agreement.

Conflicts of Interest
None declared.

Multimedia Appendix 1
This file contains the authors' responses to the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronicand Mobile HEalth Applications and onLine TeleHealth) checklist.
[PDF File (Adobe PDF File), 2966 KB-Multimedia Appendix 1]

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Abbreviations
CGM: continuous blood glucose monitors
CONSORT-EHEALTH: Consolidated Standards of Reporting Trials of Electronic and Mobile HEalth Applications
and onLine TeleHealth
EA: emerging adult
IRB: institutional review board
MES: motivation enhancement system
mHealth: mobile health
QPL: question prompt list
RA: research assistant
T1D: type 1 diabetes
TXT: SMS text message reminders

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Edited by A Mavragani; submitted 21.01.24; peer-reviewed by D Tilden; comments to author 23.03.24; revised version received
06.05.24; accepted 17.06.24; published 07.08.24
Please cite as:
Idalski Carcone A, Holtz BE, Reardon M, Vesey D, Ellis DA, Parks M
Meeting the Needs of Emerging Adults With Type 1 Diabetes Living in a Rural Area With Mobile Health Interventions: Focus GroupStudy
JMIR Form Res 2024;8:e55650
URL: https://formative.jmir.org/2024/1/e55650
doi: 10.2196/55650
PMID: 39110496©April Idalski Carcone, Bree E Holtz, Madeleine Reardon, Dariane Vesey, Deborah A Ellis, Michael Parks. Originally publishedin JMIR Formative Research (https://formative.jmir.org), 07.08.2024. This is an open-access article distributed under the termsof the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly
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