Knowledge and Self-Efficacy as Key Determinants of Transition Readiness in Adolescents with Type 1 Diabetes: Insights from Adolescents, Parents, and Clinicians

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is an interesting and important study to assess the transition readiness of adolescents with type 1 diabetes (T1D).

 

Below are my comments to improve the clarity of this manuscript.

 

1. In the abstract, provide the statistical analysis that authors used in this study.
2. Provide the information and questions in the diabetes knowledge questionnaire in the supplementary file (and make it clearer as authors did with “self-efficacy”).
3. Provide information about how authors performed the participants` sampling (random or?).
4. Provide information on how authors decide/measure the number of participants, and if the number of participants fulfilled the requirement for statistical analysis.
5. Provide the statistical tool that authors used in this study (SPSS? R?).
6. Provide the information about exclusion criteria and if there were participants who were excluded from this study.
7. According to results of this study, can it be implied that perceptions of adolescent of their diabetes knowledge is rather “inflated” than the actual knowledge? Even though this study cannot answer that, it can be added for future investigation.
8. Provide the percentage of participants who have reached HbA1C level.
9. If possible, how about providing analysis of correlations of HbA1C level with DD, self-efficacy, and diabetes knowledge of adolescents, parents, and clinician?
10. Provide the demographic table in the manuscript rather than in supplementary file.

Author Response

This is an interesting and important study to assess the transition readiness of adolescents with type 1 diabetes (T1D).

Below are my comments to improve the clarity of this manuscript.

1. In the abstract, provide the statistical analysis that authors used in this study.

The abstract on pg. 1 has been amended to include the statistical analysis used in the study. This sentenced is reflected as: “Paired sample t-tests showed that adolescents’ knowledge was comparable to parent levels (t(24)=-1.69, p=.10).”

1. Provide the information and questions in the diabetes knowledge questionnaire in the supplementary file (and make it clearer as authors did with “self-efficacy”).

The diabetes knowledge questionnaire has been provided in the supplementary file and examples of items are included in the manuscript for further clarity regarding this key domain. This can be found on pg. 5, and reads as follow:

This questionnaire comprised four sections, examples included below:

• General diabetes knowledge: “What does glucagon do?” (19 items)
• Life skills: “What should your glucose level be prior to driving a car?” (7 items)
• Insulin administration: “What is a correction factor?” (14 items)
• Insulin delivery (only for pump users): “What is a bolus?” (7 items)

 

1. Provide information about how authors performed the participants` sampling (random or?).

The type of sampling has been included and explained in the manuscript on pg 4-5. This is reflected as: “This study employed convenience sampling, where any participant who met inclusion criteria and were attending their appointment was asked by the research team if they were interested in participating”.

1. Provide information on how authors decide/measure the number of participants, and if the number of participants fulfilled the requirement for statistical analysis.

A power analysis was conducted prior to statistical analysis. To achieve a moderate effect size of 0.5 with 80% power, 34 participants would be needed to detect an effect. Our sample had 36 adolescents participated and thus fulfilled the requirement for statistical analysis.

1. Provide the statistical tool that authors used in this study (SPSS? R?).

The manuscript has now included the statistical tool used in the study. This can be seen on pg. 6 and the sentence reads: “These analyses were carried out using Statistical Package for the Social Sciences (SPSS; Version 27).”

1. Provide the information about exclusion criteria and if there were participants who were excluded from this study.

There was no exclusion criteria for our study. Line 268 to 273 of the results section provides further clarification around who was included in our study. It reads as this currently:

50 adolescents met inclusion criteria, 3 adolescents refused to complete the questionnaire without explanation, and we failed to capture 6 adolescents. Therefore, we enrolled 41 adolescents in the study and 36 completed the relevant questionnaires. Four responses were excluded due to incomplete data and one respondent who was enrolled had a diagnosis of Maturity-Onset Diabetes of the Young 5 (MODY) rather than T1D and was excluded. Participants’ characteristics are reported in Table 1.

 

1. According to results of this study, can it be implied that perceptions of adolescent of their diabetes knowledge is rather “inflated” than the actual knowledge? Even though this study cannot answer that, it can be added for future investigation.

Thank you and we acknowledge that this is possibility and therefore we have included this in the discussion on pg. 11. This explanation reads: “There is also potential that adolescents’ may feel overly confident with their diabetes care and may not necessarily represent an accurate representation of their diabetes knowledge. Further investigation may be helpful to explore these nuances”.

1. Provide the percentage of participants who have reached HbA1C level.

Thank you for this comment. The percentage of participants who reached recommended ISPAD Guidelines for HbA1c is now included in the manuscript 

Median HbA1c of our adolescents was 7.4% (IQR 6.6-8.4). 11/36 (30.6%) of our adolescents met the international consensus guidelines (ISPAD) for HbA1c <7% (18) and one adolescent met ISPAD guidelines for annual MDT appointments page 7”.

9. If possible, how about providing analysis of correlations of HbA1C level with DD, self-efficacy, and diabetes knowledge of adolescents, parents, and clinician?

We have clarified this information, page 9.

We performed preliminary correlational analysis including HbA1c with our key variables, however these findings were not statistically significant.

 

1. Provide the demographic table in the manuscript rather than in supplementary file.

The demographic table has already been provided in the manuscript.

 

Reviewer 2 Report

Comments and Suggestions for Authors

Journal: Diabetology

Type: Original article

Title: Knowledge Confers Self-Efficacy, Which Reduces Distress - An Assessment of Transition Readiness in Type 1 Diabetes from Perspectives of Adolescents, Parents and Clinicians

___________________________________

 

OVERALL COMMENTS

In this study, the authors intended to investigate the transition readiness of adolescents with Type 1 Diabetes (T1D) from adolescent, parental and, clinician perspectives. They performed a  Cross-sectional study. Adolescents had diabetes knowledge, self-efficacy, and diabetes distress measured. Parents underwent an assessment of knowledge, diabetes-related distress, and estimated the adolescent’s self-efficacy. Adolescents’ knowledge was comparable to that of their parents, and their knowledge was strongly associated with higher self-efficacy (r = .80, p < .001). Higher adolescent self-efficacy was associated with lower adolescent distress. Adolescent distress was lower than parent distress. Although adolescent self-efficacy was strongly correlated with parent and clinician evaluations, adolescents reported higher self-efficacy than estimates by their parents (t(24) = 4.76, p < .001) or clinicians (t(24) = 8.39, p < .001). Parent knowledge was moderately correlated with adolescent self-efficacy As conclusions, the authors pointed out that different Diabetes knowledge may confer greater self-efficacy and reduce

 

Keywords: diabetes; type 1 diabetes mellitus; diabetes knowledge; self-efficacy; diabetes 35 distress; transition readiness; transition of care

 

TITLE

         I suggest a different tile. Choose something like “knowledge and Self-Efficacy as Key Determinants of Transition Readiness in Adolescents with Type 1 Diabetes: Insights from Adolescents, Parents and Clinicians"

_______

 

ABSTRACT

• This section is adequate.

 

INTRODUCTION

• The Introduction needs to include newer references. I suggest including references published in 2024 and 2025.
• I suggest reduce and putting together the sections “ Key Outcomes Assessed: Knowledge, Self-Efficacy and Diabetes” and “3. Evaluating the Transition Process at Royal North Shore Hospital”

__________

 

METHODS

• No ethical issues since the authors write that (lines 161-163) “The study was approved by the NSLHD Research Ethics Committee (2022/ETH02412) and was carried out in accordance with the principles of the Declaration of Helsinki.”
• The use of validated tools (READDY, PAID-T) is very relevant for studies like this.
• In lines 168-170 the authors state that "Adolescents who have an existing diagnosis of T1D aged 16 to 19 years and currently attending the Royal North Shore Paediatric Diabetes and Endocrinology Department." Was the time of diabetes diagnosis considered?
• In statistical analysis, the use of multivariate analyses (e.g., regression) could adjust for confounders and strengthen the interpretation.

__________

 

RESULTS

1. Please improve the presentation of Table 1.

__________

 

DISCUSSION

1. I appreciate the inclusion of the limitations of this study (lines 355-368).
2. I also much appreciated this part of the text: lines 358-370.
3. The study offers concrete recommendations for multidisciplinary teams, showing the importance of parent engagement and enhanced psychosocial integration.
4. Would it not be interesting to investigate whether points regarding previous mental health, comorbidities, time since diagnosis of DM1 and socioeconomic conditions were not adjusted in the analyses?

 

_____________

REFERENCES

• In the Introduction and Discussion sections, it is necessary to include more references published in 20242025

        

Author Response

1. I suggest a different tile. Choose something like “knowledge and Self-Efficacy as Key Determinants of Transition Readiness in Adolescents with Type 1 Diabetes: Insights from Adolescents, Parents and Clinicians".

We have decided to change the title to reflect the reviewer’s suggestion.

ABSTRACT

2. This section is adequate.

Thank you for your feedback.

INTRODUCTION

3. The Introduction needs to include newer references. I suggest including references published in 2024 and 2025.

We have acknowledged these comments and have included updated references in the manuscript.

Liu J, Li J, Li L, Zeng K. Impact of family environment on mental disorders and quality of life in children with type 1 diabetes mellitus: a cross-sectional study and intervention policy analysis. Frontiers in Pediatrics. 2025;13:1516411.

Azar S, Maroun Abou Jaoude N, Kędzia A, Niechciał E. Barriers to type 1 diabetes adherence in adolescents. Journal of Clinical Medicine. 2024;13(19):5669.

4. I suggest reduce and putting together the sections “ Key Outcomes Assessed: Knowledge, Self-Efficacy and Diabetes” and “3. Evaluating the Transition Process at Royal North Shore Hospital”.

We appreciate the reviewer’s comments. This paper has been reviewed extensively by three previous reviewers prior to this current review to this journal. During this rigorous peer-review process we have condensed the introduction and believe that it is important each section is explained in the manner it is currently presented.

METHODS

5. No ethical issues since the authors write that (lines 161-163) “The study was approved by the NSLHD Research Ethics Committee (2022/ETH02412) and was carried out in accordance with the principles of the Declaration of Helsinki.”

Thank you for this comment.

6. The use of validated tools (READDY, PAID-T) is very relevant for studies like this.

Thank you – no further action needed.

7. In lines 168-170 the authors state that "Adolescents who have an existing diagnosis of T1D aged 16 to 19 years and currently attending the Royal North Shore Paediatric Diabetes and Endocrinology Department." Was the time of diabetes diagnosis considered?

There were no new diagnoses at the time for this age group that presented. The demographics table on pg. 6-7 indicates that the median duration of diagnosis is 7 years (range of 4.1-10.1).

8. In statistical analysis, the use of multivariate analyses (e.g., regression) could adjust for confounders and strengthen the interpretation. 

We consulted with our research statistician regarding multivariate analyses, specifically multiple regression. When these analyses were completed, there were no statistically significant findings, and therefore we did not proceed further to complete further analyses to adjust for confounders.

RESULTS

9. Please improve the presentation of Table 1. 

The supplementary file consists of the original formatting of the tables, including Table 1. The presentation of Table 1 appears to be re-formatted to suit the format of the journal.

DISCUSSION

10. I appreciate the inclusion of the limitations of this study (lines 355-368).

Thank you for your acknowledgements.

11. I also much appreciated this part of the text: lines 358-370.

Thank you.

12. The study offers concrete recommendations for multidisciplinary teams, showing the importance of parent engagement and enhanced psychosocial integration.

We are grateful to hear that you echo the same sentiments as we do from the results of our study.

13. Would it not be interesting to investigate whether points regarding previous mental health, comorbidities, time since diagnosis of DM1 and socioeconomic conditions were not adjusted in the analyses?

Our study collected information on pre-existing mental health conditions, comorbidities, time since diagnosis of type 1 diabetes, and socioeconomic status, in which provided context to our sample. However, this information collected was not part of the statistical analysis plan and we agreed it would have strengthened the robustness of our analyses. As noted in the limitations of the discussion section on pg. 11, “We also did not consider some confounding variables in our analyses which may have impacted our results, including pre-existing mental health issues, comorbidities, time since diagnosis of T1D and socioeconomic status”.

REFERENCES

14. In the Introduction and Discussion sections, it is necessary to include more references published in 2024-2025.

 As reflected in an earlier comment regarding the introduction, updated references have also been included in this section.

Azar S, Maroun Abou Jaoude N, Kędzia A, Niechciał E. Barriers to type 1 diabetes adherence in adolescents. Journal of Clinical Medicine. 2024;13(19):5669

Liu J, Li J, Li L, Zeng K. Impact of family environment on mental disorders and quality of life in children with type 1 diabetes mellitus: a cross-sectional study and intervention policy analysis. Frontiers in Pediatrics. 2025;13:1516411.

 

 

 

 

 

 

Reviewer 3 Report

Comments and Suggestions for Authors

This study presents a valuable contribution to the literature on transition readiness in adolescents with Type 1 Diabetes (T1D), distinguished by its triangulated approach incorporating adolescent, parent, and clinician perspectives. Its integration of validated tools and real-world clinical data from a metropolitan pediatric center provides a comprehensive overview of the psychosocial and educational factors influencing transition outcomes. The inclusion of diabetes knowledge, self-efficacy, and diabetes distress (DD) as interrelated constructs offers a nuanced understanding of the challenges faced during this critical developmental period. However, some points merit further consideration:

1. The paper suggests that higher adolescent self-efficacy correlates with lower distress and improved transition readiness. Could further exploration and validation of this hypothesis through longitudinal follow-up, qualitative interviews, or integration of behavioural health metrics strengthen the conclusions regarding long-term outcomes and resilience?

2. While the study notes poor engagement with the multidisciplinary team (MDT), it would be helpful to clarify whether barriers were logistical, perceptual, or systemic. Could the authors consider stratifying missed appointments by reason or exploring whether digital health tools (e.g., telehealth, app-based reminders) might mitigate these gaps?

3. The modified READDY and PAID-T instruments are well-chosen, yet the adaptation process for the Australian context is only briefly described. Would the authors consider providing further detail on the validation steps, pilot feedback, and any psychometric recalibration undertaken to ensure cultural and clinical relevance?

4. The finding that parents report higher distress than adolescents is compelling. Might the authors expand on how parental DD influences adolescent autonomy and glycemic control, and whether family-based interventions could be integrated into transition planning?

5. The manuscript would benefit from a more detailed discussion of policy or guideline implications. How might these findings inform updates to ISPAD recommendations or local transition protocols, particularly regarding psychosocial screening and MDT engagement?

Author Response

1. The paper suggests that higher adolescent self-efficacy correlates with lower distress and improved transition readiness. Could further exploration and validation of this hypothesis through longitudinal follow-up, qualitative interviews, or integration of behavioural health metrics strengthen the conclusions regarding long-term outcomes and resilience?

Thank you for this feedback. This study is at the initial stage of collecting data at a cross-sectional level. This study intends to collect longitudinal data and investigate the differences between three time points, which allows for a more comprehensive overview of the transition process.  It is intended to collect this data:

• 1st visit: When diabetes educator first sees the young person on their own (without carer/parent present) (around 16 years old). This visit allows baseline assessment including identification of any areas of difficulty.
• 2nd visit: When the young person first attends the young adult clinic (being the anticipated peak of knowledge/skills acquisition within the paediatric diabetes service). This visit will review the adequacy of paediatric education that has been delivered, to date, to help facilitate a smooth transition to the adult diabetes service for future patients. It will allow analysis of previously identified areas of difficulty to see if the transition process has appropriately addressed these.
• 3rd visit: After the young person is regularly attending the young adult clinic (allows overview of the whole transition process after a period of care within the adult service).

 

2. While the study notes poor engagement with the multidisciplinary team (MDT), it would be helpful to clarify whether barriers were logistical, perceptual, or systemic. Could the authors consider stratifying missed appointments by reason or exploring whether digital health tools (e.g., telehealth, app-based reminders) might mitigate these gaps?

We agree with clarifying the reasons for missed appointments to further understand these differences. As stated in the limitations in the discussion section on pg. 11, “Data were gathered on clinic attendance immediately following COVID restrictions and many families attending via telehealth did not arrange further follow-up through reception”. Moreover, adolescents are a population that struggles with clinic attendance due to competing academic or extracurricular demands, may not be managing well with their diabetes care or on the other extreme, may perceive they are managing well and do not need to attend.

All our patients receive text message reminders for their appointments, however this is only generated when they are being seen by the endocrinologist and not other members of the multidisciplinary team. This has been highlighted as a potential pitfall of attendance and hence as a service, we could improve this reminder system.

3. The modified READDY and PAID-T instruments are well-chosen, yet the adaptation process for the Australian context is only briefly described. Would the authors consider providing further detail on the validation steps, pilot feedback, and any psychometric recalibration undertaken to ensure cultural and clinical relevance?

At the time of designing the study, we performed a comprehensive literature review and could not identify a diabetes knowledge questionnaire which reflected current diabetes technologies and best practice.

In seeking to create a validated tool, these were the steps taken to ensure content validity to an Australian context. As stated on pg. 5, the questionnaire incorporated questions from the PedCarbQuiz, which is a published 72-item carbohydrate counting knowledge questionnaire for patients with T1D with demonstrated reliability, developed for an Australian context. We used items from this published measure as a starting point for our novel diabetes knowledge questionnaire.

The diabetes knowledge questionnaire was reviewed by staff from the paediatric and adult endocrine departments in Royal North Shore Hospital. This included adult and paediatric endocrinologists, diabetes educators, dietitian and a clinical psychologist. This questionnaire was then piloted in a sample population of young adults with Type 1 Diabetes in the hospital who had already transitioned to this service.

4. The finding that parents report higher distress than adolescents is compelling. Might the authors expand on how parental DD influences adolescent autonomy and glycemic control, and whether family-based interventions could be integrated into transition planning?

Thank you for your comments. The manuscript has further elaborated on these findings on pg. 10-11 and includes this: “Parental DD can impact adolescent autonomy and glycaemic control by shaping the emotional climate, dynamics and communication patterns within the family. When parents experience high levels of distress, they may become overly controlling or anxious, and lead to increased monitoring and hyperawareness of their adolescent’s management of their T1D. As a result, this can impact the adolescents’ development of self-management skills and emotional independence. This dynamic often leads to conflict, reduced motivation, and poorer glycaemic outcomes.”

Regarding family-based interventions, this has been explained within the discussion section on pg. 12-13 and also in response to comment 5.

5. The manuscript would benefit from a more detailed discussion of policy or guideline implications. How might these findings inform updates to ISPAD recommendations or local transition protocols, particularly regarding psychosocial screening and MDT engagement?

We are grateful for your feedback. The manuscript has included this explanation to expand on policy and guideline impacts, we have added our suggestions on updates to ISPAD recommendations. This is reflected in paragraphs 2-7 on pg. 12 and 13. It reads as below:

“It is evident that adolescents were not engaging with our MDT regularly and thus not meeting international guidelines. Without regular and consistent clinic attendance and engagement it will be difficult to upskill adolescents in diabetes knowledge and subsequently, increase their self-efficacy. Engaging with the MDT also allows diabetes teams to monitor levels of DD and psychosocial challenges. It is recommended that as part of routine screening, both adolescent and parental distress should be measured during these transition visits, and education around the impact on glycaemic outcomes and autonomy development should be discussed with parents. To ensure this occurs, diabetes departments need to consider a more family-centered approach to care and holistic approach to team engagement with consistent regular psychosocial assessment on an annual basis or more frequently if required in keeping with international guidelines (18).

 

Local transition protocols could implement family-based interventions that teaches parents skills to support self-efficacy and shared decision-making. In an attempt to reduce diabetes burden at each appointment, there will be discussions on division of diabetes care between the adolescent and their family members taking into account levels of self-efficacy. Transition processes require defined outcomes relevant to each adolescent’s circumstances using communication that is supportive and empowers autonomy, as well as consideration for health literacy needs (21).

 

At a policy level, appropriate members of the MDT can facilitate structured family sessions to address difficult family dynamics, improve communication patterns and foster adolescent competence. This may involve teaching parents skills to become more collaborative and supportive of self-efficacy to empower their adolescent, structured joint sessions, or parenting programs such as Tuning Into Teens (Kehoe, Havighurst & Harley, 2014). Integrating these practices into established diabetes care standards has the potential to improve both psychosocial and clinical outcomes by aligning adolescent self-management goals with family support systems.

International guidelines recommend that adolescents and their families have an annual review by a psychologist or social worker, with attention to family dynamics, care responsibilities, and mental health (4, 32). However, the results of our study suggest that assessment of distress, family relationships, and psychosocial challenges should be part of every clinic visit during this critical stage of life—for both adolescents and their caregivers (20). Including these recommendations in all ISPAD guidelines, particularly those focused on adolescent care, would be valuable. Endorsing validated screening tools would also support the multidisciplinary team in identifying and addressing psychosocial needs.

 

 

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,
Thank you very much for performing the corrections.
I wish you good luck with this manuscript.
With best regards,
Sandra M. Barbalho