Children's Learning and Goal-Setting at a Diabetes Camp Free

One hundred and thirty-one of the 144 children attending camp completed the evaluation. Campers ranged from 8 to 16 years of age (mean 11 years, 7 months, standard deviation [SD] 2 years, 1 month). There were 51 boys and 79 girls, and 1 child did not share information about his or her sex. Four children did not report their ethnic group. Of the remaining 128 children who did provide this information, 83% were Caucasian, 6% were African American, 1% was biracial, 1% was Hispanic, and 9% reported being in another ethnic group (e.g., “I am multiracial”). Children's A1C levels were obtained from the medical records reported before the start of camp (range 5.6–11.7%, mean 8.14%, SD 1.09%). Sixty percent of the children reported that they had attended diabetes camp at least once before the 2011 camp session. Although the diabetes camp accepts children with type 2 diabetes, no children with type 2 diabetes were a part of this study. Two university-based institutional review boards approved this study.

Parents provided consent and children provided assent to participate in the study. Parents provided information about their goals for what their child would learn during camp through their responses to an open-ended question on an intake form completed before the start of the camp session. Children independently selected goals with their counselors during camp. On the final day of camp, children completed a camp evaluation survey. They responded to open-ended questions assessing their report of any new diabetes management tasks they had learned during camp, their recall of their camp goals, and their satisfaction with camp.

Information provided by parents regarding their goals for their children before camp versus what the children reported that they actually learned about diabetes management after camp is presented in Table 1. Five logistic regression analyses were conducted to examine the relationships among parents' reports of what their child needed to learn, children's sex, and children's reports of learning in five areas. Predictor variables were parents' report of what their child needed to learn and children's sex, and the outcome variable was children's reports of learning in five areas. The five areas included learning about 1) high blood glucose levels, 2) low blood glucose levels, 3) carbohydrate counting, 4) blood glucose testing, and 5) expressing feelings about having diabetes. The interaction term was not a significant predictor for any of the variables and reduced model fit; therefore, it was not included in final models.

Results for the regression model for learning about high blood glucose indicated that parents' reports that their child needed to learn about high blood glucose predicted children's reports of learning about high blood glucose (β 1.23, standard error [SE] 0.669, Wald 3.396, P = 0.065, odds ratio [OR] 3.43). The sex of the child was also related to learning about high blood glucose, with boys reporting higher levels of learning than girls (β −0.7774, SE 0.388, Wald 3.968, P = 0.046, OR 0.461). Parents' reports of wanting their child to learn about testing was not related to children's reports about learning to test at camp; however, sex was significantly related to learning about testing at camp (β −1.823, SE 0.701, Wald 6.767, P = 0.009, OR 0.162). Boys learned more than girls about testing at camp. Parents' reports of wanting their child to learn about counting carbohydrates was not related to children's reports about learning to count carbohydrates at camp. Boys learned more than girls about counting carbohydrates at camp (β −0.724, SE 0.387, Wald 3.498, P = 0.061, OR 0.485). Results of the regression analyses for learning about low blood glucose and expressing feelings were not significant. Only 6 of the 130 children who completed the evaluation in Year 1 remembered their two camp goals. These children listed either counting carbohydrates or recognizing high and low blood glucose levels as their camp goals.

Children wrote down answers to open-ended questions assessing what new things they learned about diabetes management during camp. Eight themes, showcased in Table 2, exemplified their responses. These eight themes were agreed on by two coders who reviewed the children's responses. Some children also mentioned that they learned that exercise was important. Children often mentioned that the support at diabetes camp was a crucial strength of their camp experience. Many wrote that camp was “awesome.” Camp helped children learn self-management and coping skills and learn more about themselves as children who have diabetes and can manage their illness well.

Eighty-three children (63%) reported that camp was either “good” or “great” for helping them learn about diabetes management. Twenty-eight children (22%) said camp was “OK” for helping learn about diabetes management, and 17 children (13%) reported that camp “did not help.” Eighty-one percent of the children reported that camp was “very fun,” and 14% reported that camp was “fun.” Only one child reported not liking camp. Ninety-three percent of the children reported that they would recommend camp to a friend.

Sixty-eight of the 129 children attending camp completed camp evaluation forms. Eleven boys and 57 girls completed forms; 62 reported that they were Caucasian and 2 were African American. A1C levels ranged from 5.5 to 15.5% (mean 8.29%, SD 1.44%). Seventy-one percent of the children (n = 49) had attended diabetes camp at least once previously.

Year 2 procedures were similar to those described for year 1 with one exception; a new goal-setting intervention was developed. This was developed because the year 1 evaluation indicated that the majority of children did not recall their goals. Also, parents and children developed children's goals together because literature supports a positive relationship between shared goal-setting and diabetes management for children.¹³ 

For the goal-setting intervention, the children and their parent(s) met with a child psychologist during the intake process when they arrived at camp. The child psychologist described the rationale for the shared goal-setting exercise, which was to build a teamwork approach to developing the children's goals for diabetes management. Next, parent(s) and their child established two goals that the child needed to attain at camp to help manage diabetes. The child psychologist wrote down each of the child's goals and shared them with the doctor(s) assigned to that child's cabin. The doctors regularly discussed these goals with the children. Each child's goals were posted on a flyer on his or her bunk bed for the duration of camp. At the end of camp, doctors rated each child's progress toward each goal on a 4-point scale with the following anchors: 4 = good, 3 = some, 2 = low, and 1 = very low.

Information provided by parents regarding their goals for their child before camp versus what the children reported that they learned at camp is presented in Table 1. Five logistic regression analyses, identical to those for year 1, were conducted to examine the relationships among parents' reports of what their child needed to learn, children's sex, and children's reports of what they learned during camp. The interaction term was not a significant predictor in any models and thus was not included in final models.

Sex was a significant predictor of children reporting that they learned to test their blood glucose. Findings indicated that boys learned more than girls about testing their blood glucose during camp (β −2.158, SE 1.063, Wald 4.122, P = 0.04, OR 0.116). Parents having a goal for their child to learn to test blood glucose was not a significant predictor of children's learning to test during camp.

Sex was also a significant predictor for having a chance to discuss feelings about having diabetes at camp. Girls reported more opportunities than boys to discuss their feelings about diabetes at camp (β 2.053, SE 0.818, Wald 6.296, P = 0.012, OR 7.789). Parents having a goal for their child to discuss feelings was not a significant predictor of opportunities for such discussions.

No predictors were significant for learning about high and low blood glucose or counting carbohydrates. Forty-three of the 68 children who completed the evaluation in year 2 remembered their camp goals.

A summary of camp goals set jointly by parents and children in year 2 is presented in Table 3. The top three self-management goals selected together by children and parents were 1) remembering to check blood glucose regularly, 2) learning about counting carbohydrates, and 3) learning to rotate pump sites. Goals endorsed by fewer than three parent-child teams were not included in Table 3. These included: “Do not hide ketones” (n = 1), “Do not hide high blood glucose levels” (n = 1), “Keep better records” (n = 2), “Sleep better” (n = 1), “Get on a better schedule” (n =1), “Wash hands” (n = 1), “Do not get scared on high ropes” (n = 1), “Improve diabetes management at school more” (n = 1), and “Check my diabetes supplies before I leave home” (n = 1). Most children and parent teams endorsed two goals, but a few endorsed either one or three goals.

Forty-three of the 68 children (63.24%) who completed the evaluation in year 2 remembered their camp goals compared to 4.62% in year 1. Forty-nine of the children attended camp sessions and completed evaluations in both years 1 and 2. Of this subgroup, 6 of the 49 (12%) remembered their goals in the year 1 evaluation. In contrast, 43 (88%) of the same children remembered their goals in year 2 after the goal-setting intervention.

Children's reports of what they learned at camp were analyzed by two coders. Six major themes emerged: 1) improved learning about how to cope with high blood glucose, 2) learning more about eating healthful foods, 3) improved ability to independently count carbohydrates, 4) learning about how to give a shot or administer a bolus, 5) learning that it is important to test one's blood glucose regularly, and 6) camp was valued as a very supportive experience through which children could be with others who experienced the same things that they were experiencing. The children did suggest a few areas for improvement, including 1) having the counselors make sure that no one is treated “meanly” by others in the cabin, 2) improving the diet and medical educational activities by making them more fun and interesting, and 3) allowing children to take naps if needed. The themes were similar to those discovered in year 1, which were depicted in Table 2.

Forty-seven children (69%) reported that camp was “good” or “great” for helping them learn about diabetes management. Eleven children (16%) said camp was “OK” in helping them improve diabetes management, and 4 children reported that camp did not help. Camp was perceived as a fun place. In response to the question about whether camp was fun, 81% (n = 55) of the children said camp was “very fun,” 13% (n = 9) reported that camp was “fun,” and 6% (n = 4) said camp was “OK.” No children reported that camp was “not fun.” Importantly, 62 of the children (93%) reported that they would recommend camp to a friend.

The ADA's goals for teaching children diabetes self-management at camp include accurate measurement of blood glucose levels, understanding of the impact of exercise on blood glucose levels, and acute and long-term management of hypo- and hyperglycemia.¹⁰  These goals are consistent with research indicating that such goals are beneficial for improving healthy lifestyles and self-management for children who have diabetes.^7–9 

As seen in previous research,¹¹  camp was a positive experience for the majority of children. Children reported that camp was helpful in improving their ability to manage their diabetes and increasing their sense of belonging and social support. The joint goal-setting intervention in year 2, through which parents and children worked together to develop camp goals, was successful. Doctors reported that a majority of children were achieving their camp goals. Additionally, more children remembered their camp goals in year 2 than in year 1.

The results of the logistic regression analyses for year 2, through which parental goals (i.e., goals set only by parents before camp) were compared to children's reported learning did not indicate a strong match between parent goals (i.e., set before camp and without input from their child) and children's learning, which was similar to the results in year 1. Although unexpected, this finding is consistent with other research showing that parents and their children can have differing perceptions of what a child needs to learn and actually does learn at camp.¹⁴ 

In the future, in addition to joint goal-setting, it also will be important for parents and children to discuss which of their goals differ and determine whether they should work as a team toward goals that are not initially consistent. Allowing parents and children more time to process similarities and differences in goals is a perspective-taking exercise that may improve understanding and support for both members of the parent-child team.

Children benefited from camp in other ways. For example, they learned about identifying and managing blood glucose “highs” and “lows,” improving their ability to identify signs of hypo- and hyperglycemia. Staff were instrumental in assisting children in independently counting carbohydrates at meals and snack times, which is a key aspect of the training that occurs at diabetes camps.^11,12  Qualitative data from this study also indicated that children learned key information about managing their insulin pumps, including rotating sites and programming boluses. They benefited from learning about eating nutritious foods in diet education sessions and through increased vegetable intake and other healthful food choices at mealtimes. Another theme evident in children's qualitative responses is that they learned to be “proud of being a diabetic” and that their self-confidence improved as a result of attending camp. Children also reported that camp was a place to express their feelings about diabetes. Thus, the diabetes knowledge and sense of social belonging that children receive at camp are both invaluable contributions of the camp experience.¹¹ 

Findings from this study suggest that learning experiences differ for boys and girls at camp. For example, quantitative results from year 1 indicated that boys learned more about recognizing symptoms of hyperglycemia, testing their blood glucose levels, and counting carbohydrates at diabetes camp. During year 2, boys reported more than girls that they learned about testing blood glucose levels. Conversely, during year 2, girls were more likely than boys to report benefiting from opportunities to express their feelings at camp.

It is important for adults to consider sex differences when designing educational activities. At camp, nightly “cabin chats” were held to summarize daily learning. Boys may benefit more than girls from reviewing what they have learned about self-management during these discussions, whereas girls may gain additional benefit from not only reviewing what they have learned, but also having the opportunity to express their feelings about coping with and managing their diabetes.

Data were cross-sectional and relied on self-report. Future longitudinal studies are needed to assess change in children's roles in diabetes self-management before and after camp. Moreover, behavior observations would provide an objective means to verify children's reports of the skills they learned during camp.

More children completed the evaluation for year 1 than for year 2. This may have occurred because the children did not wish to complete the same evaluation questions 2 years in a row and may have skewed the findings for year 2. Providing an incentive may have improved completion of evaluations.

Also, a pre-camp assessment of children's knowledge about diabetes management would provide documentation to assess whether boys knew more or less than girls before attending camp. Assessing sex differences in learning and possibly related changes in self-management skills remains a goal for future studies.

It also will be important to determine whether children continue to employ the self-management skills they learn at camp after camp ends. Conducting longitudinal research to assess whether camp participation is related to long-term improvement in self-management, psychosocial functioning, and enhancement of autonomy and self-confidence will provide valuable information that will lead ultimately to improvement in the design of diabetes camp programs.

The authors thank the doctors working with the children on camp goals, including A. Jackson, W. Lai, C. Stringer, C. Neureiter, C. Keefe, H. Wasserman, M. Golekoh, N. Bingham, J. Howell, and N. Crimmins. Appreciation is also extended to the ADA and E. Crosby.