A published ongoing intervention study (Jaser et al., 2020) and a phenomenological study by the current authors (Kruger et al., under review)³ were used as data for the qualitative document analysis. Both studies emphasize the need for interventions for adolescents living with type 1 diabetes. It was decided to utilize the ongoing trial by Jaser et al. (2020) due to a lack of availability of published positive psychology intervention studies for adolescents living with type 1 diabetes. Jaser et al. (2020) build on previous work, namely pilot studies testing posting psychology interventions for adolescents with type 1 diabetes (Jaser et al., 2014; Zhang et al., 2018). Both of these pilot studies indicate the suitability of delivering interventions to adolescents by means of text messages. However, the interventions could not detect the effects of the intervention; hence, work in this area remains to be done. In one pilot study—Jaser et al. (2014)—a significant correlation was found between adolescents’ levels of positive affect and measures of adherence, including self-reporting and glucose monitoring device downloads. The aim of the current study is to identify the psychological constructs that should form part of a positive psychology intervention to assist with the adjustment to closed loop technology among adolescents. To achieve this aim, the authors employed two distinct documents, each containing unique types of data. Document 1 was chosen due to its specific focus on a positive psychology intervention for adolescents. This document helped the authors establish a foundational understanding of an existing positive psychology intervention in the context of type 1 diabetes. On the other hand, the second document focusing on adolescents’ experiences of adjustment to closed loop technology brought a different dimension to our study, as it contained an in-depth description of those directly adjusting to closed loop technology. This second document enriched our analysis by offering qualitative perspectives and real-life examples. The integration of these two documents into the data analysis process was a deliberate choice to foster a more comprehensive exploration of the research question. By considering both types of data, we aimed to mitigate potential biases and limitations associated with relying solely on one data source.

Document 1 is the study by Jaser et al. (2020). For the qualitative document analysis, the authors analysed the published manuscript by Jaser et al. (2020) and did not have access to the full intervention or raw results. Document 1 included background on the positive psychology framework utilised when developing the intervention, the study aims, the research design and methods, the study population, the recruitment process, an outline of the intervention, the outcome measures and the results. The above provided a rich account for the authors to utilise document 1 as a part of the qualitative document analysis. This positive psychology intervention study was an ongoing randomized control trial comparing diabetes education and a positive affect intervention based on text messages in a diabetes education control group with the aim of reducing diabetes distress in adolescents with type 1 diabetes and to improve their diabetes outcomes. The targeted sample size of this intervention was 200 adolescents diagnosed with type 1 diabetes and their caregivers (100 participants for each group). Thr1VE! was developed from a series of pilot studies of positive psychology interventions in the context of adolescents living with type 1 diabetes (Jaser et al., 2014; Zhang et al., 2018). Theoretically, the intervention was grounded in Fredrickson’s (2001) broaden-and-build theory of positive emotions, with the hypothesis that inducing positive affect leads to the broadening of thoughts and actions, thereby increasing healthy responses to stress, decreasing diabetes distress and improving diabetes self-management. The positive psychology intervention THR1VE! was developed for adolescents between the ages of 13 and 17. The intervention included a health behavior contract, where the participants had to commit to a behavior they wanted to change by writing down a goal, which was introduced during an individual session with a research assistant. They were encouraged to share this goal with their family and friends. The caregiver participants also had one session with the research assistant. The intervention also included worksheets on the following topics: gratitude, self-affirmation, writing about positive experiences, accomplishments, and diabetes education material. Automated text messages were also sent to the participants to remind them to reflect on gratitude. Worksheets were also provided to the caregivers, outlining the effect of positive messages on adolescents’ behavior. The goal of the worksheet was for the caregivers to acknowledge the adolescents’ strengths and separate these from diabetes. The intervention was delivered remotely, except for the initial session with the research assistant. Automated text messages were sent to prompt the adolescent participants to reflect on gratitude and their top value for 8 weeks and included the following content: mood booster content, important values, gratitude, and unexpected gifts. The plan was for the intervention study to be delivered to the participants for 12 months.

Document 2 is the study by Kruger et al. (under review, see footnote 1). This interpretative phenomenological analysis (IPA) study aimed to obtain an in-depth understanding of the experiences of adjustment for adolescents living with closed loop technology. Within the study, successful adjustment was viewed as adolescents using closed loop technology who achieved an HbA1c of <7% and a time in range (TIR) of >70%. As IPA aims to understand experiences in depth, a small sample was selected, in line with the literature on IPA (see Smith et al., 2009). A relatively homogenous sample is recommended by the literature on IPA (Smith et al., 2009); therefore, the researchers recruited five participants living with type 1 diabetes between the ages of 15 and 18, who had successfully adjusted to closed loop technology. In line with the literature on IPA (Smith et al., 2009), open-ended interviews lasting approximately 45 min were conducted. An interview schedule with open-ended questions and possible prompting questions was developed in line with the research question and aim. The following questions and requests were posed (excluding prompting questions): (1) please tell me about yourself. (2) Please tell me more about the role of diabetes in your life. (3) Please tell me more about living with closed loop technology. (4) Is there anything else about your journey with diabetes that you would like to share today? After the data collection, the interviews were transcribed, analyzed and interpreted using the steps outlined by Smith et al. (2009). The final results were then written up. Although the authors have access to the raw data and transcripts supporting the final results of document 2, only the written manuscript was used in the qualitative document analysis, in line with document 1. Within document 2, the recruitment process, the participants’ context, the interview process and questions posed to the participants, the methodology, data analysis and results of the study are discussed. With all the themes discussed in document 2, verbatim extracts were used to support all interpretations made, in order for the reader to be able to verify the interpretations made.

The following themes were constructed: learning to trust the technology; making diabetes visible; building a relationship with diabetes; the value of support; and experiencing positive outcomes. The study showed that psychological factors play a crucial role in people’s successful adjustment to closed loop technology and it is essential to focus on these psychological factors to experience the optimal benefits of the technology. Within the identified themes, the following psychological factors were identified: perception, attitude, willingness to learn, and motivation. In the study, the participants emphasized the importance of engagement and management for the person living with diabetes. Adjustment to closed loop technology is facilitated by the processes of learning to trust the technology, having access to visible glucose data, building a relationship with diabetes, support, and experiencing positive outcomes. Adjustment is further facilitated by being able to “see” diabetes, which leads to participants being able to make better diabetes management decisions and trust the technology, leading to improved diabetes management. In turn, improved management and control of diabetes lead to acceptance of diabetes technology and the incorporation of diabetes into one’s identity.

Within qualitative document analysis, thematic analysis is viewed as an appropriate means of analyzing data (Morgan, 2022). For this qualitative document analysis, reflexive thematic analysis (see Clarke and Braun, 2013; Braun and Clarke, 2020) was conducted with the aim of establishing themes within the data. The following process was followed: first, the authors familiarized themselves with the data by reading and re-reading the two documents individually. As stated above, the authors did not utilise the raw data, but rather the two documents in article format. The documents were read and re-read to become intimately familiar with the content in order to identify patterns and similarities in the data. Second, they generated codes for important features of the data relevant to the research question that guided the analysis, the codes included short phrases that encapsulate important concepts within the data. The entire articles were utilised, however within document 1, the focus was on the content of the intervention, while in document 2, the focus was on the themes identified as crucial to effective adjustment. Third, the authors constructed possible themes by identifying similarities in the codes. This involved searching for recurring concepts in the data. Fourth, the authors reviewed the generated themes with regard to the codes and the transcripts. This involved revisiting the codes and both documents to ensure that the themes accurately reflect the content of both documents. Fifth, they named the final themes and developed a description of each theme, while referring back to both documents analysed. The final step was producing the final report and disseminating the findings via the current manuscript.

The first author analysed the data. The second author was the co-coder and independently verified the results. The co-coder was a means of validating the themes identified and increasing the reliability of the study as well as bringing a different perspective to the themes and identifying any potential blind spots the first author might have missed. The third and fourth author read through the analysis to verify the results. Peer discussions were also held on the results and interpretations made. Throughout the study, a reflective journal was kept by the first author in order to ensure that the data was not biased. In this way, the author was constantly aware of her own assumptions, emotions, views, and personal biases regarding the research topic. Within document 2, verbatim extracts were used to support all interpretations made, to ensure that the results were grounded in the data. With the qualitative document analysis, the authors referred back to both document throughout the analysis to ensure that the themes generated were based on the data.

Both documents emphasize that it is crucial to receive education about diabetes in order to successfully manage the condition. According to the literature, diabetes management education is essential for people to effectively live with diabetes (Funnell and Anderson, 2004; Ghisi et al., 2022). Successful diabetes management requires sufficient knowledge on the part of the person living with diabetes; this knowledge includes the goals of treatment, the effect diabetes has on the body and the factors that can influence glucose levels (Gonzalez et al., 2016). It is crucial for people who live with diabetes to be treated as partners in their healthcare and diabetes management (Phiri et al., 2022).

In document 1 (Jaser et al., 2020), an education packet is provided that includes basic diabetes constructs, such as glucose levels, exercising, travelling and HbA1c, developed from the American Diabetes Association website. The participants of document 2 (Kruger et al., under review, see footnote 1) emphasized that an important part of adjusting to living with diabetes and closed loop technology is a willingness to learn and “trial and error,” in other words, learning through experience and finding what works for the individual. An important aspect for the participants in document 2 (Kruger et al., under review, see footnote 1) was to integrate what they have learnt in the past with adjusting to the closed loop system. This highlights a process of adjustment that occurs over time. The participants reported that support received from healthcare providers, training on the closed loop system and practical support from caregivers with, for example, helping with infusion sets facilitated effective adjustment. This finding highlights the importance of education in the context of managing diabetes and effectively adjusting to closed loop technology.

Most individuals living with type 1 diabetes are exposed to knowledge about diabetes management during diabetes education provided at their healthcare practitioner’s office. However, it is not known to what extent self-management practices are integrated into their daily life, as most people living with type 1 diabetes do not attain optimal control (Weller et al., 2016). It is recommended that adolescents and their caregivers receive ongoing education about diabetes self-management and diabetes technology (Dowling, 2021). It has been found that closed loop systems can be initiated by virtual training programs and that virtual training programs can improve glycemic control (Petrovski et al., 2021). This therapeutic approach to diabetes education is one of the fundamentals of a successful program. In this approach, the professional and the person living with diabetes become partners in learning how to integrate diabetes into their daily lives (Heller et al., 2020).

In the process of positive adjustment, two sub-themes were constructed, namely (1) commitment to and responsibility for managing type 1 diabetes well and (2) trusting the technology is necessary to integrate the technology into everyday life. In order to positively adjust to closed loop technology, the adolescent participants in document 2 (Kruger et al., under review, see footnote 1) had to commit to particular diabetes management behaviors and take responsibility for their diabetes management. In time, this led to them trusting the closed loop system and integrating it into their everyday life.

The sub-themes of theme 3 were (1) positive affect and (2) gratitude. Constructs of psychological well-being, such as self-efficacy, gratitude, and positive affect, have been linked to better health outcomes for people with chronic conditions (Massey et al., 2018). A positive outlook for the adolescents living with type 1 diabetes in document 2 (Kruger et al., under review, see footnote 1) was evident in their experiences of positive affect and gratitude, which contribute to good diabetes outcomes relevant to promoting well-being, despite risk factors (Steinberg et al., 2017).

In building a relationship with diabetes, two sub-themes were constructed, namely (1) identity and (2) support.

As identified in the first theme, “the importance of knowledge and education,” having sufficient knowledge about how to manage diabetes is crucial. It is recommended that an intervention program includes an educational component on basic diabetes constructs, for example the importance of good glucose control, and knowledge of diabetes self-care behavior. As identified through the document analysis, trust was facilitated by having access to visible glucose data; it is thus recommended that knowledge about the construct of time in range is included in an intervention. As identified through the qualitative document analysis, having access to visible glucose data is beneficial, but sometimes it can also be overwhelming. It is recommended that psychological topics, such as diabetes burnout (Abdoli et al., 2021), and additional resources that adolescents and their caregivers can access at their own time are included in an intervention. Within the knowledge construct, the PERMA construct of accomplishment is addressed, as well as the UTAUT construct of performance expectancy. With more knowledge, adolescents, and their caregivers will feel empowered and accomplished, have more trust in the closed loop system and view the system as beneficial for their health, which will facilitate adjustment. Examples of the educational content that should be provided include: information on the PERMA constructs and how this can be applied in daily life, information on time in range, benefits of good glucose control, nutritional information and diabetes burnout.

Within the second and fourth themes, “the process of positive adjustment to closed loop technology” and “building a relationship with diabetes,” the psychological constructs of responsibility and identity were identified. During adolescence, adolescents seek autonomy and independence (Lam et al., 2014). Chiang et al. (2014) emphasize that important tasks for adolescents living with type 1 diabetes are the development of independence and identity; therefore, healthcare providers and family members should aim to support adolescents’ transition to independence and increased responsibility. Identity development occurs continuously throughout a person’s lifetime (Timler et al., 2019). The physical and psychological aspects of living with diabetes should be taken into account when identity development among adolescents is considered (Adal et al., 2015). A clear sense of identity can help people living with type 1 diabetes cope with their diabetes appropriately and may protect them from psychological problems (Verschueren et al., 2019). It is recommended that, in an intervention for adolescents living with type 1 diabetes, the construct of responsibility is addressed by, for example, including information and activities on setting personal goals or activities such as envisioning their best version of themselves. Identity development is crucial during the adolescent phase, and there should be a focus on integrating type 1 diabetes into their identity in interventions for adolescents living with type 1 diabetes. By setting and achieving goals and by integrating diabetes and the closed loop system into one’s identity, the following constructs from the PERMA model and the UTAUT are touched on: accomplishment, engagement, and facilitating conditions.

By taking responsibility for managing type 1 diabetes, it is possible for adolescents to engage in better self-management behavior, which will increase their diabetes health behavior and result in a feeling of accomplishment. When adolescents accept more responsibility for managing their diabetes, it is possible that they will experience being empowered and fully engaged in the management of the condition. Within the document analysis, it was found that it is essential to integrate diabetes and diabetes technology into adolescents’ view of themselves, and this can be viewed as an essential facilitating condition in their adjustment to closed loop technology. This is mirrored in research by Raymaekers et al. (2019), who describe that integrating diabetes into one’s identity plays an important role in coping with diabetes. Within the context of an intervention, an example of enhancing responsibility could be to provide education on goal setting and by tasking adolescents with writing down one behavior that they would want to change within the context of diabetes and keep track of their progress on a cell phone or by writing it down on a daily basis. It could be encouraged to record any progress/ successes and to share their goal with a caregiver. Caregivers could be tasked with praising any positive change or small accomplishment that their adolescent had. Adolescents could also be asked to envision their best possible self when achieving their health goals as well as identifying the step to support their goals.

The importance of positive affect and gratitude was evident in theme 3, “positive outlook,” of the qualitative document analysis. These constructs should be included in an intervention program, as gratitude and positive affect are viewed as protective psychological factors (Loseby et al., 2021). The positive effects of gratitude interventions on adolescents’ psychological well-being have been shown in previous research (Wood et al., 2010; Kwok et al., 2022). It will be beneficial to include exercises on positive affect and gratitude that are easy to incorporate into adolescents’ daily lives in an intervention. For example, participants can be asked to engage in activities that they enjoy, which will result in their experiencing positive emotions, thus facilitating the PERMA construct of engagement and positive emotions, and thereby acting as a facilitating condition to successful adjustment. This recommendation is in line with numerous studies indicating that positive psychological states are strongly associated with higher levels of participation in health behavior (Hingle et al., 2014; Huffman et al., 2015; Celano et al., 2020). Practical applications of the constructs, positive affect and gratitude, could be the inclusion of gratitude exercises and encouraging adolescents to engage in activities that elicit positive affect.

Support was evident in theme 4 of the qualitative document analysis, “building a relationship with diabetes.” As support was identified as a crucial component of living positively with type 1 diabetes, it is recommended that caregivers should be involved during parts of the program. Research has shown that sharing experiences with people in similar situations decreases distress and improves mental health in adolescents and caregivers (Niela-Vilen et al., 2014; Ramchand et al., 2017).

In the qualitative document analysis, support from others, social media, and support groups was identified as being helpful in the process of adjustment. Therefore, support by participants of the program in the form of sharing their experiences should also be included in the intervention, as, in this way, they will motivate one another. Peer groups and online diabetes communities (e.g., blogs and social media) serve as a powerful source of support for people living with type 1 diabetes (Hilliard et al., 2015). In addition to assisting in the development of relationships with peers, social media generates a sense of belonging, reduces feelings of loneliness, increases the sharing of experiential knowledge and helps to reduce feelings of isolation (Wilson and Stock, 2021). It is recommended that within an intervention program, social support from various areas of the adolescents’ lives should be included, for example from social media, positive role models, friends, and family. Within the construct of support, the PERMA constructs of relationships and meaning are addressed and support is viewed as a facilitating condition to adjustment, in line with the UTAUT. Support is viewed as crucial in the process of adjustment to closed loop technology, as such, the inclusion of caregivers and peers are recommended in an intervention. Examples include, engaging in acts of kindness, spending quality time with people that they care about and caregivers given the task of emphasizing what they are proud of in terms of how the adolescent utilizes closed loop technology.

Within the second theme of the qualitative document analysis, “the process of positive adjustment to closed loop technology,” trust was an essential psychological construct. A lack of trust in diabetes technology is viewed as a barrier to successful adjustment (Tanenbaum and Commissariat, 2022). In the qualitative document analysis, trust in the closed loop system was facilitated when individuals adopted the view that the closed loop system was a helpful tool in managing the condition. Trust in the closed loop system was also facilitated by having access to visible glucose data. Within the qualitative document analysis, it was identified that trust is developed by creating a positive link between a self-care behavior and a visible change in glucose levels, which confirms a positive link between the behavior and the realization of the expected outcome. It is recommended that the concept of trust is included in interventions and that participants are encouraged to engage with their glucose data. It will be beneficial for participants to receive education on how to use glucose data to make informed diabetes management decisions. By addressing the construct of trust in an intervention, the PERMA aspect of engagement and the UTAUT construct of effort expectancy are included. A practical application could be empowering adolescents to use glucose data to obtain a better understanding of how closed-loop technology can benefit them and to increase their trust in the system.

Technological advancements in diabetes care, such as insulin pumps, continuous glucose sensors, and closed loop systems, offer hope and tools to improve outcomes in diabetes care (Gonder-Frederick et al., 2016). Despite these technological advances, glucose control has worsened in the adolescent population over the past decade, with adolescents showing low persistence in using these potentially enabling technologies (Bryden et al., 2001; Gonzalez et al., 2016). Although closed loop systems have many advantages, they do not work well for everyone living with diabetes, as the benefits of the technology depend largely on the individual’s engagement with the technology (Gonder-Frederick et al., 2016). A need exists to better understand and assist adolescents to benefit from closed loop technology. Positive psychology interventions in the context of type 1 diabetes may be beneficial, as such interventions would focus on the strengths of adolescents and their families to promote resilience. The key constructs identified in this qualitative document analysis are knowledge and education, responsibility, identity, positive affect, gratitude, support, and trust. The authors believe that the psychological constructs outlined in this document are a starting point in the development of interventions that assist adolescents with successful adjustment to closed loop technology.