The results of the present clinical trial revealed that self-management training through digital storytelling led to improvement in self-management behaviors amongst adolescents with TID compared to the control group. There are several reasons why digital storytelling can lead to superior performance. In comparison to the conventional approach, storytelling provides a more exciting and enjoyable experience for youths, given their general interest in stories (10). Thus, these advantages might result in greater effectiveness of training through the storytelling method.
On the other hand, patients in the control group underwent only one 2-hour group educational session and a pamphlet at the end of the class. After this training, the teenagers did not receive any training until their next visit. Many studies have been conducted on the effectiveness of face-to-face training amongst youth patients. Most of which emphasize that lecture-based training can have little effect on the level of long-term learning and the quality of self-management in young patients compared to active and attractive learning methods, such as digital storytelling. This method serves as one of the most fundamental methods to subliminally transfer concepts to audiences, especially adolescents [7]. Other research in this area also emphasizes the fact that training through digital storytelling method can have an influential effect compared to conventional methods by improving patients’ healthy behaviors (18), lowering blood pressure (13), managing diabetes mellitus(19), and psychological wellbeing (12).
In addition, we used the asynchronous method (DVD) to promote learning in our research. This method allows patients to interact with the story and its educational message and allows them to learn at their desired time, place, and pace (20). This finding is also in line with the results revealing the effects of asynchronous learning on knowledge, activation, self-management, and self-efficacy in patients with diabetes (21). Therefore, asynchronous digital storytelling allows patients to learn at their own desired time, place, and learning pace to reach mastery in learning and self-management behaviors.
Moreover, the results showed that the score for self-management in the digital storytelling group significantly increased in the collaboration with parents, diabetes communication, and goals dimensions. These upsurges revealed that the adolescents were able to set more accurate self-management goals. Also, the relationship between adolescents and parents, healthcare team, and friends had improved. Furthermore, they were able to create a proper balance in the dividing caring responsibilities between parents and themselves, which ultimately led to more independence [19].
Additionally, the results of this study showed that there was a significant reverse relationship between the age of the adolescents and collaboration with parent’s scores after digital storytelling, while this relationship was not significant in the control group. The research also showed that as teenagers grow older, they become more independent for self-management through digital storytelling methods. Thus, cooperation and dividing responsibilities in self-management go gradually towards independence as the adolescent gets older (5).
We also examined other factors that could potentially affect the results of our study. The results showed that parents’ education level had no significant relationship with the rate of change in self-management behaviors in adolescents with TID in any of the study groups. Nowadays, the ever-growing activities of mass media and social networks have risen parents' awareness with respect to various diseases (regardless of their level of education); hence, their compassion and rapid response have also increased (22). This development can be considered as the reason for the lack of any significant relationship between parental education and the rates of change in self-management behaviors in adolescents with TID.
The results also showed that in both groups there was no significant relationship between the adolescents ‘gender and the rates of change in their self-management behaviors. The results of a study by Vasli & Eshghbaz [23] similarly showed that there was no significant relationship between gender and self-management behavior in 7-14-year-old teenagers with TID. However, Martinez et al. [24] reported that self-management behavior in female adolescents with diabetes was better than in males. Of course, one should not ignore the role of context and environment in adolescent’s self-care behaviors.
Moreover, the results of this study suggested that no significant relationship was observed concerning the rate of change in the level of HbA1c in neither of the groups. Although Azizi et al. (21) and colleagues showed that self-management training with a 3-month follow-up through mobile services significantly reduced HbA1c in adolescents with TID. This is in contrast to the results of the present study and highlights the importance of long-term follow-up.
This study had several limitations. First, it was performed in only one center; hence, it has to be executed on a wider scale for its results to be applicable as general. Furthermore, only short-term effects were investigated. So, the results cannot be generalized to all adolescents with TID. Therefore, long-term follow-up is warranted.
For future research, it is recommended that diabetes self-management training through digital storytelling be administered for a much longer time and with a larger sample size to achieve a more accurate measurement of the level of HA1c and self-management behaviors in patients before and after the training course.