A Novel Miniature Equine-Assisted Diabetes Education Program for Youth: Evaluating the Diabetes Equine Empowerment Program (DEEP).

Youth with diabetes often face challenges related to self-management, problem-solving, coping with the daily demands of diabetes, and developing the skills needed for increasing independence. Innovative approaches that promote engagement and active participation may help address these challenges while supporting diabetes education and self-confidence.

The Diabetes \& Equine Empowerment Program (DEEP) was developed to integrate experiential learning with diabetes education through structured interactions with miniature horses. The program is designed to create a supportive, interactive environment in which participants can practice communication, goal setting, self-advocacy, and problem-solving while reinforcing key diabetes self-management concepts. Educational content is tailored to developmental level and incorporates activities intended to enhance engagement, self-efficacy, and readiness for independent diabetes management.

This single-arm feasibility study will evaluate the implementation of the DEEP program among youth with diabetes and their caregivers. Participants will complete a series of structured sessions facilitated by a diabetes specialist and a certified equine specialist. The study will examine the practicality of recruitment strategies, participant retention, attendance, and completion of study activities. Acceptability of the intervention will be assessed through participant and caregiver feedback regarding satisfaction, perceived value, and willingness to recommend the program to others.

In addition to feasibility and acceptability outcomes, exploratory measures will assess potential changes in diabetes-related psychosocial and behavioral outcomes, including diabetes distress, self-management behaviors, healthcare engagement, and diabetes technology utilization. Data collected through participant-reported measures and medical record review will be used to inform future research and the potential development of larger controlled studies evaluating equine-assisted diabetes education interventions. Participants will be followed for up to six months after program completion.

• Diabetes & Equine Empowerment Program (DEEP) (Behavioral), also known as DEEP, Miniature Equine-Assisted Diabetes Education: The Diabetes \& Equine Empowerment Program (DEEP) is a behavioral and educational intervention that combines evidence-based diabetes self-management education with structured, hands-on interactions involving miniature horses. Youth with diabetes and their caregivers participate in four facilitated sessions led by a diabetes specialist and a certified equine specialist. Session activities are designed to reinforce diabetes self-management skills, coping strategies, problem-solving, communication, self-advocacy, and transition readiness through experiential learning. The intervention aims to improve participant engagement, confidence in diabetes management, and readiness for increasing independence while providing a supportive and interactive learning environment. The program is being evaluated for feasibility, acceptability, participant satisfaction, and potential effects on psychosocial and behavioral outcomes.

Primary outcomes

• Participant Recruitment Rate [From study initiation through completion of enrollment (approximately 9 months)]: Recruitment feasibility will be assessed by the proportion of eligible participants who enroll in the four-session miniature equine-assisted diabetes education program, as documented in study enrollment records.
• Participant Retention Rate [From enrollment through completion of study participation (approximately 9 months)]: Retention feasibility will be assessed by the proportion of enrolled participants who remain in the study and complete scheduled study assessments, as documented in study records.
• Program Attendance Rate [From enrollment through completion of study participation (approximately 9 months)]: Attendance feasibility will be assessed by the proportion of scheduled miniature equine-assisted diabetes education sessions attended by participants, as documented in program attendance logs.
• Program Completion Rate [From enrollment through completion of study participation (approximately 9 months)]: Completion feasibility will be assessed by the proportion of enrolled participants who complete all four miniature equine-assisted diabetes education sessions.

Secondary outcomes

• Change in Diabetes Distress Assessed by the Problem Areas in Diabetes Questionnaires (PAID-C/PAID-T) [Baseline to immediately after completion of the four-session DEEP program]: Change in diabetes-related emotional distress among youth participants as measured by the Problem Areas in Diabetes questionnaires, including the PAID-C for participants ages 8-12 years and the PAID-T for participants ages 13-17 years. Higher scores indicate greater diabetes-related distress
• Change in Diabetes Self-Management Behaviors Assessed by the Self-Care Inventory-Updated (SCI-U) [Baseline to immediately after completion of the four-session DEEP program]: Change in diabetes self-management behaviors as measured by the Self-Care Inventory-Updated (SCI-U), a validated self-report questionnaire that assesses adherence to diabetes self-care activities, including blood glucose monitoring, medication administration, and diabetes-related self-management tasks. Higher scores indicate better adherence to the diabetes care plan.
• Routine Diabetes Appointment Attendance Assessed by Electronic Health Record Review [Six months before participation through six months after program completion]: Change in routine diabetes clinic appointment attendance as assessed through electronic health record review. Attendance will be evaluated by comparing the proportion of scheduled diabetes clinic visits attended before participation and following completion of the DEEP program
• Diabetes Technology Initiation Assessed by Electronic Health Record Review [Program completion through six months after program completion]: The number of participants who initiate diabetes technology, including continuous glucose monitoring and/or insulin pump therapy, within six months following program completion, as documented through electronic health record review.

Sex: All, ages: 8 Years to 20 Years

Inclusion Criteria:

* Age 8 to 20 years
* Diagnosis of type 1 or type 2 diabetes
* Most recent HbA1c greater than 9.0% OR no diabetes clinic follow-up for more than 6 months
* English-speaking participant and caregiver
* Receiving diabetes care at the participating study site
* Willing and able to participate in the DEEP intervention
* Able to attend all four study sessions
* Able to provide informed consent/assent, as applicable
* Caregiver willing to participate in study activities and assessments

Exclusion Criteria:

* Non-English-speaking participant or caregiver
* Medical, physical, cognitive, or behavioral condition that would prevent safe participation in study activities
* Significant fear of horses that would limit participation
* Allergy to horses that would limit participation
* Previous participation in the DEEP intervention
* Inability or unwillingness to complete study procedures or follow-up assessments
* Any condition that, in the opinion of the investigators, would make participation unsafe or interfere with study completion

• Study Protocol and Statistical Analysis Plan (PDF, 2026-03-28)

• Susana Patton, PhD, ABPP, CDCES, Study director, Nemours Children's Health