How Camps Can Help Adolescents Self-Manage Diabetes

by Ron Ramsing, Ph.D., and Eddie Hill, Ph.D.

Understanding how summer camps that utilize intentional programming are well situated to better meet the needs of campers is extremely valuable. The following study was presented at the 2006 Camp Research Symposium held at the American Camp Association National Conference and provides some practical applications for camp directors and camp professionals to consider for the future.

The Role of Theory-Based Programming in Camp: A Three-Year Evaluation of Diabetes Camps


With a strong tradition for more than 150 years, summer camps have been shown to be a supportive and beneficial environment for youth, especially for children and adolescents facing a variety of medical conditions (Winfree, Williams, & Powell 2002). With diabetes (type 1) being considered one of the most psychologically and behaviorally demanding chronic illnesses facing adolescents (Cox & Gonder-Fredrick 1992), the potential for camps to positively impact the lives of adolescents is great. The ultimate goal for an adolescent diagnosed with type 1 diabetes is effective self-management, resulting in his or her physiology emulating that of a nondiabetic body (Andrews 2000).

Self-determination theory (SDT) has been successfully applied to individuals with diabetes as a way to influence individual motivation for diabetes self-management (Williams, Freedman, & Deci 1996, 1998; Williams, McGregor, Zeldman, Freedman, & Deci 2004). Self-determination theory postulates that individuals whose behaviors originate from volition or choice as compared from control or pressure are more prone to long-term adherence to particular goal-oriented behaviors (Williams, Freedman, & Deci 1998). With SDT as a theoretical foundation, programming with intention has been successfully used in organized camps in effort to increase measurable outcomes. Applying a Benefits-Based Programming (BBP) approach (Hurtes, Allen, Stevens, & Lee 2000) to camp with the target outcome of increased self-determination for diabetes self-management provides adolescents the opportunity for better adherence to appropriate diabetes regimen.

Autonomy supportive environments are needed for individuals to take ownership of their behavior (Ryan & Deci 2000). Autonomy supportive environments require providing an environment involving choice, perspective taking, and rationale provision (Sheldon, Williams, & Joiner 2003). Choice allows for ownership, perspective taking offers a sense of empathy and understanding, and rationale provision may limit perceptions of control (Deci & Flaste 1995).

Although the research using summer camps appears to be promising (Hill, 2004; Sibthorp, Paisley & Hill 2003), there is limited understanding of how camps positively influence adolescents with diabetes and the specific mechanisms within camps that may foster outcomes for increased diabetes self-management. Therefore, the purpose of these studies was to examine the effects of intentionally programmed camps on motivation for diabetes management among adolescents with type 1 diabetes and explore the specific mechanisms within camp that may foster perceptions of autonomy support.

Results and Discussion

Using SDT as a foundation for intentional programming with a target outcome of increased self-management, research on organized summer camps and wilderness programs was conducted over a consecutive three-year period ending in 2004. Research also focused on the specific mechanisms within camp that could foster perceptions of autonomy support.

Utilizing a BBP design, the Recreation Opportunities for Adolescents with Diabetes (ROAD) program was created in 2002 to assess self-management of diabetes and autonomous behavior. The findings from the study were used to design a program in 2003 for teens participating in an existing summer diabetes camp. Finally, based on theoretical underpinnings of autonomy support (Deci & Ryan 2004), and the previous research on BBP applied to diabetes camps, the Activity Specific Autonomy Support Questionnaire was created to provide insight into perceptions of autonomy support by campers participating in a six-day, residential camp program during the summer of 2004.

Results from the BBP portion of the study that targeted competence, autonomy, and relatedness for diabetes management indicated that participants in a wilderness program increased their sense of relatedness and their autonomous regulation of diet. Participants in an adapted camp program reported an increase in self-efficacy for diabetes care over the comparison group (Sibthorp, et al. 2003). Moreover, the results of the research suggest that an autonomy supportive camp staff were an important component and predictor of competence, autonomy, and relatedness for diabetes management post camp (Hill & Sibthorp 2006).

In an attempt to isolate the specific camp experiences and participant characteristics in camp that yield increased perceptions of autonomy support for adolescents with diabetes, nature of competition (competitive and noncompetitive) and instructional approaches (leader-centered and camper-centered) were found to influence male and female campers perceptions of autonomy. Specifically, females indicated lower perceptions of autonomy support in competitive activities and events that used a leader-centered format for instruction, compared to their male peers.

Practical Applications

Camps utilizing a benefit-based approach to programming in conjunction with an understanding of specific camp experiences and participant characteristics are better positioned to meet the needs of adolescents diagnosed with diabetes. The findings suggest that autonomy supportive techniques and approaches can be fostered through effective training. The findings also suggest that traditional competitive activities may thwart opportunities for autonomy support, and leader-centered instruction in camp may not be the most effective approach to working with adolescents with diabetes as related to autonomy support. Finally, perceptions of autonomy support vary by gender, suggesting that meeting the needs of campers should include awareness of gender differences in nature of competition and instruction type.

Research Highlights

  • Benefits-based programming serves as a framework for camp and better positions recreation professionals to meet the needs of youth development:
    1. identify desired outcomes;
    2. program for those specific outcomes;
    3. assess the outcomes; and
    4. share findings with organizations that can benefit from results.
  • Benefits-based programming resources and research:
    • Allen, L., Stevens, B., Hurtes, K., & Harwell, R. (1998). Benefits-based programming of recreation services training manual. Ashburn, VA: National Recreation and Park Association.
    • Allen, L., Cox, J., & Cooper, N. (2006). The impact of a summer day camp on the resiliency of disadvantaged youths. Journal of Physical Education, Recreation, and Dance, 77(1),12-23.
  • Camps that provide activities based on an understanding of sex differences are better suited to increase campers’ perceptions of autonomy support.
  • Experiences may be effectively engineered to meet the needs of campers. Programming with intention, such as through the use of the benefits-based programming model, can better meet the needs of participants. For example, in a diabetes camp multiple education sessions could be offered with the intent of providing choice. In this example, choice is the intended outcome of the program and is essential for diabetes self-management.
  • Evidence exists that practitioners can create intentional activities that provide for authentic experiences. Camp programs that are perceived as being highly controlling potentially inhibit genuine emotions and feelings. Real experiences may be enhanced by camper-centered versus leader-centered approaches. For example, in wilderness settings campers may be responsible for their own shelter and food preparation. Intentional programs that focus on camper-centered activities result in a sense of authenticity that has been shown to increase independence.
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Cox, D. J., & Gonder-Frederick, L. (1992). Major developments in behavioral diabetes research. Journal of Consulting Clinical Psychology, 60, 628-638.
Deci, E. L., & Flaste, R. (1995). Why we do what we do. New York: Penguin Books.
Deci, E. L., & Ryan, R. M. (2004). Self-determination theory: An approach to human motivation and personality. Retrieved March 2, 2004, from
Hill, E. & Sibthorp, J (2006). Autonomy support at diabetes camp: A self-determination theory approach to therapeutic recreation. Therapeutic Recreation Journal, 40, 21-24.
Hill, E. (2004). The effects of an intentional recreation program on internalization of type 1 diabetes management among adolescents. Doctoral dissertation, University of Utah, Salt Lake City.
Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development and well-being. American Psychologist, 55, 68-78.
Sibthorp, J., Paisley, K., & Hill, E. (2003). Intentional programming in wilderness programs. Journal of Physical Education, Recreation, and Dance, 74(8), 21-24.
Williams, G. C., Freedman, Z. R., & Deci, E. L. (1996). Promoting motivation for diabetes self-regulation of HbA1c. Diabetes, 45, 13.
Williams, G. C., Freedman, Z. R., & Deci, E. L. (1998). Supporting autonomy to motivate glucose control in patients with diabetes. Diabetes Care, 21, 1644-1651.
Williams, G. C., McGregor, H. A., Zeldman, A., Freedman, Z. R., & Deci, E. L. (2004). Testing a self-determination theory process model for promoting glycemic control through diabetes self-management. Health Psychology, 23, 58-66.
Winfree, C., Williams, R., & Powell, G. (2002). Children with cancer: Positive benefits of camp. Camping Magazine, 75(6), 27-34.

Ron Ramsing, Ph.D., Western Kentucky University,

Eddie Hill, Ph.D., Old Dominion University.

Consulting editor: Jeff Jacobs has thirteen years of experience as a camp director and currently serves as an associate professor at California Polytechnic State University. His research and teaching focuses on outdoor and camp leadership.

Originally published in the 2007 January/February issue of Camping Magazine.