This study investigated views of young people living with Type 1 diabetes regarding the usability, benefits, and challenges of Continuous Glucose Monitoring (CGM) devices. Given the limited availability and high cost of CGMs in Ghana, the research aimed to understand how these young people navigate their diabetes management with this technology. Through qualitative interviews with ten (10) young people age 15-24 years, the study gathered insights into their daily use of CGMs. The findings revealed that while CGMs significantly enhance blood sugar control and increase awareness of the impact of lifestyle choices on glucose levels, they also presented challenges. Participants reported issues such as high cost of CGMs, technical difficulties, physical discomfort from sensors, and social stigma associated with wearing the devices. Despite these challenges, the study highlighted the potential of CGMs to improve diabetes management for young people, provided that the barriers of cost and usability can be addressed. The study recommends young people should read more about the CGM and how it can be used effectively

Type 1 diabetes (T1D) is a life-threatening chronic condition in which the pancreas produces little or no insulin—a hormone that controls the amount of sugar in a blood to produce energy [1,2]. There is no known prevention for T1D, however, it can be treated effectively with access to vital health services and supplies, living a healthy lifestyle, and monitoring blood sugar [3-6]. Globally, the prevalence of T1D continues to rise [7,8]. In 2022, approximately 8.75 million people were living with T1D, with 1.52 million under the age of 20 [9,10]. The exact causes of T1D are unknown [1,11-13]. However, research shows that the possibility of developing the condition increases slightly if a family member has it [11,14,15]. Also, environmental factors, such as exposure to a viral infection, can trigger an autoimmune reaction leading to T1D [12,16]. The potential of early screening and risk monitoring in treating T1D can be pivotal to reducing the risk of diabetes-related complications [17-19].A chronic non-communicable disease (NCD), diabetes can have severe and life-threatening outcomes if not properly managed [20,21]. Glucose self-monitoring, or the use of home-based diagnostic devices to routinely monitor glucose levels, is recommended for people living with diabetes to adjust treatment dosages and prevent dangerous fluctuations in glucose levels [22]. Glucose self-monitoring is, therefore, an integral component of diabetes management [23,24]. There are two broad product classes of glucose self-monitoring devices: (1) self-monitoring blood glucose (SMBG) systems whose basic technology has been the standard of care for decades; and (2) continuous glucose monitoring (CGM) systems, which are a newer, more expensive, and technologically advanced product class [23,24]. However, the CGM is one of those advanced approaches that track blood sugar levels in people with diabetes [23,25,26]. Unlike traditional finger-prick tests, CGM devices measure glucose in the fluid between body cells every few minutes. CGM is wearable technology that tracks patients’ glucose (sugar) levels over time [26-28]. It measures the glucose level in the interstitial fluid just under patient’s skin 24 hours a day while wearing the device [30,31]. Managing diabetes involves managing blood sugar levels [21]. A CGM gives the real-time information on how one’s glucose levels are changing [21]. For type 1 diabetic patients using CGM, they embrace a reduced fear of hypoglycemia and improved quality of life [32-34].  Besides, advances in CGM technology has made lives easier for people living with T1D [35]. Insulin administration and blood glucose (blood sugar) monitoring has transformed from multiple finger pricks in a day to a few swipes on a cell phone [29]. With a CGM, one can see in real time if they are trending high or low and take preventative measures against hypo and hyperglycemia [23,36,37]. Real time CGM monitoring has led to tremendous outcomes for people with diabetes who, without a CGM, may have experienced potentially life-threatening complications [23,38-40]. CGM, since being introduced in recent years, has become a key tool in achieving optimal diabetes management for people living with diabetes [41-44]. However, managing T1D can be a challenge and take time to get used to. Constantly trying to meet blood glucose targets can lead to a feeling of burnout [45]. Yet, maintaining a healthy blood sugar range is the best way to avoid health complications [29]. It is recommended that all people living with T1D should have equitable access to the most effective diabetes management systems, including technology which is clinically appropriate, regardless of age or concessional status [46,47]. Nonetheless, the willingness of the person with T1D and their engagement with technology should be key in deciding to either start or continue all devices [48-50].While CGM is more often recommended for people with T1D [39,51-54], Deeb et al. [55], however, recognizes that there are several barriers that can lead to discontinuation of CGM, including pain, skin reactions, concerns around accuracy, sensor loss, interference with daily activity, and alarm fatigue. Besides, research on CGM has mostly focused on its usage in high-income countries, leaving a gap in our understanding of how young people living with T1D in low-resource settings like Ghana perceive the technology [56-59]. Based on this, the study aimed to fill this gap by investigating views of young people living with T1D on CGM usage, benefits and challenges in Ghana. Specifically, the study seeks to: (1) evaluate the usability of CGM among young people living with T1D in Ghana; (2) examine the benefits of using CGM among young people living with T1D in Ghana; and (3) analyse the challenges associated with CGM use among young people living with T1D in Ghana.

Research Philosophy  
The study is grounded in interpretivism, a research philosophy that focuses on understanding the subjective experiences and meanings that individuals attach to their reality [60,61]. This approach is appropriate for investigating the personal and lived experiences of young people living with T1D, as the use of CGM devices is influenced by personal, social, and environmental factors [60,61]. Interpretivism allows for a more in-depth understanding of how these young people perceive the usability of CGM devices and how the devices impact their daily lives [60,61].
Study Design 
This study used a cross-sectional descriptive design to investigate the views of young people living with T1D on the use of CGMs. The design was chosen because it enables researchers to gather detailed information about a phenomenon at a single point in time [63,64]. 
Study Area and Participants
The study focused on young people from Accra and Kumasi, the two largest cities in Ghana. These locations were chosen because CGM devices are not easily available in Ghana and are often imported at high costs. Despite these challenges, some families in these cities have managed to obtain and use. Hence, making them ideal population for the study. 
Inclusion And Exclusion Criteria
In this study, participants were selected based on specific criteria to make sure they were suitable for the study. For a participant to be part of the study, he or she must be: (1) diagnosed with T1D for at least one year. (2) not less than or older than 15-24years, (3) using CGM device for at least one month and (4) willing to participate. However, young people who do not meet the criteria were excluded from the study. The study enrolled young people because they represent a vulnerable group in diabetes management. Hence, they deal with challenges such as increased independence, peer pressure, and the complexities of managing a chronic illness during a critical developmental stage [65-67]. 
Sampling Technique  
This study employed purposive sampling and snow balling approach to select participants who met the specific inclusion criteria. Purposive sampling allows the researcher to intentionally select individuals who have relevant experiences and can provide valuable insights into the research objectives [68-70]. This study was supported by theory of saturation. This is achieved when no additional themes or insights emerge from the data collection, and all conceptual categories have been explored, identified, and completed [71].
Interview Guide
The interview guide was developed based on the research objectives and consisted open-ended questions to facilitate rich detailed responses. The guide was divided into three main sections: (1) Usability of CGM Devices (How long have you been using the CGM device? How easy or difficult is it to use the CGM in your daily life? What challenges do you face when using the device? And What features of the CGM do you find most helpful?) (2) Benefits of Using CGM Devices (How has the CGM helped you manage your diabetes? Have you noticed any changes in your glucose levels since you started using the CGM? And How has CGM use impacted your daily activities and lifestyle?) (3) Challenges of CGM Use (Have you experienced any technical issues with the device? Do you experience any physical discomfort from wearing the sensor? How do others react to you wearing a CGM device? And Is the cost of the device affordable for you and your family?)
Data Collection Procedure
Semi-structured interviews were used as the primary method of data collection. This approach was selected because it allows for flexibility in the conversation while ensuring that all key topics related to the research objectives are covered [72,73]. Semi-structured interviews enable participants to express their thoughts and experiences openly, providing in-depth insights into their use of CGM devices [72]. The interviews were conducted through phone interviews, depending on the participants’ preferences and availability. The interviews were conducted in the English language and lasted for 10 minutes. Also, the interviews were recorded for transcription. Interview guide was used to ensure consistency. However, follow-up questions were asked to encourage participants to elaborate on their experiences. The choice of a qualitative method allowed for a deeper exploration of personal experiences, providing rich data that goes beyond mere statistics to understand the nuanced ways in which these young people interact with CGM technology [74,75]. The use of phone interviews ensured that participants could comfortably share their experiences without the pressure of face-to-face interactions, which can sometimes inhibit honest responses [76-78]. This method also allowed for flexibility in scheduling, accommodating the busy lives of the adolescents, many of whom are balancing school, work, and diabetes management [79,80]. 
 

The data collected through the phone interviews were analyzed using deductive thematic analysis, a qualitative method that involves identifying, analyzing, and reporting patterns (themes) within the data [81,82]. Thematic analysis was chosen because it allows for the systematic exploration of key themes related to the usability, benefits, and challenges of CGM devices [83,84]. This process involves careful steps to ensure that the findings accurately reflect the lived experiences of the participants. The process usually starts with transcription, followed by familiarization thus carefully readings of the transcripts multiple times to understand patterns in the data. The data was coded by highlighting significant phrases and labelling them with short descriptions. These codes were then grouped into broader themes that represented the key issues discussed by the participants, such as economic challenges, psychological benefits, and social difficulties related to CGM use. Finally, the findings were reported, with direct quotes from participants to illustrate the main themes.

Ethical Consideration 

Ethical issues were key part of the study. As a result of this, the research protocol was submitted to The University of Health and Allied Sciences Ethical Review Committee (UHAS-REC) for ethical approval. This was done to assure that the study was in accordance with ethics. Following the submission of the research protocol, The UHAS-REC approve the research protocol and granted ethical clearance with ID number UHAS-REC A./111/21-22. However, in the field, an oral informed consent was obtained from participants age 18-24 while participants below 18years assented after their parents had consented. Also, participation was made voluntary due to this, participants were not restricted from withdrawing from the study at any time they deemed appropriate without any consequences. Again, participants’ privacy and confidentiality were guaranteed. They were told that the information they provide would be used for academic purpose alone and that whatever information they provide would be kept confidential from third parties. On anonymity, data collected were devoid of names, contacts and anything which could identify a participant to a data. Then, the results were also reported in a manner that protected the identities of the participants. 

Trustworthiness 

To ensure trustworthiness of the study, effort was made to satisfy the four dimensions of trustworthiness in qualitative study. Namely:  Credibility, transferability, dependability, and confirmability. To achieve credibility, we employed rigorous in-depth interviews to gather comprehensive and accurate data. Additionally, we considered member checking where some participants were made to review and verify the accuracy of our interpretations just to ensure that the findings align with participants’ views. Further, on transferability, we made sure we provided detailed descriptions of the research context, including the setting, participants enrolled, and relevant background information. We were convinced that by offering thorough contextual information, readers can assess the applicability of the findings to their own contexts or populations hence, transferability. Further more, we ensured dependability by maintaining clear and transparent documentation of the research process, including data collection procedures, data analysis techniques, and interpretation methods. By documenting each step of the research process, we assumed it will enable others to replicate the study and verify its findings. Then, on confirmability, we maintained reflexivity, where we critically reflected on our own biases and assumptions throughout the research process. Also, we engaged in peer debriefing or member checking, where colleagues or participants reviewed and provided feedback on the interpretations we made to the data. 

Socio-Demographic Characteristics of Participants
The study comprised 60

The study revealed that CGMs are generally easy to use for most young people living with type 1 diabetes, especially after gotten used to the device. The participants appreciated that CGMs allowed them to check their blood sugar levels without having to prick their fingers all the time. This is a significant advantage because frequent finger-pricking can be painful and disruptive, especially for adolescents who need to monitor their blood sugar several times a day. The convenience of CGMs makes it easier for participants to keep track of their blood sugar levels throughout the day, which is crucial for managing their diabetes effectively. This finding corroborated with previous researches which found that half of the participants (14 out of 28) found the functionality and services of the CGM device extremely convenient, particularly appreciating the memo feature that allowed them to record changes in blood sugar levels in real-time, thereby gaining confidence in its accuracy [85,86]. This finding purport that when a medical device is easy to use, it increases the likelihood that people will consistently use it. However, a significant proportion of the participants narrated the challenges they encountered with CGMs use. The most cited was connectivity which indicates that the sensor might not be close to the transmitter. If it happens, it might not make the device to be able to track their blood sugar levels continuously. Mostly, when the device loses connection, it causes anxiety because the users might not be sure if their blood sugar levels are being monitored accurately. For young people, who may already be feeling stressed about managing their diabetes, these technical problems can add to their frustration and make them less likely to trust the device. Improving the reliability of CGMs, particularly the stability of the connection between the sensor and the transmitter, could significantly enhance the user experience. If the devices work more consistently, it would likely increase users’ confidence in the technology, leading to better and more consistent use of the device. This outcome agrees with a previous study which found that multiple barriers lead to underuse of CGM which includes pain, skin complications related to adhesive strips, alarm fatigue, concerns about accuracy, loss of sensor connectivity, discrepancies compared to capillary glucose readings, and interference with daily activity and exercise [87]. The study found that young people living with diabetes were able to use their CGMs effectively. This finding commemorates the clear guidance they had from healthcare providers and the information found online. Receiving knowledge about CGMs from the right source could play a significant role in the effectiveness and easiness use of the devices. When users, especially young users, are well-informed about how to use a device, they are more likely to use it correctly and get the most benefit from it. This highlights the need for healthcare providers to offer comprehensive training and ongoing support to ensure that users are comfortable with their CGMs and know how to use them properly. For many adolescents, using a CGM might be their first experience with advanced medical technology, and it can be challenging to learn how to use it. Without proper guidance, they might struggle with the device, leading to frustration and possibly even abandonment of the technology. Healthcare providers play a key role in this process. By providing clear instructions, answering questions, and offering continued support, they can help teenagers feel more confident in using CGMs, which can improve their overall diabetes management. This finding is in line with a previous study that structured education programs that accompany CGM have shown to improve glycemic management, improve patient knowledge and self-management skills [88]. The study found better control of blood sugar levels as one of the benefits. CGMs provide real-time information about blood sugar levels, allowing users to make immediate adjustments to their insulin doses, diet, or physical activity. This real-time monitoring is especially important for adolescents, who may experience rapid changes in blood sugar levels due to their active lifestyles and changing bodies [23]. By providing continuous data, CGMs help prevent both high and low blood sugar levels, which are critical to avoiding complications and staying healthy. This benefit is supported by other research, which shows that CGMs can significantly improve blood sugar control in people with diabetes. By using a CGM, adolescents can keep their blood sugar levels more stable, which reduces the risk of both short-term problems, like fainting from low blood sugar, and long-term complications, like damage to the eyes or kidneys from high blood sugar. For young people who are still learning how to manage their diabetes, having a tool that provides real-time feedback can be incredibly valuable. This finding corroborated with previous studies which found that CGM and intermittently scanned CGM (is-CGM) have shown to effectively manage diabetes in the specialty setting [39,89,90]. Further, the study found that CGMs helped young people become more aware of how their lifestyle choices affected their blood sugar levels. For example, participants noticed how different foods or activities impacted their blood sugar, which helped them make better decisions about what to eat and how active to be. This kind of awareness is crucial for managing diabetes effectively because it allows participants to see the direct consequences of their actions on their health.  This increased awareness empowers young people to take more control over their diabetes management aligning with a study which found that diabetes education is crucial for understanding and controlling T1D. It includes personalized sessions, webinars, group classes, and clinics that provide customized therapies. Comprehensive education enhances glycemic control and family dynamics. Nevertheless, the implementation of diabetes education for families requires specific standards, especially in the field of nursing [91]. When patients can see how their choices affect their blood sugar levels, they are more likely to make healthy decisions and stick to their treatment plans. This sense of control is especially important for adolescents, who are at a stage in life where they are seeking more independence. By using CGMs, they can take charge of their health in a way that feels empowering rather than restrictive. The study also highlighted psychological benefits of using CGMs. Many participants reported feeling less anxious about their blood sugar levels because the CGM continuously monitored their glucose levels. This reduction in anxiety allowed them to participate more fully in daily activities, such as sports, social events, and school, without constantly worrying about their diabetes [92-94]. This improved quality of life is a major benefit of using CGMs, as it helps adolescents live more normal, active lives while managing their diabetes. Other studies have also found that CGMs can reduce the stress and burden of diabetes management by providing continuous monitoring and reducing the need for frequent finger-prick tests. By making diabetes management easier and less intrusive, CGMs can help adolescents feel more confident and less overwhelmed by their condition [95-98]. The study found high cost, and physical discomfort as major challenges associated with CGMs use among young people living with diabetes. The reason for participants reporting high cost of the CGMs as a challenge reason could be that they found CGMs and its sensors to be expensive and that replacing them was not easy for them. Hence, serving as a significant barrier for participants. This outcome refuted previous studies which found that cost was not a major reason for noncompliance with the CGM use [55,99]. On the contrary, the outcome corroborated with previous researches which found that cost, concerns related to accuracy and reliability of measurements, insertion, adhesion and removal issues all emerged as barriers to CGM use. Further, the authors affirmed that the high cost of CGM imposes a heavy financial burden on patients for long-term use [100,101]. While CGMs offer many advantages, their high price makes them inaccessible to many people who could benefit from them. This is particularly problematic in low-income regions, where access to advanced medical technology is already limited. The high cost of CGMs can prevent many families from using this potentially life-changing technology, which could widen the gap in health outcomes between those who can afford the devices and those who cannot. The physical discomfort reported by young people living with type 1 diabetes could affect the wearing of the sensors consistently thereby affecting how well the CGMs work. This issue of discomfort is also supported by other researches, which has found that some users experience irritation or discomfort from the sensors, especially after wearing them for several days [85,97,102]. For young people, who are already dealing with the challenges of managing a chronic condition, this additional discomfort can be discouraging and may lead to inconsistent use of the device. The study found that young people felt uncomfortable in social situations using the CGMs. The reason for this finding could be that participants were not pleased and that felt awkward or embarrassed with the questions people ask them about the device or stare at them. This social stigma can deter young people living with T1D to stop using the CGMs. This social stigma can be a significant challenge for some young persons who might already be having ill-feeling about their peers because of their health condition. This social discomfort is a significant issue that calls on healthcare professionals to help educate the general public to refrain from the stigmatization so as to enable young people living with T1D use their CGMs effectively to help monitor their glucose levels. Hence, if they embarrassed about wearing the device, they might avoid using it in public or even stop using it altogether. And if it does happen, it can lead to poorer management of diabetes and increased health risks. Addressing this social challenge will be crucial for ensuring that young people living with T1D feel comfortable and confident to use their CGMs in all aspects of their endeavors. This finding corroborated with a previous study which found that curiosity of others can make CGMs use uncomfortable and potentially limit their social interactions with others [103].

The findings of this study demonstrate that CGM devices offer significant benefits, particularly in improving glucose management and reducing the frequency of hyperglycemic and hypoglycemic episodes. Participants reported feeling they were in control of their diabetes, as the real-time feedback provided by CGMs allowed them to make more informed decisions about their insulin use, diet, and physical activities. This sense of control contributed to an improved quality of life, as participants were able to engage in daily activities with less anxiety about their blood sugar levels. However, the study also revealed some challenges associated with CGM use. The high cost of CGM devices and sensors was a major barrier for many participants, making it difficult for them to use the technology consistently. Technical issues such as device malfunctions and the need to stay within close proximity to the sensor were also reported as significant challenges. Additionally, the social stigma associated with wearing a visible medical device was a concern for some participants leading to feelings of self-consciousness and discomfort in social situations.
Limitations of the Study
This study has a few limitations which are; small sample size, geographic limitation, and limited duration. The study only included ten participants. While we gained detailed insights from these participants, the small number of participants means that the findings might not apply to all young people with Type 1 diabetes in Ghana. The experiences of these ten individuals might not represent everyone else’s experiences. Also, the study was conducted only in Accra and Kumasi, two large cities in Ghana. These cities may have better access to healthcare and resources than rural areas. So, the findings might not reflect the experiences of young people living in smaller towns or villages, where managing diabetes could be even more challenging. The study was also conducted over a short period. Because of this, we might not have captured how the participants’ experiences with CGM devices change over time.  This study provides useful insights into how CGM devices are used by young people living with T1D in Ghana, these limitations suggest that the findings should be interpreted with some caution. Future studies could include more participants from different areas and take place over a longer period
Recommendations For healthcare providers, this study suggests that more support and information are needed to help young people living with T1D to use CGMs effectively. Providing training and ongoing support can help users overcome initial challenges and use the devices to their full potential. Additionally, making CGMs more    affordable and improving their design to reduce discomfort and social stigma could help more young people living with T1D benefit from this technology.
Recommendations for Future Research
Future research could explore ways to make CGMs more affordable and comfortable to use, especially in low-income settings. It could also look at strategies to reduce the social stigma associated with wearing CGMs, perhaps by developing more discreet designs or by increasing public awareness about the benefits of the technology. Additionally, studies could examine the long-term impact of CGM use on health outcomes and quality of life for young people living with T1D.Declaration
Abbreviations
CGM Continuous Glucose Monitor
CGMs Continuous Glucose Monitors
IDF International Diabetes Federation
SMBG Self-Monitoring Blood Glucose
T1D Type 1 Diabetes
UHAS-REC University of Health and Allied Sciences Ethical Review Committee
Ethical Approval 
The study obtained ethical clearance with ID number (UHAS-REC A./111/21-22.) from the University of Health and Allied Sciences Ethical Review Committee (UHAS-REC). This was done to assure that the study was in accordance with ethics. This approval process assure that the survey adheres to ethical guidelines and protects the rights of participants. 
Consent for publication
Participants were informed that the information they provide would be used for academic purposes thus to satisfy a requirement for an undergraduate certificate and also for publication just to add to academic literature. 
Availability of Data and Materials
The study made used of primary data which restricted sharing it publicly hence it contains some sensitive information about the participants. However, it can be made available upon request from the corresponding author through yiadomb587@gmail.com (Anthony Edward Boakye) University of Cape Coast, Ghana.
Competing Interests
No conflict of interest was declared. 
Funding
The authors did not receive any fund.
Authors’ Contributions
Derrick Anim Yeboah Contribution: conceptualise the study, methodology, data curation, formal analysis, and writing – review & editing.              
Anthony Edward Boakye Contribution: conceptualise the study, methodology, data curation, formal analysis, and writing – review & editing.  
Rita Tekpertey Contribution: Writing – original draft, formal analysis, data curation, and proof reading.       
 

We acknowledge the participants for owning out to participate in the study which helped us to obtain the needed data for the study. We are also indebted to the field assistance for assisting in the data collection we say bravo.