Parental expectations in the care of their children and adolescents with diabetes

Diabetes current and future translatable therapies

Diabetes is one of the major diseases and concerns of public health systems that affects over 200 million patients worldwide. It is estimated that 90% of these patients suffer from diabetes type 2, while 10% present diabetes type 1. This type of diabetes and certain types of diabetes type 2, are characterized by dysregulation of blood glycemic levels due to the total or partial depletion of insulin-secreting pancreatic β-cells. Different approaches have been proposed for long-term treatment of insulin-dependent patients; amongst them, cell-based approaches have been the subject of basic and clinical research since they allow blood glucose level sensing and in situ insulin secretion. The current gold standard for insulin-dependent patients is on-demand exogenous insulin application; cell-based therapies aim to remove this burden from the patient and caregivers. In recent years, protocols to isolate and implant pancreatic islets from diseased donors have been developed and tested in clinical trials. Nevertheless, the shortage of donors, along with the need of immunosuppressive companion therapies, have pushed researchers to focus their attention and efforts to overcome these disadvantages and develop alternative strategies. This review discusses current tested clinical approaches and future potential alternatives for diabetes type 1, and some diabetes type 2, insulin-dependent patients. Additionally, advantages and disadvantages of these discussed methods.

Managing type 1 diabetes of a child: Parents' perspectives

PURPOSE

Managing type 1 diabetes (T1D) challenges children and their parents. Parents need to learn the necessary skills and later transfer the responsibility of care to their children as they develop. The transition process involves autonomy in behaviour and decision-making. This study explores the shared management experiences of Taiwanese parents and their children with type 1 diabetes.

DESIGN AND METHODS

This study employed a qualitative design using a grounded theory approach. Purposive sampling was used at a medical centre in Taiwan for participant recruitment. Twenty-nine parents of children who had been diagnosed with T1D were interviewed in-depth. Data were analysed using constant comparison and repeated verification.

RESULTS

After a child was diagnosed with T1D, the parents initiated 'Life-long lesson: Growing together with the child on the road to normality'. Three main categories emerged: 'confronting the disease diagnosis', 'establishing supportive and collaborative involvement' and 'assisting the child in building a sense of belonging'. Sub-categories within each significant category were also included.

CONCLUSIONS

Taiwanese parents perhaps have a controlling or directive role for a long period in their child's lives and shared management of their health condition. This study's findings can help healthcare workers better understand the process of parents' shared management of T1D with their children and how to best communicate with children about the disease and care in accordance with the child's stage of development.

Parents' preferences for follow-up care in a type 1 diabetes paediatric population: a survey-based study in Quebec, Canada

OBJECTIVES

Examine variations in parent's preferences for their child's type 1 diabetes (T1D) follow-up care and the determinants of the preferred intensity of care. Clinical guidelines recommend multidisciplinary management of T1D, with follow-up visits with an endocrinologist at least every 3 months in the paediatric population. However, there could be heterogeneity in parents' needs, and preferences in terms of care management may deviate from clinical guidelines.

SETTING

Not applicable.

PARTICIPANTS

Parents who have a child living with T1D and who reside in Quebec, Canada.

INTERVENTION

In collaboration with a patient-partner (a parent of a child with T1D), we developed a survey to collect data from parents of children living with T1D. Our primary outcome of interest was the preferred time in months between two appointments. We ran a probit model to analyse longer time (over 3 months between appointments), compared with the standard of care (3 months or less).

RESULTS

Results suggest that about one-third (33%) of parents want to deviate from the guideline. Parents who want to increase the time between appointments are more experienced in the management of the disease and have higher costs than those who wish to follow the 3-month guideline. The number of years since the diagnosis is positively associated with a preference for a longer time between appointments, while the perceived useful of information provided during the consultation, and a parent having made a change in their professional life were negatively associated with a desire to space out appointments. The child's gender is not a significant factor in parents' preferences.

CONCLUSIONS

Adapting visit protocols could make the health system more efficient to respond to T1D patients and their parent's needs.

Enhancing Care Coordination for Students with Type 1 Diabetes

BACKGROUND

Care coordination for chronic health conditions is critical to academic success, yet concrete strategies on its operationalization in schools are not well reported in the literature. Type 1 diabetes (T1D) is one such condition that requires a team-based approach to care coordination. The purpose of this study was to gain a deeper understanding of how care coordination for T1D currently operates and identify strategies for its support and facilitation in schools.

METHODS

Focus groups were conducted with school nurses, parents of T1D children, and providers in each of the 9 Educational Service Districts in Washington State. Recorded notes were analyzed using content analytic techniques.

RESULTS

Five major themes emerged from the data, each with 3 to 4 second-order themes. Care coordination depended on family, school, and child developmental contexts, knowledge/experience about T1D among school nurses, teachers, parents, and providers, access and availability of team members, communication, and relationships.

CONCLUSIONS

Findings highlight the importance of a contextualized and holistic perspective of facilitators and barriers to care coordination in schools. Promoting the development of supportive relationships and effective team-based approaches provides a foundation and informs intersectional care coordination for all children with chronic conditions.

Filling gaps in type 1 diabetes and exercise research: a scoping review and priority-setting project

Our team examined the characteristics of patient engagement (PE) practices in exercise-based randomized trials in type 1 diabetes (T1D), and facilitated T1D stakeholders in determining the top 10 list of priorities for exercise research. Two methodological approaches were employed: a scoping review and a modified James Lind Alliance priority-setting partnership. Published (Medline, Embase, CINAHL and Central databases) and grey literature (www.clinicaltrials.gov) were searched to identify randomized controlled trials of exercise interventions lasting minimum 4 weeks and available in English. We extracted information on PE and patient-reported outcomes (PROs) to identify if patient perspectives had been implemented. Based on results, we set out to determine exercise research priorities as a first step towards a patient-engaged research agenda. An online survey was distributed across Canada to collect research questions from patients, caregivers and healthcare providers. We qualitatively analyzed submitted questions and compiled a long list that a 12-person stakeholder steering committee used to identify the top 10 priority research questions. Of 9962 identified sources, 19 published trials and 4 trial registrations fulfilled inclusion criteria. No evidence of PE existed in any included study. Most commonly measured PROs were frequency of hypoglycemia (n=7) and quality of life (n=4). The priority-setting survey yielded 194 submitted research questions. Steering committee rankings identified 10 priorities focused on lifestyle factors and exercise modifications to maintain short-term glycemic control. Recent exercise-based randomized trials in T1D have not included PE and PROs. Patient priorities for exercise research have yet to be addressed with adequately designed clinical trials.

Development of an eHealth Program for Parents of Adolescents With Type 1 Diabetes

Purpose The purpose of this study was to understand the experience of parenting an adolescent with type 1 diabetes (T1DM), to develop a prototype of an eHealth program for parents of adolescents with T1DM, and to evaluate the prototype content and acceptability from the perspective of parents and health care providers. Methods A multiphase method was used generating both qualitative and quantitative data at multiple time points. There were 27 parents of adolescents aged 12 to 18 years with T1DM and 16 health care providers who participated in semistructured interviews to identify parental challenges; 53 parents and 27 providers evaluated the prototype. Thematic content analysis was used to analyze interview transcripts, and descriptive statistics were used to summarize survey data. Results Challenges experienced by parents of adolescents with T1DM included understanding the developmental and hormonal changes of adolescence that affect diabetes care, feeling tension between adolescent independence and parent control, communicating without nagging or conflict, transferring diabetes care responsibility safely, dealing with feelings of stress and distress, and perceiving a lack of resources for T1DM care and insufficient personal time for self-care. In the prototype evaluation, both parents and providers found content to be relevant and provided feedback to guide the development of the full program. Conclusions Parents of adolescents with T1DM and providers expressed a need for parents to have more support in transitioning diabetes care from parent to adolescent. eHealth programs offer an ideal way to address these needs and ultimately can be linked to electronic medical records improving quality and efficiency of health care in this population.

Sugarsquare, a Web-Based Patient Portal for Parents of a Child With Type 1 Diabetes: Multicenter Randomized Controlled Feasibility Trial

Background

Raising a child with type 1 diabetes (T1D) means combining the demands of the disease management with everyday parenting, which is associated with increased levels of distress. A Web-based patient portal, Sugarsquare, was developed to support parents, by providing online parent-professional communication, online peer support and online disease information.

Objective

The first aim of this study was to assess the feasibility of conducting a multicenter, randomized controlled trial in Dutch parents of a child with T1D. The second aim was to assess the feasibility of implementing Sugarsquare in clinical practice.

Methods

The parents of 105 children (N=105) with T1D below the age of 13 participated in a 6-month multicenter randomized controlled feasibility trial. They were randomly assigned to an experimental (n=54, usual care and Sugarsquare) or a control group (n=51, usual care). Attrition rates and user statistics were gathered to evaluate feasibility of the trial and implementation. To determine potential efficacy, the parenting stress index (PSI-SF) was assessed at baseline (T0) and after 6 months (T1).

Results

Of a potential population of parents of 445 children, 189 were willing to participate (enrollment refusal=57.5%, n=256), 142 filled in the baseline questionnaire (baseline attrition rate=25%, n=47), and 105 also filled in the questionnaire at T1 (post randomization attrition rate during follow-up=26%, n=32). As such, 24% of the potential population participated. Analysis in the experimental group (n=54) revealed a total of 32 (59%) unique users, divided into 12 (38%) frequent users, 9 (28%) incidental users, and 11 (34%) low-frequent users. Of the total of 44 professionals, 34 (77%) logged in, and 32 (73%) logged in repeatedly. Analysis of the user statistics in the experimental group further showed high practicability and integration in all users, moderate acceptability and demand in parents, and high acceptability and demand in health care professionals. Baseline parenting stress index scores were related to the parents’ frequency of logging on (ρ=.282, P=.03) and page-views (ρ=.304, P=.01). No significant differences in change in parenting stress between experimental and control group were found (F_3,101=.49, P=.49).

Conclusions

The trial can be considered feasible, considering the average enrollment refusal rate, baseline attrition rate and postrandomization attrition rate, compared to other eHealth studies, although lower than hypothesized. Implementing Sugarsquare in clinical practice was partly feasible, given moderate demand and acceptability in parent users and lack of potential efficacy. Parents who reported higher levels of parenting stress used Sugarsquare more often than other parents, although Sugarsquare did not reduce parenting stress. These results indicate that Web-based interventions are a suitable way of providing parents of children with T1D with additional support. Future studies should determine how Sugarsquare could reduce parenting stress, for instance by adding targeted interventions. Factors potentially contributing to successful implementation are suggested.

Trial Registration

Nederlands Trial Register Number: NTR3643; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3643 (Archived by WebCite at http://www.webcitation.org/6qihOVCi6)

The parental care partnership in the view of parents of children with special health needs

OBJECTIVE To understand how the care partnership was experienced by parents of children with special healthcare needs. METHOD Qualitative, descriptive and exploratory study, carried out from December 2013 to February 2014. The method used was the narrative. The population corresponded to parents of children admitted to a medical service of a Pediatric Hospital in Portugal. The sample consisted of 10 parents. The data collection included the sociodemographic characterization and the etnobiografic orientation interview. Once transcribed, the interviews yielded 10 narratives of partnership experiences between the parents and the nursing team. RESULTS It was noted, as partnership opportunities, the training of parents and the collaborative decision-making, established in a dynamic, unique and ongoing relational process. CONCLUSION The opportunities for partnership are key assumptions for the care delivery focusing on the child and on the parents as their resources.

Trust, Health Care Relationships, and Chronic Illness: A Theoretical Coalescence

Trust in health care relationships is a key ingredient of effective, high-quality care. Although the indirect influence of trust on health outcomes has long been recognized, recent research has shown that trust has a direct effect on outcomes of care. Trust is important. However, the research on trust is disparate, organized around differing definitions, and primarily focused on patients' trust in physicians. Morse's method of theoretical coalescence was used to further develop and elaborate a grounded theory of the evolution of trust in health care relationships, in the context of chronic illness. This middle-range theory offers a clear conceptual framework for organizing and relating disparate studies, explaining the findings of different studies at a higher conceptual level, and identifying gaps in research and understanding. In addition, the grounded theory is relevant to practice.

Managing children with diabetes within the family: Entering into the Diabetes Orbit

Background

Diabetes is the disease of family and parents of children with diabetes face different problems which concerns meeting the developmental needs of children and daily control of children with diabetes. This article aims to explain how to manage diabetes around the child’s life within the family.

Methods

In this qualitative study, data was collected through semi-structured interview technique and was analyzed using Grounded Theory approach. The process of data collection was carried out by purposeful sampling. The participants included 13 individuals from nine families (11 parents and two children with diabetes). The research environment was health centers in Iran providing care to the families of children with diabetes. Data analysis was performed using Corbin and Strauss approach. Data was analyzed with using MAXQDA software (version 10).

Results

The core category of “Entering into the Orbit of Diabetes” addresses the story of how to keep track of managing children with diabetes within the family which included Main categories “bitter taste of sugar”, “drawing coordinates of diabetes”, and “taking control of diabetes”.

Conclusion

The outcome of “enter into the orbit of diabetes” results capturing the control of diabetes. The findings of the present study may play an integral part to help households with practicing appropriate strategies for the management of children with diabetes.

Valuing technology: A qualitative interview study with physicians about insulin pump therapy for children with type 1 diabetes

Insulin pumps for children with type 1 diabetes have been broadly adopted despite equivocal evidence about comparative effectiveness. To understand why and inform policy related to public funding for new technologies, we explored how physicians interpret the value of pumps. We conducted open-ended, semi-structured interviews with 16 physicians from a pediatric diabetes network in Ontario, Canada, and analyzed the data using interpretive description. Respondents recognized that pumps fell short of expectations because they required hard work, as well as family and school support. Yet, pumps were valued for their status as new technologies and as a promising step in developing future technology. In addition, they were valued for their role within a therapeutic relationship, given the context of chronic childhood disease. These findings identify the types of beliefs that influence the adoption and diffusion of technologies. Some beliefs bear on hopes for new technology that may inappropriately hasten adoption, creating excess cost with little benefit. On the other hand, some beliefs identify potential benefits that are not captured in effectiveness studies, but may warrant consideration in resource allocation decisions. Still others suggest the need for remediation, such as those bearing on disparity in pump use by socioeconomic status. Understanding how technologies are valued can help stakeholders decide how to address such beliefs and expectations in funding decisions and implementation protocols.

Parents' experiences, needs, and preferences in pediatric diabetes care: Suggestions for improvement of care and the possible role of the Internet. A qualitative study

PURPOSE

To investigate the needs and preferences of parents of children with type 1 diabetes (T1D) concerning pediatric diabetes care and use of Internet in care.

DESIGN AND METHODS

Parents of 34 children, aged 2-12, with T1D participated in seven focus group interviews.

RESULTS

Analysis revealed provision of tailored care, disease information, peer support, and accessibility of healthcare professionals as major needs in parents. Internet could be used to satisfy these needs.

PRACTICAL IMPLICATIONS

According to parents, diabetes teams should focus on the impact of the disease, parents' experience, and the child's development, and provide online professional and peer support.

Parent experiences raising young people with type 1 diabetes and celiac disease

Authors of this qualitative descriptive study interviewed 30 parents concerning their experiences raising a child or adolescent with type 1 diabetes (T1D) and celiac disease (CD). Analysis revealed six themes: (a) health complications of T1D, (b) challenges of daily disease management, (c) financial concerns, (d) the young person's emotional/mental health, (e) experiences with healthcare providers, and (f) experiences with people outside the family and at school. Results suggest nurses need to be sensitive to challenges young people living with T1D and CD and their parents face, conduct ongoing assessments, and provide time during interactions to adequately address concerns.

Balancing parental involvement with adolescent friendly health care in teenagers with diabetes: are we getting it right?

PURPOSE

Current guidance about adolescent-friendly health care emphasizes the benefits of seeing young people alone for confidential consultations. Yet in young people with Type 1 diabetes mellitus (T1DM), parental involvement has been shown to contribute to better diabetes control. This study aimed to better understand how these apparent tensions are reconciled in clinical practice by identifying how frequently adolescents with T1DM are seen alone and exploring parents' opinions about this.

METHODS

A convenience sample of consecutive parents of adolescents (aged 12-21 years) with T1DM was recruited from the outpatient clinic of a specialist diabetes service and asked to complete a 30-item written survey.

RESULTS

A total of 137 surveys were returned from 146 eligible parents (94%) of whom 106 had complete data. Thirteen percent of adolescents with T1DM had ever been seen alone for a confidential consultation with their doctor. The most common concern for parents about confidential care was not being informed about important information, not just about T1DM, but also about common adolescent risk behaviors and mental health states.

DISCUSSION

These findings suggest that young people with T1DM are not being routinely seen alone for confidential care. This could be attributed to: parents or adolescents declining confidential care; clinicians being time-poor and/or lacking the necessary skills; or a culture of uncertainty about the value of confidential care. A discussion is now required about how best to enact adolescent-friendly care in the chronic-illness outpatient setting, where parental involvement is understood to be important for effective chronic illness management.

Partnerships with providers: reflections from parents of children with type 1 diabetes

Sixty-three parents with a child or an adolescent with type 1 diabetes participated in this study that focused on what helped them "live well with diabetes." Beyond medical expertise, parents described a partnering relationship with their provider as one of the factors that supported their efforts to live well with diabetes. Parents reported that a partnership was enhanced when the provider had the ability to understand the dynamic nature of the journey in living with diabetes, connect with their family and set the tone by inviting them to openly communicate about all aspects of family life impacting diabetes care, recognize when and how the provider may have to assume the role of Captain of the Ship in times of need, and empathize and respond therapeutically to intense emotions inherent in managing diabetes over time.

Acompanhamento de familias de criancas com doenca cronica: percepcao da equipe de Saude da Familia

Este estudo objetivou caracterizar como a equipe da Estratégia Saúde da Família percebe sua dinâmica de acompanhamento de famílias que convivem com a doença crônica da criança. Trata-se de uma pesquisa qualitativa que teve como referencial teórico o Interacionismo Simbólico e como método a Análise de Conteúdo, técnica de análise categorial temática. Para a coleta de dados utilizou-se o grupo focal, que foi desenvolvido com três equipes de Saúde da Família, totalizando 32 sujeitos. Os resultados foram organizados em três categorias temáticas: Peculiaridades das famílias que convivem com a doença crônica da criança; Equipe, família e Estratégia Saúde da Família e Limitações para cuidar. A percepção da equipe é que o desenho da Estratégia Saúde da Família favorece o acesso à experiência familiar, permitindo o reconhecimento de suas especificidades. Os dados revelam ainda as limitações da equipe em sua capacidade de resolução e a necessidade de investimentos na articulação entre os distintos serviços, setores e equipamentos sociais.

Parents' experiences of living with a child with a long-term condition: a rapid structured review of the literature

BACKGROUND

Living with a child with a long-term condition can result in challenges above usual parenting because of illness-specific demands. A critical evaluation of research exploring parents' experiences of living with a child with a long-term condition is timely because international health policy advocates that patients with long-term conditions become active collaborators in care decisions.

METHODS

A rapid structured review was undertaken (January 1999-December 2009) in accordance with the United Kingdom Centre for Reviews and Dissemination guidance. Three data bases (MEDLINE, CINAHL, PSYCINFO) were searched and also hand searching of the Journal of Advanced Nursing and Child: Care, Health and Development. Primary research studies written in English language describing parents' experiences of living with a child with a long-term condition were included. Thematic analysis underpinned data synthesis. Quality appraisal involved assessing each study against predetermined criteria.

RESULTS

Thirty-four studies met the inclusion criteria. The impact of living with a child with a long-term condition related to dealing with immediate concerns following the child's diagnosis and responding to the challenges of integrating the child's needs into family life. Parents' perceived they are not always supported in their quest for information and forming effective relationships with health-care professionals can be stressful. Although having ultimate responsibility for their child's health can be overwhelming, parents developed considerable expertise in managing their child's condition.

CONCLUSION

Parents' accounts suggest they not always supported in their role as manager for their child's long-term condition and their expertise, and contribution to care is not always valued.