Gender, adolescence and the management of diabetes

Psychometric Properties of the Revised Self-Efficacy for Diabetes Self-Management Scale among Spanish Children and Adolescents with Type 1 Diabetes

A longitudinal design was used to examine the psychometric properties of the Self-Efficacy for Diabetes Self-Management (SEDM) for children and adolescents with a diagnosis of type 1 diabetes (T1D). The SEDM was adapted to Spanish and the best factorial solution was selected to test the invariance of the measures of age and gender. Individuals between the ages of 10 and 19 years old with a diagnosis of T1D completed a self-reported questionnaire (167 at Time 1 [mean age = 14.49, SD = 2.76; 56.9% boys] and 122 at Time 2 [mean age = 14.77, SD = 2.58; 56.6% boys]). Two unifactorial solutions were tested. The psychometric properties of the scale were validated. The proposed validation obtained excellent reliability indices (χ2 (26) = 25.59, p > 0.49, RMSEA = 0.00, 95% CI [0.00, 0.07], CFI = 1.00, GFI = 0.96, AGFI = 0.92, TLI = 1.00, and CMIN = 0.98), and it appeared to be invariant for gender and for age groups. The Cronbach's α was 0.85. The test-retest reliability was high (r = 0.69 [p < 0.001]). Convergent, discriminant, and external validity were proven. The nine-item SEDM is a brief measure with satisfactory structural validity. From our knowledge, this study provides the first reliable tool to assess self-efficacy in the management of T1D for Spanish children and adolescents.

Observing, 'doing' and 'making' gender in Dutch paediatric type 1 diabetes care, at home and in the clinic: Multiple-stakeholder perspectives

AIM

To investigate the perspectives of Dutch care professionals, parents and experts by experience on gender dynamics in paediatric type 1 diabetes care.

DESIGN

Qualitative research design.

METHODS

Fifteen semi-structured interviews were held with care professionals, supplemented by two focus groups with parents of children with diabetes (n = 12 parents) and three semi-structured interviews with two experts by experience and a mother. Two respondent validation interviews were conducted, one with two care professionals and one with an expert by experience. Participant observations were conducted at three clinics, a diabetes sports day, weekend for young people and their families, and a high-school. An inductive framework analysis was done, informed by relational theory on gender.

RESULTS

Care professionals 'did' and 'made' gender differences together with young people, manifesting as communicative difficulties, in particular between female care professionals and young boys. Boys were considered less skilled in articulating their needs compared to girls. At home, care professionals and parents observed, 'did' and 'made' gender differences by perpetuating gendered divisions of labour. As traditional caretakers, mothers risk focusing excessively on the diabetes of their child whilst fathers remained more at a distance.

CONCLUSION

Gender patterns have negative implications on those involved in paediatric type 1 diabetes. Leaving tacit the gendered communicative issues across child-parent and child-care professional dyads, can sustain invisible friction in a care system that normatively expects verbal participation and increased self-management.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Findings may encourage care professionals and parents to engage with the potential impact of gender dynamics on diabetes practices. Incorporating these dynamics as conversational tools would contribute to improving type 1 diabetes care for young people.

The division and transfer of care responsibilities in paediatric type 1 diabetes: A qualitative study on parental perspectives

Aim

To determine which factors other than child age play a role in the division and transfer of diabetes care responsibilities between parents and children with type 1 diabetes.

Design

Qualitative focus group study.

Methods

Across four sites in the Netherlands, 18 parents (13 mothers) of children (9–14 years) with type 1 diabetes participated in four focus groups in 2015–2016, as part of the research project 'Whose diabetes is it anyway?'. Qualitative content analysis and the constant comparison method were used to analyse the data.

Results

According to parents, the transfer process included both direct and indirect tasks, had different levels (remembering, deciding, performing), was at times a difficult and stressful process, and showed large variation between families. A large number of child, parent and context factors were identified that affected the division and transfer of diabetes care responsibilities according to parents. Both positive and negative consequences of the transfer process were described for parental and child health, behaviour and well‐being. Parental final evaluations of the division and transfer of diabetes care responsibilities appeared to be dependent on parenting values.

Conclusion

How families divide and transfer diabetes care tasks appeared to be affected by a complex interplay of child, parent and context characteristics, which had an impact on several parent and child domains.

Impact

Parents struggle with the right timing of transfer, which calls for more support from diabetes nurses. The identified factors can be used as input for integrating a more family‐based approach into current age‐based guidelines, to improve regular care.

Supporting children and young people to assume responsibility from their parents for the self-management of their long-term condition: An integrative review

BACKGROUND

Children and young people with long-term conditions (LTCs) are usually dependent on, or share management with, their families and are expected to develop self-management skills as they mature. However, during adolescence, young people can find it challenging to follow prescribed treatment regimens resulting in poor clinical outcomes. Though reviews have looked at children's and parents' experiences of self-management, none have explicitly examined the parent-to-child transfer of self-management responsibility.

METHODS

An integrative review was conducted with the aim of exploring the parent-to-child transfer of LTC self-management responsibility, through addressing two questions: (a) How do children assume responsibility from their parents for self-management of their LTC? (b) What influences the parent-to-child transfer of this responsibility? Eight databases were searched for papers published from 1995 to 2017. Methodological quality was assessed; included papers were synthesized to identify themes.

RESULTS

Twenty-nine papers were identified. Most papers used qualitative designs and focused on children with diabetes. Participants were predominantly children and/or parents; only two studies included health professionals. Assuming self-management responsibility was viewed as part of normal development but was rarely explored within the context of the child gaining independence in other areas of their life. Children and parents adopted strategies to help the transfer, but there was limited evidence around health professionals' roles and ambivalence around what was helpful. There was a lack of clarity over whether children and parents were aiming for shared management, or self-management, and whether this was a realistic or desired goal for families. Multiple factors such as the child, family, social networks, health professional, and LTC influenced how a child assumed responsibility.

CONCLUSIONS

Evidence suggests that the parent-to-child transfer of self-management responsibility is a complex, individualized process. Further research across childhood LTCs is needed to explore children's, parents', and professionals' views on this process and what support families require as responsibilities change.

Usefulness of Image Theater Workshops for Exploring Dilemmas in Diabetes Self-Management Among Adolescents

Diabetes treatment involves a demanding self-management regime that is particularly challenging to adolescents. There is a need for qualitative research into the specific contexts in which adolescents attempt to balance self-management demands with the needs and desires of adolescent life. This study investigates the usefulness of image theater, a participatory form of theater using the body as an expressive tool, to articulate these dilemmas in daily life contexts. We performed a qualitative analysis of two image theater workshops with 12- to 18-year-old adolescents living with diabetes. Our results show three areas of application: (a) unraveling the contextual complexity of lived experience, (b) the articulation of implicit understandings and underlying motives, and (c) the playful exploration of new behavior. We conclude that image theater is a promising method, especially with respect to the opportunities of a more contextual and action-oriented understanding of the trade-offs made in self-management provide for diabetes education and counseling.

Examining sex differences in glycemic index knowledge and intake among individuals with type 2 diabetes

AIM

We examined self-reported dietary behaviours and actual food intakes among adult men and women with type 2 diabetes participating in Alberta's Caring for Diabetes (ABCD) Study.

METHODS

Participants completed 3-day food records and questions about glycemic index (GI) concept knowledge and dietary behaviours. Daily average GI and glycemic load (GL) were calculated for all carbohydrates consumed. Dietary intake was analyzed using ESHA FoodPro (version 10.13.1). Sex differences in nutrient intakes were explored across categories of GI knowledge and dietary practices.

RESULTS

Participants (N=170) mean (SD) age 65.8 (9.6) years were 46.5% women, 90.6% Caucasian with a mean BMI of 31.3 (7.0)kg/m² and diabetes duration of 13.4 (8.6) years. Overall, 60% of men versus 40% of women consumed carbohydrates in quantities below Acceptable Macronutrient Distribution Ranges (AMDR). About 80% of men versus 90% of women consumed proteins above AMDR whereas 60% versus 65% of women consumed fats above AMDR. Fibre intake among men was lower than recommended (p<0.01). Men who reported having knowledge of the GI-concept also reported lower GI intake versus men who did not (p=0.03).

CONCLUSION

Sex differences exist in low-GI diabetes self-care dietary behaviours among adults with type 2 diabetes participating in this study. Gender-sensitive approaches for enhancing diabetes self-care low-GI dietary behaviour should be explored.

The Lived Experience of Adolescent Females With Type 1 Diabetes

PURPOSE

The purpose of this study was to gain a better understanding of what it means for adolescent females to live with type 1 diabetes.

METHODS

Van Manen's phenomenological framework was used to guide the project of inquiry. Adolescents were recruited from a diabetes camp. A purposive sample of 10 adolescent females, aged 16 and 17 years, volunteered to participate in the study. Unstructured, one-on-one interviews were conducted and participants' accounts were transcribed and analyzed for themes.

RESULTS

Five themes were identified: (1) blending in with the adolescent culture, (2) standing out and being watched, (3) weighing the options and making choices, (4) being tethered to the system and to diabetes, and (5) struggling with conflicts. These adolescent females struggled with several conflicts and choices they were forced to make on a daily basis. They felt tethered to a disease that would never go away and to the healthcare system. Yet, they adopted ways to handle their disease so that it was manageable within the context of their lives. Fitting in with their peers was often more important than diabetes management.

CONCLUSIONS

Making visible the experience of adolescent females living with type 1 diabetes has implications for practice, education, and research in diabetes education.

The Association of Mindful Parenting with Glycemic Control and Quality of Life in Adolescents with Type 1 Diabetes: Results from Diabetes MILES-The Netherlands

The objective of this study was to examine associations between the mindful parenting style of parents of adolescents (aged 12-18) with type 1 diabetes mellitus (T1DM), and the glycaemic control and quality of life (QoL) of the adolescents. Chronic health conditions, such as T1DM, that require demanding treatment regimens, can negatively impact adolescents' quality of life. Therefore, it is important to determine whether mindful parenting may have a positive impact in these adolescents. Age, sex and duration of T1DM were examined as potential moderators. Parents (N = 215) reported on their own mindful parenting style (IM-P-NL) and the adolescents' glycaemic control. Parents and the adolescents with T1DM (N = 129) both reported on adolescents' generic and diabetes-specific QoL (PedsQL™). The results showed that a more mindful parenting style was associated with more optimal hemoglobin A1c (HbA1c) values for boys. For girls, a more mindful parenting style was associated with not having been hospitalized for ketoacidosis. For both boys and girls, a more mindful parenting style was associated with better generic and diabetes-specific proxy-reported QoL. In conclusion, mindful parenting style may be a factor in helping adolescents manage their T1DM. Mindful parenting intervention studies for parents of adolescents with T1DM are needed to examine the effects on adolescents' glycaemic control and their quality of life.

How adolescents with diabetes experience social support from friends: two qualitative studies

Self-management of diabetes is challenging, especially for adolescents who face multiple changes, including closer peer relationships. Few studies have explored how friends can provide constructive support in this effort. The present research investigated, in two qualitative studies, the perceptions of adolescents with diabetes and their friends with respect to the positive social support that friends can offer. In study 1, 28 adolescents aged 12-15 with type 1 diabetes participated in online focus groups. In study 2, 11 of these adolescents were interviewed in person together with their best friends. The data were analysed by means of content analysis. In study 1, the adolescents with diabetes identified various supportive behaviours of friends, particularly concerning emotional support: treating them normally, showing interest, having fun, providing a distraction, and taking their diabetes into account. They differed in their attitude towards support, and this influenced which behaviours they perceived as supportive. Study 2 showed that the adolescents with diabetes and their friends often had similar opinions on the desired degree of support. Fear of stigmatization and sense of autonomy withheld some adolescents with diabetes from soliciting more support. These insights can be useful in patient education aiming to promote social support.

Gender differences in living with diabetes mellitus

CONFLICT OF INTEREST

none declared. The aim of this review is to discuss the gender difference among diabetic population. Metabolic control, age and gender significantly affect their psychosocial responses to disease. Psychosocial problems may also occur secondary to negative diabetes related experiences including diagnosis, increased stress and onset of complications. Although significant problems do not occur in all diabetic population, they occur in few patients. More work is needed in the area of identifying those patients having adjustment difficulties to diabetic related challenges. This review indicates that male diabetics are observed to be living more effectively with diabetes, lesser depression and anxiety but more energy and better positive wellbeing.

Pediatric patient-reported outcome instruments for research to support medical product labeling: report of the ISPOR PRO good research practices for the assessment of children and adolescents task force

BACKGROUND

Patient-reported outcome (PRO) instruments for children and adolescents are often included in clinical trials with the intention of collecting data to support claims in a medical product label.

OBJECTIVE

The purpose of the current task force report is to recommend good practices for pediatric PRO research that is conducted to inform regulatory decision making and support claims made in medical product labeling. The recommendations are based on the consensus of an interdisciplinary group of researchers who were assembled for a task force associated with the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). In those areas in which supporting evidence is limited or in which general principles may not apply to every situation, this task force report identifies factors to consider when making decisions about the design and use of pediatric PRO instruments, while highlighting issues that require further research.

GOOD RESEARCH PRACTICES

Five good research practices are discussed: 1) Consider developmental differences and determine age-based criteria for PRO administration: Four age groups are discussed on the basis of previous research (<5 years old, 5-7 years, 8-11 years, and 12-18 years). These age groups are recommended as a starting point when making decisions, but they will not fit all PRO instruments or the developmental stage of every child. Specific age ranges should be determined individually for each population and PRO instrument. 2) Establish content validity of pediatric PRO instruments: This section discusses the advantages of using children as content experts, as well as strategies for concept elicitation and cognitive interviews with children. 3) Determine whether an informant-reported outcome instrument is necessary: The distinction between two types of informant-reported measures (proxy vs. observational) is discussed, and recommendations are provided. 4) Ensure that the instrument is designed and formatted appropriately for the target age group. Factors to consider include health-related vocabulary, reading level, response scales, recall period, length of instrument, pictorial representations, formatting details, administration approaches, and electronic data collection (ePRO). 5) Consider cross-cultural issues.

CONCLUSIONS

Additional research is needed to provide methodological guidance for future studies, especially for studies involving young children and parents' observational reports. As PRO data are increasingly used to support pediatric labeling claims, there will be more information regarding the standards by which these instruments will be judged. The use of PRO instruments in clinical trials and regulatory submissions will help ensure that children's experience of disease and treatment are accurately represented and considered in regulatory decisions.

Asthma self-management is sub-optimal in urban Hispanic and African American/black early adolescents with uncontrolled persistent asthma

INTRODUCTION

Youth as young as 11 are given responsibility to manage their asthma. Yet, little is known regarding early adolescents' asthma self-management behaviors. This study characterizes urban early adolescents' asthma self-management behaviors and perceived responsibility to manage asthma, exploring demographic differences and examining the relationship between asthma responsibility and disease management.

METHODS

About 317 Hispanic and African American/Black early adolescents (mean age = 12.71) with persistent, uncontrolled asthma reported prevention and symptom management steps, and responsibility for asthma care. We used Poisson, cumulative logistic, logistic, and linear mixed-effects regression models to assess the relationships among demographic predictors, prevention and management behaviors, and responsibility for asthma care.

RESULTS

Fifty percent took 7-9 prevention steps; few saw physicians when asymptomatic or took daily medication. When symptomatic, 92% used medication to treat symptoms and 56% sought medical attention. Controlling for asthma responsibility, fewer older youth reported observing how they feel when asthma is likely to start, observing symptom changes, or asking for help. More boys reported taking medication daily or upon trigger exposure. Controlling for age, gender, and race/ethnicity, those reporting more asthma responsibility were less likely to report taking management steps, seeking preventive care, asking for help, or going to a doctor/hospital for their asthma.

CONCLUSIONS

Early adolescents' asthma self-management is suboptimal. With increasing age, they are less observant regarding their asthma and less likely to seek help. Although they perceive themselves to have greater responsibility for managing their asthma, early adolescents do less to care for their asthma, suggesting they are being given responsibility for asthma care prematurely.

Improving glycaemic control and life skills in adolescents with type 1 diabetes: a randomised, controlled intervention study using the Guided Self-Determination-Young method in triads of adolescents, parents and health care providers integrated into routine paediatric outpatient clinics

BACKGROUND

Adolescents with type 1 diabetes face demanding challenges due to conflicting priorities between psychosocial needs and diabetes management. This conflict often results in poor glycaemic control and discord between adolescents and parents. Adolescent-parent conflicts are thus a barrier for health care providers (HCPs) to overcome in their attempts to involve both adolescents and parents in improvement of glycaemic control. Evidence-based interventions that involve all three parties (i.e., adolescents, parents and HCPs) and are integrated into routine outpatient clinic visits are lacking. The Guided Self-Determination method is proven effective in adult care and has been adapted to adolescents and parents (Guided Self-Determination-Young (GSD-Y)) for use in paediatric diabetes outpatient clinics. Our objective is to test whether GSD-Y used in routine paediatric outpatient clinic visits will reduce haemoglobin A1c (HbA1c) concentrations and improve adolescents' life skills compared with a control group.

METHODS/DESIGN

Using a mixed methods design comprising a randomised controlled trial and a nested qualitative evaluation, we will recruit 68 adolescents age 13-18 years with type 1 diabetes (HbA1c > 8.0%) and their parents from 2 Danish hospitals and randomise into GSD-Y or control groups. During an 8-12 month period, the GSD-Y group will complete 8 outpatient GSD-Y visits, and the control group will completes an equal number of standard visits. The primary outcome is HbA1c. Secondary outcomes include the following: number of self-monitored blood glucose values and levels of autonomous motivation, involvement and autonomy support from parents, autonomy support from HCPs, perceived competence in managing diabetes, well-being, and diabetes-related problems. Primary and secondary outcomes will be evaluated within and between groups by comparing data from baseline, after completion of the visits, and again after a 6-month follow-up. To illustrate how GSD-Y influences glycaemic control and the development of life skills, 10-12 GSD-Y visits will be recorded during the intervention and analysed qualitatively together with individual interviews carried out after follow-up.

DISCUSSION

This study will provide evidence of the effectiveness of using a GSD-Y intervention with three parties on HbA1c and life skills and the feasibility of integrating the intervention into routine outpatient clinic visits. Danish Data Association ref nr. 2008-41-2322.

TRIAL REGISTRATION

ISRCTN54243636.

'Rules' for boys, 'guidelines' for girls: Gender differences in symptom reporting during childhood and adolescence

The emergence of higher reported morbidity in females compared with males is a feature of adolescent health in a large proportion of the world's industrialised countries. In this paper, qualitative data from twenty-five single-sex focus groups (90 participants in total) conducted with 10-, 13-, and 15-year olds in two Scottish schools is used to explore whether symptom reporting is influenced by perceived societal gender- and age-related expectations and the social context of symptom experiences. The degree to which these factors can help explain quantitative evidence of increases in gender differences in symptom reporting during adolescence is also examined. Accounts suggested gender-related expectations act as strict 'rules' for boys and less prohibitive 'guidelines' for girls. An unexpected finding was the extent of similarity between these 'rules' and 'guidelines'. Both boys and girls presented themselves as pressured to react to symptoms in stoic, controlled and independent ways, particularly when in the company of their peers, and both perceived that boys and girls could incur negative consequences if seen to have physical (e.g. stomach ache) or, especially, psychological symptoms (e.g. feeling like crying). These qualitative findings do not suggest that girls are simply more willing than boys to report their symptoms as they get older, which is one potential explanation for the quantitative evidence of increasing gender differences in symptom reporting in adolescence. Rather, the findings suggest a need to highlight both the potentially damaging effects of gender stereotypes which make boys reluctant to seek help for physical and, particularly, psychological symptoms, and the misconception that girls are not similarly reluctant to report illness.

The management of autonomy in adolescent diabetes: a case study of triadic medical interaction

The transfer of responsibility for diabetes management from parent to child has been seen as a central challenge for the clinical care of adolescents with Type 1 diabetes. Research is needed to better understand how clinicians, patients, and families handle the delicate balance between parental involvement and adolescent responsibility for diabetes management. The aim of this study is to investigate the interactional processes by which an adolescent's autonomy is facilitated and constrained in a clinical interaction between a nurse practitioner (NP), a 13-year-old diabetes patient, and the patient's mother. Integrating psychological perspectives on adolescent autonomy and responsibility with conversation analytic approaches to participation, I examine participation frameworks and shifting alignments to illuminate the negotiation of adolescent autonomy within a single clinical encounter. The analysis demonstrates that the patient's autonomy is emphasized while identifying problems, yet restricted when considering solutions. Clinical implications are discussed.

Physician recommendations about maternal involvement in adolescent diabetes management

OBJECTIVE

The purpose of this study was to examine whether perceptions of physician recommendations about maternal involvement in adolescent diabetes management are associated with children's reports of mothers' involvement during the subsequent week.

RESEARCH DESIGN AND METHODS

Youth with type 1 diabetes (aged 10-15 years) and mothers completed scales measuring perceptions of physician recommendations about maternal involvement. At their appointment, and again 1 week later, children reported mothers' involvement in diabetes over the preceding week.

RESULTS

A total of 53 dyads provided usable data at both time points. Perceived recommendations to increase involvement were associated with children's reports of increased maternal collaboration during the subsequent week (B = 0.81, P < 0.05), an effect that was stronger among boys (B = -1.21, P < 0.005). Increased maternal collaboration correlated with better A1C (r = -0.39, P < 0.005).

CONCLUSIONS

Physicians may facilitate adaptive forms of maternal involvement during adolescence by conveying messages about involvement to patients and families.

Oral health-related quality of life of children with neutropenia

This study evaluated the oral health-related quality of life (OHQoL) in children with neutropenia. Twenty-seven children with neutropenia were compared to 33 healthy, age-matched control subjects. Previously validated age-specific, multidimensional and self-reporting child OHQoL questionnaires were used. Overall and subscale scores were compared between the two groups. Respondents in the group of children with neutropenia reported that their disease had a significant impact on their oral health in terms of oral symptoms (p < 0.0001), functional limitations (p < 0.0001), and social well-being (p < 0.0001). In global ratings, they rated their oral health to be markedly worse than that of the healthy subjects (p < 0.0001). However, there was no difference between the groups in the extent to which their oral condition affected their lives overall. These results, along with responses to individual measures of social and emotional well-being, suggest that children in this group with neutropenia have psychologically adapted to the oral health challenges they experience because of their condition.

Technologies, diabetes and the student body

This paper uses qualitative methodologies to understand young people's use of technology in the management of Type 1 diabetes. The paper begins by outlining the nature of Type 1 diabetes. We provide an account of recent debates on the consumption of health-care technologies. We consider the advantages of qualitative approaches for studying young people with diabetes. Our specific focus is on university students with diabetes who are commonly represented as having a lifestyle that is ill-suited to good management of the disease. We consider the pros and cons that these young people associate with their technologies, and the role that place plays in these young people's accounts. We argue that diabetes' management technologies provide these young people with the ability to discipline their bodies and position their identities as 'normal' students in student spaces, as well as to manage risks to their health and identities. However, we highlight that the use of these technologies, especially in public spaces such as student night-clubs and bars, poses risks for students with diabetes, for example, by highlighting their 'difference' from other students.

Diets and discipline: the narratives of practice of university students with type 1 diabetes

Type 1 diabetes is one of the most common chronic conditions of adolescence and young adulthood. It is characterised by a demanding and complex management regime. Individuals with diabetes must engage in continual self-care actions such as eating healthily and exercising if they are to minimise their risks of developing long-term diabetes' complications. Research has demonstrated, however, that many young adults experience difficulties with exercising and eating healthily. Narrative approaches could provide important insights into the reasons why young people do or do not experience difficulties here. In this article I examine the food consumption and exercise narratives of a particular group of young adults with type 1 diabetes, university students, to see what personal, social and cultural factors influence their practices.

Teenagers with type 1 diabetes--a phenomenological study of the transition towards autonomy in self-management

BACKGROUND

Becoming autonomous is an important aspect of teenagers' psychosocial development, and this is especially true of teenagers with type 1 diabetes. Previous studies exploring the everyday problems of teenagers with diabetes have focused on adherence to self-care management, how self-determination affects metabolic control, and the perception of social support.

OBJECTIVE

The aim of the study was to elucidate lived experiences, focusing on the transition towards autonomy in diabetes self-management among teenagers with type 1 diabetes.

DESIGN AND METHOD

Data were collected using interviews, and a qualitative phenomenological approach was chosen for the analysis.

PARTICIPANTS

Thirty-two teenagers (18 females and 14 males) were interviewed about their individual experiences of self-management of diabetes.

FINDINGS

The lived experiences of the transition towards autonomy in self-management were characterized by the over-riding theme "hovering between individual actions and support of others". The findings indicate that individual self-reliance and confirmation of others are helpful in the transition process. Growth through individual self-reliance was viewed as a developmental process of making one's own decisions; psychological maturity enabled increased responsibility and freedom; motivation was related to wellbeing and how well the diabetes could be managed. The theme "confirmation of others" showed that parental encouragement increased the certainty of teenagers' standpoints; peers' acceptance of diabetes facilitated incorporation of daily self-management activities; support from the diabetes team strengthened teenagers' self-esteem.

CONCLUSION

In striving for autonomy, teenagers needed distance from others, but still to retain the support of others. A stable foundation for self-management includes having the knowledge required to practice diabetes management and handle different situations.

What do we mean by adherence to treatment and advice for living with diabetes? A review of the literature on definitions and measurements

AIMS

In order to measure the effectiveness of interventions claiming to improve adherence in diabetes, valid measurement of adherence is necessary. Any measurement must first be based on a definition. This study aimed to identify and categorize definitions and measurements of adherence in living with diabetes, from a review of the literature.

METHODS

Publications were identified from the medline database. Adherence, compliance and concordance were used as terms in the search algorithm, along with diabetes, diabetes mellitus and treatment. Two hundred and ninety-three papers were identified. Abstracts of these papers were read by two researchers independently. Two hundred and thirty-nine papers did not contain definitions or measures of adherence and were discarded. Of the remaining 54 papers, 26 included definitions and 46 described measurements of adherence.

RESULTS

Definitions and measurements fell into five categories: coincidence of behaviour with professional advice, relationship as part of the process of care, outcome and process targets, taking the medication as prescribed and others. No single definition of adherence emerged. Many authors did not provide definitions of adherence. Glycated haemoglobin was the most common measurement of adherence, although this can raise problems.

CONCLUSIONS

Research which claims to show an intervention has, or has not, improved adherence must be interpreted cautiously. Interventions which appear to fail may actually succeed in aspects of adherence which were not defined or measured in the study. Clinicians and researchers could use clear definitions and measurements, such as the ones presented in this review.

'Pressure of life': ethnicity as a mediating factor in mid-life and older peoples' experience of high blood pressure

Hypertension is a common condition which disproportionately affects African Caribbean people in England, yet this experience is rarely reported in the literature. Whilst a body of literature exists that explores chronic illness experience, little attention is paid to hypertension, nor to ethnicity as a mediating concept in chronic illness experience. This paper explores the meaning and consequences of hypertension for African Caribbean people residing in England. The study conducted was a qualitative study, informed by the ethnographic tradition. The study methods included the conduct of two focus group interviews (10 participants), 21 in-depth interviews and five vignette interviews. Thirty-six people in total participated in the study, both men and women, aged between 37 and 82 years (median age = 59.5 years) in two English cities. The sample was generated by contacting GP surgeries, community groups and associations and included economically active and retired people. The narrative accounts provided illuminate the personal biographies of the mid-life and older participants in the study, providing evidence as to how issues such as ethnicity, migration, cultural adaptation, racism and discrimination may impact upon the chronic illness experience. Participants' understandings of their self-defined condition of high blood pressure differed greatly from medical conceptualisations of the condition of hypertension. The implications of the study are that in order to provide effective health and social care for individuals of African Caribbean origin with hypertension, care-providers require insight into how migration and cultural adaptation may create major disruption to an individual's life trajectory, to which the subsequent diagnoses of chronic illness are relative in terms of the individual's response and adaptation.

Self-care of young adolescents with type 1 diabetes

The purpose of this study was to describe the universal and health deviation self-care of adolescents with Type 1 diabetes and the associations of basic conditioning factors with universal and health deviation self-care. Subjects for this study were 152 adolescents aged between 11 and 15 years with a diagnosis of Type 1 diabetes. Data were collected in the home setting of each adolescent and his or her family. The mean universal self-care scores ranged from 66.62% to 90%. The overall mean for this sample was 75.37, indicating that these adolescents took care of their self-care needs 75% of the time. Health deviation self-care was a mean of 27.26, indicating more positive self-care behaviors and treatment adherence. Health deviation and universal self-care were significantly and positively related (r = .36, p < .001). Ethnicity and adolescent sex were statistically significant in predicting universal self-care. Adolescent age was statistically significant in predicting health deviation self-care. Health deviation self-care decreases with age, suggesting that early adolescence or late school age is an appropriate time for interventions to strengthen self-care behaviors. Furthermore, the interrelationship of the two types of self-care supports the potential for a synergistic effect of intervention.

Mothers’ Perceptions of Self-Care in School-Age Children With Diabetes

PURPOSE

To describe mothers' perceptions of the diabetes-related self-care abilities and practices of their school-age children with Type 1 diabetes.

STUDY DESIGN AND METHOD

Qualitative study using the naturalistic inquiry method. Mothers of school-age children with diabetes were interviewed by means of a semi-structured interview guide. The children were between the ages of 11 and 12 and had been diagnosed with diabetes for a minimum of 2 years. Twelve mothers were interviewed, generating 20 hours of qualitative data.

RESULTS

Mothers reported that their children with diabetes had learned skills in a predictable sequence, were usually motivated by events in the here and now, and did not consistently perform all diabetes-related skills of which they were capable. Most of the children were becoming embarrassed about having diabetes. There were considerable gender differences in the children's self-care development.

CLINICAL IMPLICATIONS

Nurses can use this study to help with anticipatory guidance for parents. It may be helpful for parents to know the sequence in which many children learn diabetes-related skills, and to learn that even though a child is capable of task performance, he or she may not necessarily be ready for the independent practice or daily execution of the skill. Encouraging parents to stay involved with their children's self-care practices past the early adolescent years may be effective in improving self-care practices, and helping children to identify reasons to meet the self-care demands associated with diabetes can be beneficial.

Retaining school children and families in community research: lessons from the Study of Children's Activity and Nutrition (SCAN)

Retaining school-aged study participants poses a major challenge in any longitudinal research study. Dropouts produce bias in the remaining sample and this loss may affect study findings and their interpretation. Dominant factors that influence retention in pediatric research studies include family versus individual participation, patient management strategies of study personnel, knowledge about the condition or therapy, age and gender factors, credibility within the community, monetary incentives, and altruism. Eleven years after baseline assessment, Studies of Children's Activity and Nutrition boasts a 53% retention of the original biethnic cohort in San Diego. Retention occurred partly due to a trained measurement team which completed sequential observations primarily in family homes and implemented continuous participant follow-up procedures. Approaches for increasing student retention based on carefully designed studies and adherence indicators can assist researchers seeking maximum retention of school-aged participants.

Drug compliance in adolescents: assessing and managing modifiable risk factors

Many studies have found that adolescence represents a problem in compliance with prescribed drug regimens. Multiple factors contribute to this problem, including the developmental evolution taking place in the adolescent physique and psyche. Health belief and patient demographic factors, inherent disease and regimen factors, as well as the dynamics between patient and provider may also contribute to problems with compliance to treatment. Simple interventions such as working with the teen to construct a tolerable treatment regimen, assessing anticipated compliance, discussing potential adverse effects, and establishing cues from the adolescent's daily routine can positively impact treatment compliance. Healthcare providers should recognize the fact that psychosocial changes in an adolescent's life can impact upon compliance with medications and enlist the help of their patients in constructing treatment regimens taking into account the individual's lifestyle that may impact upon compliance. In particular, the healthcare provider should ask the adolescents what they anticipate their success with compliance to treatment might be, adverse effects they are concerned about and what cues could best aid the treatment plan. The healthcare provider should then synthesize this information to create the best treatment plan for that patient.

Gender differences in the psychological adjustment to type 1 diabetes mellitus: an explorative study

This study examined gender differences in (1) the psychological adjustment to diabetes and (2) the relation between psychological adjustment and metabolic control in patients with type 1 diabetes. The 280 adult patients attending the outpatient diabetes clinic completed psychological self-rating questionnaires evaluating coping, depression, marital satisfaction, cognitive and emotional adjustment to diabetes. Glycaemic control was measured with HbA(1c)-values. This study revealed that men used significantly more active coping, less avoiding, less social support seeking and less depressive coping. Despite these differences, glycaemic control was not significantly better in men than in women. Women reported more depressive symptomatology than men did and more women were depressed. Significant gender differences were also found in psychological adjustment to diabetes. The psychological factors negatively related with the psychological adjustment to diabetes in men and women are depressive coping and depressive symptomatology.

The concept of self-management of type 1 diabetes in children and adolescents: an evolutionary concept analysis

AIM

An evolutionary concept analysis was undertaken to clarify the concept of self-management of type 1 diabetes in children and adolescents.

BACKGROUND

Several problems exist in the literature on self-management of type 1 diabetes in children and adolescents. There is no uniform terminology and there is no uniform definition of the concept. Also, there is no differentiation in the literature between self-management of diabetes in children and adults.

METHODS

Ninety-nine references were reviewed and analysed in the disciplines of nursing, medicine, and psychology. After separate analyses revealed no significant differences across disciplines, the analyses were combined to describe the attributes, antecedents, consequences, and surrogate and related concepts.

RESULTS

The three essential attributes of the concept were identified as process, activities, and goals. Self-management of type 1 diabetes in children and adolescents is an active and proactive process; it is daily, lifelong, and flexible, and it involves shifting and shared responsibility for diabetes care tasks and decision-making between child and parent. It is a process that involves collaboration with health care providers. Self-management of type 1 diabetes in children and adolescents also consists of varied and many activities related to giving insulin, monitoring metabolic control, regulating diet and exercise, to name just a few. The concept also involves goals, which may differ from one parent/child dyad to another. A working definition of the concept is suggested.

CONCLUSIONS

It is hoped that a more uniform definition of the concept will enable researchers to continue investigating antecedents and consequences of the concept in a way that allows for aggregating results.

Achieving optimal diabetic control in adolescence: the continuing enigma

The transition from childhood through adolescence to adulthood is a difficult stage, particularly for patients with type 1 diabetes. The yearning for autonomy and independence, as well as the hormonal changes around the time of puberty, can manifest in poor glycaemic control. The focus on diet and weight increases the prevalence of eating disorders, compounding the difficulties in supervising diabetes patients. This can be exacerbated by the realisation that hyperglycaemia induces weight loss and the use of this knowledge to further manipulate diabetes control to gain a desired body image. The management of adolescents with type 1 diabetes is therefore challenging and requires close collaboration between psychological medicine and diabetes teams. This review describes the difficulties frequently encountered, with a description of four cases illustrating these points. Case 1 demonstrates the problem of needle phobia in a newly diagnosed patient with type 1 diabetes leading to persistent hyperglycaemia, the recognition of weight loss associated with this and the development of bulimia. The patient's overall management was further complicated by risk-taking behaviour. By the age of 24 years, she has developed diabetic retinopathy and autonomic neuropathy and continues to partake in risk-taking behaviour. Case 2 illustrates how the lack of parental support shortly after the development of type 1 diabetes led to poor glycaemic control and how teenagers often omit insulin to accommodate lifestyle and risk-taking behaviour. Case 3 further exemplifies the difficulty in managing patients with needle phobia and the fear of hypoglycaemia. Case 4 adds further weight to the need for parental support and the impact of deleterious life events on glycaemic control by manipulation of insulin dosage.