Self-management as a mediator of family functioning and depressive symptoms with health outcomes in youth with type 1 diabetes

Self-care activities in pediatric patients with type 1 diabetes mellitus

INTRODUCTION

Effective diabetes self-management and collaborative responsibility sharing with parents are imperative for pediatric patients with type 1 diabetes mellitus, particularly as they gradually assume more self-care responsibilities. The primary goal of this study was to assess differences in adherence to self-care activities regarding sociodemographics and clinical characteristics in pediatric patients with type 1 diabetes. The secondary goal of this study was to understand the level of parental involvement in diabetes management and to assess the pediatric patients' behaviors (independent or dependent on disease self-management) that relate to sociodemographic and clinical characteristics.

METHODS

This was a comparative cross-sectional and correlational study. The study sample included 182 children and adolescents who had been diagnosed with type 1 diabetes at least 3 months prior. Data collection instruments included a sociodemographic and questionnaire about Adherence to self-care activities and parental involvement in diabetes self-management, as well as a documentation sheet for recording clinical data.

RESULTS

A majority of participants (71%) exhibited non-adherence to self-care tasks, despite 78.0% asserting their independence in diabetes self-management. Notably, insufficient parental involvement in administering insulin therapy significantly predicted severe hypoglycemic episodes.

CONCLUSIONS

Pediatric patients dealing with type 1 diabetes demonstrate a substantial degree of autonomy in managing their condition, paradoxically coupled with self-reported non-adherence to critical self-care responsibilities. Notably, children (aged 8-12) rely more heavily on parental support, especially concerning insulin therapy administration. The study underscores the crucial role of parental engagement in insulin therapy, as its deficiency significantly predicts the likelihood of severe hypoglycemic episodes.

Protocol for a feasibility study and process evaluation of a psychosocially modelled diabetes education programme for young people with type 1 diabetes: the Youth Empowerment Skills (YES) programme

INTRODUCTION

Adolescence is a challenging period for young people with type 1 diabetes, associated with worsening glycaemia and care disengagement. Educational interventions in this period tend to focus on diabetes-specific skills, with less emphasis on the psychosocial challenges associated with diabetes experienced by young people. To address this limitation, we codesigned with young people a psychosocially modelled programme of diabetes education, named 'Youth Empowerment Skills' (YES). The programme aims to facilitate a positive adaptation to life with diabetes and engagement with diabetes care through peer-based learning, immersive simulations and support from an outreach youth worker. Here, we present a protocol for a feasibility study of the YES programme.

METHODS AND ANALYSIS

The study was designed following the Medical Research Council Complex Intervention Evaluation Framework to: test the feasibility (acceptance, implementability, recruitment and completion) of the YES programme; and estimate its efficacy in relation to metabolic and psychosocial outcomes. The study will take place in diabetes centres serving socioculturally diverse populations. We will conduct a feasibility randomised controlled trial (waiting-list design) with integrated process evaluation. Fifty young people with type 1 diabetes (aged 14-19 years) will be randomly allocated to either the YES intervention or a waiting-list control. Randomisation acceptability will be assessed with provision for a preference allocation. Outcomes will be evaluated at 6 months, at which point the waiting list participants will be exposed to the YES programme with further follow-up to 12 months. A simultaneous process evaluation will use a mixed-methods approach collecting qualitative and quantitative data. Study findings will be used to optimise the intervention components, outcome measures and recruitment methods to inform a subsequent definitive trial.

ETHICS AND DISSEMINATION

The protocol has ethical approval from the UK Health Research Authority (approval IRAS project ID: 279877). Findings will be disseminated in multiple formats for lay and professional audiences.

PROTOCOL DATE AND VERSION

7 April 2021, V.1.1.

TRIAL REGISTRATION NUMBER

NCT04670198.

Symptoms of depression and anxiety in adults with type 1 diabetes: Associations with self-care behaviour, glycaemia and incident complications over four years - Results from diabetes MILES-Australia

OBJECTIVE

To examine whether symptoms of depression or anxiety predict glycaemia and incident diabetes complications four years later, and whether diabetes self-care behaviours mediate these associations, in adults with type 1 diabetes (T1DM).

METHODS

Data of 205 adults with T1DM from the 2011 and 2015 Diabetes MILES-Australia surveys were analysed. Variables of interest were: baseline depression and anxiety (PHQ-8 and GAD-7, respectively) symptoms; HbA_1c and incident complications at four-year follow-up; and self-care behaviours at both time points. Longitudinal associations were analysed using structural equation modelling.

RESULTS

Forty-two participants (20.6%) reported incident complications. Baseline depressive symptoms predicted higher HbA_1c at follow-up indirectly via less optimal self-care at follow-up (β = 0.19, P = 0.011). Baseline anxiety was not independently associated with HbA_1c or self-care at follow-up (P ≥ 0.64). Neither depressive nor anxiety symptoms predicted incident complications, although depressive symptoms were associated with less optimal self-care at baseline (β = -0.67, P < 0.001), and this predicted microvascular complications (β = -0.38, P = 0.044); however, the indirect association via self-care was not significant (β = 0.25, P = 0.067).

LIMITATIONS

Participants were self-selected; all study variables were assessed using self-report measures; and adjusting for baseline HbA_1c was not possible.

CONCLUSIONS

Depressive symptoms predicted suboptimal self-care behaviour and glycaemic outcome four years later, while anxiety symptoms did not. The findings suggest that tailored diabetes care should take the potential impact of comorbid depression into consideration to help people improve their diabetes self-care and achieve best possible health outcomes.

Family conflict in type 1 diabetes: Who is at risk?

BACKGROUND/OBJECTIVE

Diabetes-related conflict between caregiver and child has been associated with lower quality of life, reduced treatment adherence, and higher hemoglobin A1C. The objective of this project was to identify patient and family characteristics associated with higher levels of diabetes-specific family conflict.

METHODS

This was a cross-sectional study. Caregivers of children aged 4- to 18-years-old with type 1 diabetes were recruited from diabetes clinics across British Columbia. Data were collected through chart reviews and patient surveys, including the Diabetes Family Conflict Scale and the Adherence in Diabetes Questionnaire. All caregivers and children ≥8-years-old were invited to complete the survey. Potential predictors were explored using univariate and multivariable linear regression models.

RESULTS

In the unadjusted analysis, higher caregiver report of conflict (n = 196) was associated with: low family income, non-Caucasian ethnicity, missed school, older age at diagnosis, and insulin regimen (2-3 injections/day rather than multiple daily injections or pump). When all variables were adjusted for simultaneously, income, insulin regimen, one or more stay at home parent and recent hospitalization were significant. For the child report (n = 111), higher maternal education was associated with lower conflict in the unadjusted analysis and non-Caucasian ethnicity was associated with higher conflict in the adjusted analysis.

CONCLUSIONS

This exploratory study identified possible novel associations between patient and family characteristics and diabetes-related family conflict.

Construct Validity and Reliability of the Chinese Version Personal Adjustment and Role Skills Scale III for Adolescents With Chronic Disease

PURPOSE

A valid and reliable scale to evaluate psychosocial adjustment in adolescents with chronic disease is prudent for improving their health outcome. This study aimed to develop a Chinese version Personal Adjustment and Role Skills Scale III for Adolescents (C-PARSIII-A) with chronic disease and to examine its construct validity and reliability.

DESIGN AND METHODS

A cross-sectional design was conducted. A total of 145 participants were enrolled from a hospital in Taiwan. Content validity, exploratory factor analysis, and corrected item-total correlations were used to explore a factor structure with appropriate items in a C-PARSIII-A. Confirmatory factor analysis was conducted to confirm its factor structure. Cronbach's α and test-retest reliability were performed to examine the reliability.

RESULTS

The 18-item C-PARSIII-A with six inter-correlated factors was developed. The standardized factor loadings of each item on its corresponding factor were statistically significant and higher than 0.50; composite reliability and average variance extracted were higher than 0.70 and 0.50 respectively. The correlation coefficients among the six factors in the C-PARSIII-A ranged from 0.10 to 0.84. Cronbach α and test-retest reliability of the C-PARSIII-A were 0.86 and 0.92 respectively.

CONCLUSIONS

The six-factor 18-item C-PARSIII-A is supported by sufficient empirical evidence for construct validity and reliability to assess the psychosocial adjustment of adolescents with chronic disease.

PRACTICE IMPLICATIONS

Nurses can use the C-PARSIII-A to perform assessment and follow-up on the psychosocial adjustment of adolescents with chronic disease, as well as develop interventions.

Depressive symptoms and glycaemic control in adults with type 1 diabetes: an exploratory study on the role of family functioning

AIMS

Psychological distress and family functioning have a considerable impact on diabetes self-management and glycaemic control in individuals with type 1 diabetes (T1D). However, the influence of both individual and family factors on glycaemic control has not been adequately investigated yet. This study aimed at examining the relationship between perceived family functioning and depressive symptoms with the frequency of capillary self-monitoring of blood glucose (SMBG) and glycaemic control (HbA_1c) in a large sample of adults with T1D.

METHODS

In a cross-sectional study design, we consecutively enrolled 90 adults with T1D diagnosis from at least 1 year and currently living in their family of origin or conjugal family from at least 1 year before the enrolment. Questionnaires were administered to assess family functioning and depressive symptoms. The SMBG frequency over the past 3 months and the most recent HbA_1c measurement were also collected in each individual. Correlation and mediation analyses were carried out.

RESULTS

Glycaemic control showed a positive relationship with depressive symptoms and family balanced cohesion, while SMBG frequency was correlated with family balanced flexibility and rigidity, but not with depressive symptoms. Mediation analyses showed that family rigidity mediates the effect of depressive symptoms on glycaemic control.

CONCLUSIONS

This exploratory study highlighted the significance of a cohesive family context to facilitate the achievement of individual glycaemic goals in individuals with T1D. These observations, if confirmed in larger data sets, would timely call for a comprehensive family care assessment as part of the evaluations routinely carried out in the ambulatory care of these individuals.

The effects of family functioning and resilience on self-management and glycaemic control among youth with type 1 diabetes

AIMS AND OBJECTIVES

To examine the effects of family functioning and resilience on self-management and glycaemic control among youth with type 1 diabetes and to determine whether resilience mediates the effects of family functioning on self-management and glycaemic control.

BACKGROUND

Poor self-management and glycaemic control are common in youth with type 1 diabetes. Family functioning and resilience are known to be important psychosocial factors that contribute to individual health and development. However, no studies have explored the effects of family functioning and resilience on self-management and glycaemic control among youths with type 1 diabetes in mainland China.

DESIGN

This study was conducted using a survey with a convenience sample following the STROBE guidelines.

METHODS

A total of 204 Chinese youth who had been diagnosed with type 1 diabetes for at least 6 months were recruited. Family functioning, resilience, self-management and diabetes distress were measured using self-reports and standard measurement tools. Glycaemic control was assessed by glycated haemoglobin (HbA_1C ) levels. A structural equation model was used to test the hypothesised model.

RESULTS

The final model accounted for 52.1% and 19.5% of the total variance of self-management and HbA_1C level, respectively. Resilience had a direct effect on self-management and an indirect effect on control of HbA_1C . Family functioning had an indirect effect on both self-management and control of HbA_1C through resilience. The model remained invariant across the mild-distress and severe-distress groups.

CONCLUSION

In Chinese youth with type 1 diabetes, resilience positively affected self-management and ultimately optimised glycaemic control, even in the presence of diabetes distress. Family functioning positively affected self-management and glycaemic control by promoting resilience.

RELEVANCE TO CLINICAL PRACTICE

This study found that family functioning and resilience had positive effects on self-management and glycaemic control in youth. This study confirms the importance of incorporating resilience assessments and family-based resilience interventions into clinical nursing practice with youth with type 1 diabetes.

Multi-informant path models of the influence of psychosocial and treatment-related variables on adherence and metabolic control in adolescents with type 1 diabetes mellitus

Background

We assessed the associations between metabolic control and adherence and a broad range of adolescent and family characteristics (e.g., gender, family structure), treatment-related variables (e.g., disease duration, treatment modality), and psychosocial factors (e.g., symptoms of depression and anxiety, parental support, self-efficacy) in a nationwide study of Danish adolescents (age 12–17 years) with type 1 diabetes mellitus (T1DM).

Methods

Sixty-four percent of invited families participated by completing a survey and providing a blood sample. Two path models of associations between generic and diabetes-related family factors, adolescent self-efficacy, emotional difficulties, and metabolic control and adherence were tested, one for adolescents and one for caregivers. Demographic variables were included as covariates.

Results

Both path models demonstrated a satisfying model fit. In both models, metabolic control was associated with adherence, age, and T1DM duration. In the adolescent model, metabolic control was also related to treatment modality, single-parent household, caregiver non-support, and anxiety, whereas in the caregiver model metabolic control was associated with family conflict and caregiver support. In both models, adherence was related to age, duration, treatment modality, family conflict, caregiver support, family functioning, and emotional difficulties of the adolescent. In the adolescent model, adherence was also related to adolescent self-efficacy, whereas in the caregiver model adherence was associated with adolescent gender and caregiver non-support and support. Adolescent self-efficacy, emotional well-being, and difficulties related to adolescent/caregiver interaction appeared to be particularly important, as indicated by their stronger association with adherence and/or metabolic control.

Conclusion

The results highlight the value of applying a multi-informant approach to address the psychosocial well-being of adolescents with diabetes in a large national sample. Self-efficacy, emotional, and family-related difficulties are important aspects to address in both clinical care and future research regarding adolescents with T1DM.

Patterns of Family Functioning and Diabetes-Specific Conflict in Relation to Glycemic Control and Health-Related Quality of Life Among Youth With Type 1 Diabetes

Objectives

General and diabetes-specific family functioning may be associated with youth’s adaptation to type 1 diabetes (T1D); however, empirically derived patterns of family functioning and diabetes-specific conflict among youth have not been explored in relation to T1D adaptation.

Methods

Youth (N = 161, aged 12–18) with T1D and caregivers completed measures of family functioning and diabetes-specific conflict that served as indicators in latent profile analyses. Differences in glycemic control (measured by hemoglobin A1cs [HbA1c] and health-related quality of life [HRQoL]) were compared across profiles.

Results

Four profiles that varied by levels of family functioning, diabetes-specific conflict, and congruence between youth and caregiver perspectives emerged and related to T1D adaptation differently. Greater agreement between caregiver and youth and lower diabetes-specific conflict was associated with lower HbA1c and greater HRQoL.

Conclusions

Person-centered approaches are useful to quantify how many individuals fit into a particular pattern and determine how specific family dynamics may function together differently in relation to T1D adaptation for various subgroups of the population.

Exploring the Influence of a Smartphone App (Young with Diabetes) on Young People's Self-Management: Qualitative Study

Background

Adequate self-management is the cornerstone of preventing type 1 diabetes mellitus (T1DM) complications. However, T1DM self-management is challenging for young people, who often struggle during the transition from childhood to adulthood. The mobile health (mHealth) app Young with Diabetes (YWD) was developed in collaboration with young people to enhance their T1DM self-management during this transition.

Objective

The purpose of this study was to explore the influence of YWD on young people’s self-management during a 12-month period.

Methods

A qualitative explorative approach was used, comprising a purposive sample of 20 young people (11 females and 9 males, ages 15 to 23 years, with app use of 3 to 64 days) from 3 pediatric and 3 adult departments. Participants were interviewed individually using a semistructured interview guide. Data were collected from January to March 2017 and analyzed using thematic analysis.

Results

A total of 5 themes were identified: (1) not feeling alone anymore (“we are in this together”); (2) gaining competence by sharing experiences and practical knowledge (“they know what they are talking about”); (3) feeling safer (“it’s just a click away”); (4) breaking the ice by starting to share thoughts and feelings and asking for help (“it is an outstretched hand”); and (5) lack of motivating factors (“done with the app”). Young people reported that YWD promoted self-management by peer-to-peer social support, exchanging messages with health care providers, and sharing YWD with parents. Participants recommended YWD as a supplement to self-management for newly diagnosed young people with T1DM and suggested improvements in app content and functionality.

Conclusions

The mHealth app YWD has the potential to support self-management. In particular, peer-to-peer support reduced feelings of loneliness and helped young people to gain knowledge and skills for managing T1DM. A need exists for alternative ways to train health care providers in using YWD and to support collaboration between young people and their parents to further improve young people’s self-management of T1DM.

Diabetes conflict outstrips the positive impact of self-efficacy on youth adherence and glycemic control in type 1 diabetes

OBJECTIVE

To examine whether self-efficacy buffers the deleterious consequences of diabetes-specific family conflict on self-monitoring blood glucose (SMBG) and glycated hemoglobin (HbA1c) in youth with type 1 diabetes mellitus (T1DM).

METHODS

A total of 129 youth with T1DM (aged 10-16 years) completed measures of diabetes-specific family conflict and self-efficacy for diabetes management, and their blood glucose meter data and HbA1c were extracted from the electronic medical record. We preformed moderation analyses to examine whether self-efficacy moderated the association that diabetes-specific family conflict had with SMBG and HbA1c. We used simple slopes analyses to probe significant interactions.

RESULTS

Our results indicated that self-efficacy moderated the association that diabetes-specific family conflict had with SMBG and HbA1c. The pattern of these findings showed that high self-efficacy buffered the negative impact of diabetes conflict on HbA1c. However, benefits of high self-efficacy for more frequent SMBG was only apparent in the context of low diabetes-specific family conflict.

CONCLUSIONS

Study findings highlight the interactive relationship between diabetes-specific family conflict and self-efficacy in relation to SMBG and glycemic control. These findings suggest that family functioning and youth's self-efficacy are promising intervention targets for families having trouble with SMBG and HbA1c.

Self-Management Strategies in Emerging Adults With Type 1 Diabetes

INTRODUCTION

We examined changes in self-management behaviors after high school graduation in a cohort of emerging adults with type 1 diabetes.

METHODS

Sixty-four emerging adults reported on diabetes self-management behaviors at three time points over a 1-year period. Glycemic control and blood glucose monitoring frequency data were collected from the medical chart.

RESULTS

Collaboration with parents decreased, diabetes problem-solving and communication increased, and glycemic control worsened during the first year after high school (p < .05). Problem solving appeared to be protective against worsening glycemic control; higher baseline diabetes problem solving significantly predicted better glycemic control at the 1-year follow-up.

DISCUSSION

Emerging adults demonstrate increased independence in diabetes problem solving and communication with health care providers in the year after high school. Problem-solving skills may help emerging adults adapt type 1 diabetes self-care in response to unpredictable schedules after high-school, and promoting these skills may prevent deteriorations in glycemic control during this risky period.

PREP-T1 (Preteen Re-Education With Parents-Type 1 Diabetes) Feasibility Intervention Results

There has been a 2% to 3% increase in Type 1 diabetes (T1D) in children below 11 years old. Preteens (9-12 years old) with T1D are often overlooked regarding future diabetes self-management (DSM) expectations because parents are still in the "driver's seat." The study purpose was to explore feasibility/ability to recruit and conduct a two-arm trial on reeducation, collaboration, and social support. One component of DSM was reviewed (hypoglycemia) with preteens (n = 22) and parents (n = 22). The experimental preteens discussed hypoglycemia management with a teen mentor and nurse educator using a human patient simulator for practice, and working collaboratively with parents. Concurrently, mothers met with a parent mentor and psychologist to discuss growth and development, and collaborative shared management. Comparison dyads discussed hypoglycemia management with a nurse. Preteens slightly improved in diabetes knowledge; the experimental arm had higher problem-solving scores. Parents in the experimental arm had higher self-efficacy scores. Findings will inform future research.