Adherence and glycemic control among Hispanic youth with type 1 diabetes: role of family involvement and acculturation

Severe and Recurrent Diabetic Ketoacidosis in Children and Youth with Type 1 Diabetes: Risk and Protective Factors

Objective: To examine the risk and protective factors for severe and recurrent diabetic ketoacidosis (DKA) in a large sample of children in the Southwestern United States. Methods: Retrospective chart review of children age 0-18 years with type 1 diabetes (T1D) seen at a large children's hospital/integrated care delivery system between October 2019 and December 2022. Data from the preceding 2 years were used to predict postdiagnosis DKA in each subsequent year. Logistic regression and recursive feature elimination (RFE) were used to select significant predictors of any DKA, severe DKA, and recurrent DKA. Model performance was evaluated using fivefold cross-validation, with area under the curve in the receiver operating characteristic plot as the performance metric. Results: Records were obtained for 4649 encounters, representing 1850 patients and 846 prior DKA events. Based on RFE, single prior DKA, recurrent prior DKA, and hemoglobin A1c were significant shared predictors for subsequent DKA, severe DKA, and recurrent DKA, and female sex was positively associated with any DKA and recurrent DKA. The model for recurrent DKA also included age between 10 and 14 years as an unshared risk factor, and Hispanic ethnicity and use of an insulin pump (with or without automated insulin delivery) as unshared protective factors. Incidence of severe DKA was highly correlated (r = 0.95) with number of prior DKA events. Black and female patients were more likely to experience multiple recurrent DKA episodes and repeated episodes of severe DKA. Conclusions: Severe and recurrent DKA have both shared and unshared risk factors. Severe DKA may be a singular phenomenon in most cases, although a subset of patients (primarily Black and female) experience repeated severe events, placing them at high risk for adverse health outcomes. Recurrent DKA appears to be more of a chronic issue, although a number of variables emerged as protective factors, suggesting ways in which recurrent DKA might be prevented.

A Conceptual Model for Understanding the Division and Transfer of Diabetes Care Responsibilities Between Parents and Children with Type 1 Diabetes

Background/Objectives: For families with a child with type 1 diabetes, it is often complex and challenging to decide how responsibilities for diabetes care should be divided between parents and children, and how and when these responsibilities should be transferred from parent to child. A smooth transfer of responsibilities is assumed to be key for optimal diabetes outcomes and a successful shift from paediatric to adult health care. However, a theoretical framework to conceptualise the division and transfer of diabetes care responsibilities that brings together the scattered literature regarding these topics is still lacking. Methods: This narrative review synthesises insights from (a) prior quantitative and qualitative studies in the context of paediatric diabetes care, (b) prior reviews regarding the transfer of treatment responsibilities for families of children with a chronic condition, and (c) existing theoretical models in paediatrics, child development and parenting. Results: The division of responsibilities appears to be affected by a complex interaction between child, parent and context characteristics. These factors seem to change the division of diabetes care responsibilities by affecting (1) child/parental readiness to assume responsibility, (2) the alignment between the child's and the parent's readiness and (3) context support and demands. The "success" of the division and transfer of diabetes care responsibilities can be defined by biomedical, emotional, behavioural and parent-child interaction outcomes. Conclusions: The presented conceptual framework can guide research and clinical practice in studying and evaluating the division and transfer of diabetes care responsibilities.

Feasibility and acceptability of the TEAM pilot trial with African American and Latino families

OBJECTIVE

We adapted the empirically supported Family Teamwork intervention protocol to support collaborative parent involvement in type 1 diabetes (T1D) management among African American and Latino parents of children with T1D. This randomized pilot study aimed to evaluate feasibility and acceptability of the Type 1 Diabetes Empowerment and Management (TEAM) intervention.

METHODS

African American and Latino parents (n = 59; 65% recruitment rate) of youth (ages 5-10 years, M = 8.9 ± 1.6 years; 59% female, M hemoglobin A1c 9.0% ± 1.9%) with diabetes duration of ≥1 year and who were fluent in English and not planning to leave the geographic area were recruited and randomized 3:1 to the TEAM intervention (n = 44) or usual diabetes care alone (n = 15). The intervention consisted of six group-based sessions co-led by a study interventionist and a trained parent leader, plus five phone calls with the parent leader. Secondary outcomes included psychosocial questionnaires and HbA1c at baseline and 12 months post-baseline.

RESULTS

Participants attended a mean of 2.1 ± 2.0 (33%) TEAM intervention sessions. Acceptability ratings (5-point scale) among parents who completed ≥1 session (n = 28) were high: helpfulness (4.5 ± 0.75), encouraged new perspectives (4.5 ± 0.58), enjoyment (4.4 ± 0.70), learned new information/skills (4.3 ± 0.70), prompted change to diabetes management (4.6 ± 0.69), and positive impact on family (4.5 ± 0.69). Qualitative interviews (n = 35) indicated positive perspectives about emotional and informational support and suggestions for adding child intervention components. Pre-post data completion rates were 92% for questionnaires.

CONCLUSIONS

Despite feasibility challenges, the TEAM intervention was acceptable among parents who attended sessions. Reducing barriers to session attendance may be warranted to impact psychosocial and clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04053504.

Effects of Parental Involvement on Glycemic Control in Adolescents With Type 1 Diabetes Mellitus: A Scoping Review

Type 1 diabetes mellitus (T1DM) is typically diagnosed in pediatric patients. Transitioning from supported management in childhood to self-management in adolescence is an important step. Parental psychosocial influence is a possible factor in adolescents' disease control. This review summarized the effects of parental involvement on glycemic control in adolescents with T1DM by focusing on hemoglobin A1c (HgbAIc). A scoping review per the Guidance for Systematic Scoping Reviews was conducted with the following inclusion criteria: (a) studies in English, (b) focused on adolescents with T1DM, (c) outcomes included HgbAIc, and (d) focused on parental influence of children with T1DM. Of 476 articles, 14 were included. The study outcomes were classified based on direct or indirect influence. "Parental support for adherence" and "parental conflict" significantly affected HgbAIc control. This study provides current evidence on parental influence on glycemic control in adolescents.

Psychometric analysis of the cross-cultural Spanish version of the diabetes management questionnaire

Evaluation of the degree of adherence to self-care among Spanish type 1 diabetes (T1DM) pediatric population lacks of a validated tool.

PURPOSE

To cross-culturally adapt and determine the psychometric properties of the Spanish version of the Diabetes Management Questionnaire to assess the degree of adherence to self-care among children with T1DM.

METHODS

Translation, back-translation, and patient suggestions, were considered to obtain the Spanish version (DMQ-Sp). A cross-sectional study was conducted with 323 children (aged 8-18 years) with T1DM and their parents to determine internal reliability, structural validity, and external validity. Responsiveness to change was analyzed through a prospective longitudinal study involving 102 newly diagnosed T1DM patients. Psychometrics were evaluated for the entire sample and stratified by age (8-12 and 13-18 years).

RESULTS

A total of 323 children with T1DM [49.8% female; age 13.3 ± 2.8 years; 155 aged 8-12; glycated hemoglobin (HbA1c) value 7.7 ± 1.0%] answered the Spanish final version. The internal consistency Cronbach's alpha was 0.76 and intraclass correlation coefficient 0.84. Test-retest reliability was r = 0.84 (p < 0.001). Fit index of structural validity was >0.7. External validity correlated inversely with HbA1c (r = -0.39; p < 0.001). The DMQ-Sp score increased significantly after 6 months of receiving the full therapeutic education program (TEP) (baseline 57.07 ± 10.81 vs. 6 months 78.80 ± 10.31; p < 0.001).

CONCLUSION

The DMQ-Sp is reliable, valid, and sensitive to change in a large sample of children (aged 8-18 years) with T1DM and their parents.

PRACTICE IMPLICATIONS

DMQ-Sp can be a useful tool for diabetes teams to identify adherence to different tasks and to evaluate TEPs.

Effect on Glycemic Control of an Early Intensive Dietary Structured Education Program for Newly Diagnosed Children with Type 1 Diabetes in Jordan

Methods

This is a retrospective medical chart review study at Jordan University Hospital. The glycemic control of children who were diagnosed with T1D and included in the SEP between June 2017 and December 2019, was compared with those who were exposed to the conventional diabetes education, between January 2014 and December 2016. Various factors were assessed for the possible effects on the SEP outcomes.

Results

The average age at diagnosis for the 112 persons with diabetes (PwD) included in the dietary SEP was 8.30 ± 3.87 years. Glycated hemoglobin was lower in children in the SEP group at 6 months (P value = 0.001) and 12 months (P=0.032) but not at 24 months (P=0.290). SEP had better effect on patients older than 5 years. The possible predictors of glycemic control for the SEP group at 12 months included the mother's educational level and the number of hospital admissions due to DKA and hyperglycemia during the first year after diagnosis.

Conclusion

Our dietary SEP was associated with better glycemic control than conventional diabetes education, at 6 and 12 months after diagnosis. It had a positive effect, mainly in PwD patients who are older than 5 years and had higher maternal educational level.

Forty Years of Behavioral Diabetes Research: A Personal Journey

This article was adapted from the address Dr. Delamater delivered as the recipient of the American Diabetes Association's Richard R. Rubin Award for 2022. This award recognizes a behavioral researcher who has made outstanding, innovative contributions to the study and understanding of the behavioral aspects of diabetes in diverse populations. Dr. Delamater delivered the address in June 2022 at the Association's virtual 82nd Scientific Sessions. A webcast of this speech is available for viewing on the DiabetesPro website (https://professional.diabetes.org/webcast/stigma-diabetes-care%E2%80%94evidence-and-solutions-richard-r-rubin-award-lecture).

Division of Type 1 Diabetes Responsibility in Latinx and Non-Latinx White Mother-Adolescent Dyads

Incidence rates of type 1 diabetes are increasing faster in Latinx youth than other ethnic groups, yet this population remains understudied. The current study (1) tested differences in division of diabetes-related responsibility (adolescent alone, mother alone, and shared) across Latinx and non-Latinx White families (N = 118 mother-adolescent dyads, 56 = Latinx dyads, M_age=13.24 years), and (2) examined associations between diabetes responsibility and adolescent health (HbA1c, diabetes self-management behaviors, and depressive symptoms). Latina mothers reported more shared and less adolescent responsibility than non-Latinx White mothers, but there were no ethnic differences in adolescent reports of responsibility. Independent of demographic and illness-related characteristics, mother- and adolescent-reports of shared responsibility were associated with higher self-management behaviors, while individual responsibility (adolescent or mother alone) was generally associated with lower self-management behaviors. Shared responsibility associations with higher mother-reported self-management behaviors occurred among Latinx families, but not non-Latinx White families. Shared and individual responsibility were not associated with HbA1c or depressive symptoms. The findings suggest the importance of shared responsibility for diabetes management in adolescence, particularly in Latinx families.

Diabetes Technology Experiences Among Latinx and Non-Latinx Youth with Type 1 Diabetes

BACKGROUND

Diabetes technologies, such as insulin pumps and continuous glucose monitors (CGM), have been associated with improved glycemic control and increased quality of life for young people with type 1 diabetes (T1D); however, few young people use these devices, especially those from minority ethnic groups. Current literature predominantly focuses on white patients with private insurance and does not report experiences of diverse pediatric patients with limited resources.

METHODS

To explore potential differences between Latinx and non-Latinx patients, English- and Spanish-speaking young people with T1D (n = 173, ages 11-25 years) were surveyed to assess attitudes about and barriers to diabetes technologies using the Technology Use Attitudes and Barriers to Device Use questionnaires.

RESULTS

Both English- and Spanish-speaking participants who identified as Latinx were more likely to have public insurance (P = .0001). English-speaking Latinx participants reported higher Hemoglobin A1c values (P = .003), less CGM use (P = .002), and more negative attitudes about technology (generally, P = .003; and diabetes-specific, P < .001) than either non-Latinx or Spanish-speaking Latinx participants. Barriers were encountered with equivalent frequency across groups.

CONCLUSIONS

Latinx English-speaking participants had less positive attitudes toward general and diabetes technology than Latinx Spanish-speaking and non-Latinx English-speaking peers, and differences in CGM use were associated with socioeconomic status. Additional work is needed to design and deliver diabetes interventions that are of interest to and supportive of patients from diverse ethnic and language backgrounds.

Youth Temperament Moderates Associations Between Parental Involvement and Pediatric Type 1 Diabetes Treatment Outcome

Objective

Both youth self-regulation and quality of parental involvement have been associated with blood glucose levels (HbA1c) of youth with type 1 diabetes mellitus (T1DM). However, it is unclear whether and how youth and parental factors interact in their relation to youth HbA1c. The differential susceptibility hypothesis proposes that youth with high negative affectivity (NA) and low effortful control (EC) may be more susceptible to the deleterious impact of lower quality parenting behaviors but also reap greater benefit from higher quality parenting behaviors. This study investigated whether youth temperament would moderate the link between diabetes-specific parental assistance (e.g., checking blood sugar) or support (e.g., encouraging, praising) and HbA1c among youth with T1DM.

Methods

Primary caregivers of youth with T1DM (N = 101; M age = 12.02, SD = 2.43) completed surveys on diabetes-specific parental involvement and youth temperament. Medical information (i.e., HbA1c) was obtained from chart review.

Results

Multiple regression analyses indicated that youth NA and EC significantly interacted with parental assistance, but not support. Specifically, higher parental assistance was associated with higher HbA1c among youth with high NA or high EC. High assistance was only linked to lower HbA1c for youth with low NA.

Conclusions

Results suggest that optimal levels of parental involvement related to better T1DM outcomes depend on youth’s NA or EC. Consistent with the goodness-of-fit framework, when parenting approaches match youth’s temperament, youth with T1DM may be better able to maintain lower HbA1c. Family interventions for pediatric T1DM management may take into consideration youth temperament.

Hispanic Caregivers' experience of pediatric type 1 diabetes: A qualitative study

OBJECTIVE

It is widely recognized that Type 1 Diabetes (T1D) outcomes are worse among Hispanic children; however, little is published about the perspectives of these patients and their caregivers. Our intent was to characterize the lived experience of Hispanic caregivers of children with T1D, focusing on the role of language and culture and their perspectives on current medical care and alternative care models. We studied Hispanic caregivers of patients (age 2-17 years) with T1D of greater than 6 months' duration.

RESEARCH DESIGN AND METHODS

We completed semi-structured interviews and focus-groups of a purposive sample of 20 members of our population of interest. We developed a codebook and completed multidisciplinary consensus coding, then conducted iterative thematic analysis using qualitative software and discussion to generate themes.

RESULTS

We gathered data from 20 Hispanic caregivers of T1D patients (11.37 ± 3.00 years old, 4.80 ± 2.84 years since diagnosis). 85% of caregivers were female, 80% preferred Spanish, and 15% were college-educated. Our analysis yielded 4 themes across the participants: (1) Culturally-based nutrition challenges, (2) Social isolation and lack of support for T1D care, (3) Hesitancy to fully embrace diabetes technology, and (4) Deferential views of care experience and providers. Overarching all of these themes was support for Hispanic group-based models of care tailored to address these concerns.

CONCLUSIONS

The unique concerns among Hispanic caregivers of children with T1D suggest the importance of culturally tailored interventions to improve care. With successful implementation, such interventions could diminish widening disparities in healthcare outcomes.

Cost and healthcare utilization analysis of culturally sensitive, shared medical appointment model for Latino children with type 1 diabetes

OBJECTIVE

This study evaluated costs and healthcare utilization associated with a culturally-sensitive, medical and education program for pediatric Latino patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Program participants included Latino children ages 1-20 years old diagnosed with type 1 diabetes (n = 57). Control subjects with type 1 diabetes were matched by age, sex, and zip code to intervention participants from the Colorado All Payer Claims Database. Data included emergency department (ED) visits, hospitalizations, demographic information, and health insurance claims data 180 days prior to program start/index date through 1 year after program start/index date. We tracked program staff time and estimated costs for healthcare utilization using data from the scientific literature. Generalized Estimating Equation (GEE) models with logit link were used to estimate group differences in probabilities of ED visits and hospitalizations over 6-month periods pre/post-study, accounting for correlation of within-subject data across time points. Sensitivity analyses modeled longer-term cost differences under different assumptions.

RESULTS

The intervention group had fewer hospitalizations, 2% versus 12% of controls (p = 0.047,OR = 0.13;95%CI: 0.02-0.97) for 6 months following start date. The intervention group had fewer ED visits, 19% versus 32% in controls (n.s.; p = 0.079,OR = 0.52;95%CI:0.25-1.08) and significantly fewer hospitalizations, 4% versus 15% of controls (p = 0.039,OR = 0.21;95%CI: 0.05-0.93) 6-12 months post-start date. One-year per-patient program costs of $633 and healthcare cost savings of $2710 yielded total per-patient savings of $2077, or a 5-year cost savings of $14,106.

CONCLUSION

This unique type 1 diabetes management program altered health service utilization of program participants, reducing major healthcare cost drivers, ED visits, and hospitalizations.

Comprehensive psychosocial screening in a pediatric diabetes clinic

OBJECTIVE

The ISPAD recommends routine, comprehensive psychosocial screening for adolescents with diabetes. However, few clinics have implemented procedures consistent with these guidelines. This study describes the results of a universal, comprehensive psychosocial screening program in an integrated pediatric diabetes clinic located within an academic medical center.

RESEARCH DESIGN AND METHODS

Participants included 232 ethnically diverse adolescents with type 1 diabetes (55.5% female; M age = 14.85; 58.5% Hispanic; 20% Black). Adolescents completed screening measures on iPads in the waiting room before their medical visit. The proportion of adolescents screening positive on each psychosocial measure was assessed, and regression analyses evaluated how psychosocial variables accounted for variance in insulin non-adherence and glycemic control (measured by A1c).

RESULTS

Psychosocial concerns were common and ranged from 7% of adolescents screening positive for disordered eating and suicide risk to 52% screening positive for low motivation to manage diabetes. A1c and insulin non-adherence were positively correlated with suicide risk, depressive symptoms, anxiety, disordered eating, diabetes stress, blood glucose monitoring stress, family conflict, and total number of elevations, and negatively correlated with intrinsic motivation. Insulin non-adherence, disordered eating, diabetes stress, and family conflict uniquely predicted A1c. Age, motivation, and family conflict uniquely predicted insulin non-adherence. Eighty-three percent of eligible youth completed the screener. Referrals by physicians to the team psychologist increased by 25% after the screening program was implemented.

CONCLUSIONS

Comprehensive psychosocial screening can be effectively implemented as part of routine pediatric diabetes care and can identify adolescents in need of additional supports.

Barriers and Facilitators to Involvement in Children's Diabetes Management Among Minority Parents

OBJECTIVE

This study aimed to describe parents' perceptions of the factors that facilitate or are barriers to their involvement in children's type 1 diabetes (T1D) management among African American and Latino parents.

METHODS

African American and Latino parents (N = 28) of 5- to 9-year-old children with T1D completed audio-recorded, semi-structured interviews that were transcribed and analyzed using thematic analysis. Themes were identified that aligned with the theoretically-derived Capability-Opportunity-Motivation-Behavior (COM-B) framework.

RESULTS

Parents described Capability-based facilitators of parent involvement, including positive stress management, religious/spiritual coping, organizational/planning skills, and diabetes knowledge. Capability-based barriers included child and parent distress. Interpersonal relationships, degree of flexibility in work environments, and access to diabetes technologies were both Opportunity-based facilitators and barriers; and Opportunity-based barriers consisted of food insecurity/low financial resources. Parents' desire for their child to have a "normal" life was described as both a Motivation-based facilitator and barrier.

CONCLUSIONS

African American and Latino families described helpful and unhelpful factors that spanned all aspects of the COM-B model. Reinforcing or targeting families' unique psychological, interpersonal, and environmental strengths and challenges in multilevel interventions has potential to maximize parental involvement in children's diabetes management.

The Role of Socioeconomic Status in Latino Health Disparities Among Youth with Type 1 Diabetes: a Systematic Review

PURPOSE OF REVIEW

Type 1 diabetes (T1D) incidence is growing faster among Latino than non-Latino White youth, but ethnic disparities in self-management behaviors and HbA1c are unclear. Socioeconomic status (SES) is a key factor in T1D, which may confound or contribute to disparities in Latino pediatric T1D management. A systematic review examined whether ethnic differences in pediatric T1D outcomes occur and are independent of socioeconomic status (SES).

RECENT FINDINGS

Latino youth displayed lower self-management and higher HbA1c in approximately half of the identified studies prior to including SES in analyses. Ethnic differences in self-management were found for objective (i.e., frequency of blood glucose checks), but not subjective measures. Ethnic differences were often eliminated when SES was statistically controlled. SES moderated some differences, suggesting complex sociocultural processes. Articles varied widely in SES measures and the analytic methods used to evaluate ethnic disparities. Pediatric Latino T1D disparities are inconsistent and at least partially dependent on the SES context. Recommendations for future research to systematically evaluate SES and Latino T1D disparities are made.

Featured Article: Comparison of Diabetes Management Trajectories in Hispanic versus White Non-Hispanic Youth with Type 1 Diabetes across Early Adolescence

OBJECTIVE

Ethnic minority youth with type 1 diabetes (T1D) often have poorer glycemic control and lower rates of adherence compared to White Non-Hispanic (WNH) youth. Variables such as family conflict, autonomy support, and youth regimen responsibility have been shown to change over adolescence and impact diabetes management. However, these factors have been investigated in predominantly White samples. Few studies have examined potential differences in these variables and their trajectories for Hispanic youth over early adolescence.

METHODS

Youth with T1D (178 WNH and 33 Hispanic youth participants), as well as their maternal caregivers (174 WNH and 32 Hispanic maternal caregivers), completed measures of diabetes-specific autonomy support, diabetes-related family conflict, regimen responsibility, and blood glucose monitoring frequency at 4 timepoints over a 3-year period.

RESULTS

At baseline, Hispanic youth had significantly poorer glycemic control, more family conflict, and fewer blood glucose checks on average compared to WNH youth. Similar to WNH youth, Hispanic youth have increasing independence for regimen tasks and decreasing parent autonomy support during this developmental period. However, while Hispanic youth had worsening diabetes management during early adolescence (as did WNH youth), Hispanic parents reported a more gradual change in youth's diabetes management over early adolescence.

CONCLUSIONS

This study presents an important contribution to the existing literature on youth with T1D. Findings suggest potential strengths and targets for Hispanic youth navigating diabetes management during the adolescent period. It is important to continue to investigate the trajectories of ethnic minority youth with diabetes.

Medication Adherence During Adjunct Therapy With Statins and ACE Inhibitors in Adolescents With Type 1 Diabetes

OBJECTIVE

Suboptimal adherence to insulin treatment is a main issue in adolescents with type 1 diabetes. However, to date, there are no available data on adherence to adjunct noninsulin medications in this population. Our aim was to assess adherence to ACE inhibitors and statins and explore potential determinants in adolescents with type 1 diabetes.

RESEARCH DESIGN AND METHODS

There were 443 adolescents with type 1 diabetes recruited into the Adolescent Type 1 Diabetes Cardio-Renal Intervention Trial (AdDIT) and exposed to treatment with two oral drugs-an ACE inhibitor and a statin-as well as combinations of both or placebo for 2-4 years. Adherence was assessed every 3 months with the Medication Event Monitoring System (MEMS) and pill count.

RESULTS

Median adherence during the trial was 80.2% (interquartile range 63.6-91.8) based on MEMS and 85.7% (72.4-92.9) for pill count. Adherence based on MEMS and pill count dropped from 92.9% and 96.3%, respectively, at the first visit to 76.3% and 79.0% at the end of the trial. The percentage of study participants with adherence ≥75% declined from 84% to 53%. A good correlation was found between adherence based on MEMS and pill count (r = 0.82, P < 0.001). Factors associated with adherence were age, glycemic control, and country.

CONCLUSIONS

We report an overall good adherence to ACE inhibitors and statins during a clinical trial, although there was a clear decline in adherence over time. Older age and suboptimal glycemic control at baseline predicted lower adherence during the trial, and, predictably, reduced adherence was more prevalent in subjects who subsequently dropped out.

Perceptions and experiences of living with type 1 diabetes among Latino adolescents and parents with limited English proficiency

We explored perceptions and experiences of living with type 1 diabetes mellitus (T1DM) among U.S. Latino adolescents (age 12-19 years) with T1DM and parents with limited English proficiency. We used a qualitative descriptive approach with semi-structured interviews of adolescents together with their parents. Interview data were reviewed, coded, and combined into themes about participant experiences with T1DM. Twenty-four adolescents (mean age: 15.4 years) and 23 parents participated. Analysis resulted in three themes: (a) Understanding and adapting to T1DM (i.e., initial fear and misunderstandings of T1DM; adolescents' reflections on living with a chronic health condition); (b) Coming to terms with social and environmental influences on T1DM self-management (i.e., T1DM as disruptive to school and social activities; dealing with stigma and judgments related to diabetes); and, (c) Integrating T1DM self-management expectations with components of Latino cultures (i.e., orientation toward family well-being; parent concerns about cultural preferences that influence food choices, positive influence of spirituality and religiousness; parental views of their current health care in comparison to that available in their place of birth). Adolescents and their parents reported experiences that are universal to adolescents with T1DM in addition to challenges that are unique to Latinos. Efforts aimed at improving T1DM self-management during adolescence with this population need to be tailored to meet the unique social and cultural contexts and delivered in a culturally and linguistically congruent manner.

Family Support and Its Association with Glycemic Control in Adolescents with Type 1 Diabetes Mellitus in Riyadh, Saudi Arabia

The prevalence of type 1 diabetes mellitus (T1DM) among children in Saudi Arabia is increasing with unfavorable outcomes. Therefore, in addition to pharmacotherapy, other measures should be studied regarding psychological aspects mainly among adolescents. The family, which acts as the primary caregiver at this age, may play a major role in disease management. Thus, this study is aimed at assessing the perception of adolescents about the behaviors of their families initially and at investigating the correlation between these behaviors and glycemic control. Up to our knowledge, there was no study in Saudi Arabia that addressed this issue previously. This cross-sectional observational study assessed adolescents aged 10-19 years diagnosed with T1DM on insulin and receiving follow-up care at the King Saud University Medical City in Riyadh, Saudi Arabia. Data were collected via telephone interview and the verified "Modified Diabetes Social Support Questionnaire-Family version". Glycemic control was then assessed using the most recent hemoglobin A1c (HbA1c) level recorded in their electronic files. Fifty-six adolescents participated in this study with an equal sex distribution (each n = 28). Almost all participants were Saudis, and the majority were living in Riyadh (n = 41). The mean age was 16.1 ± 2.41 years with a mean of 6.1 ± 4.14 years history of diabetes. The mean HbA1c level was 9.6 ± 2.12%. Participants perceived all behaviors as supportive with "support in critical situations" being the highest (77.3%) and the only factor significantly related to HbA1c (p = 0.017). Age was significantly related to all factors (p > 0.05). Family plays a major role in the management of diabetes. Their supportive behaviors are perceived by their family members diagnosed with T1DM, but there has been no optimal association with disease control. However, the involvement of the family can aid in decreasing possible complications of the disease by intervening in critical situations.

Discussing End-of-Life Care Preferences With Family: Role of Race and Ethnicity

This study examined racial, ethnic, and other factors associated with whether older adults discussed their end-of-life (EOL) care wishes with family. A sample of 223 White, 95 African American, and 46 Hispanic adults aged 50 and older from a five-county area of Florida answered questions about sociodemographics, health, and preferences for involving family/friends in health-care decision-making. Analyses describe associations between whether discussions occurred and race/ethnicity and other factors, including preferences for family/friend involvement in health care. In descriptive analyses, one third ( n = 113) had not discussed EOL care. No differences were evident between African Americans and non-Hispanic Whites. In multivariate analyses, EOL care discussions were less likely for Hispanics. Further analysis showed this lower likelihood existed among Hispanics with lesser family/friend involvement. Ethnicity influences EOL care discussion, moderated by family/friend involvement, though results are considered preliminary. Knowing the involvement of patients’ family/friends could help providers initiate EOL care discussions.

Psychological characteristics of caregivers of pediatric patients with chronic rheumatic disease in relation to treatment adherence

BACKGROUND

Adherence to treatment for chronic diseases is lower in children than in adults, less extensively studied in children and is associated with multiple related factors. The aim of this study is to perform a descriptive analysis of psycho-cognitive aspects of primary caregivers of pediatric patients with chronic rheumatic diseases, as well as socioeconomic and clinical factors, family functioning and treatment satisfaction.

METHODS

Primary caregivers of 90 patients were included. Pairs (caregiver plus patient) were grouped as presenting good adherence (n = 50) or poor adherence (n = 40) according to the Morisky Adherence Test. Psycho-cognitive aspects were evaluated by Adult Self-Report and Wechsler Adult Intelligence Scale tests. For statistical comparisons, quantitative variables with normal distribution were analyzed by Student's t test, and those with non-Gaussian distribution with the Mann Whitney test. Categorical variables were analyzed by Chi square test. A multivariate logistic regression analysis was performed to estimate the contribution of the independent variables to adherence.

RESULTS

Compared to caregivers in the good adherence group, caregivers in the poor adherence group were more likely to be classified as clinical on the scales for attention problems and externalizing problems, which include impulsiveness and aggressiveness. They also scored higher on the depressive problem scale. In addition, the average number of children per caregiver and the mean age of caregivers and patients were significantly higher in the poor adherence group, while the proportion of caregivers with higher education was lower. The poor adherence group also included a higher incidence of pediatric patients assuming sole responsibility for managing medications. Economic status, clinical factors, treatment satisfaction, family functioning and caregiver cognitive profile were not related to adherence, except for working memory index.

CONCLUSION

Older patients, patients as the one solely responsible for medication management, and caregivers with externalizing problems, were observed to be the most strongly associated to poor adherence. Interventions aimed at adolescent patients are needed. Also, psychological programs and interventional studies to better determine caregivers' behavioral/emotional status, and parent-child relationships are recommended.

Pragmatic Trial to Evaluate the Effect of a Promotora Telephone Intervention on the Duration of Breastfeeding

OBJECTIVE

To evaluate the effectiveness of a telephone intervention delivered by promotoras (lay health care workers) to increase the duration of exclusive breastfeeding (EBF) in Hispanic women at 12 weeks postpartum. Secondary objectives were to assess breastfeeding duration (BFD) and to evaluate background variables that may be associated with EBF and BFD.

DESIGN

Pragmatic trial.

SETTING

Two obstetric clinics affiliated with a community medical center in Southern California.

PARTICIPANTS

We recruited 61 participants from the two clinics. Participants were 18 to 45 years old and planned to breastfeed their infants. Women who showed interest in the study were sequentially divided into an intervention (n = 31) or a control group (n = 30).

METHODS

The intervention consisted of telephone support for breastfeeding provided by certified and trained promotoras.

RESULTS

Fourteen out of 31 (45%) participants in the intervention group continued to practice EBF compared with 4 out of 30 (13%) in the control group (odds ratio = 3.39, p = .04). Breastfeeding duration in days was significantly longer for the participants in the intervention group (F =1/59 = 29.88, p < .01). The positive predictors of EBF at 12 weeks after birth were prior breastfeeding experience, perceived breastfeeding support, promotora telephone support, and higher scores on the acculturation scale. Positive predictors of BFD were breastfeeding support, promotora telephone support, and higher scores on breastfeeding self-efficacy. A negative predictor was lower household income.

CONCLUSION

Our results indicate that a telephone support intervention delivered by promotoras may increase the rates of EBF by threefold at 12 weeks after birth.

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.

HLA-B*39:06 Efficiently Mediates Type 1 Diabetes in a Mouse Model Incorporating Reduced Thymic Insulin Expression

Type 1 diabetes (T1D) is characterized by T cell-mediated destruction of the insulin-producing β cells of the pancreatic islets. Among the loci associated with T1D risk, those most predisposing are found in the MHC region. HLA-B*39:06 is the most predisposing class I MHC allele and is associated with an early age of onset. To establish an NOD mouse model for the study of HLA-B*39:06, we expressed it in the absence of murine class I MHC. HLA-B*39:06 was able to mediate the development of CD8 T cells, support lymphocytic infiltration of the islets, and confer T1D susceptibility. Because reduced thymic insulin expression is associated with impaired immunological tolerance to insulin and increased T1D risk in patients, we incorporated this in our model as well, finding that HLA-B*39:06-transgenic NOD mice with reduced thymic insulin expression have an earlier age of disease onset and a higher overall prevalence as compared with littermates with typical thymic insulin expression. This was despite virtually indistinguishable blood insulin levels, T cell subset percentages, and TCR Vβ family usage, confirming that reduced thymic insulin expression does not impact T cell development on a global scale. Rather, it will facilitate the thymic escape of insulin-reactive HLA-B*39:06-restricted T cells, which participate in β cell destruction. We also found that in mice expressing either HLA-B*39:06 or HLA-A*02:01 in the absence of murine class I MHC, HLA transgene identity alters TCR Vβ usage by CD8 T cells, demonstrating that some TCR Vβ families have a preference for particular class I MHC alleles.

Family-Based Interventions Targeting Improvements in Health and Family Outcomes of Children and Adolescents with Type 1 Diabetes: a Systematic Review

PURPOSE OF REVIEW

A systematic review was conducted of family-based interventions to improve glycemic control, adherence, and psychosocial outcomes in children and adolescents with type 1 diabetes (T1D). Electronic databases were searched for randomized controlled trials (RCTs) published since the seminal Diabetes Control and Compliance Trial (DCCT). Interventions are summarized and findings reviewed to help guide clinical practice and future research.

RECENT FINDINGS

Twenty-five RCTs are reviewed. The majority of studies (n = 15) focused on interventions targeting both children and adolescents and their caregivers and were delivered in diabetes clinics, outpatient settings, mental health clinics, or participants' homes. Family-based interventions for youth with T1D appear effective at improving diabetes and family-centered outcomes. Additional research is needed to examine the pathways to improvement in glycemic control, as outcomes were mixed. Future research should also involve measures beyond HbA1c given new markers for sustained health improvement and outcomes are being explored.

Parents' Traditional Cultural Values and Mexican-Origin Young Adults' Routine Health and Dental Care

PURPOSE

To investigate the prospective associations between Mexican-origin mothers' and fathers' traditional cultural values and young adults' health and dental care utilization and to test the moderating role of youth gender.

METHODS

Mexican-origin parents and youth (N = 246 families) participated in home interviews and provided self-reports of parents' cultural values (time 1) and young adults' health status and routine health and dental care (time 2; 5 years later). Logistic regressions tested parents' traditional cultural values as predictors of routine health and dental care, accounting for parent nativity, parent acculturation, family socioeconomic status, youth gender, youth age, and youth physical health status. We also tested whether youth gender moderated the associations between parents' cultural values and young adults' routine care.

RESULTS

Young adults whose mothers endorsed strong familism values when they were in mid-to-late adolescence were more likely to report at least one routine physician visit in the past year as young adults (odds ratio [OR] = 3.47, 95% confidence interval [CI]: 1.23-9.83, p = .019). Furthermore, for females only, mothers' more traditional gender role attitudes predicted reduced odds of receiving routine health (OR = .22; 95% CI: .08-.64, p = .005) and dental care (OR = .26; 95% CI: .09-.75, p < .012) in young adulthood.

CONCLUSIONS

Our findings highlight the importance of examining intragroup variability in culturally specific mechanisms to identify targets for addressing ethnic/racial disparities in health care utilization among Mexican-origin young adults, during a period of increased risk for health-compromising behaviors and reduced access to care.

Common Factors in Pediatric Psychiatry: A Review of Essential and Adjunctive Mechanisms of Treatment Outcome

OBJECTIVE

The purpose of this article is to review the literature on hypothesized behavioral correlates of pharmacotherapy treatment response. A particular focus is placed on what have been referred to as "common factors" across mental health treatments, including medication adherence, therapeutic alliance, motivation for behavior change, and expectancies for positive treatment outcomes. These understudied factors may provide unique explanations for mechanisms of symptom change, patient risk as a result of protocol deviation, and attenuated treatment outcomes.

METHOD

A literature search was conducted to evaluate the relationship between treatment processes in pediatric psychiatry and medication adherence, therapeutic alliance, motivation for behavior change, and expectancies for positive treatment outcomes.

RESULTS

Substantial variability and room for improvement was identified for each common factor. Behavioral protocols have already been developed to address many aspects of common factors in pediatric psychiatric treatment, but are not yet a part of many practice parameters.

CONCLUSION

Interventions to improve common factors can be used immediately in tandem with psychopharmacological interventions to provide increased symptom relief and reduce patient risk. Furthermore, incorporating instruction in common factors interventions can positively affect training of future providers and enhance understanding of the mechanisms of effect of medications. An increased focus on common factors, with a particular emphasis on quantifying the magnitude and mechanisms of their effects on psychopharmacological interventions stand to benefit child patients, their families, treatment providers, training facilities, and pharmaceutical manufacturers.

Psychosocial aspects of type 1 diabetes in Latino- and Asian-American youth

Latino and Asian-Americans represent the fastest growing immigrant populations in the United States. We aimed to review the current knowledge on the psychosocial factors that influence type 1 diabetes (T1D) care, education, and outcomes in Latino and Asian-American youth immigrants in the United States, as well as culturally sensitive programs to address health disparities. We conducted a narrative, conceptual review of studies on T1D in Latino and Asian-American youth and relevant studies in type 2 diabetes and adults. Approximately 50% of both Latino and Asian-American youth with T1D are in suboptimal glycemic control. Socioeconomic status, literacy, English proficiency, acculturation, access to health care, family functioning, mental health, and nutrition influence T1D care and outcomes. However, the degree to which these complex, inter-related and dynamic factors affect long-term T1D outcomes is largely unknown. Culturally sensitive programs for Latino or Asian-American youth with T1D are scarce in the United States. Research is needed among Latino and Asian-American youth with T1D so that comprehensive, culturally sensitive diabetes education, and care programs can be developed to decrease disparities in the health burden of these groups.

You never transition alone! Exploring the experiences of youth with chronic health conditions, parents and healthcare providers on self-management

BACKGROUND

Recent evidence suggests that fostering strategies to enable youth with chronic health conditions to work towards gradual self-management of their health is key in successful transition to adult healthcare. To date, there is limited research on self-management promotion for youth. The purpose of this study is to explore self-management from the perspectives of youth, parents and healthcare providers in transition to adult healthcare.

METHODS

Part of a larger longitudinal transition (TRACE-2009-2013) study, interpretive phenomenology was used to explore the meaning of the lived experiences and perceptions of youth, parents, and healthcare providers about transition to adult healthcare. Purposeful sampling was utilized to select youth with a range of chronic health conditions from the TRACE cohort (spanning 20 diagnoses including developmental disabilities and chronic conditions), their parents and healthcare providers.

RESULTS

The emerging three themes were: increasing independence of youth; parents as safety nets and healthcare providers as enablers and collaborators. The findings indicate that the experiences of transitioning youth, parents and service providers are interconnected and interdependent.

CONCLUSIONS

Results support a dynamic and developmentally appropriate approach when working with transitioning youth and parents in practice. As youth depend on parents and healthcare providers for support in taking charge of their own health, parents and healthcare providers must work together to enable youth for self-management. At a policy level, adequate funding, institutional support and accreditation incentives are recommended to allow for designated time for healthcare providers to foster self-management skills in transitioning youth and parents.

Life With Type 1 Diabetes

Purpose

The purpose of this study was to describe the experience of Hispanic adolescents with type 1 diabetes (T1DM) from the perspectives of adolescents and their diabetes clinicians.

Methods

Nine Hispanic adolescents with T1DM and 7 clinicians at a tertiary academic medical center participated in in-depth individual semistructured interviews. Adolescents were purposively sampled to obtain a range in age and metabolic control. Based on interpretive descriptive methodology, data were coded and combined into themes, which were constructed separately for the 2 groups and then compared across groups. Data were analyzed concurrently with data collection.

Results

Adolescents and clinicians reported similar themes related to (1) cultural aspects of living with T1DM; (2) finding the balance of: food, insulin, and exercise; being “perfect at diabetes” versus being a “normal teenager”; and being independent versus needing support, and (3) ways to improve life for Hispanic adolescents with T1DM. Although there were some key cultural distinctions, Hispanic adolescents with T1DM and their clinicians described life and daily management issues as being similar to those of their non-Hispanic peers.

Conclusions

Hispanic adolescents with T1DM have unique experiences and beliefs that affect their living with T1DM, but in many respects, their experiences are similar to those of their non-Hispanic peers with T1DM. Hispanic adolescents with T1DM want their clinicians to learn about their personal lives. Preferably, clinicians and parents should speak the same language. If not possible, interpreters should be used instead of having adolescents translate during clinic appointments.

Prevalence of and disparities in barriers to care experienced by youth with type 1 diabetes

OBJECTIVE

To describe the prevalence of access and process barriers to health care and to examine their relationship to sociodemographic and disease factors in a large and diverse cohort of US youth with type 1 diabetes.

STUDY DESIGN

A cross-sectional analysis of 780 youth who participated in the SEARCH for Diabetes in Youth Study and were diagnosed with type 1 diabetes in 2002-2005. Experience of barriers to care was collected from parent report on questionnaires. Analyses included multivariate regression models to predict the presence of specific barriers to care.

RESULTS

Overall, 81.7% of participants reported at least one barrier; the 3 most common were costs (47.5%), communication (43.0%), and getting needed information (48.4%). Problems with access to care, not having a regular provider, and receiving contextual care (care that takes into account personal and family context) were associated with poorer glycated hemoglobin levels. Adjusted multivariate models indicated that barriers related to access (regular provider, cost) were most likely for youth with low family income and those without public health insurance. Barriers associated with the processes of quality care (contextual care, communication) were more likely for Hispanic youth and those whose parents had less education.

CONCLUSIONS

This study indicates that a large proportion of youth with type 1 diabetes experience substantial barriers to care. Barriers to access and those associated with processes of quality care differed by sociodemographic characteristics. Future investigators should expand knowledge of the systemic processes that lead to disparate outcomes for some youth with diabetes and assess potential solutions.

"We are all gonna get diabetic these days": the impact of a living legacy of type 2 diabetes on Hispanic young adults' diabetes care

PURPOSE

The purpose of this study was to investigate how an intergenerational legacy of type 2 diabetes affected the knowledge, attitudes, and treatment strategies of Hispanic young adults with diabetes.

METHODS

Eight Hispanic young adults (ages 18-30 years) participated in a series of in-home longitudinal qualitative interviews, and 11 of their family members completed single in-home interviews, regarding their diabetes management practices. Interview transcripts were analyzed thematically by a team of researchers.

RESULTS

Five themes emerged that characterized the influence of an intergenerational legacy of diabetes on young adults: food and family (how meal preparation and eating are shared within families), doing together (activity participation is contingent on others' participation), knowledge and expectations (expectations for the future and understandings of diabetes are shaped by family members), miscarried helping (well-intentioned actions have negative consequences), and reciprocal support (children and parents support each other's diabetes care).

CONCLUSIONS

Hispanic young adults' knowledge, attitudes, and self-care practices related to diabetes are strongly influenced by the diabetes management practices of family members with diabetes, which often depart from current standards of diabetes care. Care providers should consider family members as a potentially significant influence, either positive or negative, on the diabetes self-care practices of this population.

The role of alternate caregivers in the management of pediatric asthma

OBJECTIVE

The current study examined the role of alternate caregivers (i.e., caregivers living outside of the home who spend at least 6 hr per week caring for the child) in a sample of Latino and non-Latino White (NLW) families with a child with asthma.

METHODS

Participants included 665 families of children with asthma from NLW, Puerto Rican, and Dominican backgrounds from Rhode Island and Puerto Rico. All caregivers completed a validated semistructured family interview assessing asthma management strategies in the family context.

RESULTS

22 percent of families identified an alternate caregiver. Alternate caregiver involvement was highest among Island Puerto Rican families. Island Puerto Rican families who reported alternate caregiver involvement were rated as having higher medication adherence and more balanced adaptation to the demands of asthma management.

CONCLUSIONS

Alternate caregivers may play an important role in family asthma management, especially among some Latino subgroups.

Psychometric Evaluation of the Brief Acculturation Scale for Hispanics

This study examined the psychometric properties of the Brief Acculturation Scale for Hispanics (BASH), a four-item, language-based measure of acculturation. Participants in the study were 435 Hispanic Americans from a large metropolitan area with English or Spanish language preference. Internal consistency reliability was strong in both language-preference groups. Multiple-group confirmatory factor analysis was used to evaluate the structural validity of the measure. A unidimensional factor structure was found for both English and Spanish language-preference groups and items loaded equivalently across groups, demonstrating measurement invariance. The BASH had good convergent validity and incremental validity. Overall, this study provides further evidence that the BASH offers a brief, reliable, and valid measure of acculturation to be used among Hispanic Americans.

Developmental processes associated with longitudinal declines in parental responsibility and adherence to type 1 diabetes management across adolescence

OBJECTIVE

To identify whether changes in pubertal status and self-efficacy for diabetes management are associated with longitudinal declines in parental responsibility for diabetes, and to determine whether these factors moderate associations between declining parental responsibility and deteriorating adherence across adolescence.

METHODS

Adolescents (N = 252; 53.6% females) with type 1 diabetes, mothers, and 188 fathers participated in a 2.5-year longitudinal study. Self-reports of pubertal status, adolescent efficacy, parental responsibility, and adherence were completed every 6 months (6 time points).

RESULTS

Latent growth curve modeling revealed that longitudinal increases in efficacy and pubertal maturation were uniquely associated with longitudinal declines in parental responsibility. Declines in parental responsibility were related to deterioration in adherence especially when adolescents did not report concomitant growth in self-efficacy.

CONCLUSIONS

Transfer of responsibility for diabetes management across adolescence may be more optimal when adolescents' increased independence is titrated to their changing self-efficacy beliefs.

Good cop, bad cop: quality of parental involvement in type 1 diabetes management in youth

Sustained parental involvement in diabetes management has been generally advised to counteract the deteriorating adherence and glycemic control often seen during adolescence, yet until recently, little attention has been given to the optimal amount, type, and quality of parental involvement to promote the best health outcomes for adolescents with type 1 diabetes (T1D). This review synthesizes research regarding the involvement of caregivers-primarily mothers and fathers-of youth with T1D, with a focus on biopsychosocial outcomes. The recent literature on parental involvement in diabetes management highlights a shift in focus from not only amount but also the types (e.g., monitoring, problem-solving) and quality (e.g., warm, critical) of involvement in both mothers and fathers. We provide recommendations for ways that both parents can remain involved to facilitate greater collaboration in shared direct and indirect responsibility for diabetes care and improve outcomes in youth with T1D.

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

This study examined the relationship of family functioning and depressive symptoms with self-management, glycemic control, and quality of life in a sample of adolescents with type 1 diabetes. It also explored whether self-management mediates family functioning, depressive symptoms, and diabetes-related outcomes. Structural equation modeling was used to estimate parameters in the conceptual causal pathway and test mediation effects. Adolescents (n = 320) were primarily female (55%), younger adolescents (58%), and self-identified as White (63%). Self-management mediated the relationship between family conflict, family warmth-caring, parent guidance-control, and youth depressive symptoms with glycosylated hemoglobin (A1C). In addition, self-management mediated the relationship between family conflict and youth depressive symptoms with quality of life. Supporting optimal family functioning and treating elevated depressive symptoms in adolescents with type 1 diabetes has the potential to improve self-management, glycemic control, and quality of life.

Everyday living with diabetes described by family members of adult people with type 1 diabetes

The aim of this study was to explore family members' experiences of everyday life in families with adult people living with type 1 diabetes. The grounded theory method was used to gather and analyse data from the interviews of nineteen family members. Six concepts describing the family members' views on everyday living with diabetes were generated on the basis of the data. Everyday life with diabetes is described as being intertwined with hypoglycemia. Becoming acquainted with diabetes takes place little by little. Being involved in the management and watching self-management from the sidelines are concepts describing family members' participation in the daily management of diabetes. The family members are also integrating diabetes into everyday life. Living on an emotional roller-coaster tells about the thoughts and feelings that family members experience. Family members of adult people with diabetes are involved in the management of the diabetes in many ways and experience many concerns. The family members' point of view is important to take into consideration when developing education for adults with diabetes.

The relationship between hemoglobin A1C in youth with type 1 diabetes and chaos in the family household

PURPOSE

The purpose of the study was to examine how physical and social environments, as measured by household chaos, affect the diabetes control (i.e., A1C) in youth with type 1 diabetes (T1DM).

METHODS

One hundred and four patients (53 male, 51 female) with T1DM (aged 1-13 years) and their caregivers were recruited from a diabetes clinic at a Midwestern children's hospital. The caregivers completed a demographic questionnaire as well as a questionnaire pertaining to chaos in the household. A medical record review at baseline and 3- and 6-month follow-up was also conducted.

RESULTS

Results found that above and beyond the demographic covariates, there still remained a significant relationship between household chaos and glycemic control. Those who scored more than 1 standard deviation above the mean Confusion, Hubbub, and Order Scale (CHAOS) measure score showed significantly worse glycemic control at 6-month follow-up.

CONCLUSIONS

This study demonstrated the relationship of family environment and glycemic control for youth with T1DM. The findings highlight the need to individually assess the youth's home environment to promote diabetes management and care during clinic visits.

Demographic and personal factors associated with metabolic control and self-care in youth with type 1 diabetes: a systematic review

Optimal use of recent technological advances in insulin delivery and glucose monitoring remain limited by the impact of behaviour on self-care. In recent years, there has been a resurgence of interest in psychosocial methods of optimizing care in youth with type 1 diabetes. We therefore sought to examine the literature for demographic, interpersonal and intrapersonal correlates of self-care and/or metabolic control. Studies for this systematic review were obtained via an electronic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO databases. Seventy studies fulfilled the inclusion criteria. These studies have indicated that identifiable individual characteristics in each domain are robustly associated with metabolic control and/or self-care in children and adolescents. We present these characteristics and propose a theoretical model of their interactions and effect on diabetes outcomes. There is currently no consensus regarding patient selection for insulin pump therapy. In this era of scarce healthcare resources, it may be prudent to identify youth requiring increased psychosocial support prior to regimen intensification. The importance of this review lies in its potential to create a framework for rationally utilizing resources by stratifying costly therapeutic options to those who, in the first instance, will be most likely to benefit from them.

Treatment adherence among adolescents with epilepsy: what really matters?

Treatment adherence is often suboptimal among adolescents with epilepsy. However, knowledge is lacking regarding factors that affect adherence. Empirical studies and theories of human development suggest that self-management skills, self-efficacy, and sense of control are related to adherence. Eighty-eight adolescents with epilepsy, and their parents, completed standardized measures assessing epilepsy knowledge and expectations, treatment self-management, sense of control, and self-efficacy. Better self-reported parent adherence was correlated with greater epilepsy knowledge/expectations (p<0.001) and more medications (p = 0.042). Better self-reported adolescent adherence was correlated with fewer siblings (p = 0.003) and higher adolescent epilepsy knowledge/expectations (p<0.001). Greater adolescent epilepsy knowledge/expectations correlated with parent self-reported adherence (p<0.001), Powerful others locus of control (p = 0.008), and adolescent/parent discordance regarding epilepsy knowledge/expectations (p<0.001). Interventions that enhance adolescent's knowledge of epilepsy and their treatment plan, while ensuring that teens and parents are in agreement with regard to epilepsy treatment, might contribute to better adherence.

Adherence decision making in the everyday lives of emerging adults with type 1 diabetes

PURPOSE

The purpose of this study was to explore motivations underlying nonadherent treatment decisions made by young adults with type 1 diabetes.

METHODS

Eight emerging adults each completed a series of semi-structured interviews concerning their approaches to diabetes care, relationships with clinicians, and everyday activities and routines. A narrative thematic analysis was used to develop initial themes and refine them through continued data collection and review of the research literature.

RESULTS

FIVE THEMES WERE IDENTIFIED AS MOTIVATING NONADHERENCE: (1) efforts to mislead health care providers, (2) adherence to alternative standards, (3) treatment fatigue and burnout, (4) social support problems, and (5) emotional and self-efficacy problems.

CONCLUSION

Instances of nonadherence generally involved a combination of the five identified themes. Participants reporting nonadherence also described difficulties communicating with care providers regarding their treatment. Nonjudgmental communication between providers and emerging adults may be particularly important in promoting positive health outcomes in this population.

Migration status in relation to clinical characteristics and barriers to care among youth with diabetes in the US

Migration status and the accompanying diversity in culture, foods and family norms, may be an important consideration for practitioners providing individualized care to treat and prevent complications among youth with diabetes. Approximately 20 % of youth in the US have ≥1 foreign-born parent. However, the proportion and characteristics of youth with diabetes and ≥1 foreign-born parent have yet to be described. Study participants (n = 3,086) were from SEARCH for Diabetes in Youth, a prospective multi-center study in the US. Primary outcomes of interest included HbA1c, body mass index and barriers to care. Multivariable analyses were carried out using logistic regression and analysis of covariance. Approximately 17 % of participants with type 1 diabetes (T1D) and 22 % with type 2 diabetes (T2D) had ≥1 foreign-born parent. Youth with T1D and ≥1 foreign-born parent were less likely to have poor glycemic control [adjusted odds ratio (OR) (95 % confidence interval): 0.70 (0.53, 0.94)]. Among youth with T2D, those with ≥1 foreign-born parent had lower odds of obesity [adjusted OR (95 % CI): 0.35 (0.17, 0.70)]. This is the first study to estimate the proportion and characteristics of youth with diabetes exposed to migration in the US. Research into potential mechanisms underlying the observed protective effects is warranted.

Individual adjustment, parental functioning, and perceived social support in Hispanic and non-Hispanic white mothers and fathers of children with spina bifida

OBJECTIVE

To compare Hispanic and non-Hispanic White mothers and fathers of children with spina bifida on measures of individual adjustment, parental functioning, and perceived social support.

METHOD

Mothers (29 Hispanic, 79 non-Hispanic white) and fathers (26 Hispanic, 68 non-Hispanic white) completed questionnaires regarding psychological distress, parental functioning, and perceived social support.

RESULTS

Mothers and fathers reported similar individual adjustment across groups. Hispanic mothers reported lower levels of parenting satisfaction, competence as a parent, and social support, as well as higher perceptions of child vulnerability. Hispanic fathers reported lower levels of parenting satisfaction and higher perceptions of child vulnerability. Effect sizes were reduced when socioeconomic status was included as a covariate.

CONCLUSIONS

Hispanic parents, particularly mothers, are at risk for lower feelings of satisfaction and competence as parents. More research is needed to understand cultural factors related to these differences.