Behavioral Assessment and Intervention in Pediatric Diabetes

Systematic Review: Diabetes Family Conflict in Young People With Type 1 Diabetes

OBJECTIVE

To investigate the relationships between diabetes-specific family conflict and health outcomes of young people with type 1 diabetes (T1D).

METHODS

A systematic review was performed according to the PRISMA statement (registration number: CRD42020164988). PubMed, Embase, PsycNET, reference lists of included studies, and other relevant reviews were searched (1990-2020). Two independent reviewers screened titles, abstracts, and full-texts. Studies were included if they sampled young people with T1D (mean age between 14 and 25 years) and examined the relationship between diabetes-specific family conflict and the following outcomes: glycated hemoglobin (HbA1c), treatment adherence, blood glucose monitoring, depression, anxiety, quality of life, and/or well-being.

RESULTS

A total of 20 studies met the predetermined inclusion criteria. Greater diabetes-specific family conflict was significantly related to higher HbA1c values in 17 studies. Seven studies reported a significant association between greater diabetes family conflict and suboptimal treatment adherence and/or less frequent blood glucose monitoring. However, significant relationships between conflict and HbA1c and/or treatment adherence were not found in four studies. Seven studies in total reported that greater diabetes family conflict was significantly related to poorer quality of life or well-being and greater depressive and/or anxiety symptoms in young people.

CONCLUSIONS

Diabetes-specific family conflict is associated with some adverse health outcomes for young people with T1D. However, more longitudinal studies of young people aged older than 16 years are needed. Screening for and addressing diabetes-specific family conflict is recommended, given the growing number of studies linking family conflict to various adverse health outcomes in young people with T1D.

Patient-reported outcome measures for diabetes self-care: A systematic review of measurement properties

OBJECTIVES

The aims of the present systematic review were to identify currently available patient-reported outcome measures for diabetes self-care that have been psychometrically evaluated and to evaluate their measurement properties.

DESIGN

A systematic literature review with a meta-analysis.

DATA SOURCES

A systematic literature search was conducted of the MEDLINE, EMBASE, and CINAHL databases.

REVIEW METHODS

The updated COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) was applied using the following steps to evaluate the measurement properties of the diabetes self-care measures: (1) evaluating the methodological quality, (2) evaluating either quantitatively summarized or quantitatively pooled data against criteria for good measurement properties, and (3) the evaluating the quality of evidence by applying the modified Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

Among 8434 articles yielded by the database search, 27 full-text articles that reported 34 studies of 13 different patient-reported outcome measures were included in this systematic review. The Diabetes Self-Management Instrument demonstrated the best content validity, with sufficient moderate-quality evidence for relevance, comprehensiveness, and comprehensibility. The Diabetes Self-Management Instrument exhibited sufficient moderate-quality evidence for structural validity and internal consistency, and sufficient high-quality evidence for convergent validity of hypothesis testing and sufficient low-quality evidence for reliability. The eight-item Summary of Diabetes Self-Care Activities-Revised was the most frequently investigated and shortest instrument with sufficient high-quality evidence for structural validity and internal consistency. However, the sufficient but very-low-quality comprehensiveness and the inconsistent very-low-quality comprehensibility for content validity, and the insufficient low-quality evidence for reliability must be considered when selecting this instrument.

CONCLUSIONS

None of the identified diabetes self-care instruments appears to be universally superior to the others. The Diabetes Self-Management Instrument might be the best based on current evidence, but this requires further evaluation of the measurement of invariance across languages. The eight-item Summary of Diabetes Self-Care Activities-Revised is the shortest instrument, but current evidence with regards to its content validity and reliability needs to be considered before applying this instrument. Further studies are recommended to evaluate the reliability, measurement error, and responsiveness of the diabetes self-care measurements.

Impact and Cost-Effectiveness of Integrated Psychology Services in a Pediatric Endocrinology Clinic

Including psychology services in pediatric endocrinology clinics may improve patients' adherence to diabetes management behaviors, and, subsequently, glycemic control; however, an evaluation of the impact and cost-effectiveness of this integration is needed. The change in HbA1c and cost-effectiveness of integrated psychology services, from the hospital and insurance provider perspectives, were evaluated using a linear effects model and Incremental Cost-Effectiveness Ratios (ICERs). Data from 378 patients with T1D (50% female; 65% Caucasian; M age = 12.0 years) were obtained via medical chart review (2241 appointments). Patients demonstrated significant improvements in HbA1c following clinic visits in which they met with psychology (b = - 0.16, p = 0.006). A larger proportion of the distribution of ICER values fall below the $1000/1% HbA1c threshold from both the insurance (89%) and hospital (94%) perspectives. These results indicate that providing integrated psychology services in the endocrinology clinic is highly beneficial from the patient, hospital, and insurance provider perspectives.

Metabolic control and academic achievement over time among adolescents with type 1 diabetes

The relation between metabolic control (HbA1c) and achievement (grade point average [GPA]) was examined over a period of 2.5 years (every 6 months) employing a dynamical systems approach that allowed for the examination of whether HbA1c was associated with change in subsequent GPA and vice versa. Metabolic control tends to deteriorate (i.e., with higher HbA1c reflecting poorer metabolic control) during adolescence. It was hypothesized that these higher levels of HbA1c would limit subsequent increases in GPA. The sample included 252 adolescents (Mbaseline age = 12.49 years, SD = 1.53; 53.6% female) with Type 1 diabetes. Mothers' report and school records provided information on relevant demographics and GPA; medical records provided values of HbA1c. Two simultaneous coupled change equations (i.e., examining current values in 1 variable associated with changes in the other) controlling relevant risk indicators (i.e., age, sex, disease duration, insulin delivery method, IQ) revealed higher levels of HbA1c limited increases in GPA. Higher levels of GPA, however, were not associated with change in HbA1c except for 2 instances where moderation existed by disease duration and IQ. Higher GPA was associated with slower increases in HbA1c over time for youth with shorter disease duration and lower IQ. These results affirm the importance of maintaining good metabolic control to facilitate adequate school performance across the adolescent years. Further, the results suggest that factors related to school achievement may protect adolescents who are newly diagnosed or who have low cognitive ability from subsequent deterioration in metabolic control. (PsycINFO Database Record

Cognitive, behavioral and goal adjustment coping and depressive symptoms in young people with diabetes: a search for intervention targets for coping skills training

The aim of the present study was to find relevant coping factors for the development of psychological intervention programs for young people with Type 1 (T1) diabetes. A wide range of coping techniques was studied, including cognitive coping, behavioral coping and goal adjustment coping. A total of 78 young people with T1 diabetes participated. They were contacted through a social networking website, several Internet sites, and flyers. A wide range of coping techniques appeared to be related to depressive symptoms. Especially the cognitive coping strategies self-blame, rumination, refocus positive, and other-blame, together with goal adjustment coping, were of importance. A large proportion of the variance of depressive symptoms could be explained (65 %). These findings suggest that these specific coping strategies should be part of coping skills trainings for young people with T1 diabetes.

Moving the Journey Towards Independence: Adolescents Transitioning to Successful Diabetes Self-Management

PURPOSE

To gain a greater understanding of adolescent's experiences living with Type 1 diabetes mellitus (T1DM) and create a theoretical paradigm.

METHODS

Grounded theory as described by Glaser was used. Fifteen in-depth interviews were conducted with adolescent's ages 11-15 with T1DM. Symbolic interactionism is the theoretical framework for grounded theory. Data were collected; transcribed, coded, and analyzed simultaneously using constant comparative analysis and findings were grounded in the words of participants.

RESULTS

A theoretical model was created with the concept of "normalizing". Normalizing was defined as the ability to integrate diabetes into one's daily life to make diabetes 'part of me'. Phase four of the model, and the focus of this manuscript was "Moving the Journey towards Independence" and included: 1) taking over care, 2) experiencing conflict with parents, and 3) realizing diabetes is hard. The major task for adolescents in this phase was separating from parents to independently manage diabetes. The normalizing task for this phase was: "taking on the burden of care". Adolescents described challenges with independent care and increased parental conflict including: fearing needles, forgetting insulin, feeling embarrassed and believing that diabetes was a burden in their life. Additionally, juggling the multiple responsibilities of home, school and work along with managing a chronic illness during adolescence is challenging.

CONCLUSIONS

Transitioning to diabetes self-management is a challenge for adolescents. This model advances understanding of the moving processes in adolescents transitioning; additionally, hypotheses are presented that may be used for developing interventions to promote success in self-management.

Developing and evaluating a child-centred intervention for diabetes medicine management using mixed methods and a multicentre randomised controlled trial

Aim

To develop and evaluate an individually tailored age-appropriate diabetes diary and information pack for children and young people aged 6–18 years with type 1 diabetes to support decision-making and self-care with a specific focus on insulin management and blood glucose monitoring, compared with available resources in routine clinical practice.

Design

Four-stage study following the Medical Research Council framework for designing and evaluating complex interventions. Stage 1: context – brief review of reviews and mixed-method systematic review; updating of database of children’s diabetes information; children’s diabetes information quality assessment and diabetes guideline analysis; and critical discourse analysis. Stage 2: intervention development – working with expert clinical advisory group; contextual qualitative interviews and focus groups with children and young people to ascertain their information preferences and self-care practices; ongoing consultation with children; development of intervention programme theory. Stage 3: randomised controlled trial (RCT) to evaluate the diabetes diaries and information packs in routine practice. Stage 4: process evaluation.

Findings

The RCT achieved 100% recruitment, was adequately powered and showed that the Evidence into Practice Information Counts (EPIC) packs and diabetes diaries were no more effective than receiving diabetes information in an ad hoc way. The cost per unit of producing the EPIC packs and diabetes diaries was low. Compared with treatment as usual information, the EPIC packs fulfilled all NHS policy imperatives that children and young people should receive high-quality, accurate and age-appropriate information about their condition, self-management and wider lifestyle and well-being issues. Diabetes guidelines recommend the use of a daily diabetes diary and EPIC diaries fill a gap in current provision. Irrespective of allocation, children and young people had a range of recorded glycated haemoglobin (HbA1c) levels, which showed that as a group their diabetes self-management would generally need to improve to achieve the HbA1clevels recommended in National Institute for Health and Care Excellence guidance. The process evaluation showed that promotion of the EPIC packs and diaries by diabetes professionals at randomisation did not happen as intended; the dominant ‘normalisation’ theory underpinning children’s diabetes information may be counterproductive; risk and long-term complications did not feature highly in children’s diabetes information; and children and young people engaged in risky behaviour and appeared not to care, and most did not use a diabetes diary or did not use the information to titrate their insulin as intended.

Limitations

Recruitment of ‘hard to reach’ children and young people living away from their families was not successful. The findings are therefore more relevant to diabetes management within a family context.

Conclusions

The findings indicate a need to rethink context and the hierarchical relationships between children, young people, parents and diabetes professionals with regard to ‘partnership and participation’ in diabetes decision-making, self-care and self-management. Additional research, implementation strategies and service redesign are needed to translate available information into optimal self-management knowledge and subsequent optimal diabetes self-management action, including to better understand the disconnection between children’s diabetes texts and context; develop age-appropriate Apps/e-records for recording blood glucose measurements and insulin management; develop interventions to reduce risk-taking behaviour by children and young people in relation to their diabetes management; reconsider what could work to optimise children’s self-management of diabetes; understand how best to reorganise current diabetes services for children to optimise child-centred delivery of children’s diabetes information.

Study registration

Current Controlled Trials ISRCTN17551624.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Methodological issues in the assessment of diabetes treatment adherence

Improving treatment adherence in patients with diabetes remains an important objective of behavioral science research. However, progress is often limited by the heterogeneity in methods used to measure treatment adherence and difficulties in generalizing across methodologies. Various measurement methods are often used with little attention paid to questions regarding validity. Doubts about validity of adherence measurement often lead investigators to measure distal clinical outcomes instead, such as glycemic control, resulting in a loss of information. This article provides an overview of the literature on diabetes medication adherence, with a focus on measurement issues. We also consider work conducted in other chronic illnesses, particularly HIV/AIDS, that may have value in guiding future directions of diabetes medication adherence research. We highlight the need for focused investigation on how characteristics of self-report methodologies affect the validity of patient responses and conclude with practical recommendations based on the current state of the science.

Short-term use of continuous glucose monitoring system adds to glycemic control in young type 1 diabetes mellitus patients in the long run: a clinical trial

BACKGROUND/AIM

Balancing strict glycemic control with setting realistic goals for each individual child and family can optimize growth, ensure normal pubertal development and emotional maturation, and control long term complications in children with type 1 diabetes (T1DM). The aim of this study was to evaluate the efficacy of short-term continuous glucose monitoring system (CGMS) application in improvement of glycemic control in pediatric type 1 diabetes mellitus (T1DM) patients. METHODS. A total of 80 pediatric T1DM patients were randomly assigned into the experimental and the control group. The experimental group wore CGMS sensor for 72 hours at the beginning of the study. Self-monitored blood glucose (SMBG) levels and hemoglobin A1c (HbA1c) levels were obtained for both groups at baseline, and at 3 and 6 months. RESULTS. There was a significant improvement in HbA1c (p < 0.001), in both the experimental and the control group, without a significant difference between the groups. Nevertheless, after 6 months the improvement of mean glycemia was noticed only in the experimental group. This finding was accompanied with a decrease in the number of hyperglycemic events and no increase in the number of hypoglycemic events in the experimental group.

CONCLUSIONS

The results suggest that the CGMS can be considered as a valuable tool in treating pediatric T1DM patients, however further research is needed to more accurately estimate to what extent, if any, it outperforms intensive self-monitoring of blood glucose.

Contracting and monitoring relationships for adolescents with type 1 diabetes: a pilot study

BACKGROUND

Adolescents are developmentally in a period of transition-from children cared for by their parents to young adults capable of self-care, independent judgment, and self-directed problem solving. We wished to develop a behavioral contract for adolescent diabetes management that addresses some negotiable points of conflict within the parent-child relationship regarding self-monitoring and then assess its effectiveness in a pilot study as part of a novel cell phone-based glucose monitoring system.

METHODS

In the first phase of this study we used semistructured interview techniques to determine the major sources of diabetes-related conflict in the adolescent-parent relationship, to identify factors that could facilitate or inhibit control, and to determine reasonable goals and expectations. These data were then used to inform development of a behavioral contract that addressed the negotiable sources of conflict between parents and their adolescent. The second phase of this research was a 3-month pilot study to measure how a novel cell phone glucose monitoring system would support the contract and have an effect on glucose management, family conflict, and quality of life.

RESULTS

Interviews were conducted with 10 adolescent-caregiver pairs. The major theme of contention was nagging about diabetes management. Two additional themes emerged as points of negotiation for the behavioral contract: glucose testing and contact with the diabetes clinical team. Ten adolescent-parent pairs participated in the pilot test of the system and contract. There was a significant improvement in the Diabetes Self-Management Profile from 55.2 to 61.1 (P < 0.01). A significant reduction in hemoglobin A1c also occurred, from 8.1% at the start of the trial to 7.6% at 3 months (P < 0.04).

CONCLUSIONS

This study confirms previous findings that mobile technologies do offer significant potential in improving the care of adolescents with type 1 diabetes. Moreover, behavioral contracts may be an important adjunct to reduce nagging and improve outcomes with behavioral changes.

Nonpharmacological management and psychosocial support for children and adolescents with type 1 diabetes

Compared to that in the Caucasian population, type 1 diabetes mellitus (T1DM) incidence rates are very low in Koreans. Therefore, compared to the recent development of pharmacological therapy applicable to Korean children with T1DM, interest in nonpharmacological therapy and psychosocial support systems remains low, as is the development of Korean-style T1DM education programs for therapeutic application. Children who have been newly diagnosed with diabetes are placed in completely new environments for treatment. For appropriate control of diabetes, patients have to self-monitor blood glucose levels and inject insulin several times a day and must use extreme self-control when they eat foods to avoid increases in blood glucose levels. Blood glucose excursions resulting from impaired pancreatic β cell functions cause mental stress due to vague fears of chronic complications of diabetes. In addition, children with diabetes cannot be excluded from the substantial amount of studies required of Korean adolescents, and the absolute shortage of time for ideal control of diabetes adds to their mental stress. Many of these patients are psychologically isolated in school where they spend most of their time, and they are not appropriately considered or supported with respect to blood glucose control in many cases. In this respect, this author will introduce some of the newest views on nonpharmacological therapy and psychosocial support systems that account for important parts of T1DM management and seek measures to apply them in conformity with the social characteristics of Korea.

Cognitive-behavioral therapy for children with comorbid physical illness

In addition to the usual developmental challenges, children and adolescents with chronic physical illness face psychosocial challenges that affect their quality of life. This review describes different aspects of coping with chronic physical illness in childhood and the empirical evidence examining the usefulness of cognitive-behavioral therapy (CBT) for the treatment of children and adolescents with chronic physical illnesses and related psychological comorbidities. Four diseases (diabetes, inflammatory bowel disease, cancer, and sickle cell disease) were chosen as model illnesses to demonstrate key CBT findings in more detail. Future research recommendations in this challenging population are also addressed.

Helping high-risk youth move through high-risk periods: personally controlled health records for improving social and health care transitions

BACKGROUND

New patient-centered information technologies are needed to address risks associated with health care transitions for adolescents and young adults with diabetes, including systems that support individual and structural impediments to self- and clinical-care.

METHODS

We describe the personally controlled health record (PCHR) system platform and its key structural capabilities and assess its alignment with tenets of the chronic care model (CCM) and the social-behavioral and health care ecologies within which adolescents and young adults with diabetes mature.

RESULTS

Configured as Web-based platforms, PCHRs can support a new class of patient-facing applications that serve as monitoring and support systems for adolescents navigating complex social, developmental, and health care transitions. The approach can enable supportive interventions tailored to individual patient needs to boost adherence, self-management, and monitoring.

CONCLUSIONS

The PCHR platform is a paradigm shift for the organization of health information systems and is consistent with the CCM and conceptualizations of patient- and family-centered care for diabetes. Advancing the approach augers well for improvement around health care transitions for youth and also requires that we address (i) structural barriers impacting diabetes care for maturing youth; (ii) challenges around health and technology literacy; (iii) privacy and confidentiality issues, including sharing of health information within family and institutional systems; and (iv) needs for evaluation around uptake, impacts, and outcomes.

Psychosocial problems in adolescents with type 1 diabetes mellitus

Adolescents with diabetes are at increased risk of developing psychiatric (10-20%) or eating disorders (8-30%), as well as substance abuse (25-50%), leading to non-compliance with treatment and deterioration of diabetic control. At high risk are female adolescents with family problems and other comorbid disorders. Impaired cognitive function has also been reported among children with diabetes, mainly in boys, and especially in those with early diabetes diagnosis (< 5 years), or with episodes of severe hypoglycaemia or prolonged hyperglycaemia. Type 1 diabetes mellitus contributes to the development of problems in parent-child relationships and employment difficulties, and negatively affects the quality of life. However, insulin pumps appear to improve patients' metabolic control and lifestyle. The contributions of family and friends to the quality of metabolic control and emotional support are also crucial. In addition, the role of the primary-care provider is important in identifying patients at high risk of developing psychosocial disorders and referring them on to health specialists. At high risk are patients in mid-adolescence with comorbid disorders, low socioeconomic status or parental health problems. Multisystem therapy, involving the medical team, school personnel, family and peer group, is also essential. The present review focuses on the prevalence of nutritional and psychosocial problems among adolescents with diabetes, and the risk factors for its development, and emphasizes specific goals in their management and prevention.

Validity and reliability of an adolescent and parent rating scale of type 1 diabetes adherence behaviors: the Self-Care Inventory (SCI)

OBJECTIVE

Accurate assessment of diabetes regimen adherence behaviors in youth is a challenging endeavor and is limited by a paucity of empirically supported measures. The purpose of this research is to further demonstrate the validity and reliability of the Self-Care Inventory (SCI), a youth and parent report measure of adherence with diabetes self-care behaviors. The SCI was chosen given its ease of implementation, applicability to multiple diabetes regimens, and dual parent/youth formats.

METHODS

Participants were 164 youth with type 1 diabetes and a parent. Measures were administered at regular office visits to a tertiary care diabetes clinic.

RESULTS

The SCI has strong psychometric properties, including adequate internal consistency, parent-youth agreement, and test-retest agreement. Relations between the SCI and a structured interview of diabetes adherence (the Diabetes Self-Management Profile; DSMP) and hemoglobin A1c (HbA1c) were strong.

CONCLUSIONS

In addition to demonstrating strong psychometrics, this research provides independent support for the SCI. Thus, the SCI is consistent with recent criteria proposed by Quittner et al. (Journal of Pediatric Psychology, 33, 916-936) for an empirically supported measure of regimen adherence. Although other methods of accessing adherence may provide more comprehensive assessments, the brevity, ease-of-implementation, and robustness for multiple regimens makes the SCI an ideal tool for clinicians and researchers.

Review of family-centered interventions to enhance the health outcomes of children with type 1 diabetes

PURPOSE

The purpose of this systematic literature review was to examine family-centered interventions that enhance the health outcomes of children with type 1 diabetes. The review summarizes the interventions and outcome measures that consisted of A1Cs, family relationships, and family conflict.

METHODS

Multiple electronic databases were searched from their start date to September 2008 for reports of studies that examined family-centered interventions among children with type 1 diabetes.

RESULTS

Nine publications, all randomized controlled trials, were located that investigated the effectiveness of family-centered interventions. Findings indicated that family-centered interventions significantly improved A1Cs, enhanced family dynamics, and decreased family conflict.

CONCLUSIONS

Family-centered interventions targeting children diagnosed with type 1 diabetes appear to be effective in enhancing health outcomes. These interventions focused on traditional 2-parent families, and many did not report race or ethnicity. Given the increasing number of single-parent households and divorced parents, a need exists to explore and develop family-centered interventions that target nontraditional family structures as well as addressing cultural differences.

A token economy for exercise adherence in pediatric cystic fibrosis: a single-subject analysis

OBJECTIVE

In cystic fibrosis (CF), adherence to airway clearance techniques (e.g., chest physiotherapy and exercise) is poor. Exercise is important because pulmonary difficulties are associated with the highest mortality rate. Despite this, very little research has focused on exercise adherence in CF. This study examined a token economy for increasing exercise in children with CF.

METHODS

An ABAB single-subject design evaluated a token economy for increasing and maintaining exercise in three children with CF. Patient report, parent report, and physiological measures were used to assess treatment integrity, medical stability, and changes in exercise.

RESULTS

Measures suggested that treatment integrity was strong. Results indicated strong treatment effects for all participants without negative medical side effects. Follow-up of 1 and 3 months supported continued exercise for all participants.

CONCLUSIONS

A token economy effectively increased exercise in children with CF, and the single-subject design highlighted some of the intricacies of individualized treatment of adherence. Implications and recommendations for further research are discussed.

Are family factors universally related to metabolic outcomes in adolescents with Type 1 diabetes?

AIMS

To assess the importance of family factors in determining metabolic outcomes in adolescents with Type 1 diabetes in 19 countries.

METHODS

Adolescents with Type 1 diabetes aged 11-18 years, from 21 paediatric diabetes care centres, in 19 countries, and their parents were invited to participate. Questionnaires were administered recording demographic data, details of insulin regimens, severe hypoglycaemic events and number of episodes of diabetic ketoacidosis. Adolescents completed the parental involvement scale from the Diabetes Quality of Life for Youth--Short Form (DQOLY-SF) and the Diabetes Family Responsibility Questionnaire (DFRQ). Parents completed the DFRQ and a Parental Burden of Diabetes score. Glycated haemoglobin (HbA(1c)) was analysed centrally on capillary blood.

RESULTS

A total of 2062 adolescents completed a questionnaire, with 2036 providing a blood sample; 1994 parents also completed a questionnaire. Family demographic factors that were associated with metabolic outcomes included: parents living together (t = 4.1; P < 0.001), paternal employment status (F = 7.2; d.f. = 3; P < 0.001), parents perceived to be over-involved in diabetes care (r = 0.11; P < 0.001) and adolescent-parent disagreement on responsibility for diabetes care practices (F = 8.46; d.f. = 2; P < 0.001). Although these factors differed between centres, they did not account for centre differences in metabolic outcomes, but were stronger predictors of metabolic control than age, gender or insulin treatment regimen.

CONCLUSIONS

Family factors, particularly dynamic and communication factors such as parental over-involvement and adolescent-parent concordance on responsibility for diabetes care appear be important determinants of metabolic outcomes in adolescents with diabetes. However, family dynamic factors do not account for the substantial differences in metabolic outcomes between centres.

Health beliefs, disease severity, and patient adherence: a meta-analysis

BACKGROUND

A large body of empirical data exists on the prediction of patient adherence from subjective and objective assessments of health status and disease severity. This work can be summarized with meta-analysis.

OBJECTIVES

Retrieval and summary analysis of r effect sizes and moderators of the relationship between patient adherence and patients': (1) beliefs in disease threat; (2) rated health status (by physician, self, or parent); and (3) objective disease severity.

METHODS

Comprehensive search of published literature (1948-2005) yielding 116 articles, with 143 separate effect sizes. Calculation of robust, generalizable random effects model statistics, and detailed examination of study diversity with moderator analyses.

RESULTS

Adherence is significantly positively correlated with patients' beliefs in the severity of the disease to be prevented or treated ("disease threat"). Better patient adherence is associated with objectively poorer health only for patients experiencing disease conditions lower in seriousness (according to the Seriousness of Illness Rating Scale). Among conditions higher in seriousness, worse adherence is associated with objectively poorer health. Similar patterns exist when health status is rated by patients themselves, and by parents in pediatric samples.

CONCLUSIONS

Results suggest that the objective severity of patients' disease conditions, and their awareness of this severity, can predict their adherence. Patients who are most severely ill with serious diseases may be at greatest risk for nonadherence to treatment. Findings can contribute to greater provider awareness of the potential for patient nonadherence, and to better targeting of health messages and treatment advice by providers.

A controlled study of psychosocial factors in young people with diabetes in the United arab emirates

Psychosocial factors were studied in 30 young people with diabetes and 30 control subjects in the UAE. Patients perceived themselves more negatively than their parents on several domains. Also, they had lower scores in the areas of physical appearance and athletic competence when compared to control subjects. There were significant gender differences, with girls perceiving themselves more negatively. Better maternal education and availability of social support were associated with a positive self-image in the child. Parents of children exhibiting behavioral/emotional problems had a higher score on the parental General Health Questionnaire. Awareness and understanding of these psychosocial variables can help healthcare providers to target these issues as part of comprehensive diabetes management.