Journal of Pediatric Psychology, Vol. 25, No. 6, 2000, pp. 393-402
© 2000 Society of Pediatric Psychology
Pathways From Emotional Adjustment to Glycemic Control in Youths With Diabetes in Hong Kong
1 The University of Hong Kong, 2 Princess Margaret Hospital, 3 Pamela Youde Hospital, 4 Yan Chai Hospital
All correspondence should be sent to Sunita Mahtani Stewart, Department of Community Medicine, The University of Hong Kong, Hong Kong, China. E-mail: commed{at}hku.hk .
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Abstract |
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Objective: To examine factors that influence emotional adjustment, adherence to diabetic care, and glycemic control in Hong Kong youths with insulin-dependent diabetes mellitus (IDDM).
Methods: Seventy youths, their mothers, and matched controls provided information on health beliefs, authoritarian parenting style, parent-child conflict, emotional adjustment, and adherence to medical regimen. Glycosylated hemoglobin levels were obtained to measure glycemic control.
Results: Predictors explained 34% of the variance in emotional adjustment and 39% of the variance in glycemic control. The data supported a pathway from emotional adjustment to self-efficacy to adherence behaviors to glycemic control. In contrast to Western culture and consistent with prediction, parenting style did not associate with negative outcomes, and even relatively low levels of parent-child conflict correlated negatively with emotional adjustment in this culture.
Conclusions: Management of conflict and self-efficacy enhancing interactions are suggested interventions to enhance adherence to diabetic care in Hong Kong youths with IDDM.
Key words: childhood diabetes; glycemic control; Hong Kong; emotional adjustment.
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Introduction |
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This article presents an investigation of factors that influence emotional adjustment, adherence to diabetic care, and glycemic control in a group of 70 Hong Kong Chinese youths with insulin-dependent diabetes mellitus (IDDM) and their mothers. The variables investigated were health beliefs, family style, and parent-child conflict. These factors have been found to influence emotional and health outcomes in Western samples. The study had two primary aims, both related to current gaps in the literature. The first aim was to examine risk variables for emotional distress in the Hong Kong Chinese pediatric diabetes population. Much of what is known about adjustment to chronic illness in youths is based on information from Western samples. The second aim was to investigate the pathway from emotional adjustment to glycemic control. Whereas it has been documented that nonadherent youths show emotional and behavioral problems (e.g., Kovacs, Goldston, Obrosky, & Iyengar, 1992
), there is less information about how such effects occur.
Such information would be particularly useful in designing interventions to
maximize the emotional and health status of young people with diabetes.
Numerous factors have been associated with adjustment of the patient with
diabetes in particular (see, e.g.,
Johnson, 1995) and pediatric
patients with chronic illness in general (see, e.g.,
Eiser, 1990;
Wallander & Varni, 1998).
The variables assessed, health beliefs, parenting styles, parent-child
conflict, were chosen with two guiding principles in mind. Variables that
might be moderated by cultural differences between the West and Hong Kong in
their influence on emotional adjustment were of particular interest. A second
guideline was that predictors be amenable to clinical intervention.
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Variables |
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Health Beliefs
The health belief model (Becker, 1974
) has contributed to the understanding of compliance with
health care and medical recommendations
(La Greca & Schuman,
1995). Self efficacy, or the individual's belief that he or she
has the ability to follow health care recommendations, has been found to
relate positively with adherence in Western studies of youths with diabetes
(Littlefield et al., 1992).
The association of locus of control beliefs and emotional adjustment in a
culture where the supernatural and "luck" are given important
roles as sources of influence is of theoretical interest. We predicted that
chance beliefs would relate negatively to adjustment in both the diabetic and
non-health-impaired samples. Furthermore, we predicted that internal locus of
control would associate with self efficacy, as the belief that health is
influenceable would logically associate with the belief that one is actually
effective in influencing one's own health. We also predicted that beliefs that
powerful others (physicians and health care personnel) have the key to
improving health will improve adherence behaviors.
Parenting and Family Styles
In the Western developmental literature, authoritative parental style has
been linked with various positive outcomes
(Steinberg, Dornbusch, & Brown,
1992). An essential component of this style is a negotiating and
compromising attitude on the part of the parents, with children given a voice
in decision making. In contrast, the authoritarian style involves a rigid,
power assertive attitude and has been associated with negative outcomes in the
West. In studies of Chinese-American and other Asian groups in the West, the
authoritarian family style has been noted as common
(Steinberg et al., 1992).
Furthermore, it has been noted that in contrast to Western teenagers, Asian
teenagers do not show negative outcomes in at least some areas of function in
the presence of authoritarian parenting
(Leung, Lau, & Lam, 1998;
Steinberg et al., 1992). In
line with these studies with similar populations, we predicted that
authoritarian family structure would not have a negative effect on the
emotional adjustment of Hong Kong Chinese youths.
Parent-Child Conflict
In Western theories of adolescence, parent-child conflict has been seen as
normative and related to the task of gaining autonomy from parents
(Steinberg, 1990).
Parent-child conflict is present with lower frequency and intensity in Chinese
families with adolescents than in Western families
(Yau & Smetana, 1996).
Numerous investigations have found an inverse relationship between family
conflict and youngsters' treatment adherence
(Friedman & Litt, 1987;
Hauser et al., 1990). We
therefore hypothesized that in a culture where obedience is emphasized and
autonomy from parents not recognized as an important developmental task,
conflict between young people and their parents will relate to negative
emotional adjustment not just in patients with diabetes but also in
non-health-impaired controls.
Perceptions of conflict and family style have generally been obtained from
the offspring (Steinberg et al.,
1992; Yau & Smetana,
1996). We obtained information from mothers and offspring,
allowing examination of disparities and differential influences on
outcomes.
Glycemic Control and Adherence to Medical Regimen
Stabilizing control over blood glucose levels in diabetes requires
adherence to a complex regimen of glucose monitoring, insulin injections,
diet, and exercise. A decline in insulin sensitivity accompanies puberty
(Bloch, Clemens, & Sperling,
1987). An additional reason for poor glycemic control in
adolescents compared to children is nonadherence. Maximizing adherence to
diabetes regimens is an important goal for most treatment programs.
Models of the Relationships Among Predictors, Adherence, and Glycemic
Control
The literature has emphasized theory-driven research
(Wallander & Varni, 1998)
and the importance of assessing critical intervening variables in developing
models (Johnson, 1995). Of
particular interest in this study was the pathway from emotional adjustment to
disease control, two variables that have been linked in the pediatric chronic
illness literature. Predictors were restricted to measures derived from the
patients themselves, because simple causal pathways were more appropriate in
this first study in this culture. An additional practical concern was that
sample size restrictions did not allow for a complex multivariate model to be
tested with adequate power.
The variables studied were organized into a logical causal model as
follows. Certain of the measures were predicted as influencing emotional
adjustment: parent-child conflict, chance locus of control, and duration of
disease (Hanson, Cigrang, et al.,
1989). We also included gender, because there is some evidence of
differences between girls and boys in their emotional response to development
of diabetes (Ryan & Morrow,
1986). In Hong Kong (Stewart
et al., 1999), as in the West, postpubertal girls show more
symptoms of emotional distress than do boys. Although gender differences have
not been emphasized in the compliance literature in the West, there is more
gender differentiation in Hong Kong than in most Western cultures
(Cheung, 1996). We predicted
that emotional adjustment in turn would influence glycemic control in several
steps. First, well-adjusted youths would be more likely to have a greater
sense of self-efficacy. Higher self-efficacy would lead to better adherence.
We predicted that self-efficacy would be the mediator of emotional
adjustment's effects on adherence. Finally, with better adherence, glycemic
control would be higher. In addition to this pathway from emotional adjustment
to glycemic control, we hypothesized that self-efficacy would also be
influenced by internal locus of control. Adherence would also be affected by
belief in powerful others' ability to influence good health. Finally, we
predicted that pubertal status (Bloch et
al., 1987) would exercise a direct effect on glycemic control.
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Method |
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Participants
This study includes 70 patients with IDDM and their mothers, and a parallel age- and gender-matched set of non-health-impaired control mother-offspring pairs. Patients with diabetes were recruited during a clinic visit from four pediatric endocrinology clinics in Hong Kong where they are being followed. Inclusion criteria were: age 9 to 21 years and availability of mother (or the primary caretaker if mother was not living in the home). Exclusion criteria were concurrent primary diagnoses such as Cooley's anemia or significant sensory impairment. Of patients who met eligibility requirements, only two were not included in the sample as their parent refused participation. Control families were recruited from the rolls of a government dental clinic and selected to match the participants with diabetes in age and gender on a case-by-case basis. Exclusion criteria for control participants were presence of chronic illness or sensory handicap. Approximately twice as many families had to be contacted as agreed to participate. The study was not conducted during a scheduled clinic visit, and the major reason given for refusal was inconvenience. There were no gender or age differences between those who agreed and those who refused participation. No other information was available, so the possibility of a bias in the group that served as controls in this study is acknowledged. All participants were assured of the confidentiality of the data, and forms were coded for anonymity. Approval was obtained from the university ethics committee. Signed informed consent was obtained from patients and parents.
The samples consisted of 33 boys and 37 girls in each group. The average age was 15 years and 1 month for both patients with diabetes and 15 years and 2 months for control patients. The average grade placement for diabetic patients was 8.5, and for control patients 8.6. Eighty-three percent of fathers and 91% of mothers of diabetic patients had no more than a secondary school education, and 24% of fathers and 29% of mothers had not studied beyond primary school. The sample was largely lower to middle class, as would be expected from their attendance at government-funded public clinics. Patients with diabetes and controls were approximately equivalent (p value for difference >.05) for age, grade placement, mothers' and fathers' education, birthplace, family structure, number of people in household, birth order, and whether they lived in private or public housing.
Physicians provided information regarding coexisting disease and pubertal stage (Tanner's stages graded from I to V). Table I presents descriptive information on the diabetes patients.
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Measures
All measures were administered in Chinese. Two bilingual individuals
translated those forms that did not exist in Chinese translation, using a
forward-backward translation procedure. All youths completed the forms
independently with the research assistant available to clarify questions.
Mothers were offered the option for independent completion versus support with
reading the questions.
Glycemic Control. Glycosylated hemoglobin (HbA1c) levels are routinely obtained in each clinic. All levels obtained in the 12 months prior to the participation were included. Multiple HbA1c measures were highly correlated (Cronbach's alpha coefficient =.92); therefore the average score was used as the measure. Values were converted for pooling as follows. The mean HbA1c value was subtracted from the high value of the normal range (high values ranged from 5.9% to 6.5%), and the result divided by the high value and multiplied by 100. The scores reported thus reflect percentage above the normal range adjusted for each laboratory.
Adherence. In line with the emphasis in the literature on
assessing adherence behaviors and glycemic control separately, and using
multidimensional instruments to assess adherence
(Glasgow & Anderson, 1995;
Johnson, 1995), a scale
(Littlefield et al., 1992)
covering the different aspects of the diabetes regimen was used. These aspects
were regular blood glucose testing, keeping blood glucose at the recommended
level, taking insulin shots on schedule, following diet plan, exercising,
treating a reaction, and remembering to do everything every day. Patients
rated their adherence to these different aspects of the diabetes regimen by
giving themselves grades on each care behavior from 0 to 100 (substituted for
letter grades). This scale was found to have good internal consistency in our
sample (
=.85). The average was computed across the seven areas and
used as the measure of adherence. This measure was obtained only from
patients.
Emotional Adjustment. Emotional adjustment was assessed by the
General Health Questionnaire (GHQ). A questionnaire designed to assess
emotional adjustment in youths with chronic illness would have been ideal;
however, there is not one available that has been validated for use with the
Hong Kong population. A 12-item short form of the GHQ has been adapted for use
in Hong Kong (Lee, Lam, Ong, Wang, &
Kleevens, 1985). High scores indicate poor adaptation. Internal
consistency was found to be adequate for patients and control subjects
( =.75 and.78, respectively).
Health Beliefs. The Multidimensional Health Locus of Control
(MHLOC) (Wallston, Wallston, &
De-Vellis, 1978) is an 18-item instrument that provides scores for
internal, chance, and powerful others as determinants of
health status and has been translated into Chinese
(Chan, 1997). For patients with
diabetes, the questions were reworded to reflect control over diabetes.
Parallel measures were obtained from mothers and offspring. However, mothers
were asked to describe their beliefs about control over their offspring's
health. Chance locus of control beliefs showed good internal consistency for
mothers and youths in both diabetes and control groups ( ranged from.71
to.88). The alphas for powerful others and internal scales, respectively, were
as follows: diabetic patients:.64,.44; mothers of diabetic patients:.42,.73;
control youths:.53,.46; mothers of control youths:.72,.61.
Self-Efficacy. Patients with diabetes indicated their beliefs
about their own ability to follow each of the seven adherence prescriptions
using a scale from 1 to 100 (Littlefield
et al., 1992). The alpha coefficient for the seven-item scale
was.90.
Parent-Offspring Conflict. Conflict was measured by a scale
covering nine domains of disagreement and asking both offspring and their
mothers to rate the frequency (on a scale from "1, very rarely" to
"5, very frequently") and severity (from "1, very
mild" to "5, very severe") of the conflict between child and
parents. Eight of the domains have been found to be salient in a previous
study with a Hong Kong sample (Yau &
Smetana, 1996). Disagreement about child's health was included as
the ninth domain. The scales showed Cronbach reliability alphas from.73 to.79
for frequency and from.76 to.84 for severity of conflict in this sample.
Frequency and intensity of conflict were highly correlated (rs
ranging from.82 to.90) for youths with diabetes, control participants, and
both sets of mothers. They were averaged to obtain one conflict score for
multivariate analyses.
Authoritarian Family Function. Ten items from the Self-Report
Measures of Family Function (Bloom,
1985) were completed by patients, controls, and their mothers.
These items were grouped by Bloom into two scales, democratic and
authoritarian function. As these scales have not been previously used in Hong
Kong, the items were subjected to a principal components factor analysis with
oblimin rotation, with two scales extracted. The two scales showed significant
overlap of items, with signs reversed for loading on the two separate factors.
Given the complementarity of many of the items on these scales, and of the
authoritarian and democratic constructs, this finding is not unexpected. For
example, the item "Parents make all the important decisions in the
family" is intended to be part of the authoritarian scale as
conceptualized by Bloom. It is quite expected that it would correlate
negatively with the democratic family scale that includes the item "In
our family, parents do not check with children before making important
decisions" (reverse scored in the Bloom's democratic scale). For this
reason, a single scale was extracted. Seven items emerged as loading on a
single factor. The alpha coefficients for this scale were.63 and.65 for
patients with diabetes and their mothers, respectively. For the control group
and mothers, the alphas were.62 and.57.
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Results |
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Differences Between Participants With Diabetes and Controls
Table II presents the means and standard deviations for the main variables of the study, for participants with diabetes and controls. Participants with diabetes differed significantly from their age- and gender-matched controls on locus of control beliefs (ts ranging from 2.91-6.85 [66], ps =.005), with the patients reporting higher powerful other and internal, and lower chance locus of control than the controls. Mothers of youths with diabetes showed a similar pattern relative to control mothers (ts ranging from 3.4-5.16 [66], ps =.001). Within families, offspring reported lower powerful others (ts = 2.37 and 3.98 [66], ps =.02) and higher internal locus of control (ts = 2.49 and 2.52 [66], ps =.01) than mothers. Mothers of patients with diabetes reported more intense conflict than did control mothers (t = 2.46 [66], p =.02).
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Bivariate Correlations Among Health and Emotional Outcomes and
Predictors
Table III presents the
bivariate correlations of predictors to emotional adjustment, adherence, and
glycemic control for diabetic patients and control group participants. Almost
none of the mothers' measures showed significant association to their
offsprings' emotional adjustment, adherence, or glycemic control. One
exception was that in the control group, mothers' chance locus of control
associated with offsprings' emotional adjustment (r =.33, p
=.006). In addition, internal locus of control measures obtained from mothers
of diabetic patients in relation to their offsprings' illness associated
negatively with HbA1c (r =.25, p =.04). An
association was also predicted between internal locus of control and
self-efficacy. The correlation was nonsignificant (r =.00, p
=.99).
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Constructing a Model to Predict Glycemic Control
Causal modeling utilizing path analyses and multiple regression
(Munro & Page, 1993) was
used to test the model described in the introduction, linking predictors to
emotional adjustment, and emotional adjustment to adherence through the
mediating agency of self-efficacy, and finally adherence to metabolic control.
The model was tested in four steps. All variables in the earlier steps were
included to test later steps (Munro &
Page, 1993). Table
IV presents the results of the analyses at each step. At step 1,
emotional adjustment was regressed on predictors. At step 2, internal locus of
control was included. Powerful others locus of control was included at step 3
to predict adherence. Pubertal status was added at step 4.
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Gender was a significant predictor of emotional adjustment; boys showed better adjustment than did girls. Gender also showed direct effects on adherence at step 3, with boys reporting better adherence than girls.
The revised model consistent with these analyses is presented as Figure 1, showing the significant pathways from the regression equations rerun following trimming of the model. Thirty-nine percent of the variance in glycemic control was predicted by this model, F(8, 61) = 4.80, p =.0001.
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Whereas numerous indirect paths were charted, one goal of our study was to
elucidate the mechanisms of the effect of emotional adjustment on adherence.
We hypothesized that the association between emotional adjustment and
adherence was mediated by self-efficacy. The criteria for mediation
(Baron & Kenny, 1986) were
met as follows: (1) the predictor of emotional adjustment correlated with the
proposed mediator of self-efficacy (Table
III); (2) self-efficacy correlated with the outcome of adherence
(Table III); and (3) when
self-efficacy was included in the equation, the previously significant
relationship between emotional adjustment and adherence became nonsignificant
(Table IV, step 3).
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Discussion |
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This study investigated disease-related and psychosocial influences on emotional adjustment and glycemic control in youths with diabetes in Hong Kong. Our findings contribute to the literature by elucidating a pathway from emotional adjustment to glycemic control through the agency of self-efficacy and adherence (Figure 1). In addition, the findings suggest intervention strategies to improve glycemic control in young people with diabetes.
Parent-child conflict is particularly common during the teenage years,
where a majority of the participants in this study fall. Developmental theory
(e.g., Steinberg, 1990) gives
conflict a normative place, relating it to the offspring's achievement of
autonomy from parents. While intense and persistent conflict is expected to
have a negative and long-term effect on both offspring and parent emotional
adjustment, such concerns have not been previously expressed relative to low
levels of conflict. It is notable that in the families of patients with
diabetes, the level of conflict from the youth's perspective was equivalent to
that of a nonclinic age- and gender-matched set of control families. The
association between conflict and adjustment is also present in control
families. In Chinese culture, where obedience to parents is emphasized,
harmonious family function is valued, and independence from parents is not an
explicit goal, conflict may be particularly disruptive.
To further explore the association between conflict and emotional
adjustment, we inquired whether patients and mothers showed congruence in
their ratings of conflict. We found that in families of both diabetic patients
and controls, the congruence between mothers and children with regard to
frequency (rs = 11 and -.02, respectively, for families with and
without a child with diabetes, ps >.05) and intensity (rs
=.14 and.04, ps >.05) of conflict was poor. We are not aware of
Western data on rates of congruence of parents' and children's perceptions of
conflict, although there is literature to suggest that lack of congruence with
regard to family processes is typical of dysfunctional families
(Olson at al., 1983). In
Chinese families there is a strong sanction against the expression of negative
affect (Wu, 1996), which may
contribute to the lack of agreement in perceptions.
The association between chance locus of control and emotional adjustment in
both patients and controls has some implication for the universality of the
psychological importance of having control. Even in a culture where
supernatural beliefs are common, absence of control associates with distress.
These findings are consistent with those of a study of Hong Kong adults with
nasopharyngeal cancer (Sun & Stewart,
in press), which found that chance locus of control associated
positively with depression. In the same study, however, also reported was the
finding that internal locus of control has strong positive association with
emotional adjustment. Low reliability of the internal locus of control scale
in this sample may well have contributed to low sensitivity in detecting
associations. Furthermore, multicollinearity might have obscured the
relationships among some of the locus of control variables and outcomes in the
multivariate predictions. However, contradictory evidence regarding the
relationship between internal beliefs and disease management in the pediatric
population has been reported in Western studies as well
(La Greca & Schuman,
1995).
Boys were better than girls were at adhering to their diabetes regimen. There is a parallel difference in glycemic control and girls have significantly higher HbA1c levels, suggesting that these findings are not a reflection simply of greater truthfulness among girls than boys. This finding, though not prospectively hypothesized, was not surprising to the clinicians in our group. Girls have been observed to have more difficulty with separating themselves from peer activities, which can interfere with the demands of the diabetic regimen. Further studies examining the specific barriers girls face in managing their regimens would be worthwhile.
Duration of disease exerted direct effects on glycemic control. The
mediators of this effect are unknown. Duration of illness has been found in
other investigations (Hanson, Henggeler,
Harris, Burghen, & Moore, 1989) to relate to glycemic control
and to have a complex relationship with other variables, particularly family
cohesion and adaptation, in predicting glycemic control. Coping styles have
also been found to associate with duration
(Hanson, Cigrang, et al.,
1989), such that older adolescents with longer duration of illness
show less effective coping styles. These associated variables were not
measured here and may present as confounding factors in the relationship
observed.
As shown in Figure 1, our data emphasize the need for assessment and promotion of emotional adjustment even when the medical professional's primary interest is in disease management. Girls with diabetes in Hong Kong appear to be at higher risk for emotional and adherence difficulties. Family counseling for conflict management would be a worthwhile proactive effort at time of diagnosis. Frank discussion regarding conflict between mothers and children may enhance their shared reality regarding levels of conflict. Increasing mothers' awareness of their own role in their child's distress may also have positive effects.
The association between self-efficacy and adherence has implications for health professionals. Relatively simple techniques can be incorporated into routine care to enhance patients' sense of efficacy. Examples of such techniques include initial setting of realistic goals, reassurance with regard to (or "normalization") of early difficulties in smooth management, and a problem-solving approach in reviewing patient "diaries."
Our sample included a wide developmental range. Some of the variables we
examined may well change in level over the life span. Family function may
become more democratic as youths mature. Parent-child conflict levels have
been shown to fluctuate with age in nonclinical Western families, with an
increase in early adolescence, and a decrease after about age 18
(Papalia & Olds, 1992). In
exploratory analyses, we examined whether the central variables of this study
correlated with age and found that older youths with diabetes reported less
authoritarian parenting (r = -.34). None of the other variables
showed age-related linear changes in families of youths with diabetes. The
association among these variables may also change. Authoritarian styles may be
more age-atypical for older teenagers and therefore be more likely to
contribute to conflict and distress. Conflict with parents may decrease in
importance as late adolescents form important attachments outside the family.
In our study, authoritarian family function did not associate significantly
with adaptation in younger (below age 18) or older (18 year and above)
participants. On the contrary, youths over age 18 showed an even stronger
association between conflict with parents and emotional adjustment (r
=.62, p =.004) than did participants below age 18 years (r
=.33, p =.01). Adolescents with chronic illness face many
complications around issues of individuation
(Anderson & Coyne, 1993).
All participants with diabetes, for example, were still living at home. These
post-hoc analyses raise questions about age-related complexities in
parent-child interactions in families of youths with diabetes in Hong Kong.
These questions cannot be adequately explored with our sample size and age
distribution but should be addressed in future studies.
This study has several limitations. The sample size is relatively small, precluding exploration of interaction effects. The findings cannot be generalized to patients from the private health care sector. Adherence was measured by self-report with no independent observer ratings. The data were obtained in a cross-sectional methodology; longitudinal data would allow for tests of the causal model proposed. Mothers were included; however, family influences and perceptions are not restricted to those from mothers. The absence of findings in relation to maternal influences may reflect the importance of fathers and siblings in parental and family influences in this strongly family-oriented culture. The majority of the instruments used were designed in the West. As might be expected, some of the measures had relatively weak coherence in this culture, increasing the possibility of Type I error. Internal locus of control and family function may be better detected by a different set of questions than those on our imported instruments. Future qualitative investigations are recommended to derive measures that may be more culturally accurate.
Despite these shortcomings, our study presents an initial examination of emotional adjustment, adherence with diabetes regimen, and glycemic control in a sample of Hong Kong youths. In summary, this study adds to the present literature by expanding investigations into non-Western cultures and addressing the culture-general nature of some of the relationships that have been found in Western studies. Further, the data support a model linking emotional adjustment to glycemic control through the mediating agency of self-efficacy to adherence, which then has a direct effect on glycemic control. The data and the model presented in this study suggest that interventions designed to decrease parent-child conflict and increase patients' self-efficacy may improve adherence to diabetic regimens and glycemic control.
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Acknowledgments |
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This work was supported by the Committee on Research and Conference Grants of the University of Hong Kong. We thank the patients and their families for their willingness to participate in this project. We also thank the nursing and clinic staff of the pediatric diabetes clinics at Queen Mary, Queen Elizabeth, Pamela Youde Nethersole, and Yan Chai Hospitals, and Julia C. Y. Lam and Jeannie Cheang, who contributed to data collection.
Received February 24, 1999; revision received September 9, 1999; accepted September 18, 1999
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