Use a study of children or adolescents with diabetes and a study of adults with diabetes to illustrate issues that arise when applying health psychology to a chronic illness.

There are essentially two main types of diabetes; Type I insulin dependent diabetes mellitus (IDDM) and Type II non-insulin dependent diabetes mellitus (NIDDM). IDDM patients make up 5% to 10% of the diabetic population and results from the bodies failure to produce insulin; this type of diabetes is considered to be an autoimmune system disease, but can have genetic and environmental factors as well; it is most common in children and adolescents12.  NIDDM patients make up around 90% to 95% of the population and result from insulin resistance where the body has failed to produce enough insulin or is unable to use the insulin properly; it is also associated with obesity, older age, physical inactivity, genetic history, and race/ethnicity; this type of diabetes is most commonly diagnosed in adults aged 30+; however there has been an increase in the number of children and young adults being diagnosed with NIDDM; Dr. Teresa Hillier explains “that the main reason for this is that up until a decade or so ago, it was pretty rare to see type 2 diabetes in young adults, and that has changed dramatically with a 70% increase of obesity in our population. People have a genetic risk for type 2 diabetes, but obesity essentially brings that out at a younger age”.

Complications that arise from diabetes are both physical and psychological an in fact approximately 1/3 of all patients with diabetes have diagnosable psychological problems at some point in their life time and of these affective and anxiety based problems are the most common and occur significantly more often in diabetes then in the general public. Complications that arise from poorly controlled diabetes can be both acute and chronic some of which are peculiar to diabetes and others which although common in the general public are greatly enhanced by diabetes; they can range from hypoglycaemia, hyperglycaemia, coma, amputation, severe weight loss, microvascular disease, cardiovascular disease, ketosis and finally death. Overall, the risk for death among people with diabetes is about 2 times that of people without diabetes12. Effective diabetes management requires adherence to a complex and time consuming regimen including strict dietary control, exercise, blood glucose monitoring, regular daily (1 to 3) insulin injections prescribed mostly in Type I diabetes, and weight loss, pills and (rarely insulin) mainly prescribed to Type II diabetes. In spite of all of this, diabetes is treatable, research has shown that following a set of these behaviours will keep blood glucose under control and reduce incidence of complications, however the most common reason for diabetic complication is non-adherence to medical regimen. Non adherence is also the most common reason for psychological referral although in a statistical sense it is the norm and not the exception . And thus not surprisingly a large portion of psychological research has focused on diabetic compliance and non-compliance behaviour and amount of glycemic control.

A study that illustrates the implementation of theory and the different issues that arise in Adults with type II diabetes in compliance vs. non compliance was carried out by Savoca, Miller and Quandt (2003) in which they studied diabetes self-management practices and philosophies of individuals with poor (HbA1c > 8.0%) or excellent (HbA1c < 6.5%) glycemic control. They interviewed 44 individuals who were 40 -65 years of age and who had been diagnosed with diabetes for over 1 year. These participants included African Americans, women and persons with low income, all of which have been identified to be at a higher risk for diabetes and diabetes complication12  . There is an abundance of research in diabetes which illustrates that patients who follow a set of health promoting behaviours related to good glucose control (diet, exercise and medication use) will then have the incidence of complications greatly reduced15; however as was mentioned earlier non-compliance is common and a large proportion of patients are unable to attain optimal glycemic control. Savoca et al (2003) implemented two theoretical approaches into their study one sociological; Elder’s (1985) Life Course Perspective, which holds that an individuals life history and the changes that take place at various life stages will influence a wide variety of health related attitudes and behaviours; this approach had not yet been applied to diabetes but support for it comes from studies that applied it to eating practices and attitude towards health practice. The second approach was anthropological; Kleinman’s  explanatory model approach which ‘proposes that patients hold a model of aetiology, symptoms, consequences and appropriate treatment of illness developed from their cumulative experiences’. Studies such as Chesla et al (2000) and Skinner et al (2000) show that personal beliefs/models about the cause and treatment of diabetes are related to self- care practices. In this study Savoca et al set out to ‘provide a view of how diverse individuals who represent the upper and lower ranges of glycemic control differ in their beliefs and attitudes towards treatment within the context of their life course experience and explanatory models of diabetes’.

The results for this study illustrate the different issues that arise when treating a chronic illness some of those being just how diverse people are in their emotions upon diagnosis, attributions of the illness, self management behaviours, type of diabetes control they receive, level of family support and relationships they have with their doctors, and how the diversity among these individuals in their ethnic background, income levels and types of medical management made it possible to observe distinctions in individual self management. Savoca et al found five self management styles, two from the excellent glycemic control group (labelled committed and tentative) and three from the poor Glycemic control group (labelled hopeful, hassled and overwhelmed). There were three life course concepts; perseverance, coping skills (of which depression and binge eating have been reported frequently 14) and age at diagnosis. They also found there to be elements of the explanatory model that distinguished these groups; they were differences in beliefs about the cause of their disease, physical changes they went through due to diabetes and level of acceptance they had for diabetes consequences. Individuals’ life course concepts and their personal explanatory model about the disease were related to their Self-Care practices and thus their level of glycemic control. Savoca et al conclude that it is ‘within these contexts that opportunities to improve self-management should be created’.  

Very little is known about children’s’ perceptions of what type of support they need at school; thus this study of adolescents with diabetes was carried out by Nabors et al (2003) to discern just that. This study used a mixed methods approach combing Quantitative (surveys) and Qualitative (interviews) techniques to examine children’s perception of support in carrying for their type I diabetes from school nurses, teachers and friends. The sample consisted of 105 children, 60 boys and 45 girls, 21 children attended a day camp for children aged 5-10 and 84 attended a camp for older children aged 9-14 Only six of these children were African American and all other were Caucasian. All children participated in both the ‘How is school’ survey designed specifically for this research to address three issues of support monitoring blood glucose level, administering insulin and following their meal plan; and the Interview which consisted of 6-8 children in the younger group who answered questions about how supported they felt in managing their diabetes at school; the older group consisted of 25 -30 children per group where participants were instructed to go to each table write an answer to the question and put a check mark next to it if they agreed with what someone else wrote. Only 78 parents completed surveys to provide info about their child’s diabetes. There haven’t been any other documented pieces of research looking at children’s perceptions of support for diabetes at school.      

School is just one of the areas where many important issues concerning children with diabetes will arise, for one they will spend a large proportion of their daily life at school and the thus will have to incorporate effective diabetes management into their routine.  Some of these issues revolve around the fact that school staff may not have the proper knowledge on how to assist children with diabetes, children may become embarrassed about having there diabetes and become conscious of being different from their peers ; children may find it difficult to keep up diabetes regimens because it gets in the way of their after school activities30; research has also shown that children fear hypoglycaemic attacks these kinds of episodes can cause significant distress for youths thus it is important that staff and peers have some knowledge of hypoglycaemia  and are flexible so that children don’t feel singled out and different from the rest  .

Results from this study show that 56% of parents believed their child exercised good glycemic control whilst 61% of parents reported their children needed help from adults to manage diabetes. Only 4 children out of 37 in the younger group could manage diabetes on their own whilst 25 of the 39 children in the older group could manage diabetes on their own. There were six categories identified as key themes in the interview group; Improving staff knowledge, availability of supplies and snacks, flexibility, help with lows, reminders and support from other people to help manage diabetes. Children of all ages reported that sports coaches, teachers, nurses and friends needed to improve their knowledge. Both younger and older children reported needing flexibility to have breaks, carry test kit and snacks with them and be allowed to retest glucose level if prior results were poor, if and whenever they needed to regardless of what was going on. Several children reported fear of hypoglycaemic attack especially if it was on a day the nurse wasn’t there children wanted teachers and nurses to understand and not call undue attention to them. Children also reported wanting reminders however there was a fine line between too many and too little. The Generaliseability of this research is limited to that population able to attend camps and those who would be more likely to volunteer for participation. Over half of the participants were able to keep good control of their diabetes so these findings may prove more applicable to children already doing fairly well. Nabors et al 2003 postulated that future studies may yield more information if researchers ask children what type of education would be most helpful to improve support of staff. Overall the findings of this research lend a great deal into the perceptions children have of their life at school and the support they get in order to practice good diabetic care the issues mentioned are also consistent with the previous findings mentioned earlier29 30 31 32.

These studies illustrate the implementation of theory by psychologists in order to measure behaviour for the final goal of every health psychologist which is to achieve change and create appropriate intervention for the treatment of diabetes and other acute or chronic diseases.  Diabetes is not just a medical issue requiring only biomedical treatment it effects the family of the diabetic and requires psychological intervention that is based on an understanding of the developmental stages, knowledge of the course of the treatment and sensitivity to the emotional and life issues the may sabotage the treatment .

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