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VOLUME 14 NUMBER 1 • JULY 2017
REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
development.
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These proximal processes drive development and
are often seen as either protective or preventative systems, for
example parental warmth, affection and discipline strategies. The
form, power, content and direction of the proximal processes
affecting development vary systematically as a joint function of the
characteristics of the developing person and environment.
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Other than proximal processes, distal processes are at work in the
life of a child with diabetes. Distal processes involve a unidirectional
transaction between the child and environment, incorporating
persons, objects and factors away from the centre of the child.
To have an effect on the child, distal processes should have an
enduring interaction with the child. Examples of distal processes
may include the family’s ability to support the child financially or
emotionally.
Person
The person component of the model centres on the biological and
genetic aspects of a child, including the personal characteristics
that a child brings into any social situation.
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The characteristic
that a child brings in any situation can be divided in to three
types: demand, resource and force characteristics.
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Demand
characteristics relate to ‘personal stimulus’, those that act as an
immediate stimulus to another person, such as age, gender, skin
colour, coping skills, reasoning and physical appearance. These
types of characteristics may influence initial interactions because of
the expectations formed immediately. Therefore, to some extent,
the degree and nature of interactions involving family members,
caregivers or peers is partially determined by the characteristics of
the child itself.
Resource characteristics relate to mental and emotional
resources such as past experiences, skills and intelligence and
also to social and material access.
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Force characteristics are those
that have to do with differences of temperament, motivation and
persistence among others.
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Two children may have equal resource
characteristics, but their developmental trajectories will be quite
different if one is motivated to succeed and persists in tasks.
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Context
The context is the best-known component of the bioecological
model and perhaps the most important of all four components
in conceptualising and designing interventional studies in child
development.
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The context contains four distinct systems: micro-,
meso-, exo- and macrosystems and each has either a direct or
indirect influence on the child’s development. The four systems
within the framework of diabetes are depicted in the PPCT
framework in Table 1.
The first system (the microsystem) is any environment such as
home, school or peer group in which a person spends a good deal of
time.
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The second system is the mesosystem, which focuses on the
connections between two or more systems within the microsystem.
At this level, the model proposes that socialisation is influenced
by those who interact with the child, such as schools, peers and
neighbourhood. The systems here are believed to interact; for
example, the home environment of the child can influence what
happens in the playground with other children.
The exosystem is the third layer and looks at the context within
a developing child’s environment that the child does not directly
encounter but impacts on the development. A decision to adjust
the work schedule for a parent can, for example, indirectly affect
the parent–child interaction or attachment time.
Finally, the fourth layer of the context is the macrosystem, which
is a context encompassing any group (culture, subculture or other
extended social structures) whose members share values or belief
systems, resources, hazards, lifestyles, opportunity structures, life
course options and patterns of social interchange.
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An example
of the macrosystem is an economic crisis in a country, which may
shape the development of a child.
Time
The final element of the PPCT model is time. The time element of
the model, also known as the chronosystem, includes components
such as chronological age, and duration and nature of periodicity.
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Time-related events such as a parent’s debilitating illness, divorce
or change of residence can have a more profound impact on a
younger child compared to older ones.
Application of the bioecological model on diabetes
care and psychosocial issues
‘Nothing is as practical as a good theory’ – Lewin Kurt, 1951: 169.
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As with any robust theoretical model, Bronfenbrenner’s ecological
model of development is parsimonious and applicable to areas
such as paediatric diabetes. The basic premise of the PPCT model
of Bronfenbrenner’s thinking is that health, behaviour and their
determinants are interrelated.
Table 1.
The PPCT framework explaining bioecological factors affecting
diabetes care and psychosocial functioning in children with diabetes
mellitus
PPCT component
Diabetes care and psychosocial functioning
issues
Process
Transactions between child with diabetes and
immediate environment; e.g. low self-efficacy
coupled with lack of family support affects
glycaemic control
Person
Biological and genetic predispositions: alleles
associated with T1DM, age, gender, weight
and race are associated with diabetes care. Self-
efficacy, motivation and personality traits affect
and influence diabetes management. Co-morbid
HIV and malaria complicate care
Context
Microsystem
Home, school, peers’ role in diabetes care and
buffer psychosocial problems
Mesosystem
Interaction and effect of interaction on diabetes
care and psychosocial well-being between parents
and school, community health workers and
child/family, church and counselling centre for
psychological support
Exosystem
Parents’ schedule, work stress/frustrations and how
they affect diabetes care and child relationships
Macrosystem Diabetes policies, budget for health, diabetes
food and drug regulation, and cultural practices
influence diabetes care
Time
Honeymoon period, the dawn phenomenon,
adolescent period and counter-regulatory
hormones, transition times, e.g. urbanisation and
sedentary times