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VOLUME 14 NUMBER 1 • JULY 2017
REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
carefully consider predispositions of children with diabetes, such as
age and gender, when deciding on a treatment plan. Psychological
predisposition such as self-efficacy should be considered to optimise
diabetes self-care and adherence to treatment.
Context
The environment or context in which a child with diabetes develops
has implications for diabetes care and psychosocial well-being. The
microsystem contains environments such as home, school or peer
groups that have direct and indirect effects on diabetes care and
psychosocial well-being. The home environment, especially family
support and good home structure, is useful for diabetes care, in
particular glucose monitoring. There is also a link between QoL
and metabolic control, since poor metabolic control burdens the
family.
41
Diabetes can cause enormous pressure on how the family
functions, which can either strengthen or break family ties,
depending on the characteristics of a family.
32
During adolescence
there is increasing independence and adolescents often challenge
parents’ supervision of their diabetes care. This may lead to
conflicts within a family. T1DM is demanding and affects everyday
lives of not only patients with diabetes but also their families and
significant others. This may in turn exert stress on the family that is
already burdened by diabetes management expenditure.
Diabetes-specific family conflict is related to poorer adherence
and glycaemic control.
13
Advice given by parents or family members
(e.g. ‘Shouldn’t you check your blood glucose? I think you are
low!’) can be perceived as offensive or intrusive behaviours in
diabetes management, especially in adolescents who want to be
or become independent.
32
On the other hand, constant respectful
and unconditional support of patients’ diabetes management may
improve diabetes treatment outcomes.
In some cases, poor glycaemic control is because of lack of care-
giver involvement, and poor or inconsistent family management and
punitive or negative parenting. This is where healthcare providers
should encourage developmentally appropriate family involvement
in diabetes management tasks for children and adolescents,
recognising that premature transfer of diabetes care to the child can
result in non-adherence and deterioration in glycaemic control.
13
In low-income homes, apportioning resources to household
food stuffs can be a source of conflict, given that patients with
diabetes are supposed to take certain diets that have low saturated
fat composition and are rich in vegetables, part of a healthy diet,
which may not be liked by other family members. This underscores
the importance of family and friends in diabetes management.
Peers are useful in diabetes care. The literature suggests that
friends’ support for blood glucose testing is related to the patient’s
disease adaptation and QoL.
42
Peers can be supportive in diabetes
care and can also thwart adaptation to the disease. Because
adolescents with diabetes sometimes face discrimination from
peers, they may want to hide the condition from others.
32
Some
adolescents want to feel normal like their peers, which in turn
makes them abandon their medical kits that often attract interest
from their healthy peers, for fear of discrimination or unwanted
attention.
Adolescents spend much of their time at school. Therefore, the
school is an important agent for diabetes care and psychosocial
well-being for children with diabetes. Despite the underscored
importance of schools, children with diabetes in the school and
day-care setting still face discrimination from teachers and the
school system. Some schools may refuse admissions to children
with diabetes and children in classrooms may not be provided with
the assistance necessary to monitor glucose levels and may be
prohibited from eating the necessary snacks.
13
Sometimes the school may not know how to handle a child with
a hypo- or hyperglycaemic episode. Therefore, each school should
be acquainted with general guidelines for the care of a child with
diabetes in the school and day-care setting, developed by various
organisations such as the American Diabetes Association and
national diabetes associations.
13
Broadly the guidelines include: (1)
diabetes medical management plan, (2) responsibilities of various
care providers, and (3) expectations of the student in diabetes
care.
13
The mesosystem from the diabetes perspective entails linkages
and processes that influence diabetes care and psychosocial
well-being in two or more settings containing the child with
diabetes. This linkage of more settings can be exemplified by the
recommendation from the American Diabetes Association that
the parent/guardian should provide the school or day-care with
materials and equipment necessary for diabetes care tasks, provide
supplies to treat hypoglycaemia, and provide information about the
student’s meal/snack schedule and an emergency phone number
for parent or guardian, among others.
13
Diabetes-related stress in a family may contribute to poor
glycaemic control. Given the developmental age of children, some
may think the conflict is their fault due to their diabetes and may
engage in self-destructive behaviour such as skipping injecting
insulin or hospital appointments, or even resort to drastic measures
such as suicide. This is when the relationship between community
health workers, diabetes peer educators and family of the child with
diabetes should be strengthened. This also includes encouraging the
parent/guardian to accompany the child to hospital appointments
in order to enable the heathcare provider to assess psychosocial
issues in the family, which may affect diabetes care.
The connection between other larger structures such as church
or community support groups can also be expected to have distal
processes at work because they help the child and family cope with
diabetes-related stress and get the necessary support for the child.
Counselling services available to the family in times of need can
influence the functioning of the mesosystem.
5
The exosystem contains linkages and processes that indirectly
influence processes within the immediate setting in which the
developing child lives. For example, a parent’s work schedule may
influence the parent’s involvement in diabetes care. In cases where
a parent does not accompany a child to a hospital appointment, a
common practice observed in Zambia,
19
the parent will have limited
interaction with the healthcare provider, and for young children,
they may perceive this as if they are unwanted by their parents.
In addition, parental work stress or frustrations from everyday
household chores may in turn cause the parent to behave more
irritably, which may make children think that it’s their fault the
parent is going through that anger and stress. Such perceptions
may be the cause of drastic measures some children with diabetes
sometimes go through, such as stopping taking medication or
suicide attempts, to gain attention from the parents. Policies on
how many appointments a child should attend at the hospital to
receive certain services, for example, free insulin or syringes can all
be considered as exosystem influences on the child.
The macrosystem contains the societal blueprint and influences
the other systemsmentioned above. Cultural beliefs and propensities