Introduction
Childhood-onset type 1 diabetes (T1D) is an international priority associated with vast individual burden and societal costs. Treatment of T1D is largely based on self-care, as the patients themselves need to monitor and regulate blood glucose levels and adjust the insulin dose according to various factors, including blood glucose, food intake, emotional state, and physical activity. This is a demanding and continuous regulation task, placing major responsibility on the young individuals with T1D and their families. Adolescence is a particularly challenging period due to the gradual transfer of treatment responsibility from the parents to the young patients themselves.1 Adolescents with T1D have been found to suffer from more psychological problems than non-diabetic peers, including depression,2 ,3 anxiety,4 and eating disorders.5–7 Additionally, key clinical outcomes such as metabolic control (measured by glycated hemoglobin (HbA1c))8 and eating disorder psychopathology9 have been shown to be significantly related to psychological aspects, including illness perceptions, insulin beliefs, and coping strategies.
Illness perceptions refer to the individual's experience and beliefs about their illness and are found to be associated with outcome in a variety of somatic and psychological illnesses, including cancer,10 cardiovascular diseases,11 chronic fatigue syndrome,12 eating disorders,13 and T1D.14 ,15 Although previous research have reported more negative illness perceptions in females than males in the context of other illnesses,16 ,17 no studies have, to the best of our knowledge, investigated this in adolescents with T1D.
Insulin beliefs refer to individual perceptions or attitudes toward insulin. Insulin beliefs have been found to be associated with adherence to treatment18 ,19 and diabetes control.20 Additionally, insulin concerns have been found to be significantly correlated with insulin restriction motivated by weight and shape concerns, and linked to eating disorder psychopathology.9
Coping strategies (behaviors adopted to handle negative or stressful events) have been reported to be associated with metabolic control among adolescents and adults with T1D. For example, greater use of emotion-focused coping styles is found to be significantly associated with poorer metabolic control.21
Gender differences in psychological aspects have previously been suggested from a theoretical perspective, commonly by means of socialization theory and the role-constraint theory (hypothesizing that traditional socialization patterns and gender roles influence how males and females cope with stress).22 ,23 Also, prior research has documented significant gender differences in the association between psychological aspects and HbA1c,8 as well as eating disorder psychopathology.9 In these studies, psychological aspects were significantly associated with HbA1c and eating disorder psychopathology among adolescent females, but not among males. Furthermore, mode of treatment (insulin pump vs pen) has been found to impact HbA1c.24 To the best of our knowledge, no studies have previously investigated gender differences or mode of treatment in terms of psychological aspects among adolescents with T1D. Greater knowledge about such potential psychological barriers to important clinical outcomes may potentially inform treatment innovation and address the issue of whether interventions should be specifically tailored according to gender and mode of treatment.
Consistent with data from Hilliard et al25 and Petitti et al,26 only one-third of adolescents in the Norwegian Childhood Diabetes Registry (NCDR) manage the international targets of HbA1c values <7.5%.27 Given that psychological aspects have been shown to be significantly associated with key outcomes such as HbA1c, investigating psychological barriers to treatment in young males and females with T1D may both improve our understanding of patient self-care and subsequent metabolic control, and ultimately, improve the poor prognosis associated with childhood-onset T1D.
Aim of study
The aim of this study is to investigate potential psychological barriers (illness perceptions, insulin beliefs, and coping strategies) to optimal insulin therapy among adolescents with T1D, with a specific focus on gender differences and mode of treatment. It is anticipated that adolescent females are more concerned than males; specifically, we hypothesize that females display more negative illness perceptions than males.