This is the first study to address the issue of youth knowledge of the most commonly used test to assess glycemic control in diabetes. In this sample of mostly lower-income, minority youths with type 1 diabetes, there was a significant lack of knowledge concerning the meaning and implications of the HbA1c test: only 13% of youths could define the test, less than 10% understood its health risk implications, and just 4-8% could correctly identify the corresponding blood glucose levels in mg/dl for various HbA1c levels. Despite their initial diabetes education at diagnosis and the ongoing discussions in clinic with the physician about HbA1c test results, it is clear that the majority of youths in our setting do not understand the meaning and implications of this important test.
Although most (70%) youth demonstrated awareness of their target blood sugar range (i.e., daily glycemic goals), very few were able to generalize this knowledge to understanding the HbA1c test and grasp the sequelae of specific HbA1c values. In the current study, knowledge of HbA1c was not related to the patients’ actual HbA1c. However, analyses did reveal an association between age and knowledge, such that older children were more likely to know what the HbA1c test measures and to accurately identify complications of maintaining an elevated HbA1c. It is likely that younger children’s conceptualization of the HbA1c test and diabetes knowledge differs from that of older children, due to developmental differences, including differences in cognitive processes, maturity, and illness beliefs, as well as expectations for self care, etc… Compared to younger children, older children may be more able to grasp the association between feeling symptoms (i.e., dizziness) and certain blood glucose values, as well as understand the concept of long-term consequences associated with poor blood glucose control (i.e., amputation). Our finding is consistent with previous findings of older children displaying higher levels of general diabetes knowledge than younger children (Auslander, Haire-Joshu, Rogge, & Santiago, 1991
). Findings from this study indicating that longer disease duration was associated with poorer ability to estimate health consequences based on HbA1c, suggests that the youth’s age or perhaps cognitive maturity is a more important factor in determining the youth’s ability to anticipate the negative sequelae of poor blood glucose control.
Our unique sample of primarily low-income minority youth may limit the generalizability of these findings, as we did not have the sufficient number of participants in each racial or ethnic group to test for group differences. Because there was limited variability of youths’ knowledge, analyses of gender and ethnic or racial group effects were constrained. However, we did find that participants with higher socioeconomic status had increased knowledge of HbA1c. Further research assessing a broader range of patients in terms of knowledge, HbA1c levels, and ethnic, racial, and socioeconomic status is needed.
Previous research with adult patients with type 1 and type 2 diabetes has shown not only a relationship between regular HbA1c testing and improved metabolic control (Larsen, Horder, & Mogensen, 1990
), but also that immediate feedback, point of care (POC) A1c, and discussion of values (including use of graphs) resulted in decreased HbA1c values and increased understanding of what the values mean (Cagliero et al., 1999
; Miller et al., 2003
; Chapin, Williams, & Adair, 2003
; Peterson et al., 2007
). This metabolic improvement has demonstrated short-term effects (six and twelve months) post-study (Cagliero et al., 1999
), as well as long-term impacts (3.5 years) on metabolic control (Peterson et al., 2007
). Although it is unclear whether the above findings would be generalizable to children with diabetes or their parents, it is possible that POC A1c, education of HbA1c test and values, and increased knowledge will lead to positive results. For example, a recent study revealed that children of caregivers with higher diabetes knowledge scores tended to have lower HbA1c levels (Stallwood, 2006
). The rapid and accurate results provided by the POC A1c not only allow health care professionals to provide immediate feedback to patients, but also the opportunity to conduct face-to-face counseling.
There are some limitations of the current study. The data are cross-sectional in nature; therefore, predictions of the impact knowledge has on subsequent glycemic control cannot be determined in this study. Since this study only evaluated youths’ knowledge, future studies should include assessment of parents’ knowledge of the HbA1c test. Additional studies should determine the effect of increasing knowledge about the HbA1c test on the child’s actual HbA1c values. Also, family functioning, general diabetes knowledge, and cognitive ability should be assessed in future research as these could increase our understanding of additional variables that may be related to deficiencies in HbA1c knowledge.