By concentrating on the role of fathers in diabetes management, this work expands on the existing body of research that has emphasized the importance of mother–child collaboration—and, to a lesser extent, the involvement of two parents—in self-care with relation to mitigating the risk for deteriorating adherence and glycemic control during this period (Berg et al., 2008
; Wysocki et al., 2009
). This study extends the initial work of Wysocki and Gavin (2004
) in that it provides a focused examination of alternative relationships between paternal involvement and youth outcomes among preadolescents with type 1 diabetes.
The methodological and statistical advances employed in this study contribute to the growing literature on the quantity, quality, and impact of paternal contributions to children’s health care (e.g., Dashiff et al., 2008
; Phares et al., 2005
; Wysocki & Gavin, 2006
). A recently developed, standardized measure of fathers’ contributions to children’s health care was used, lending validity to the measurement of the central construct. The sample size was larger than previous father-focused studies and drew from multiple sites across the country, thus contributing to increased power and generalizability. Moreover, we analyzed family data appropriately by employing statistical methods that allowed us to account for nonindependence among family member’s responses as necessary. Structural equation modeling effectively aggregated these nonindependent data from multiple reporters and partialled out random measurement error, which strengthened the measurement of the primary constructs of interest in the study. The measurement models fit the data well, thereby supporting our use of this modeling strategy. The examination of three feasible and clinically relevant models was an additional strength of this study, as it allowed us to explore a series of alternative relationships between the constructs of interest.
While the central role of mothers during the transition to adolescence has been well-documented (e.g., Berg et al., 2008
; Nansel et al., 2009
; Wiebe et al., 2005
), the current study provides evidence that fathers may play an active role in family diabetes management in this age range as well. These data demonstrate that the association between preadolescents’ diabetes outcomes is linked to a small degree with the level of paternal involvement in diabetes care. In contrast to previous studies (Gavin & Wysocki, 2006
; Wysocki & Gavin, 2006
), in this study with youth with type 1 diabetes at the entry to adolescence, the amount and helpfulness of paternal involvement did not demonstrate a direct association with regimen adherence. The data indicated small and nonsignificant associations between paternal involvement and better adherence. The indirect and direct effects model was supported by the data. However, contrary to hypotheses, greater paternal involvement was associated with higher HbA1c values, which were also linked with poorer adherence. It may be that some fathers become more involved in diabetes care as a result of their escalating concerns about poor glycemic control. Fathers may also engage with their children with diabetes differently than mothers (Povey, Hallas, White, Clarke, & Samuel, 2005
) or play unique roles in their children’s lives (e.g., engagement in leisure, athletics, and other activities) that may interfere with glycemic control (Seiffge-Krenke, 2002
). Each of the findings in this study may be specific to the transitional preadolescent age range in this study, and paternal engagement during later adolescence may demonstrate stronger links with adherence and ultimately impact glycemic control (Wysocki & Gavin, 2006
). If fathers indeed become more directly involved in care as HbA1c values begin to rise, their ongoing contributions throughout adolescence might cumulatively result in improvements in adherence and glycemic control that were not detected in the age range included in this cross sectional study (Palmer et al., 2010
). For these reasons, longitudinal research during adolescence is needed to determine the reasons for and point at which fathers increase their involvement in diabetes management and the impact on adherence and HbA1c over time.
Data suggest that fathers may undervalue their impact on their children’s health relative to mothers. Mothers and fathers in this sample agreed on the amount of paternal involvement. This is comparable with findings from the developmental literature, which indicate that mothers generally report similar or slightly lower amounts of time fathers spend with children than do fathers (Coley & Morris, 2004
; Wical & Doherty, 2005
). The interparental agreement in this study is likely related to behavioral nature of the measurement and its narrow focus on illness-related involvement behaviors. Further, overall time spent with a child does not necessarily have a direct correlation with involvement in diabetes management. Consistent with previous research (Wysocki & Gavin, 2004
), fathers in this study provided lower helpfulness ratings of their contributions than did mothers. It may be that mothers, who tend to take on primary parental responsibility for diabetes management, appreciate any helpful contributions from fathers and as such more highly rate the benefit of the assistance fathers provide. Fathers, on the other hand, may compare the quantity and quality of their contributions to what mothers do and judge their own additions to care as having relatively less impact. If fathers do become more involved as their children achieve higher HbA1c values, mothers may be particularly appreciative of their contributions or efforts to assist during a time of worsening diabetes control. However, fathers may feel ineffective if HbA1c values do not quickly improve when they become involved.
The study had limitations that need to be considered in interpreting our findings. The measures and data analysis in this study did not assess potential influences on glycemic control outside of paternal involvement and adherence. While mothers and fathers rated the amount and helpfulness of paternal involvement, valuable subjective ratings from children regarding their perceptions of their father’s role in diabetes management (Povey et al., 2005
; Seiffge-Krenke, 1998
) were not collected due to a lack of available measures. There was also no measure of the amount and helpfulness of maternal involvement to parallel that of paternal involvement. In addition, the participants had a relatively low mean HbA1c value and were primarily from well-educated, middle- to upper-middle class families with two parents present, and regularly attended diabetes clinics and consented to participate in research. This convenience sample likely overrepresents families with greater resources and may not adequately represent the medical or socio-economic status or family structure of many patients with type 1 diabetes. Those fathers who were unable or opted not to participate in this study likely have distinct patterns of involvement in diabetes and differential impact on their children’s adherence and glycemic control outcomes. Similarly, those families who were screened out of the study due to no father involvement may also demonstrate different diabetes management and glycemic control (Hanson, Henggeler, Rodrigue, Burghen, & Murphy, 1988
). The primary caregivers in this study were overwhelmingly mothers, which is consistent with previous research yet limits our understanding of families in which fathers take a primary or equally shared caregiving role. For example, these results do not speak about what may be unique roles for fathers in single-parent households, where they may have greater or sole responsibility for diabetes care. Finally, these cross sectional data represent a single time-point and cannot be used to infer causality between the constructs assessed.
Nevertheless, the results of this study are meaningful for future research and clinical care of children and families with type 1 diabetes. Clinically, the direct and indirect effects model results suggest that both paternal involvement and youth’s adherence behaviors may be useful targets of intervention to improve HbA1c. A number of empirically supported family-based treatments exist that target adherence promotion with the ultimate goal of improving glycemic control (e.g., Anderson, Brackett, Ho, & Laffel, 1999
; Ellis et al., 2005
; Wysocki et al., 2008
). The results of this study indicate that modifications to these intervention programs focusing on the involvement of not only mothers, but also fathers, could be valuable. As noted by Phares and colleagues (2005)
, fathers are disproportionately absent from treatment outcome studies in pediatric psychology, and these interventions should be tested in samples that include more fathers. In addition, as fathers may not perceive themselves to be as helpful as mothers do, it is likely important to reinforce their roles in diabetes care, as this may enhance family management of diabetes among preadolescents with poorer glycemic control.
In order to answer empirical family-level questions, such as how maternal perceptions about fathers’ help with diabetes predict fathers’ subsequent involvement and vice versa, future researchers should consider using available analytic methods designed for dyadic data in longitudinal samples. For example, the actor–partner interdependence model (APIM) can be used to analyze the influences of two individuals’ past behavior on their own and the other individuals’ future behavior (i.e., actor effects and partner effects) (Cook & Kenny, 2006
). This would be an important step for understanding the reciprocal mechanisms by which each parent can impact the other’s contributions to family illness management, treatment adherence, and glycemic control. Dyadic and family-level analytic approaches (e.g., structural equation modeling and combined path models for mothers and fathers) can also be used by researchers to compare the similarities and differences between mothers’, fathers’, and children’s contributions to diabetes care, thereby providing greater specificity in our understanding of families’ collaborative illness management. Resulting data will likely inform family-based interventions to encourage helpful parent engagement and promote better adolescent diabetes outcomes, as particular family interaction patterns could be identified. For example, specific communication styles (e.g., explicitly requesting fathers’ assistance and expressing appreciation) could be used to increase the amount and helpfulness of fathers’ involvement in their children’s diabetes care.