The Diabetes Control and Complication Trial confirmed the significant association between poor glycemic control and higher risk of long-term complications among adolescents with type 1 diabetes [1
]. Since then, insulin treatment and technologies for insulin delivery have improved and international guidelines for managing diabetes among children and adolescents have been established. Although some studies have reported improved glycated hemoglobin (HbA1c
) among children in recent decades [2
], no unambiguous evidence indicates that technical and medical progress has substantially improved glycemic outcomes [5
]. Many children and adolescents still do not achieve HbA1c
less than 7.5% as recommended by the International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines [7
Several studies have highlighted the importance of not only considering the effects of medical and technical factors but also psychosocial family factors for glycemic outcomes among children with type 1 diabetes. The results of studies focusing on associations between psychosocial factors on glycemic control are, however, mixed. In addition, most results are based on small sample sizes and considerable variation in the instruments used to assess psychosocial variables.
Sherifali & Ciliska [8
] claimed that most of the parenting research literature as related to children with diabetes lacks a conceptualization of the determinants influencing parental functioning. They suggested Jay Belsky's determinants of parenting model as a conceptual framework to guide future research on parenting children with diabetes. Belsky [9
] stated that most parenting research has focused on the characteristics and consequences of parenting. By developing the determinants of parenting model Belsky drew attention to the determinants of individual differences in parenting. The model emphasizes 1) the parents' personal psychological resources, 2) the characteristics of the child and 3) contextual sources of stress and support as three important domains influencing the parenting process and subsequently the child's development. The contextual sources of stress and support include work, marital relations and social network support [9
Caring for a child with diabetes requires continual sensitive adaptation to the child's growing and stage of development. Belsky [9
] discussed what kind of personal psychological resources are needed to provide developmentally flexible and growth-promoting care. As part of the answer, Belsky claimed that previous research has provided some support for links between parents' mental well-being and their parental functioning. In accordance, the Hvidøre Study Group on Childhood Diabetes [10
] has demonstrated a positive association between parents' experience of well-being and glycemic control among children with diabetes. Subjective well-being has been reported to be facilitated by a person's trait of optimism, which has been shown to strongly protect adults who have experienced stressful life events such as the illness of a family member [11
]. Based on this, it would be of interest to further examine the relationship between glycemic control among children with type 1 diabetes and variables related to the parents' life orientation regarding optimism as a marker for competent parental functioning for parents' caring for a child with type 1 diabetes.
Belsky's model emphasizes how contextual sources of stress and support such as social support, work and marital relations influence both parents' psychological resources and how they parent [9
]. Sullivan-Bolyai et al. [12
] have described how social support enhances mothers' abilities to cope with the demanding daily treatment tasks related to diabetes treatment in a child. Thus, the associations between social support and glycemic control should be further explored. The study of Sullivan-Bolyai further reported that mothers of children with type 1 diabetes had lower employment status than mothers in a control group, with the additional responsibility because of the child's diabetes as an explanatory factor. Although the association between employment status and glycemic control has not been fully explored, fathers' higher education level has been reported to be associated with better glycemic control among children with diabetes [13
Parents living together have previously been stated as a robust determinant for lower HbA1c
among adolescents with type 1 diabetes [10
]. According to Belsky's model the parents' satisfaction with the marital relationship may also be important for how families handle the daily challenges related to a child's diabetes treatment. A study among 109 children 8-18 years old and one of the parents showed that family functioning, the families' adherence to diabetes treatment, family structure, the child's age and age at diagnosis explained 49% of the variation in HbA1c
An important part of parenting children with type 1 is the frequent daily treatment tasks required. Helgeson [15
], Ziegler [16
] and others have shown that the daily frequency of blood glucose measurement is correlated with better glycemic outcomes among children and adolescents with type 1 diabetes. Frequent measurement helps the parents and the child to adjust the insulin treatment and/or adjust dietary behavior. In addition, more frequent blood glucose measurement has been claimed to be a potential marker for good adherence to the diabetes management behavior [17
]. Transferred to Belsky's conceptual framework, the frequency of blood glucose measurement may be a marker for good quality of care related to diabetes-specific parenting behavior and appropriate daily management of the child's diabetes.
Based on previous research and inspired by the Belsky's determinants of parenting model the objectives of our study were 1) to examine associations between glycemic control among children with type 1 diabetes and variables related to the parents' personal psychological resources (optimistic life orientation) and contextual sources of stress and support (social support, work and education and marital relations) and 2) to examine the association between glycemic control among the children and the frequency of blood glucose measurement as a marker for good quality of care related to the diabetes-specific parenting behavior. We hypothesized:
that an optimistic life orientation, higher parental education, higher degree of employment, two-parent status or higher perceived satisfaction with the marital relationship, higher degree of social support or less perceived social limitation because of the child's diabetes would be associated with lower HbA1c among children with type 1 diabetes; and.
that high frequency of blood glucose measurement would be associated with lower HbA1c when controlled for important child characteristics: frequency of problematic hypoglycemic events, the child's age, duration of diabetes, insulin regimen and comorbid diseases.