Introduction

Type 1 diabetes mellitus (T1DM) [1] is a prevalent pediatric disease requiring comprehensive self-care behaviours to mitigate long-term complications [4,7,18-20]. Optimal management faces obstacles from developmental stages [10-17], family dynamics, and the shifts accompanying adolescence.

These elements may hinder adherence to self-care practices, inducing metabolic discrepancies and familial conflicts [10,15,2430].

Diabetes education, while essential [31], does not consistently induce behaviour change, highlighting the value of integrating psychosocial concepts, specifically self-efficacy [1,12,33-36] and attachment style. Attachment theory postulates that distress activates the attachment system, affecting adolescents’ coping and healthcare approaches [113]. Caregiver attachment styles, too, play a role in adapting to a child’s diabetes diagnosis, with certain patterns correlating with increased parental stress [30, 52,82,84].

This study delves into the relationships between self-efficacy, resilience, attachment theory, and A1c levels, seeking strategies to bolster patient and caregiver commitment to self-care. Incorporating psychological elements into diabetes care allows for the creation of targeted interventions, enhancing patient outcomes. This article guides diabetes care specialists, proposing strategies to augment patient engagement and refine care approaches.

This Perspective in Practice piece introduces innovative methodologies in diabetes care and education, rooted in the intersections of self-efficacy, resilience, attachment, and A1c levels. A holistic, patient-focused approach is endorsed over traditional didactic methods.

Literature Review:

Attachment theory provides a framework for understanding the drive to form relationships rooted in early-life caregiver interactions [46]. Four styles-secure, dismissing, preoccupied, and fearful- determine perceptions of oneself and others [56]. Notably, a dismissing style, having a positive self-view and negative views of others, correlates with higher A1c levels [52,59]. Thus, this study emphasizes secure and dismissing styles, merging the preoccupied and fearful groups.

Resiliency theory addresses coping during adversity, often equated with strength [74,75]. While secure attachment in caregivers aids adaptation to their child’s diabetes [30], avoidant attachment correlates with increased parental stress [82,84]. The data indicates the need for resilience-focused interventions for adolescents with type 1 diabetes [74,75]. This research expects a connection between self-efficacy, attachment, and resilience influencing adolescent diabetes management [30,52].

Method

The objective of this study was to evaluate diabetes management self-efficacy in type 1 diabetes patients, parental perceptions of their children’s self-efficacy, the attachment style between teenagers and their parents, and the level of resilience in children with diabetes. The primary focus was to investigate the impact of the three attachment styles (secure, mixed, and scared) on type 1 diabetes management, as assessed by A1C levels. The secondary goal was to examine the effects of attachment styles on both patients and parents’ self-efficacy and compare diabetes management selfefficacy and attachment styles between patients and their parents.

Participants

This cross-sectional pilot study involved 170 patients with type 1 diabetes and their primary caregivers. The participants were recruited from the Hospital for Sick Children (SickKids), where approximately 1000 patients within the age range of 0-17.9 years receive diabetes care. Among these patients, 60% (660) fall within the inclusion age range of 12.0-17.9 years. The study included a diverse population in terms of race and socioeconomic status, with patients attending diabetes clinics regularly (every three months). Approximately 60-80 patients attend the clinic each week, and the study aimed to recruit 4-5 patients per week, requiring approximately 6-8 months to reach the target of 170 patients and their primary caregivers. Exclusion criteria included non-Englishspeaking families, recent diabetes diagnosis (less than a year), medication induced diabetes, type 2 diabetes, or cystic fibrosisrelated diabetes.

Procedure

The participants completed several questionnaires: the Self Efficacy for Diabetes Scale (SEDM), the Self Care Inventory (SCI), and the Relationship Scales Questionnaire (RSQ). The questionnaire took approximately 15 to 20 minutes to complete, while the entire study visit (consent and questionnaire) lasted about 20 to 25 minutes. Additionally, each participant was assigned a study identification number and required to submit Case Report Forms (CRF) containing relevant data, including:

• Study identification number
• Full name
• Date of birth or age
• Gender
• Recent/last HbA1c
• Ethnicity (to consider potential effects of different ethnicities on attachment style)
• Parental education level (to consider the role of parents in helping their children with diabetes
• Management based on their understanding and learning)
• Income and marital status
• Duration of diabetes
• Age of diagnosis
• Method of insulin administration (e.g., 2 times a day, 3 times a day-TID, pump, multiple daily injections-   MDI)

Self-Efficacy of Diabetes Self-Management (SEDM)

The SEDM is a 10-item questionnaire that assesses perceived self-efficacy in performing diabetes care behaviours. Participants rate their responses on a Likert scale ranging from 1 (“not at all sure”) to 10 (“completely sure”). The SEDM has been used for convergent validation of other tools, such as the Perceived Coping Effectiveness measure and the Adherence in Diabetes Questionnaire [85,86,94,95,96].

Self-Care Inventory (SCI)

The SCI is a 14-item self-report scale that assesses patients’ perceptions of their adherence to diabetes self-care over the previous 1-2 weeks. Participants rank how closely each item resonates with them on a 5-point Likert scale, ranging from 1 (“never do it”) to 5 (“always do this as recommended without fail”). The scale explores various areas of adherence to diabetes management, including blood sugar monitoring, insulin injections, diet, and activity [97,98,99]. The SCI scores of both youth and parents have shown negative correlations with the adolescent’s A1c levels [98].

Relationship Scales Questionnaire (RSQ)

The RSQ is a 30-item questionnaire measures attachment style and is considered valid and reliable. Re-test reliability of the RSQ ranges from 0.54 to 0.78, and correlation coefficients between the RSQ and RQ range from 0.41 to 0.61 [57,76].

Adolescent Relationship Scale Questionnaire (A-RSQ)

The A-RSQ, with reported validity of 0.7-0.95 and internal consistency of 0.82, was used to assess attachment style in adolescents. It has been used in studies involving adolescents aged 11-16 years and 12-17 years [103-105].

Diabetes Strengths and Resilience Measure for Adolescents (DSTAR-Teen)

The DSTAR-Teen is a 12-item self-report questionnaire that assesses adolescents’ diabetes strengths and resilience. It was administered to participants based on their age group (9-13 or 1418 years). The questionnaire measures adolescents’ perceptions of their competence in managing diabetes routines, flexibility in dealing with diabetes-related unforeseen circumstances, and seeking help with diabetes issues [102]. Participants rate each item on a 5-point Likert scale, ranging from 1 (“never”) to 5 (“almost usually”). The DSTAR-Teen has demonstrated strong internal consistency (Cronbach’s alpha of 0.89) [10].

By employing these measures, the study aimed to explore the relationship between self-efficacy, attachment style, and resilience in diabetes management among patients and their parents. The data collected through the questionnaires and CRFs provided valuable insights into the psychosocial factors influencing diabetes care and education, enabling the development of innovative approaches to enhance patient engagement and improve overall diabetes care delivery.

Results

This investigation aimed to discern the influence of disparate attachment styles on glycated hemoglobin (HbA1c) levels among individuals living with type 1 diabetes mellitus (T1DM) while adjusting for a myriad of demographic and clinical variables. The data analysis utilized an Analysis of Variance (ANOVA) model, an instrumental statistical methodology that facilitates the comparison of means across multiple groups to identify significant disparities. This robust model enabled the elucidation of potential correlations between attachment styles and HbA1c levels.

Descriptive statistics encapsulating patient demographics, clinical variables, and self-report instrument data are comprehensively delineated in Table 1 (refer to appendix). Continuous variables, namely age and HbA1c levels, are presented as Mean ± Standard Deviation (SD) and range. The average age of the participating adolescents was 14 years, and for the caregivers, it was 48 years. Pertaining to gender, a majority of both adolescents (56%) and caregivers (73.8%) were male, with 52.8% of the adolescent participants identifying as Caucasian.

Upon analysis of HbA1c levels and adolescent attachment styles, no statistically significant association was detected, as evinced by p-values exceeding the standard 0.05 threshold (Figure A – refer to appendix). However, the data displayed a positive skew for A1c levels due to an outlying value of 14.00, necessitating a cautious interpretation of these results.

Intriguingly, the study unveiled a negative correlation between the preoccupied attachment style and self-efficacy. This significant finding accentuates the potential impact of attachment styles on self-efficacy levels and, subsequently, diabetes management outcomes.

In conclusion, these findings underscore the essentiality of considering attachment styles when providing care for individuals with diabetes. These results underscore the potential for psychological factors such as attachment styles to influence selfefficacy and health outcomes in a diabetic population. This study thus contributes to an enriched understanding of the psychosocial facets of diabetes management, highlighting the necessity for further research and practical implementation in this domain. The perspectives outlined here offer a compelling case for the integration of attachment style considerations in the formulation of patient care plans, potentially fortifying self-efficacy and augmenting overall diabetes management outcomes [106-117].