Psychometric properties and factor structure of the adapted Self-Regulation Questionnaire assessing autonomous and controlled motivation for healthful eating among youth with type 1 diabetes and their parents.

BACKGROUND: The purpose of this cross-sectional study was to examine the psychometric properties of 2 adapted Self-Regulation Questionnaire (SRQ) measures assessing youth with type 1 diabetes motivation internalization for healthful eating and their parents motivation internalization for providing healthy meals for the family. METHODS: External validity of the adapted SRQ was evaluated with respect to healthy eating attitudes (healthful eating self-efficacy, barriers, and outcome expectations) assessed by questionnaire, diet quality (Healthy Eating Index-2005 [HEI-2005]; Nutrient-Rich Foods Index 9.3 [NRF9.3]; Whole Plant Food Density [WPFD]) assessed by 3-day food records, and body mass index assessed by measured height and weight in youth with type 1 diabetes (N = 136; age 12.3 ± 2.5 years) and their parents. RESULTS: Exploratory factor analysis with varimax rotation yielded a 2-factor structure with the expected autonomous and controlled motivation factors for both youth and parents. Internal consistencies of subscales were acceptable (α = .66-.84). Youth autonomous and controlled motivation were positively correlated overall (r = 0.30, p < .001); however, in analyses stratified by age (<13 vs. ≥13 years), the correlation was not significant for youth ≥13 years. Autonomous motivation was significantly associated (p < .001) with greater self-efficacy (youth: r = 0.39, parent: r = 0.36), positive outcome expectations (youth: r = 0.30, parent: r = 0.35), and fewer barriers to healthful eating (youth: r = -0.36, parent: r = -0.32). Controlled motivation was positively correlated with negative outcome expectations for parents (r = 0.29, p < .01) and both positive (r = 0.28, p < .01) and negative (r = 0.34, p < .001) outcome expectations for youth. Autonomous motivation was positively associated (p < .05) with diet quality indicators for parents (NRF9.3 r = 0.22; WPFD r = 0.24; HEI-2005 r = 0.22) and youth ≥13 years (NRF9.3 r = 0.26) but not youth < 13years. Among parents, but not youth, body mass index was associated negatively with autonomous motivation (r = -.33, p < .001) and positively with controlled motivation (r = .27, p < .01). CONCLUSIONS: Findings provide initial support for the SRQ in this population and suggest potential developmental differences in the role of motivation on healthful eating among children, adolescents, and adults.

Reduction of hypoglycaemic events with a behavioural intervention: a randomized clinical trial for paediatric patients with Type 1 diabetes mellitus.

AIMS: To determine if a low-intensity, clinic-integrated behavioural intervention reduced the incidence of hypoglycaemic events in children with Type 1 diabetes. METHODS: A total of 390 families with children with Type 1 diabetes were enrolled in a 2-year, randomized clinical trial of a behavioural intervention. The intervention was designed to improve diabetes management practices by targeting the family's diabetes problem-solving skills. Hypoglycaemic events were categorized in two groups: those treated by oral ingestion and those treated by parenteral therapy. Events were self-reported by participants at each clinic visit, which occurred approximately every 3-4 months. Analyses included two-sample t-tests, the mean cumulative function test, and the Cox proportional hazards model for recurrent events to compare the incidence between groups. RESULTS: Across the entire 2-year study period, the incidence of hypoglycaemic events treated by oral ingestion of glucose-rich foods and events requiring parenteral therapy did not significantly differ between study conditions; however, during the second year of participant enrolment, the incidence of events treated by oral ingestion in the intervention group was 13.6 per 100 person-years compared with 27.3 per 100 patient-years in the control group (P = 0.02). The hazard ratio of these events during the second year was 0.49 (95% CI 0.27-0.90; P = 0.02). CONCLUSIONS: Our findings suggest the need for a long-term (> 1 year) focus on the implementation of interventions targeting diabetes management in young people. Behavioural interventions targeting problem-solving skills could be considered as practical, non-pharmacological strategies to reduce hypoglycaemia in adolescents with Type 1 diabetes.

Body mass index and adiposity indicators associated with cardiovascular biomarkers in youth with type 1 diabetes followed prospectively.

BACKGROUND: The impact of excess weight on cardiovascular disease risk in type 1 diabetes patients is unclear. OBJECTIVE: This study examined associations of BMI and body composition with cardiovascular risk factors in youth followed prospectively for 18 months. METHODS: The sample includes youth with type 1 diabetes (N = 136, baseline age = 12.3 ± 2.5y, glycated hemoglobin = 8.1 ± 1.1%) participating in an 18-month behavioral nutrition intervention trial. BMI, body composition (by dual energy x-ray absorptiometry), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C); triglycerides (TG), c-reactive protein (CRP), 8-iso-prostaglandin-F2alpha (8-iso-PGF2α), adiponectin and systolic and diastolic blood pressure (SBP and DBP, respectively) were assessed at clinic visits every 6 months. Random effects regression models for repeated measures estimated associations of time-varying BMI and body composition with time-varying cardiovascular risk factors, adjusted for treatment assignment and covariates. RESULTS: There was no intervention effect on cardiovascular risk factors. Percent body fat was positively associated with TG, LDL-C, CRP, SBP and DBP, while trunk fat mass and trunk %fat were associated positively with TG, LDL-C, CRP, SBP and DBP, and inversely with HDL-C. Higher BMI was associated with greater TG, CRP, SBP and DBP and lower HDL-C. BMI and body composition indicators were unrelated to 8-iso-PGF2α and adiponectin. CONCLUSIONS: Excess adiposity is associated with increased cardiovascular risk factors in this sample of youth with type 1 diabetes. Non-significant associations with adiponectin and 8-iso-PGF2α suggest potential differences from the general population in the role of adiposity in cardiovascular health.

Power of Food Scale in association with weight outcomes and dieting in a nationally representative cohort of U.S. young adults.

Food reward sensitivity may influence susceptibility to overeating in a permissive food environment, contributing to unintended weight gain and intentional weight loss behavior. This study examined associations of food reward sensitivity, assessed by the Power of Food Scale (PFS), with weight outcomes and dieting in a nationally representative cohort of U.S. emerging adults. Wave 5 (W5, 5th year of follow-up) respondents from the NEXT Generation Health Study were included (N = 2202, W5 age = 20.3 ± 0.02 years). Baseline and W5 BMI, W5 weight status (normal weight = 18.5 ≤ BMI < 25, overweight = 25 ≤ BMI < 30, obese = BMI ≥ 30), BMI change (W5-baseline BMI) and onset of overweight or obesity (OWOB) were calculated from self-reported height and weight. PFS (aggregate and 3 domain scores: food available, present, and tasted) and dieting for weight-loss were assessed at W5. Adjusted linear regressions estimated associations of PFS with W5 BMI and BMI change. Log-binomial regressions estimated associations of high W5 BMI (≥25), OWOB onset and dieting with PFS. Post hoc analyses estimated associations of PFS with W5 perceived weight status (overweight vs. about right or underweight). W5 BMI = 25.73 ± 0.32 kg/m(2), and OWOB onset occurred in 27.7% of participants. The PFS-food available score was associated with BMI change, ß ± SE = 0.41 ± 0.19. Other PFS scores were not associated with weight outcomes. Dieting prevalence was higher in participants with high versus low W5 BMI (61% versus 32%), and was positively associated with all PFS scores except the PFS-food tasted score, e.g., relative risk (RR) of dieting for PFS-aggregate = 1.13, 95%CI [1.01-1.26]. Post-hoc analyses indicated perceived overweight was positively associated with PFS-food available, 1.12, [1.01-1.24], and PFS-food present, 1.13, [1.03-1.24]. PFS was positively related to dieting and perceived overweight, but not concurrent or change in weight status in a representative cohort of U.S. emerging adults.

Validation of a contemporary adherence measure for children with Type 1 diabetes: the Diabetes Management Questionnaire.

AIMS: To evaluate the psychometric properties of the Diabetes Management Questionnaire, a brief, self-report measure of adherence to contemporary diabetes management for young people with Type 1 diabetes and their caregivers. METHODS: A total of 273 parent-child dyads completed parallel versions of the Diabetes Management Questionnaire. Eligible children (aged 8-18 years) had Type 1 diabetes for ≥1 year. A multidisciplinary team designed the Diabetes Management Questionnaire as a brief, self-administered measure of adherence to Type 1 diabetes management over the preceding month; higher scores reflect greater adherence. Psychometrics were evaluated for the entire sample and according to age of the child. RESULTS: The children (49% female) had a mean ± sd (range) age 13.3 ± 2.9 (8-18) years and their mean ± sd HbA1c was 71 ± 15 mmol/mol (8.6 ± 1.4%). Internal consistency was good for parents (α = 0.83) and children (α = 0.79). Test-retest reliability was excellent for parents (intraclass correlation coefficient =0.83) and good for children (intraclass correlation coefficient = 0.65). Parent and child scores had moderate agreement (intraclass correlation coefficient = 0.54). Diabetes Management Questionnaire scores were inversely associated with HbA1c (parents: r = -0.41, P < 0.0001; children: r = -0.27, P < 0.0001). Psychometrics were stronger in the children aged ≥13 years compared with those aged < 13 years, but were acceptable in both age groups. Mean ± sd Diabetes Management Questionnaire scores were higher among children who were receiving insulin pump therapy (n = 181) than in children receiving multiple daily injections (n = 92) according to parent (75.9 ± 11.8 vs. 70.5 ± 15.5; P = 0.004) and child report (72.2 ± 12.1 vs. 67.6 ± 13.9; P = 0.006). CONCLUSIONS: The Diabetes Management Questionnaire is a brief, valid self-report measure of adherence to contemporary diabetes self-management for people aged 8-18 years who are receiving either multiple daily injections or insulin pump therapy.

Body size perception and weight control in youth: 9-year international trends from 24 countries.

OBJECTIVES: To examine 9-year trends and relationships regarding misperceptions of body size and dieting for weight loss among adolescents from 24 countries, and explore the influence of country-level overweight prevalence. METHODS: Sociodemographic characteristics, body size perception and dieting for weight loss were assessed in the Health Behaviour in School-aged Children survey conducted in 24 countries cross-sectionally at three time points (2001/2002, 2005/2006 and 2009/2010). Logistic regression models examined change over time in overestimation of body size in non-overweight adolescents, underestimation of body size in overweight adolescents, dieting for weight loss in non-overweight and overweight adolescents and relationships between body size perception and dieting. Analyses were stratified by weight status and sex. Covariates included country-level overweight prevalence, family affluence and country level of development. Body mass index was only included in models examining dieting for weight loss. RESULTS: Country-level overweight prevalence increased over time (11.6-14.7%). Compared with Time 1, overweight adolescents had greater odds of body size underestimation at Time 3 (odds ratio (OR)=1.68 for girls; OR=1.10 for boys), whereas non-overweight adolescents had lower odds of body size overestimation at Time 3 (OR=0.87 for girls; OR=0.89 for boys). Controlling for country-level overweight prevalence attenuated these relationships. Compared with Time 1, overweight and non-overweight boys were 10% more likely to diet at Time 3, whereas overweight and non-overweight girls were 19% and 16%, respectively, less likely to diet at Time 3. Controlling for country-level overweight prevalence did not impact trends in dieting for weight loss. Additionally, the association of self-perceived overweight with increased odds of dieting diminished over time. CONCLUSIONS: Body size perceptions among adolescents may have changed over time concurrent with shifts in country-level body weight. However, controlling for country-level overweight prevalence did not impact trends in dieting for weight loss, suggesting a potentially stronger impact of social comparison on weight-related perceptions than on behavior.

Relationships of neophobia and pickiness with dietary variety, dietary quality and diabetes management adherence in youth with type 1 diabetes.

BACKGROUND/OBJECTIVES: Neophobia, pickiness and diet variety are associated with diet quality and health outcomes in young children. Limited research has examined these associations among youth with type 1 diabetes (T1D), a population at risk for poor health outcomes when dietary quality is inadequate. SUBJECTS/METHODS: Youth (n=252, age 13.2 ± 2.8 years, 92% white, diabetes duration 6.3 ± 3.4 years) with T1D and their parents completed 3-day youth diet records; parents completed questionnaires regarding youth neophobia, pickiness and diabetes management adherence. Medical records provided biomedical data. Dietary quality indicators included Nutrient-Rich Foods Index 9.3 (NRF9.3), Healthy Eating Index-2005 (HEI-2005), Whole Plant Food Density (WPFD) and key single nutrients. Dietary variety was operationalized as a count of 20 recommended food groups consumed. Relationships of dietary quality and diabetes management adherence with neophobia, pickiness and dietary variety as independent variables were examined using multiple linear regression analyses adjusted for total energy intake, age, height and weight. RESULTS: In multiple linear regression analyses, NRF9.3 and HEI-2005 were each inversely associated with neophobia and pickiness, and positively associated with dietary variety. WPF and potassium were each positively associated and saturated fat was inversely associated with dietary variety. However, in models simultaneously including neophobia, pickiness and dietary variety as independent correlates of dietary quality, only relationships with dietary variety remained significant. Diabetes management adherence was negatively associated with both neophobia and pickiness and positively associated with dietary variety. CONCLUSIONS: Findings suggest that increasing dietary variety may contribute toward improved dietary quality among youth with T1D, despite potentially adverse influences of neophobia and pickiness.

Associations of family meal frequency with family meal habits and meal preparation characteristics among families of youth with type 1 diabetes.

BACKGROUND: While benefits of family mealtimes, such as improved dietary quality and increased family communication, have been well-documented in the general population, less is known about family meal habits that contribute to more frequent family meals in youth with type 1 diabetes. METHODS: This cross-sectional study surveyed 282 youth ages 8-18 years with type 1 diabetes and their parents on measures regarding diabetes-related and dietary behaviours. T-tests determined significant differences in youth's diet quality, adherence to diabetes management and glycaemic control between those with and without regular family meals (defined as ≥ 5 meals per week). Logistic regression analyses determined unadjusted and adjusted associations of age, socio-demographics, family meal habits, and family meal preparation characteristics with regular family meals. RESULTS: 57% of parents reported having regular family meals. Families with regular family meals had significantly better diet quality as measured by the Healthy Eating Index (P < 0.05) and the NRF9.3 (P < 0.01), and adherence to diabetes management (P < 0.001); the difference in glycaemic control approached statistical significance (P = 0.06). Priority placed on, pleasant atmosphere and greater structure around family meals were each associated with regular family meals (P < 0.05). Meals prepared at home were positively associated with regular family meals, while convenience and fast foods were negatively associated (P < 0.05). Families in which at least one parent worked part-time or stayed at home were significantly more likely to have regular family meals than families in which both parents worked full-time (P < 0.05). In the multivariate logistic regression model, greater parental priority given to family mealtimes (P < 0.001) and more home-prepared meals (P < 0.001) predicted occurrence of regular family meals; adjusting for parent work status and other family meal habits. CONCLUSIONS: Strategies for promoting families meals should not only highlight the benefits of family meals, but also facilitate parents' skills for and barriers to home-prepared meals.

Cross-sectional and longitudinal relationships of body mass index with glycemic control in children and adolescents with type 1 diabetes mellitus.

AIMS: Weight gain is an oft-cited outcome of improved glycemic control in adults with type 1 diabetes, though few studies have investigated this in youth. The purpose of this paper was to examine cross-sectional and longitudinal associations of body mass index (BMI, kg/m(2)) with glycemic control in youth with type 1 diabetes (n=340, 12.5 ± 1.7 year, 49% female, duration ≥ 1 year) participating in a 2-year multi-center intervention study targeting family diabetes management. METHODS: BMI was calculated from height and weight measured at clinic visits. Glycohemoglobin (HbA1c) at each visit was assayed centrally. Cross-sectional associations of baseline BMI with glycemic control, and of change in BMI and HbA1c with baseline values, were examined. Longitudinal associations of time-varying BMI and HbA1c were examined using a multilevel linear mixed effects model controlling for time-varying time (months), insulin dose (units/kg/day), regimen, Tanner stage, and time invariant baseline diabetes duration, BMI, treatment group and sociodemographic characteristics. RESULTS: Baseline HbA1c was unrelated to baseline BMI, but was related positively to subsequent BMI change (p=0.04) and inversely to HbA1c change (p=0.002). Baseline BMI was inversely related to BMI change (p=0.01) and unrelated to HbA1c change. In multilevel regression, BMI was related inversely to HbA1c (%) (ß ± SE=-0.11 ± 0.02, p<0.001) and positively to insulin dose (0.23 ± 0.07, p=0.001). In the treatment group only, BMI was positively related to pump regimen (0.18 ± 0.08, p=0.02). CONCLUSIONS: Increased insulin administered to improve glycemic control may contribute to increased BMI in youth with type 1 diabetes, indicating the importance of determining ways to minimize weight gain while optimizing glycemic control.

Associations of food preferences and household food availability with dietary intake and quality in youth with type 1 diabetes.

The objective of this study was to examine associations of food preferences and availability with dietary intake in youth with type 1 diabetes, for whom dietary intake and quality are essential to disease management. Youth (n=252, age 13.2±2.8 y, diabetes duration 6.3±3.4 y) reported preferences and parents reported household availability for 61 food items categorized as fruit, vegetables, whole grains, refined grains and fats/sweets. Youth energy-adjusted daily servings of food groups, Healthy Eating Index-2005 and Nutrient Rich Foods 9.3 scores were calculated from 3-day diet records. Associations of dietary intake and quality variables with preference and availability of all food groups were evaluated by linear regressions adjusted for sociodemographic characteristics. Fruit and whole grain intake were positively related to corresponding preference and availability; whole grain intake and refined grain availability were inversely related. Vegetable, refined grain and fats/sweets intake were unrelated to preference and availability. Diet quality measures were related positively to fruit preference and whole grain availability and inversely to refined grains availability. Findings indicate associations of dietary intake with food preference and availability vary by food group in youth with type 1 diabetes. Measures of overall dietary quality were more consistently associated with food group availability than preferences.

Validation of an abbreviated adherence measure for young people with Type 1 diabetes.

AIMS: Adherence to diabetes-related tasks is an important construct. The Diabetes Self-Management Profile is a validated, semi-structured interview assessing adherence in paediatric patients with Type 1 diabetes. We created and validated a brief questionnaire version of the Diabetes Self-Management Profile called the Diabetes Self-Management Questionnaire. METHODS: Young people with Type 1 diabetes, ages 9-15 years (n = 338) and their parents provided data from chart review, interview and questionnaires. RESULTS: Diabetes Self-Management Questionnaire scores correlated significantly with Diabetes Self-Management Profile scores, HbA(1c) , blood glucose monitoring frequency and other measures associated with adherence and/or glycaemic control (P ≤ 0.01 for all). Young people and parent scores were correlated (r = 0.55, P < 0.0001). The Diabetes Self-Management Questionnaire demonstrated modest internal consistency (Cronbach's α = 0.59), adequate for a brief measure of multidimensional adherence. In addition, factor analysis confirmed one factor. CONCLUSIONS: This brief adherence questionnaire demonstrated construct validity in young people 9-15 years old and their parents and may have utility in clinical and research settings.

Comparison of longitudinal point-of-care and high-performance liquid chromatography HbA1c measurements in a multi-centre trial.

AIMS: Point-of-care HbA(1c) is routine in clinical practice. Comparison of point-of-care HbA(1c) against laboratory measurements across sites and over time is warranted. METHODS: One hundred and twenty-one young persons with Type 1 diabetes from four centres provided 450 paired samples collected over 10 months for point-of-care HbA(1c) and central laboratory-based high-performance liquid chromatography (HPLC) HbA(1c) determinations. Change in HbA(1c) over time was assessed by difference from initial to final HbA(1c) and by growth modelling with annualized slope calculation. Change in HbA(1c) was categorized as improved (decrease of ≥ 0.5% or negative slope), no change (± 0.4% of initial HbA(1c) or slope = 0) or worsened (increase of ≥ 0.5% or positive slope). RESULTS: The 450 paired samples (median of four pairs/patient) were highly correlated (r = 0.97, P < 0.0001), as were time-specific and site-specific pairs (r = 0.94 to 0.98, P < 0.0001). Initial-to-final point-of-care HbA(1c) and HPLC HbA(1c) changes were 0.3 ± 1.1% (range -2.7 to 4.1) and 0.4 ± 1.2% (-3.9 to 4.5), respectively, with 21% of patients (n = 26) discordant for change categories. ΔHbA(1c) by point-of-care HbA(1c) vs. HPLC HbA(1c) differed across the HbA(1c) range and by ≥ 0.5% absolute difference in ΔHbA(1c) in 14 (54%) of the 26 patients discordant for HbA(1c) change categories. Mean annual HbA(1c) slope was 0.4 ± 1.5% (-5.4 to 4.8) for point-of-care HbA(1c) and 0.4 ± 1.6% (-6.9 to 5.2) for HPLC HbA(1c), with 18% (n = 22 pairs) discordant for change categories. CONCLUSIONS: Assessment of absolute HbA(1c) change may not be different for point-of-care HbA(1c) compared with HPLC HbA(1c); however, misclassification of patients by discrete cut-off values may occur with point-of-care HbA(1c) compared with HPLC HbA(1c) determinations.

Socioeconomic position, macroeconomic environment and overweight among adolescents in 35 countries.

OBJECTIVE: It is important to understand levels and social inequalities in childhood overweight within and between countries. This study examined prevalence and social inequality in adolescent overweight in 35 countries, and associations with macroeconomic factors. DESIGN: International cross-sectional survey in national samples of schools. SUBJECTS: A total of 11-, 13- and 15-year-olds from 35 countries in Europe and North America in 2001-2002 (N=162 305). MEASUREMENTS: The main outcome measure was overweight based on self-reported height and weight (body mass index cut-points corresponding to body mass index of 25 kg/m(2) at the age of 18 years). Measures included family and school affluence (within countries), and average country income and economic inequality (between countries). RESULTS: There were large variations in adolescent overweight, from 3.5% in Lithuanian girls to 31.7% in boys from Malta. Prevalence of overweight was higher among children from less affluent families in 21 of 24 Western and 5 of 10 Central European countries. However, children from more affluent families were at higher risk of overweight in Croatia, Estonia and Latvia. In Poland, Lithuania, Macedonia and Finland, girls from less affluent families were more overweight whereas the opposite was found for boys. Average country income was associated with prevalence and inequality in overweight when considering all countries together. However, economic inequality as measured by the Gini coefficient was differentially associated with prevalence and socioeconomic inequality in overweight among the 23-high income and 10-middle income countries, with a positive relationship among the high income countries and a negative association among the middle income countries. CONCLUSION: The direction and magnitude of social inequality in adolescent overweight shows large international variation, with negative social gradients in most countries, but positive social gradients, especially for boys, in some Central European countries. Macroeconomic factors are associated with the heterogeneity in prevalence and social inequality of adolescent overweight.

Quality of life in children with Type 1 diabetes: a comparison of general and diabetes-specific measures and support for a unitary diabetes quality-of-life construct.

AIMS: To assess the factor structure of the Pediatric Quality of Life Inventory (PedsQL) Diabetes Module and to compare the PedsQL general and diabetes-specific quality of life (QOL) measures regarding psychometric properties and relations to relevant outcomes. METHODS: The instruments were completed by 447 children age 9 to 15.5 years with Type 1 diabetes > 1 year from four US paediatric diabetes clinics; parents completed the parallel parent-proxy measures. Principal components factor analysis was used to examine the factor structure of the PedsQL diabetes module. Analyses of the generic and diabetes QOL measures included psychometric properties, parent-child correlations and correlations with depression, adherence and glycated haemoglobin (HbA(1c)). RESULTS: The factor structure of the PedsQL diabetes module did not support the original five subscales. Both one- and two-factor models were supported; however, parallel parent and child subscales did not emerge. While the generic and diabetes-specific measures of QOL were moderately to highly correlated with each other, the constructs were differentially associated with relevant diabetes outcomes. Generic QOL was more highly associated with depression than diabetes QOL. Conversely, diabetes QOL was more highly associated with adherence and HbA(1c), although this was seen to a greater extent for parent-proxy report than for child report. CONCLUSIONS: Factor analysis of the PedsQL diabetes module supports the use of a total diabetes QOL score. Findings regarding the associations of the generic and diabetes modules with diabetes outcomes underscore the unique contribution provided by both generic and diabetes QOL.

Responsive parenting is associated with improved type 1 diabetes-related quality of life.

BACKGROUND: Improved quality of life is an important treatment goal for children and adolescents with type 1 diabetes. While previous research supports a relationship between family environment and quality of life, little research has addressed the relationship of parenting style constructs to quality of life in children with chronic disease. The present investigation assesses the relationship of parent responsiveness and demandingness with diabetes-related quality of life among children and adolescents with type 1 diabetes. METHODS: Baseline and 12-month follow-up self-report assessments were collected on a sample of 81 children with type 1 diabetes participating in an efficacy trial of a behavioural intervention to enhance adherence. The sample had a mean age of 13.3 years (SD=1.7) and duration of diabetes of 7.7 years (SD=3.7). Multiple regression analyses were conducted to determine the relationship of parent responsiveness and demandingness to diabetes-related quality of life at each time point. RESULTS: After adjusting for demographic and diabetes characteristics, as well as diabetes-specific parent-child behaviours, parent responsiveness was significantly associated with baseline diabetes-related quality of life (beta=0.23; P=0.04). This relationship was sustained at 12-month follow-up (beta=0.22; P=0.04) after adjusting for baseline quality of life and treatment group assignment, suggesting that parent responsiveness is associated with improved quality of life. CONCLUSIONS: Findings indicate the importance of a supportive and emotionally warm parenting style in promoting improved quality of life for children with type 1 diabetes. Appropriate parenting skills should be an element of diabetes family management health care.

Quality of life and acceptability of medical versus surgical management of early pregnancy failure.

OBJECTIVE: This study compares quality of life (QOL) and acceptability of medical versus surgical treatment of early pregnancy failure (EPF). DESIGN: A randomised clinical trial of treatment for EPF compared misoprostol vaginally versus vacuum aspiration (VA). SETTING: A multisite trial at four US Urban University Hospitals. POPULATION: A total of 652 women with an EPF were randomised to treatment. METHODS: Participants completed a daily symptom diary and a questionnaire 2 weeks after treatment. MAIN OUTCOME MEASURES: The questionnaire assessment included subscales of the Short Form-36 Health Survey Revised for QOL and measures of wellbeing, recovery difficulties, and treatment acceptability. RESULTS: The two groups did not differ in mean scores for QOL except bodily pain; medical treatment was associated with higher levels of bodily pain than VA (P < 0.001). Success of treatment was not related to QOL, but acceptability of the procedure was decreased for medical therapy if unsuccessful (P = 0.003). Type of treatment was not associated with differences in recovery, and the two groups reported similar acceptability except for cramping (P = 0.02), bleeding (P < 0.001), and symptom duration (P = 0.03). CONCLUSIONS: Despite reporting greater pain and lower acceptability of treatment-related symptoms, QOL and treatment acceptability were similar for medical and surgical treatment of EPF. Acceptability, but not QOL, was influenced by success or failure of medical management.

Differential strength of association of child injury prevention attitudes and beliefs on practices: a case for audience segmentation.

OBJECTIVE: Many injuries to children cannot be prevented without some degree of active behavior on the part of parents. A better understanding of social and cognitive determinants of parents' injury prevention behavior and the identification of potential subgroups for targeted message delivery could advance the effectiveness of educational and behavioral interventions. This study assessed the degree to which parents' injury prevention behavior is associated with theoretical determinants and examined whether this relation differs by age or birth order of child. DESIGN: Cross sectional observational study. SETTING: Three Midwestern pediatric clinics. SUBJECTS: 594 parents of children ages 0-4 attending routine well child visits. MEASURES: Injury prevention attitudes, beliefs, and practices. RESULTS: Overall, only modest relations were observed between injury beliefs and attitudes and injury prevention behaviors. However, these relations differed substantially by child age and birth order, with stronger associations observed for parents of older first born children. Outcome expectations and social norms were more strongly related to injury prevention behavior among parents of preschool children than among parents of infants and toddlers, while attitudes were more predictive for parents of first born children than parents of later born children. CONCLUSIONS: These findings highlight the complexity of relations between theorized determinants and behavior, and suggest the potential utility of using audience segmentation strategies in behavioral interventions addressing injury prevention.

Bullying behaviors among US youth: prevalence and association with psychosocial adjustment.

CONTEXT: Although violence among US youth is a current major concern, bullying is infrequently addressed and no national data on the prevalence of bullying are available. OBJECTIVES: To measure the prevalence of bullying behaviors among US youth and to determine the association of bullying and being bullied with indicators of psychosocial adjustment, including problem behavior, school adjustment, social/emotional adjustment, and parenting. DESIGN, SETTING, AND PARTICIPANTS: Analysis of data from a representative sample of 15 686 students in grades 6 through 10 in public and private schools throughout the United States who completed the World Health Organization's Health Behaviour in School-aged Children survey during the spring of 1998. MAIN OUTCOME MEASURE: Self-report of involvement in bullying and being bullied by others. RESULTS: A total of 29.9% of the sample reported moderate or frequent involvement in bullying, as a bully (13.0%), one who was bullied (10.6%), or both (6.3%). Males were more likely than females to be both perpetrators and targets of bullying. The frequency of bullying was higher among 6th- through 8th-grade students than among 9th- and 10th-grade students. Perpetrating and experiencing bullying were associated with poorer psychosocial adjustment (P<.001); however, different patterns of association occurred among bullies, those bullied, and those who both bullied others and were bullied themselves. CONCLUSIONS: The prevalence of bullying among US youth is substantial. Given the concurrent behavioral and emotional difficulties associated with bullying, as well as the potential long-term negative outcomes for these youth, the issue of bullying merits serious attention, both for future research and preventive intervention.

Women's douching practices and related attitudes: findings from four focus groups.

PURPOSE: Vaginal douching is a common hygiene practice for many U.S. women, but is associated with several health risks. Little is known about the beliefs and attitudes that promote and maintain douching practices. This qualitative study, consisting of four focus groups of 31 southern women, was conducted to gather in-depth information about attitudes and beliefs associated with douching. The focus groups consisted of separate groups of low-income and middle-income Caucasian and African-American women. RESULTS: The African-Americans and low-income Caucasians were more likely to douche than middle-income Caucasians. The participants reported douching after menstruation, after sexual intercourse, and at other times for cleanliness and odor control. Concern about odor and cleanliness was a recurrent theme, and douching was represented as an expected and necessary part of feminine hygiene. Several socioeconomic and racial differences were observed in douching practices and attitudes. CONCLUSIONS: This study provides preliminary information about women's douching practices and attitudes that may inform practitioners' educational efforts and future research.