Gender differences in reports of self-reliance for diabetes tasks in a pediatric sample.
In this study we explored whether there are gender differences in perceptions of child self-reliance for diabetes tasks in 104 families of youth aged eight to 16 with Type 1 diabetes. We gathered questionnaire data to measure the degree to which parents and children report that children are serf-reliant with regard to diabetes tasks. In each family, one parent and the child with diabetes completed a battery of questionnaires independently. Results of a 2(sex) x 3(age) x 2(parent/child) ANOVA indicated that parents of boys reported that boys were less self-reliant than the boys themselves reported while no significant differences between girls' selfreports and their parents' reports were found. Future research should attempt to replicate these findings and explain the discrepancy between boys' self-reports and parent reports of children's self-reliance for diabetes tasks.
Keywords: diabetes, children, sex-differences
Although much is known about the importance of parental involvement and familial responsibility sharing in diabetes care, less is known about whether gender shapes reports of self-reliance for disease tasks. Research on rates of service utilization suggests that adult men make less use of medical services than adult women. Indeed, according to the U.S. Department of Health and Human Services (1998), men made fewer physician contacts than did women between 1987 and 1995. In addition, men suffer higher mortality rates than women, but seek help less often than women for a variety of problems in living (DHHS, 1997; Stillion, 1995; Waldron, 1995). Similarly, Helgeson (1995) has addressed the ways in which being male can pose health risks for men. For example, she pointed out that mortality rates for men with coronary disease are higher than those for women. Furthermore, many researchers have attested to the barriers adult American men face in asking for help or social support (Bergman, 1995; Courtenay, 2000; Helgeson, 1995; Tudiver & Talbot, 1999.)
Despite what is known about men's rates of help-seeking for medical problems, little is known about how or when such patterns develop over the life span. As a result, the current knowledge base on this topic is dominated by theory rather than research. Levant (1995), Bergman (1995), and Pollack (1998) have written about the ways in which American boys and men learn the importance of self-reliance and stoicism at the price of connection, intimacy, and vulnerability. Autonomy, independence, self-reliance, and stoicism are hallmarks of mainstream American cultural ideals of masculinity, and although these traits may be adaptive and helpful in some contexts, they may hinder necessary help-seeking in American men and boys with chronic illness. With these theories in mind, we set out to examine whether boys report greater self-reliance with regard to diabetes care tasks than do their parents or than do girls. In order to investigate this, we collected questionnaire data to explore whether there are differences in perceived child self-reliance for diabetes tasks between families of boys and girls with Type 1 diabetes. We hypothesized that boys would report taking on more responsibility for their diabetes care than would girls and that boys would report taking on more responsibility for diabetes tasks than their parents.
The sample consisted of 104 children and adolescents with Type 1 diabetes and one or both of their parents who were recruited to participate in a longitudinal study whose results have not yet been published. In order to be eligible to participate in the study, prospective participants had to be between eight and 17 years old, receive their primary diabetes care at the Joslin Diabetes Center in Boston, and have been diagnosed between one month and six years prior to enrollment in the study (M = 2.65 years, SD = 1.5), and the participant and his/her parents had to be free of other serious medical and psychiatric diagnoses. The enrollment period lasted from February 1998 to March 2000. Of the 201 eligible families, 128 came to the clinic during the enrollment period, and 104 families agreed to participate. We asked whichever parent came to the clinic with the child to fill out the questionnaire. If both parents came to the clinic, we asked that only one parent fill out the questionnaire. We did not collect data on the sex of the parent who filled out the questionnaire because this was not relevant to the longitudinal study for which these data were collected. There were 55 boys and 49 girls in the study; 32 of the youth were between eight and 10 years old, 46 were between 11 and 13 years old, and 26 were between 14 and 17 years old. The mean age of the children was 11.65 years. With regard to ethnicity, 93% (n = 97) of the parents identified their children's ethnicity as European American, 1% (n = 1) as African American, 1% as Latino/a (n = 1), 1% (n = 1) as Native American, 3% (n = 3) as Asian/Pacific Islanders, and 1% (n = 1) as "other."
The Hollingshead Scale (Hollingshead, 1957) was used to rate socioeconomic status based on parents' self-report of jobs. In addition, researchers used self-report data from parents to ascertain parents' highest completed level of education. Of the parents participating in the study, 34% were classified as either major or minor professionals, 38% were classified as skilled or semi-skilled workers, 6.7% as unskilled workers, and the remaining 21% either did not record a response or reported being unemployed. Eighty percent of the parents in the study reported having completed at least some college.
Diabetes Family Responsibility Questionnaire (DFRQ). Anderson et al. (1990) developed the DFRQ, a self-report questionnaire designed to measure parental involvement in diabetes care. The measure yields a total score and three subscale scores. The General Health Maintenance (DFRQgh) subscale includes such items as noticing changes in weight and remembering the day of clinic appointments. The Regimen Tasks subscale (DFRQr) concerns giving insulin, noticing the signs of an insulin reaction, and remembering to check blood sugar levels. The Social Presentation subscale (DFRQsoc) includes items related to telling friends and teachers about diabetes and explaining absences from school. Each item on the DFRQ asks participants to identify who takes responsibility for a given task. Items are rated using the following scale: Child takes responsibility (1), parent and child share responsibility (2), or parent takes responsibility (3). Higher scores indicate that parents take more responsibility for diabetes tasks than children. Subscale scores are computed by calculating the mean of participants' responses on the items that constitute the subscale and the total score is computed by calculating the mean of all of the items. Anderson et al. (1990) found the DFRQ to be reliable (a = .84 for the 17-item scale) and to have concurrent validity with the independence subscale of the Moos Family Environment Scale (1986), r = .27, p < .01 (Anderson et al., 1990). We replicated Anderson et al.'s (1990) internal consistency findings for DFRQ total scores (a = .84 for parents, a = .80 for children) and checked the internal consistency of the subscales (DFRQgh a = .73 parent, a = .58 child; DFRQsoc a = .59 parent, a = .43 child; DFRQr a = .63 parent, a = .60 child). Internal consistencies were probably lower for subscales than for the total scale because subscales consist of only three or four items.
Research coordinators reviewed medical records of all children/adolescents who attended the Joslin Clinic between 1994 and 2000 to determine who might be eligible. They then approached eligible families at their next appointment at the clinic. Questionnaires were given to families at enrollment or during their next visit to the clinic. Research coordinators explained that no harm was likely to result from filling out the questionnaires but that families were free to skip any questions that made them uncomfortable. In addition, research coordinators explained that families were free to terminate participation in the study at any time. Parents and children/adolescents completed the questionnaires in the waiting room of the Joslin Clinic. Five of the younger children who participated in the study were not confident in their reading skills, so research coordinators read the questions aloud for these children.
In order to test our hypotheses, we conducted a 2(sex, between subjects) x 3(age group, between subjects) x 2(parent as compared with child, within subjects) ANOVA on the DFRQ total and subscale scores. We designed our analysis this way because Anderson et al. (1990) explain that, in order to assess how parents and children perceive the manner in which they work together on diabetes care tasks, data interpretation requires both within- and between-subject analyses. In addition, previous research (Anderson et al., 1990, 1997; Hanson et al., 1995; Wysocki et al., 1996) indicates that parental involvement in diabetes care tasks tends to drop off as children enter adolescence. Based on previous research (Anderson et al., 1999), we categorized children into three age groups: group one (eight-10 years, n = 32), group two (10-12 years, n = 46) and group three (13-17 years, n = 26).
Contrary to our hypothesis, there was no main effect for child gender. Interestingly, however, we found a gender by parent/child interaction effect on the DFRQr. The DFRQr measures perceptions of cooperation on diabetes-related tasks such as remembering to take insulin, noticing the signs of low blood sugar, injecting insulin, carrying fast-acting carbohydrates in case of low blood sugar, rotating injection sites, and remembering when to check blood sugars. We discovered a statistically significant child-gender difference in discrepancies between parent perceptions of children's self-reliance and child reports of self-reliance for diabetes tasks, F(1,98) = 4.45, p <.05, M boys = 1.80, SD = .39, M boys' parents = 2.05, SD = .38, M girls = 1.87, SD = .45, M girls' parents = 1.97, SD = .42. In order to specify the direction in which this interaction effect was located, we conducted a within-subjects ANOVA, which revealed that boys reported taking significantly more responsibility for diabetes care tasks than their parents said they did, F(1,54) = 20.28, p <.01, while the difference between girls' self-reports and their parents' reports was not significant.
In addition to these findings, we found a main effect for age F(2,98) = 48.00, p <. 01, and a main effect for parent/child discrepancies F(1,98) = 37.27, p <.01. Our results replicated Anderson et al.'s (1997) finding that families of older children report less parental involvement with diabetes tasks than do families of younger children; parents of younger children provide more help than parents of older children. In addition, children reported greater self-reliance for diabetes care tasks than their parents (M children = 2.02, SD = .33, M parents = 2.22, SD = .32). Consistent with total scores on the DFRQ, we found main effects for parent/child discrepancies on the DFRQr, F (1, 98) = 13.64, p < .01, the DFRQsoc, (1,98) = 13.64,p <.05, and the DFRQgh scales, F(1,98) = 13.64, p <.05. There were no significant interaction effects for gender on the DFRQsoc or DFRQgh scales.
In this study we explored whether there are gender differences in the manner in which boys and girls with Type 1 diabetes report self-reliance for diabetes tasks. We found that, although there were no differences between boys and girls on the DFRQ total score or any of the subscale scores, there were significant differences between boys' self-reports of self-reliance for diabetes tasks and their parents' reports. That is, boys reported more self-reliance for diabetes tasks than did their parents while there were no differences between girls' self-reports and their parents' reports. It is possible that, in an effort to appear independent, boys tend to over-report or exaggerate their level of self-reliance for these concrete tasks. Still, our findings should be interpreted with caution as we found gender differences in only one interaction effect in a series of analyses.
We did not find significant between-group differences in self-reports of boys and girls. Indeed, girls and boys reported similar levels of self-reliance for their diabetes care.
This study represents a first attempt to explore correlates of gender and selfreliance for diabetes care. Further study is necessary to learn more about the conditions that might lead boys to report more self-reliance for diabetes tasks than do their parents. Results from this study suggest only a perceptual difference between the level of self-reliance for diabetes tasks that boys perceive in themselves and the level their parents report. The study design prohibits commentary on what might have caused this discrepancy. In addition, no conclusions can be drawn at this time as to the significance of these findings for health-care behaviors or metabolic control. Future research should focus on the possible causes of the perceptual discrepancies and their impact on health. For example, future researchers might attempt to correlate the degree to which children value self-reliance with self-reliance for diabetes tasks. Alternatively, a future study that tracks the youth in this study as they enter adulthood might illuminate whether boys who report higher levels self-reliance for diabetes tasks become more isolated and independent in their diabetes care in adulthood. Future research might also examine whether it is possible to alter expectations about sharing responsibility for diabetes care tasks.
Anderson, B.J., Auslander, W.F., Jung, K.C., Miller, P., & Santiago, J.V. (1990). Assessing family sharing of diabetes responsibilities. Journal of Pediatric Psychology, 15, 477-492.
Anderson, B.J., Brackett, J., Ho, J., & Laffel, L.M.B. (1999). An office-based intervention to maintain parent-adolescent teamwork in diabetes management. Diabetes Care, 2, 713-721.
Anderson, B., Ho, J., Bracket, J., Finkelstein, D, & Laffel, L. (1997). Parental involvement in diabetes management tasks: Relationships to blood glucose monitoring adherence and metabolic control in young adolescents with insulindependent diabetes mellitus. Journal of Pediatrics, 130, 257-265.
Bergman, S. (1995). Men's psychological development: A relational perspective. In R.F. Levant & W.S. Pollack (Eds.), A new psychology of men (pp. 68-90). New York: Basic Books.
Courtenay, W.H. (2000). Constructions of masculinity and their influence on men's well-being: A theory of gender and health. Social Science and Medicine, 50, 1385-1401.
Department of Health and Human Services. (1997). Report of final mortality statistics, 1995. Monthly vital statistics report, 45(11). Hyattsville, MD: Public Health Service.
Department of Health and Human Services. (1998). Health, United States, with socioeconomic status and health chartbook. Hyattsville, MD: National Center for Health Statistics.
Hanson, C.L., DeGuire, M.J., Schinkel, A.M., & Kolterman, O.G. (1995). Empirical validation for a family-centered model of care. Diabetes Care, 18, 1347-1356.
Helgeson, V.S. (1995). Masculinity, men's roles, and coronary heart disease. In D. Sabo & D.F. Gordon (Eds.), Men's health and illness: Gender, power and the body (pp. 68-104). Thousand Oaks, CA: Sage.
Hollingshead, A.B. (1957). Four factor index of social status. Unpublished manuscript. New Haven, CT: Yale University.
Levant, R.F. (1995). Toward the reconstruction of masculinity. In R.F. Levant & W.S. Pollack (Eds.), A new psychology of men (pp. 229-251). New York: Basic Books.
Moos, R.H. (1986). Family environment scale manual. Palo Alto, CA: Consulting Psychologist Press.
Pollack, W. (1998). Real boys: Rescuing our sons from the myths of boyhood. New York: Random House.
Stillion, J.M. (1995). Premature death among males. In D. Sabo & D.F. Gordon (Eds.), Men's health and illness (pp. 46-67). Thousand Oaks: Sage.
Tudiver, F., & Talbot, Y. (1999). Why don't men seek help? Family physicians' perspectives on help-seeking behavior in men. Journal of Family Practice, 48, 4752.
Waldron, I. (1995). Contributions to changing gender differences in behavior and social roles to changing differences in mortality. In D. Sabo & D.F. Gordon (Eds.), Men's health and illness (pp. 68-104). Thousand Oaks: Sage.
Wysocki, T., Taylor, A., Hough, B.S., Linscheid, T.R., Yeates, K.O., & Naglieri, J.A. (1996). Deviation from developmentally appropriate self-care autonomy. Diabetes Care, 19, 119-125.
This project was supported in part by grant R01 DK-46887 from the National Institute of Diabetes, Digestive, and Kidney Diseases.
Correspondence concerning this article should be addressed to Abigail K. Mansfield, Department of Psychology, Clark University, 950 Main Street, Worcester, MA 10610. Electronic mail: email@example.com
ABIGAN K. MANSFIELD MICHAEL E. ADDIS Clark University
LORI M.B. LAFFEL BARBARA J. ANDERSON Joslin Diabetes Center, Boston