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Diabetes Care 28:2034-2035, 2005
© 2005 by the American Diabetes Association, Inc.

Emerging Treatments and Technologies
Brief Report

Diabetes Self-Management Profile for Flexible Insulin Regimens

Cross-sectional and longitudinal analysis of psychometric properties in a pediatric sample

The Diabetes Research in Children Network (DirecNet) Study Group*

Address correspondence and reprint requests to Tim Wysocki, PhD, DirecNet Coordinating Center, Jaeb Center for Health Research, 15310 Amberly Dr., Suite 350, Tampa, FL 33647. E-mail: direcnet{at}jaeb.org

Abbreviations: DirectNet, Diabetes Research in Children Network • DSMP, Diabetes Self-Management Profile • DSMP-F Diabetes Self-Management Profile for flexible regimens • GW2B, GlucoWatch G2 Biographer


   INTRODUCTION
TOP
 INTRODUCTION
RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 APPENDIX
 REFERENCES
 
Available measures of diabetes treatment adherence (1–5) are typically based on measuring deviation from a prescribed regimen and cannot readily capture problem solving and self-regulation that typify modern regimens. Measurement of diabetes self-management must accommodate these advances in therapy.

The Diabetes Self-Management Profile (DSMP), a previously validated, structured interview assessment of adherence in type 1 diabetes (6–8) was modified by the Diabetes Research in Children Network (DirecNet) research group and the authors of the DSMP to construct the DSMP for Flexible regimens (DSMP-F). This study evaluates the psychometric properties of the DSMP-F both cross-sectionally and longitudinally. Data were obtained from youths with type 1 diabetes and their parents during a DirecNet Study Group trial of the GlucoWatch G2 Biographer (GW2B; Cygnus, Redwood City, CA) (9).


   RESEARCH DESIGN AND METHODS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
RESULTS
 CONCLUSIONS
 APPENDIX
 REFERENCES
 
The randomized trial included 200 youths with type 1 diabetes who were enrolled at five centers; the methodological details have been published previously (9). Each child was randomized to GW2B use or usual care. Diabetes management in both groups was similar, except for use of the GW2B. Within the sample, 161 youths were treated using flexible insulin regimens (93 on insulin pumps and 68 on "basal-bolus" regimens). HbA1c (A1C) was measured at baseline and after 3 and 6 months at the DirecNet central laboratory.

The DSMP-F interview quantifies adherence to the prescribed regimen and self-management behaviors such as remediation or prevention of unwanted glucose excursions through adjustment of insulin, diet, or exercise. Four DSMP diet items were reworded to be more consistent with dietary management using carbohydrate counting and insulin adjustment based on carbohydrate-to-insulin ratios. Two trained interviewers completed the 15- to 20-min DSMP-F interview by telephone separately with parents and children ≥11 years of age and jointly with parents and children <11 years of age at baseline and after 6 months. Higher scores reflect more meticulous self-management. Analyses for this report were limited to DSMP total scores.


   RESULTS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
CONCLUSIONS
 APPENDIX
 REFERENCES
 
Table 1 presents descriptive statistical analyses of the DSMP-F (n = 161 parents and 117 adolescents). Total scores (means ± SD) were virtually identical for parents (62.7 ± 8.7) and adolescents (62.7 ± 7.0). There were no significant between-group differences in baseline DSMP-F total scores for parents (62.0 ± 8.6 and 63.5 ± 8.8 for GW2B and usual care, respectively) or adolescents (63.5 ± 6.4 and 61.8 ± 7.4 for GW2B and usual care, respectively). These scores indicate mean adherence scores of 73% of the maximum DSMP total score (86), suggesting that overreporting of adherence was unlikely.


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  		Table 1— Raw scores for each DSMP-F subscale and total obtained from 161 parents and 117 youths ≥11 years of age

 
Internal consistency (Cronbach’s {alpha} coefficient) for the DSMP-F total score, with the GW2B and usual care groups combined, was 0.69 for parents and 0.47 for adolescents at baseline and 0.70 for parents and 0.65 for adolescents at 6 months. The {alpha} coefficient obtained in the earlier DSMP study (6) was 0.76 for parents and for youths. Among the 117 parent-adolescent pairs who were both interviewed with the DSMP-F, parent and adolescent DSMP total scores correlated (0.59, P < 0.001). Test-retest reliability of the DSMP-F (Pearson correlations between baseline and 6-month scores) were similar in the usual care (parents r = 0.73, P < 0.001; adolescents r = 0.42, P = 0.002) and GW2B (parents r = 0.71; adolescents r = 0.51; both P < 0.001) groups.

Compared with the prior study (6), associations of the total score with A1C were similar in this study (r = –0.20 vs. –0.28). The present study enrolled a more selected sample of patients that were in better glycemic control and were well motivated to improve their diabetes self-management. These characteristics might decrease variability in DSMP-F scores and A1C, reducing the magnitude of statistical associations. Changes in DSMP-F total scores from parents or adolescents were not correlated significantly with change in A1C over the 6-month study (P = 0.79 and 1.00, respectively).


   CONCLUSIONS
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
APPENDIX
 REFERENCES
 
The present study yielded substantial psychometric data on the DSMP-F, including descriptive data obtained from a multicenter sample that can be used for comparison with DSMP-F scores obtained in future studies. The modest internal consistency estimates may indicate that the DSMP-F measures several independent dimensions of diabetes self-management behavior, as has been shown by others (10, 11), and thus, a high {alpha} coefficient would not be expected.

This work extends the previous validation of the DSMP-F by evaluating an adapted interview protocol appropriate for patients treated with flexible insulin regimens. Further research could compare the interview procedure with varied modes of data collection such as questionnaires, hand-held computers, or automated interactive telephone interview methods. Examination of the psychometric properties of the DSMP when administered to adult patients would be another valuable contribution.


   APPENDIX
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 APPENDIX
REFERENCES
 
DirecNet Study Group Writing Committee
Tim Wysocki, PhD, ABPP; Dongyuan Xing, MPH; Rosanna Fiallo-Scharer, MD; Elizabeth A. Doyle, MSN; Jennifer M. Block, RN, CDE; Eva Tsalikian, MD; Roy W. Beck, MD, PhD; Katrina J. Ruedy, MSPH; Craig Kollman, PhD; Michael Harris, PhD; and William V. Tamborlane, MD.


   Acknowledgments
 
This research has been supported by National Institutes of Health/National Institute of Child Health and Human Development Grants HD041919-01, HD041915-01, HD041890, HD041918-01, HD041908-01, and HD041906-01 and by Nemours Research Programs.

The GlucoWatch G2 Biographers were purchased from Cygnus at a discounted price.

Alexandra Taylor, MACP, and Amy Milkes, MA, of Nemours Children’s Clinic completed all interviews of participants in this study.

Portions of these data were previously published as an abstract in Diabetes [53 (Suppl. 2): A436, 2004] and presented at the Scientific Sessions of the American Diabetes Association in Orlando, Florida, 4–8 June 2004.


   Footnotes
 
* A complete list of DirecNet Study Group members can be found in ref. 9. The writing committee for this article can be found in the APPENDIX. Back

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

Received for publication December 2, 2004. Accepted for publication May 11, 2005.


   REFERENCES
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS
 RESULTS
 CONCLUSIONS
 APPENDIX
 REFERENCES
 

  1. Greco P, LaGreca AM, Auslander WF, Spetter D, Skyler JS, Fisher EB, Santiago JV: Assessing adherence in IDDM: a comparison of two methods (Abstract). Diabetes 39:165A, 1990
  2. Schafer LC, Glasgow RE, McCaul KD, Dreher M: Adherence to IDDM regimens: relationship to psychosocial variables and metabolic control. Diabetes Care 6:493–498, 1983[Abstract]
  3. Johnson SB, Silverstein J, Rosenbloom A, Carter R, Cunningham W: Assessing daily management of childhood diabetes. Health Pscyhol 5:545–564, 1986
  4. Hanson CL, Henggeler SW, Burghen GA: Social competence and parental support as mediators of the link between stress and metabolic control in adolescents with insulin-dependent diabetes mellitus. J Consult Clin Psychol 55:529–533, 1987[Medline]
  5. Wysocki T, Green L, Huxtable K: Blood glucose monitoring by diabetic adolescents: Compliance and metabolic control. Health Pscyhol 8:267–284, 1989
  6. Harris MA, Wysocki T, Sadler M, Wilkinson K, Harvey LM, Buckloh LM, Mauras N, White NH: Validation of a structured interview for the assessment of diabetes self-management. Diabetes Care 23:1301–1304, 2000[Abstract/Free Full Text]
  7. Wysocki T, Harris MA, Wilkinson K, Sadler M, Mauras N, White NH: Self-management competence as a predictor of outcomes of intensive therapy or usual care for children with type 1 diabetes. Diabetes Care 26:2043–2047, 2003[Abstract/Free Full Text]
  8. Wysocki T, Harris M, Buckloh L, Mertlich D, Lochrie A, Mauras N, White NH: Randomized trial of behavioral family systems therapy for adolescents with diabetes: effects on diabetes outcomes (Abstract). Diabetes 53(Suppl. 2):A19, 2004
  9. Diabetes Res in Children Network (DirecNet) Study Group: A randomized multicenter trial comparing the GlucoWatch Biographer with standard glucose monitoring in children with type 1 diabetes. Diabetes Care 28:1101–1106
  10. Johnson SB: Managing insulin-dependent diabetes in adolescence: a developmental perspective. In Advances in Pediatric Psychology: Adolescent Health Problems; Behavioral Perspectives. Wallander S, Siegel LJ, Eds. New York, Guilford Press, 1995, p.265–288
  11. Glasgow RE, McCaul KD, Schafer LC: Self-care behaviors and glycemic control in type 1 diabetes. J Chronic Dis 40:399–412, 1987[Medline]

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