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10 girls and 10 boys who were 15–18 years of age and had had diabetes for >1 year were identified by diabetes specialist nurses (n=15), by a general practitioner (n=1), from a magazine advertisement (n=1), and through snowball sampling (n=3). Most were white and all social classes were represented. The mothers of these 20 adolescents also participated.
Adolescents and their mothers were interviewed separately in their homes. The semistructured conversations were guided by prompts relating to treatment, stigma, and gender issues of living with diabetes. Interviews were taped, transcribed, and coded using a system of open coding to develop conceptual categories.
Girls and boys differed in the meanings that diabetes held for them and the degree to which they incorporated diabetes into their identities. Whereas all of the girls perceived diabetes as very important and had incorporated it into their identities, almost all of the boys tended to dismiss diabetes and chose to manage it by making it a minimal part of their lives.
Although most clinics that the adolescents attended recommended 4 daily insulin injections (for greater flexibility and potentially better control of blood glucose levels), there was a marked difference in the number of daily injections given by girls and boys. Most of the girls were on a regimen of either 3 or 4 injections each day and felt comfortable injecting themselves in public settings. In contrast, the boys chose a regimen of only 2 or 3 injections each day, which enabled them to manage their diabetes at home and in private. In this way, boys were able make their diabetes publicly invisible and could avoid the perceived stigma attached to the illness.
Most of the girls, with encouragement from health professionals, had taken responsibility for their own care. Boys, on the other hand, had the practical and emotional support of their mothers, who acted as “alert assistants”; this support enabled the boys to manage diabetes by “passing” or dismissing their illness.
With the help of their mothers and a strict routine, 9 of the 10 boys maintained good control of their diabetes. In contrast, many of the mothers and their daughters agreed that the girls had only moderate control. Because they were more responsible for self care, and because they were on the more flexible regimen of 4 insulin injections per day, many girls extended this flexibility into potentially harmful non-adherence. Several girls reported intentional periods of stopping their medication for varying lengths of time, which was unknown to their mothers and healthcare providers. Because of the high expectations placed on the girls by themselves and by others to be independent, they seemed reluctant to ask for support.
Adolescent girls and boys differed in how they managed their illness and how they incorporated diabetes into their identities. Girls tended to assimilate diabetes into their identities, and take responsibility for managing it. Boys tended to minimise the role of diabetes in their lives and managed it in private with the support of their mothers.
The study by Williams provides an indepth view of self management of diabetes during adolescence and suggests possible differences in how girls and boys manage their disease. This finding seems consistent with other studies that have been done both with adolescents and with adults.1 Much of the research to date, however, suggests that gender is probably only one of many factors that might influence diabetes self management, and so caution is advised when applying these findings to nursing practice. Beyond gender, it seems likely that ethnicity and socioeconomic status might play an important role in shaping diabetes self management, and research also seems to point to such influences as the relationship with health professionals, perceptions of self efficacy, and social norms as being important.2 Nevertheless, this study helps us to appreciate how little is currently known about personal models of diabetes and the effect they have on how individuals self manage their disease.
This study offers nurses some direction for understanding the possible influence of gender on diabetes self management among adolescents, and therefore gives some direction for providing psychosocial support to those living with the disease and their parents. It highlights the dichotomy that is created between encouraging compliance about disease management at the same time that the culture is encouraging increasing independence among young people, and it considers the effect that this social climate may have on their illness careers. It also suggests that there may be some advantages to tailoring the structures and strategies of diabetes education and support in order to meet the different needs of adolescent boys and girls.
Source of funding: no external funding.
For correspondence: Dr C Williams, Social Science Research Unit, Institute of Education, University of London, 18 Woburn Square, London WC1H 0NS, UK. Fax +44 (0)20 7612 6400.
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