**3. The family support in adherence to self-care**

ence their adherence to self-care. This set of emotions may also hinder the behaviors neces‐

A chronic condition, such as diabetes, implies a permanent process of compliance with selfcare in order to minimize the effects of its progression and, as a result, is often associated with lower therapeutic adherence [14, 49, 53, 54]. The methods aimed at increasing the suc‐ cess of therapeutic adherence can be classified into four main groups: 1) patient education; 2) existing communication between healthcare professionals and patient; 3) dosage and type of drugs and 4) the accessibility of health services to attend the patient [55]. However, evi‐ dence showed that through a multidisciplinary approach comprising educational and be‐ havioral interventions, treatment adherence rates can significantly improve, when compared to the strategies that use each intervention separately [56, 57]. So, taking in con‐ sideration the different variables that contribute to noncompliance, it is fundamental to con‐ sider a multifactorial approach, to the extent that a single approach will not successfully

Adherence to diabetes self-care involves a complex set of daily behaviors that require the frequent monitoring of blood glucose, insulin administration, recommendations about nutri‐ tion and physical exercise [58] as well as making changes and adjustments whenever one of these factors changes [47, 59]. Therefore, the complexity of self-care behaviors may explain low adherence rates and may lead to significant suffering, although compliance significantly reduces the incidence and progression of associated complications [60-62]. Positive out‐ comes regarding adherence may be related to how each adolescent interprets, learns and draws conclusions regarding the meaning of the disease and its treatment [17]. However, some adolescents with diabetes may lie about their self-care behaviors to avoid being repri‐

Good adherence to self-care, in adolescents, may be explained by feelings of social accept‐ ance, distorted or optimistic perception of their behavior or by minimizing the importance of strict compliance with the treatment [51, 65]. On the other hand, non-adherence may be related to specific psychosocial characteristics of adolescent's developmental phase [15, 43, 47, 50, 58]. Peer pressure and fear of a negative reaction from the group can lead to loss of support from colleagues, thus increasing the risk of diabetes complications [58]. The de‐ mands associated with self-care does not facilitate the adolescent's growing desire for au‐ tonomy and both diabetes and its treatment may result and be perceived as limitations in

Whereas the responsibility for diabetes self-care increases with adolescent's age, compliance follows in the opposite direction, indicating that adolescents show better adherence when they are more in tune with the guidelines and values of their parental figures [50, 66, 68, 69]. In fact, in the late adolescence stage, older adolescents show a greater concern with the body, sexuality and with independence from parents and authority figures what may ex‐ plain poor results regarding adherence compared to younger adolescents [50, 65, 70-72].

The increase of emotional distress and autonomy and less acceptance of diabetes, due to a higher awareness of the impact of diabetes on the adolescent's identity and psychosocial de‐

sary for adherence to treatment [51, 52].

448 Type 1 Diabetes

improve patients' adherence to treatment [55].

manded by their parents or physician [63, 64].

physical activities, and one's lifestyle [44, 66, 67].

Family impacts on its members' health and the opposite is also true [82]. Family support consists of the individual perception regarding the availability and the caregiving received from their family that allows the development of greater resilience and psychological wellbeing in the face of stress-inducing events [83-85]. Family support is a complex multidimen‐ sional concept associated with the individual's mental health and in direct relation to support received from family members [84, 86, 87]. Hence, family support relates to the be‐ haviors of affection, sensitivity, cooperation and trust, encouraging the autonomy and inde‐ pendence amongst family members [86].

There are numerous types and qualities of support available to families: tangible family sup‐ port, such as actions that cause well-being among family members; family emotional sup‐ port, which has to do with empathy, listening, and attention to family members giving advice, which is vital in moments of great difficulties and important decision-making [86, 88]. However, the perception of family support is influenced by personal factors, stable traits and intrinsic changes, in each person, over time [86, 88].

The perception of high levels of family support is associated with a positive disposition [89] and, as a result, when family support is positively perceived, feelings of well being within the family members are promoted [86].

The concept of family support can also be defined as a part of one's informal and close rela‐ tionship network, benefiting the individual with the exchanges among family members [85]. In this sense, the individual develops greater resilience and psychological well-being, that enables the development of more adjusted responses to stress-inducing events that are closely related to a better coping with a chronic disease [85, 90, 91]. Therefore, it is necessary for family dynamics to show a set of fundamental aspects which favor the development of family support among its members, such as: 1) congruent, directional, functional and emo‐ tional communication; 2) consistent and flexible rules; 3) democratic leadership shared with the offspring; 4) self-esteem, 5) integrated couple's relationship, allowing the family to act as a whole but ensuring each individual's personality [92]. The accomplishment of these func‐ tions, in association with the perception of the family as loving, cohesive and with clear boundaries, provides members with important tools for individual growth as well as pro‐ viding its members with a support system [92].

Regarding diabete's treatment, parents are considered the major providers of social support, even more than peers. Those adolescents, whose parents are less involved and therefore less supportive, show lower adherence to self-care behaviors [70, 102, 103]. The existence of good communication, good skills for an effective resolution of problems and conflicts and flexibil‐ ity among family members are essential conditions for the adolescent to effectively adapt to the demands of diabetes [17]. Therefore, parental support is positively associated with ado‐ lescents' adherence to the prescribed therapeutic regimen [98, 104-106]. In a study involving adolescents with diabetes, a higher family support was a good indicator of adherence to self-care, suggesting the influence that perceived family support has on the implementation and management of diabetes in the daily life of adolescents [107]. In fact, family support ap‐ pears to have a direct effect on adolescents' adherence to self-care through direct parental supervision on self-care activities. The authors found family support to be a moderator be‐ tween adolescents' adherence to self-care and quality of life i.e. when family support was high, a positive relationship between adherence and quality of life was found [108]. Howev‐ er, the adolescent may sometimes perceive family support as invasive [109, 110]. In fact, dia‐ betes may modify the process of adolescent's development and family dynamics, and the psychosocial tasks of progressively acquiring autonomy and independence, on the part of the adolescent, may be affected. Therefore, the family's challenge relies on allowing the ado‐ lescent to acquire independence with the consequent constraints associated with diabetes,

The Influence of Family Support, Parental Coping and School Support on Adherence to Type 1 Diabetes' Self-Care in

Adolescents

451

http://dx.doi.org/10.5772/53062

Given the specific tasks and behaviors in managing diabetes self-care, family support was significantly higher among younger children and in those where the disease was more re‐

Diabetes requires from the adolescent, family and health professionals a set of efforts in or‐ der to achieve a good metabolic control and reduce future complications [112]. Family's par‐ ticipation and collaboration play an important role when it comes to ensure the well-being

Coping is related to efforts, whether cognitive or behavioral, used by the individual to face internal or external demands caused by a specific stress-inducing situation [113, 114]. Cop‐ ing also implies a dynamic process depending on individual differences and circumstances

Given that coping is a changing process, the individual is not limited to a single coping strategy, since changes will occur resulting from the assessment of stressful situations [116-118]. For this reason, the individual can begin the process by using a strategy and later keep the same strategy, change it or use a combination of different strategies, as the relation‐

Coping strategies represent actions, thoughts or behaviors to cope with a stress-inducing event that may, according to their function, be subdivided into two types: emotion-focused

without being super-protective [111].

of the adolescent with diabetes [111].

occurring throughout life [115-117].

ship with the environment changes [119, 120].

**4. Adherence to self-care and parental coping**

cently diagnosed [70, 82].

In situations of chronic disease, family support proves to be an important resource in selfcare behaviors for adolescent, with a direct correlation between the perception of family support and an increased motivation for self-care behaviors and health in general [82, 90, 93]. This support appears to be of greatest importance in children and adolescents who ex‐ perience high levels of stress due to a chronic condition and may also affect their develop‐ ment and the quality of their social relationships within their family system [94-96]. However, on one hand, some families become so close that its members are attached, in a way that may affect the autonomy of the patient and, on the other hand, there are families who may become more distant due to the strain that the disease imposes on the family [82]. Within this perspective, a family providing support, affection, guidance and adjusted strat‐ egies to solve problems, establishes and promotes best conditions for adherence to self-care, evidencing its responsibility in sharing diabetes' self-care activities with the adolescent [14, 97]. In fact, the family is the main source of support in chronic disease, whether through tan‐ gible support, such as preparing meals, administering the medication and in the daily care or through emotional and social support ([82, 90]. Both family and friends influence the con‐ trol of diabetes, regarding compliance with the medical treatment, diet and the practice of physical exercise [98, 99].

Family support represents an important factor in understanding treatment adherence in adolescents with type 1 diabetes, helping the adolescent to adapt to the demands of the dis‐ ease and consequently to diabetes self-care. A low family support is a good predictor of poor adherence to self-care in diabetes [73, 100, 101].

Family organization significantly affects family health behaviors in the same way that indi‐ vidual's health also affects the family. Therefore, the family is a resource of strategic impor‐ tance, since it may or may not help the adolescent with diabetes to properly manage the disease and to achieve treatment's goals [90]. Family support entails emotional and behavio‐ ral benefits for its members and is therefore, a reciprocal and proactive process with both parties benefiting from its positive effects, which are particularly important in adolescents who experience high levels of stress, such as in the process of a chronic disease [94, 99]. In the case of diabetes, a direct relationship between family support, characteristics of adoles‐ cents with diabetes and therapeutic adherence has been found [70, 82]. The family can act as a support unit for the adolescent's daily self-care tasks, such as motivating physical activity and compliance with the nutrition plan and encouraging insulin administration, after receiv‐ ing proper guidance, [71, 90].

Regarding diabete's treatment, parents are considered the major providers of social support, even more than peers. Those adolescents, whose parents are less involved and therefore less supportive, show lower adherence to self-care behaviors [70, 102, 103]. The existence of good communication, good skills for an effective resolution of problems and conflicts and flexibil‐ ity among family members are essential conditions for the adolescent to effectively adapt to the demands of diabetes [17]. Therefore, parental support is positively associated with ado‐ lescents' adherence to the prescribed therapeutic regimen [98, 104-106]. In a study involving adolescents with diabetes, a higher family support was a good indicator of adherence to self-care, suggesting the influence that perceived family support has on the implementation and management of diabetes in the daily life of adolescents [107]. In fact, family support ap‐ pears to have a direct effect on adolescents' adherence to self-care through direct parental supervision on self-care activities. The authors found family support to be a moderator be‐ tween adolescents' adherence to self-care and quality of life i.e. when family support was high, a positive relationship between adherence and quality of life was found [108]. Howev‐ er, the adolescent may sometimes perceive family support as invasive [109, 110]. In fact, dia‐ betes may modify the process of adolescent's development and family dynamics, and the psychosocial tasks of progressively acquiring autonomy and independence, on the part of the adolescent, may be affected. Therefore, the family's challenge relies on allowing the ado‐ lescent to acquire independence with the consequent constraints associated with diabetes, without being super-protective [111].

Given the specific tasks and behaviors in managing diabetes self-care, family support was significantly higher among younger children and in those where the disease was more re‐ cently diagnosed [70, 82].

Diabetes requires from the adolescent, family and health professionals a set of efforts in or‐ der to achieve a good metabolic control and reduce future complications [112]. Family's par‐ ticipation and collaboration play an important role when it comes to ensure the well-being of the adolescent with diabetes [111].
