Type 2 Diabetes Nursing SPSS Logistic Regression

Type 2 Diabetes Nursing SPSS Logistic Regression ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Type 2 Diabetes Nursing SPSS Logistic Regression Logistic regression is used to analyze a wide variety of variables that may surround a singular outcome. For example, logistic regression could be used to identify the likelihood of a patient having a heart attack or stroke based on a variety of factors including age, sex, genetic characteristics, weight, and any preexisting health conditions. The biological systems and issues with which the health care field is concerned represent the kinds of applications for which logistic regression is especially useful. Type 2 Diabetes Nursing SPSS Logistic Regression Logistic regression is used in the health care field for many purposes, including diagnoses, predictions, and forecasting. The three articles in this week’s Learning Resources illustrate the many uses of logistic regression in the health care field. This Discussion allows you to explore the different uses of logistic regression and cultivate a deeper understanding of the application of logistic regression in evidence-based practice. To prepare: Review the three articles in this week’s Learning Resources and evaluate their use of logistic regression. Select one article that interests you to examine more closely in this Discussion Critically analyze the article you selected considering the following questions: What are the goals and purposes of the research study the article describes? How is logistic regression used in the study? What are the results of its use? What other quantitative and statistical methods could be used to address the research issue discussed in the article? What are the strengths and weaknesses of the study? How could the weaknesses of the study be remedied? How could findings from this study contribute to evidence-based practice, the nursing profession, or society? attachment_1 attachment_2 attachment_3 attachment_4 NIH Public Access Author Manuscript Res Nurs Health. Author manuscript; available in PMC 2010 August 1. NIH-PA Author Manuscript Published in final edited form as: Res Nurs Health. 2009 August ; 32(4): 405–418. doi:10.1002/nur.20336. Effects of Coping Skills Training in School-age Children with Type 1 Diabetes Margaret Grey, DrPH, RN, FAAN[Dean and Annie Goodrich Professor], Yale School of Nursing, New Haven, CT Robin Whittemore, PhD, APRN[Associate Professor], Yale School of Nursing Sarah Jaser, PhD[Post-doctoral Associate], Yale School of Nursing Jodie Ambrosino, PhD[Clinical Instructor], Department of Pediatrics, Yale School of Medicine NIH-PA Author Manuscript Evie Lindemann, LMFT, ATR[Assistant Professor], Albertus Magnus College, New Haven, CT Lauren Liberti, MS[Trial Coordinator], Yale School of Nursing Veronika Northrup, MPH, and Yale Center for Clinical Investigations, New Haven, CT James Dziura, PhD Yale Center for Clinical Investigations, New Haven, CT Abstract NIH-PA Author Manuscript Children with type 1 diabetes are at risk for negative psychosocial and physiological outcomes, particularly as they enter adolescence. The purpose of this randomized trial (n=82) was to determine the effects, mediators, and moderators of a coping skills training intervention (n=53) for school-aged children compared to general diabetes education (n=29). Both groups improved over time, reporting lower impact of diabetes, better coping with diabetes, better diabetes self-efficacy, fewer depressive symptoms, and less parental control. Treatment modality (pump vs. injections) moderated intervention efficacy on select outcomes. Findings suggest that group-based interventions may be beneficial for this age group. Keywords coping skills training; child; type 1 diabetes Effects of Coping Skills Training in School-age Children with Type 1 Diabetes Type 1 diabetes (T1D) is one of the most common severe chronic illnesses in children, affecting 1 in every 400 individuals under the age of 20, over 176,000 American youth Corresponding Author: Robin Whittemore, Yale School of Nursing, 100 Church Street South, New Haven, CT 06536-0740, [email protected]. Grey et al. Page 2 NIH-PA Author Manuscript (National Institute of Diabetes and Digestive and Kidney Disease, 2002). Diabetes is the seventh leading cause of death in the United States, and adults with T1D are twice as likely to die prematurely from complications compared to adults without T1D National Institute of Diabetes and Digestive and Kidney Disease, 2007). Management of T1D is demanding, requiring frequent monitoring of blood glucose levels, monitoring and controlling carbohydrate intake, daily insulin treatment (3-4 injections/day or infusion from a pump), and adjusting insulin dose to match diet and activity patterns (American Diabetes Association, 2008). Such an intensive treatment regimen and maintenance of near-normal glycemic control may delay or prevent long-term complications of T1D by 27-76% (Diabetes Control and Complications Trial [DCCT] Research Group, 1994). Interventions are needed to assist children and families in coping with the considerable demands of living with T1D. Type 2 Diabetes Nursing SPSS Logistic Regression The purpose of this study was to evaluate the efficacy of a coping skills training (CST) intervention, specific to school-aged children and their parents, on metabolic control and psychosocial outcomes, and to examine mediators and moderators of these outcomes. NIH-PA Author Manuscript Tasks of childhood development can compromise diabetes management. Metabolic control declines during adolescence (Travis, Brouhard, & Schreiner, 1987). Although the physiological changes of puberty contribute to insulin resistance, a premature transfer of responsibility for diabetes-related tasks from parents to children also may result in poor adherence and metabolic control (Anderson, Ho, Brackett, Finkelstein, & Laffel, 1997; Holmes et al., 2006; Schilling, Knafl, & Grey, 2006). As children enter adolescence and strive for autonomy, parents’ attempts to monitor or control their child’s treatment may be viewed as intrusive or nagging, which may result in adolescents becoming resistant, defiant, and noncompliant (Berg et al., 2007; Cameron et al., 2008; Weinger, O’Donnell, & Ritholz, 2001). Low levels of family support and increased family conflict have been consistently associated with poor diabetes self-management, metabolic control, psychosocial adaptation, and quality of life (QOL) in adolescents with T1D (Pendley et al., 2002; Whittemore, Kanner, & Grey, 2004; Wysocki, 1993). In addition, T1D is a risk factor for depression in youth, with the prevalence of clinically significant depressive symptoms ranging from 12-15% in children to 15-27% in adolescents with T1D (Hood et al., 2006; Kokkonen, Lautala, & Salmela, 1997; Kovacs, Goldston, Obrosky, & Bonar, 1997; Whittemore et al., 2002). NIH-PA Author Manuscript Due to the risks associated with poor metabolic control and psychosocial adjustment for adolescents with T1D, increasing attention is being paid to the developmental transition between pre-adolescence and adolescence for the promotion of better health outcomes. Parents may need to adjust their level of involvement, so that children can exercise developmentally-appropriate gains in autonomy, while continuing to rely upon parents for support, guidance, and encouragement (Anderson, Auslander, Jung, Miller, & Santiago, 1990). Research supports the need for children and parents to work cooperatively with open communication and flexible problem-solving skills in order to negotiate shared responsibility for treatment management (Schilling et al., 2006; Wysocki, 1993). Parental guidance, warm and caring family behaviors, open communication, and expression of feelings have demonstrated protective effects on metabolic control and psychosocial adjustment (Davis et al., 2001; Faulkner & Chang, 2007; Grey, Boland, Davidson, & Tamborlane 2001). Family-based psychosocial interventions have been developed to improve family interactions and enhance the well-being of youth with T1D. In several randomized trials family-based interventions improved family relations, communication, problem-solving skills, treatment adherence, and metabolic control. Type 2 Diabetes Nursing SPSS Logistic Regression For example, Anderson and colleagues showed that a low-intensity office-based, family intervention increased parental involvement, while decreasing diabetes-related family conflict (Anderson, Brackett, Ho, & Res Nurs Health. Author manuscript; available in PMC 2010 August 1. Grey et al. Page 3 NIH-PA Author Manuscript Laffel, 1999; Laffel et al., 2003). Other researchers have targeted families at high risk for problems. Wysocki and colleagues (2008) demonstrated that intensive behavior family systems therapy improved outcomes in families with high levels of conflict. Ellis and colleagues (2007) demonstrated that a comprehensive home- and community-based intervention improved outcomes in families with low socioeconomic status. The majority of these family-based interventions targeted adolescents and were focused primarily on problem solving and communication. However, variables such as coping and self-efficacy also have been associated with improved adherence, family functioning, psychosocial adjustment, and metabolic control in youth with T1D (Graue, Wentzel-Larsen, Bru, Hanestad, & Sovik, 2004; Grey, Lipman, Cameron, & Thurber, 1997; Griva, Myers, & Newman, 2000). NIH-PA Author Manuscript Coping skills training (CST) is based on social cognitive theory, which proposes that individuals can actively influence many areas of their lives, particularly coping and health behaviors (Bandura, 1997). A major premise of this approach is that practicing and rehearsing a new behavior, such as learning how to cope successfully with a problem situation, can enhance self-efficacy and promote positive behaviors (Marlott & Gordon, 1985). The goal of CST is to increase competence and mastery by retraining nonconstructive coping styles and behaviors into more constructive behaviors. There is evidence supporting the potential efficacy of CST to promote positive health outcomes in youth with and without a chronic illness (see review by Davidson, Boland, & Grey, 1997). A randomized clinical trial of a CST program, based on Forman’s (1993) protocol, and modified for adolescents with T1D (Grey, Boland, Davidson, Yu, & Tamborlane, 1999), demonstrated improvements in metabolic control, psychosocial adjustment, and QOL at 6 and 12 month follow-up (Grey, Boland, Davidson, Li, & Tamborlane, 2000). Because a CST intervention demonstrated efficacy for adolescents with T1D, the potential to provide the intervention to other developmental phases, such as school-aged children, seems warranted. In this study, we report long-term treatment effects of a coping skills training (CST) program for school age children (8-12 years old) and their parents compared to an attention control group who received supplemental diabetes education. A report of the preliminary short-term efficacy indicated that children and parents who received CST showed promising trends for more adaptive family functioning and greater life satisfaction than those families in group education (Ambrosino et al., 2008). These results support the potential application of CST in the developmental phase of 8-12 year olds. If school-aged children and parents can learn effective coping skills, a positive transition to adolescence may occur, one in which parents and children collaborate to maintain effective diabetes management. NIH-PA Author Manuscript Conceptual Framework Stress-adaptation models provide a framework for the study of interventions to promote adaptation to chronic illness and posit that adaptation may be viewed as an active process whereby the individual adjusts to the environment and the challenges of a chronic illness. (Grey et al., 2001; Grey & Thurber, 1991; Pollock, 1993). Type 2 Diabetes Nursing SPSS Logistic Regression Adaptation, in this framework, is the degree to which an individual adjusts both physiologically and psychosocially to the stress of living with a long-term illness. The framework suggests that individual characteristics, such as age, socioeconomic status, and in children with T1D, treatment modality (pump vs. injections), individual responses (depressive symptoms), and context (coping, self-efficacy, family functioning) influence the level of individual adaptation. In this model, adaptation has both physiologic (metabolic control) and psychosocial (QOL) components (see Figure 1). The CST was hypothesized to influence the individual’s responses (depressive symptoms) and context (coping, self-efficacy, family functioning) directly and level of adaptation (metabolic control, QOL) both indirectly and directly. Res Nurs Health. Author manuscript; available in PMC 2010 August 1. Grey et al. Page 4 Purpose NIH-PA Author Manuscript The primary aim of this randomized clinical trial was to determine the effect of group-based CST for school-aged children with T1D and their parents compared to an attention-control group receiving supplemental general diabetes education (GE) over a period of a year on children’s metabolic control, QOL, depressive symptoms, coping, self-efficacy, and family functioning at 12-month follow-up. The data in this analysis include only child outcomes. The secondary aim was to explore mediators (coping, self-efficacy, family functioning) and moderators (age, sex, socioeconomic status, treatment modality) of intervention efficacy based on the conceptual framework. The following hypotheses were tested: 1. Children with T1D who participate in CST will demonstrate better metabolic control (lower HbA1c levels), better QOL, fewer depressive symptoms, fewer issues in coping, better diabetes self-efficacy, and better family functioning (stable or less family guidance and control and more family warmth and caring) compared to children with T1D who participate in GE. 2. Age, sex, socioeconomic status, and treatment modality will moderate the intervention effect on metabolic control and QOL. 3. Changes in coping, self-efficacy, and family functioning will mediate the intervention effect on metabolic control and QOL. NIH-PA Author Manuscript Method Design and Sample A two-group experimental design was used. Data were collected at baseline and 1, 3, 6, and 12 months post-randomization by trained research assistants who were blinded to group assignment. Children were eligible to participate if they were: (a) between the ages of 8 and 12 years; (b) diagnosed with T1D and treated with insulin for at least 6 months; (c) free of other significant health problems; and, (d) in school grade appropriate to within 1 year of child’s age. NIH-PA Author Manuscript A sample of 100 subjects was determined by a power analysis based on the effect size seen in our adolescent study (Grey et al., 2000) and in our pilot work with younger children (difference in HbA1c was .7%). A two-way analysis of variance with 100 subjects with a .05 significance level would have 98% power to detect a variance among the 2 group means of . 04, 99% power to detect a variance among the 3 time means of .051, and 80% power to detect a interaction among the 2 group levels and the 3 time levels of .022, assuming that the common standard deviation is .04, when the sample size in each group is 50 (Elashoff, 1995). Type 2 Diabetes Nursing SPSS Logistic Regression Due to problems scheduling groups, we were unable to meet our projected goal of 100 subjects (Figure 2). Of those approached for participation, approximately 58% agreed; 18% expressed interest and asked to be approached later, and 21% refused (e.g., too busy). Twenty-four percent of participants were unable to be scheduled for the group-based intervention and were excluded from the analysis due to lack of exposure to any aspects of the intervention (18% in the CST group and 33% in the GE group). This report is based on the 82 children who were exposed to the interventions. There were 53 children in the CST group and 20 in the GE group. Comparison of those who received the intervention (CST or GE) to those who enrolled but did not receive either intervention demonstrated that groups were comparable on baseline measures, other than an increased likelihood for white children and children whose mothers had higher education to receive the intervention. Data comparing attenders to nonattenders has previously been reported (Ambrosino et al., 2008). Attrition was low with only 10 participants dropping out or lost to follow up over the 1-year period (14%). Once scheduled, Res Nurs Health. Author manuscript; available in PMC 2010 August 1. Grey et al. Page 5 NIH-PA Author Manuscript attendance at sessions was good. Participants of CST attended an average of 4.6 of 6 sessions (range=1-6; SD = 1.21); those in GE attended on average 3.3 of 4 sessions (range=1-4; SD = .75). Descriptive statistics for the sample are provided in Table 1. Children were predominately white and of high income, which is consistent with the overall clinic composition. On average, children’s duration of diabetes was 3.5 years; most were on pump therapy and had metabolic control comparable with the ADA’s recommendations for age. Setting and Procedures Children and their parents were approached for participation in the trial during regularly scheduled visits at a pediatric diabetes clinic in the northeast. Families interested in the study completed a consent/assent process approved by the university’s Human Subjects Research Review Committee, as well as baseline questionnaires. Children who scored above criteria for elevated depressive symptoms on standardized questionnaires were referred for follow up, but not excluded from the intervention unless they required hospitalization for suicidality. After consent, participants were randomized by a sealed envelope technique to either CST or GE. Both groups received diabetes team care throughout the course of the study, and clinicians at the recruitment site were blinded to study group assignment. NIH-PA Author Manuscript Interventions Coping Skills Training (CST)—The goal of CST in this age group is to increase a child’s and his or her parents’ sense of competence and mastery by retraining inappropriate or nonconstructive coping styles and forming more positive styles and patterns of behavior. Unlike previous research with CST in T1D where the intervention was provided only to youth, CST in this study was provided as a family intervention, to both parents and youth. Specific coping skills that were addressed in the intervention included: communication, social problem solving, recognition of associations between thoughts, feelings, and behavior and guided self-dialogue, stress management, and conflict resolution around diabetes-specific stressors (Table 2). Six weekly sessions were conducted in small groups of 2-6 children; parents met simultaneously but separately. At the end of each session, children and their parents met together to share salient issues and discuss possible connections between group themes and family concerns. Type 2 Diabetes Nursing SPSS Logistic Regression NIH-PA Author Manuscript Within each session, coping skills were presented and discussed. Role-play also was used for participants to practice a specific coping skill in a potentially difficult social situation. Trainers provided coaching on child or parent responses to the situation to enable participants to learn more skillful responses. All participants were encouraged to practice the specific skills at home in between sessions. Each 1.5 hour session was facilitated by a mental health professional. All CST groups were audio taped and reviewed for treatment fidelity. Group Education (GE)—Because the usual method of working with youth with T1D is education, GE was provided as an attention-control condition, supplementing the individual diabetes education provided in clinic to all study participants. All children in this study received ongoing diabetes education within the context of quarterly clinic visits. The session content of the control condition provided a review of intensive insulin regimens (multiple daily injections and pump), carbohydrate counting and nutrition, sports and sick days, and updates on diabetes care and technology (Table 3). Age-appropriate written materials were provided at each session. Participants were encouraged to discuss the materials in each session and apply it to their individual family situations. Four weekly sessions were conducted in small groups of 2-6 children and their parent(s). Each 1.5 hour session was Res Nurs Health. Author manuscript; available in PMC 2010 August 1. Grey et al. Page 6 taught by an advanced practice nurse, and all sessions were audio taped and reviewed for treatment fidelity. NIH-PA Author Manuscript Measures Data were collected from children on metabolic control, QOL, depressive symptoms, coping, self-efficacy, and family functioning. Self-report instruments were completed by the children, and demographic data were collected from a parent. The HbA1c and other treatment-related values were extracted from medical charts. Metabolic control was assessed with HbA1c, a measure of the glycosylation of the hemoglobin molecule that reflects the child’s average blood sugar over the past 3 months. Analyses were performed using the Bayer Diagnostics DCA2000®, which has evidence of high reliability (Tarrytown, NY, normal range = 4.2-6.3%). The ADA recommendation for the treatment goal for children age 6-12 years is <8% (Silverstein et al., 2005). NIH-PA Author Manuscript Child QOL was measured by the Diabetes Quality of Life Scale which has 3 subscales to assess youth perceptions of the impact of T1D management (21 items), their general satisfaction with life (18 items), and worries related to T1D (8 items). Scores range from 21-84 for impact, 18-72 for satisfaction, and 8-32 for worry. Higher scores indicate greater impact of diabetes on child’s li … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10