Youth-onset type 2 diabetes: self-management among adolescents in Bangkok

The increasing prevalence of type 2 diabetes, in parallel with increased obesity among young people, has been a global concern, as these health issues are dual risks for developing cardiovascular disease in adulthood. The built environment, shaped by rapid urbanisation, industrialisation, and Westernisation, is one of the most important factors of endemic childhood obesity in Thailand. In this urban environment, eating out or public eating has expanded, together with an increase of nuclear families and the shift in the roles and positions of women, fading their role as primary caregivers. Weight reduction and blood glycemic control are major goals of paediatric treatment and self-management of pre-diabetes and type 2 diabetes. Many young patients find it difficult to comply with these medical requirements, because of various underlying factors, both personal and social. This thesis explores how Thai adolescents with pre-diabetes and type 2 diabetes understand causes of their illness and lifestyle, including prior to their diagnosis. The study site is Bangkok and its surroundings. This study is mainly based on a qualitative approach, using grounded theory, as a systematic method of qualitative research rather than a philosophy or theoretical standpoint. Fieldwork was conducted between December 2006 and January 2008. Data were collected through in-depth interviews and participant observation methods. Sixteen young people who were diagnosed with pre-diabetes or type 2 diabetes, aged 12-19, were study participants. They were recruited in three selected hospitals located in Bangkok. Their parents or primary caregivers were also included in the recruitment. Information from primary caregivers, other family members, and healthcare providers was gathered to broaden and contextualise data obtained from adolescents. I also draw on quantitative data collected from 60 healthy adolescents to supplement the qualitative findings. Information gathered from healthy adolescents provided a broad picture of teenagers’ attitudes and lifestyles in contemporary Thailand, and provided some insight about potential factors associated with the development of pre-diabetes and type 2 diabetes among young people. In doing so, a 10-minute interview was conducted at two selected shopping malls – Siam Square and the Mall Baang Khae - to obtain data related to adolescents’ lifestyle, i.e. daily food intake and activity. The findings from both quantitative and qualitative methods are concordant in that they indicate poor diet and inadequate physical activity among young people. Overall, in this study, family history of diabetes and childhood obesity, caused by poor diet and limited physical activity, predominantly influenced the development of pre-diabetes and diabetes among participants in this study. Similar to the healthy group, all adolescents with chronic illness who had had a history of childhood obesity followed an unhealthy lifestyle prior to their diagnosis. Unlike adults with type 2 diabetes, most young participants are diagnosed without delay as their caregivers seek help promptly from paediatric endocrinologists. Young participants’ and caregivers’ explanatory models of the causes of their illness are close to biomedical models, despite study participants not fully understanding the latter. Young participants’ health beliefs are not affected by folk or supernatural notions of illness. Most of them perceive that their illness is caused by their personal lifestyle, behaviour and heredity. Living in a built urban environment which does not support an active lifestyle, the majority failed to change their unhealthy eating and sedentary behaviours, despite advice they received from health professionals. They frequently reported low self-efficacy and intention in adhering to diet control and regular exercise, perceived their illness as non-severe, understood that the disease cannot be cured, even if they followed health professionals’ advice, and believed that they would face barriers in their social life if they modified their behaviours. Adolescents and their caregivers also reported that food availability at home and elsewhere (e.g. schools) is a barrier to changing lifestyle or maintaining healthiness. According to adolescents’ and their caregivers’ perceptions and management behaviours, four patterns of diabetes self-management were identified: thriving, accommodating, indulging and indifferent. The findings suggested that two illness management styles – thriving and accommodating – resulted in improved health outcomes. The remaining two illness management styles - indulging and indifferent - worsened blood glucose levels and body weight. The ‘indifferent’ adolescents reported both internal barriers (i.e. lack of self control, low self-efficacy, and no life goal) and external barriers (i.e. lack of social support and easy access to unhealthy food) to their diet control and exercise. Barriers to taking medication regularly commonly reported by those regarded as belonging to the ‘indulging’ and the ‘indifferent’ groups included skipping breakfast and forgetting to take medicine. Overall, parental involvement and the perceived benefits of weight loss and/or the perceived severity of the illness facilitate adolescents in the thriving and the accommodating management style to be able to control their food and exercise, but also psychological factors, including intention and self-efficacy, play a role in these illness management styles. The perceived barriers of adhering to diabetes self-management (i.e. social life disruption) and limited parental involvement predict low intention and self-efficacy in changing unhealthy behaviours among adolescents in the indulging and the indifferent management style. In the family setting, my study confirms that parents’ modelling and parenting styles, such as authoritative parenting, can prevent children from developing unhealthy habits and behaviours from childhood to adolescence, and enhance young people’s lifestyle modification. The families of young people with chronic illness need social support. Healthcare providers can potentially support or help caregivers or families by facilitating parental involvement, setting up dietary plans and raising awareness of unhealthy foods countrywide. This study also demonstrates a need to enhance self-efficacy and actual intention among adolescents, and to increase parental involvement in diabetes tasks in the achievement of treatment goals. The encouragement of life goals, to increase internal motivation and self-efficacy among young people, is a key strategy to help them achieve their diabetes self-management. This could be a solution for eliminating internal barriers. The enhancement of the social networks of ill adolescents, including young people with or without chronic illness and sportsmen, in self-help groups or as peer supporters, would benefit both ill adolescents and their peers to reduce a discrepancy between them; they can share life and learn from each other through lifestyle modification to be healthy. Furthermore, intervention programs for primary caregivers, aiming to encourage them to be highly involved in diabetes self-management and to be “healthy” role models, and enhancing their willpower in taking care of children with chronic illness, may be useful diabetes management strategies. These strategies would not only improve the health outcomes of ill young people but also the whole family, and in particular those who themselves have type 2 diabetes. As my study has a small sample size, with limited diversity in age, ethnicity, and the place of residence, and is based predominantly on qualitative research, the findings cannot be generalised. In addition, future research needs to investigate the social and environmental context (i.e. peers, teachers and school) and its impact on the lifestyle of healthy and ill adolescents and the illness management strategies of those who are diagnosed with type 2 diabetes.