Complete Advanced Nursing Discussion (JACKIE)

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.

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 other quantitative and statistical methods could be used to address the research issue discussed in the article?

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Res Nurs Health. Author manuscript; available in PMC 2010 August 1.
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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
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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
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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,
robin.whittemore@yale.edu.
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(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. 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.
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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).
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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. 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, &
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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).
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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.
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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). 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.
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Purpose
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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.
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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.
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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). 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,
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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.
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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.
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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
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taught by an advanced practice nurse, and all sessions were audio taped and reviewed for
treatment fidelity.
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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