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Glycemic control in young children with diabetes: The role of parental
Elizabeth R. Pulgaro ´na,*, Lee M. Sandersb, Anna Maria Patin ˜o-Fernandeza, Diana Wilea,
Janine Sancheza, Russell L. Rothmanc, Alan M. Delamatera
aDepartment of Clinical Pediatrics, University of Miami, Miller School of Medicine, Miami, USA
bDepartment of Pediatrics, Stanford University School of Medicine, Stanford, USA
cCenter for Health Services Research, Vanderbilt University, Nashville, USA
Type 1 diabetes mellitus is a chronic illness typically diagnosed
in childhood that requires lifelong medical care and consistent self-
management to prevent significant health complications. It is
recommended for young children with diabetes to maintain a
certain level of glycemic control (i.e. below 8.5% on an HbA1c test)
. Diabetes management is complex and challenging, particularly
during childhood and adolescence. Families must reconcile tedious
self-care tasks, cognitive demands, and deal with logistical
burdens such as navigating the health care system and procuring
medical supplies. Health literacy (HL) has been defined as: ‘‘the
degree to which individuals have the capacity to obtain, process,
and understand basic health information and services needed to
make appropriate health decisions’’ . Each of the three
components of HL presents a modifiable barrier to optimal care
for patients with diabetes: (1) reading skills (understanding
written texts, such as health management plans), (2) numeracy
skills (accomplishing simple calculations, such as dosing insulin
appropriate to blood glucose, diet and activity), and (3) naviga-
tional skills (accessing resources, such as clinics, clinicians, and
other services) . Numeracy skills are especially important in
diabetes management due to the many calculations needed to
implement medical regimens accurately.
Among adults with diabetes, increased risk of hospitalization
and increased health costs have been independently associated
with HL [4–6]. Health-literacy-based interventions for adults with
diabetes have been shown to be beneficial, especially for adults
with limited HL skills . A recent study reported that for
adolescents with intensive insulin regimens, parents’ HL was
associated with better diabetes management . Lower parental
HL has also been associated with poorer glycemic control in school
aged children . In an adolescent sample, teenagers’ own
numeracy skills have been associated with diabetes outcomes
. However, the impact of reading skills or numeracy skills of
adult caregivers on young children’s diabetes management is
Patient Education and Counseling 94 (2014) 67–70
A R T I C L E
I N F O
Received 24 April 2013
Received in revised form 16 August 2013
Accepted 3 September 2013
Type 1 diabetes
A B S T R A C T
Objective: This cross sectional study examined the relationship between parental health literacy (HL),
diabetes related numeracy, and parental perceived diabetes self-efficacy on glycemic control in a sample
of young children with Type 1 DM.
Methods: Seventy primary caregivers of children (age 3–9 years) with Type 1 DM were recruited and
surveyed at diabetes outpatient clinic visits. Patients’ medical histories were obtained by medical chart
Results: Parental diabetes related numeracy (r = ?.52, p < 01), but not reading skills (r = ?.25, p = NS)
were inversely correlated with the child’s glycemic control (HbA1c). Parental perceived diabetes self-
efficacy was also negatively correlated to their child’s HbA1c (r = ?.47, p < 01). When numeracy and
parental perceived diabetes self-efficacy were included as predictors of HbA1c, the model was significant
(F = 12.93, p < .01) with both numeracy (b = ?.46, p < .01) and parental perceived diabetes self-efficacy
(b = ?.36, p = .01) as significant predictors of HbA1c.
Conclusions: Data from this study highlight the importance of considering the role of parental numeracy,
in health outcomes for children with Type 1 DM.
Practice implications: Practitioners should assess parental health literacy and consider intervention
? 2013 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author at: Department of Clinical Pediatrics, University of
Miami, Miller School of Medicine, Mailman Center for Child Development, 1601 NW
12 Avenue, Miami, FL 33136, USA. Tel.: +1 305 243 6857; fax: +1 305 243 4512.
E-mail address: firstname.lastname@example.org (E.R. Pulgaro ´n).
Contents lists available at ScienceDirect
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unclear and to date no studies have examined the relationship
between the HL of parents of young children with Type 1 DM and
their physical health.
As with many chronic illnesses, parents of young children with
diabetes are largely responsible for disease management. Part of
what distinguishes parents who are able to properly manage their
child’s illness from those who cannot is how efficacious they feel
regarding the medical regimen. Perceived parental efficacy has
been defined as ‘beliefs or judgments a parent holds of their
capabilities to organize and execute a set of tasks related to
parenting a child’ . In general, more perceived efficacy has been
associated with better health outcomes .
This study examined the relationship between parental health
literacy, including reading skills and numeracy skills, and glycemic
control in a sample of young children with Type 1 DM. In addition,
parental perceived diabetes self-efficacy was examined as a
potential mediator of the relationship between HL and glycemic
control. Based on the adult HL literature, we hypothesized that
parents with lower HL would have children with poorer glycemic
control. It was also predicted that parental perceived diabetes self-
efficacy would mediate the relationships between HL and glycemic
2.1. Participants and procedures
This is a cross-sectional study in which participants were
recruited at their child’s regularly scheduled diabetes outpatient
appointment in a pediatric endocrinology clinic. The inclusion
criteria for this study were for the child between the ages of 3 and
9.9 years old to have been diagnosed with Type 1 DM for at least
one year and for the primary caretaker able to read and write in
Spanish or English. University human subjects’ approval was
obtained and followed for all procedures. All eligible primary
caregivers who attended outpatient clinic appointments for their
children were approached to participate in the study. Few primary
caregivers refused to participate and most of those who refused
stated not having enough time as the reason for not participating.
Seventy primary caregivers agreed to participate, signed a written
consent, and completed assessment measures. HbA1c closest to
the date that the study measures were completed was obtained via
medical chart review. The physicians instruct patients to go to the
lab directly after their medical visit to obtain an HbA1c test.
Children in the sample (54% female) had been diagnosed with
Type 1 DM for an average of 3 years (SD = 2.30). Eighty-four
percent of the children were White and 16% were African
American. Sixty-five percent of the sample was of Hispanic
descent. Participants were on one of three insulin regimens, (1)
conventional regimen consisting of twice daily insulin injections
including long acting and rapid acting insulins; (2) multiple daily
injections consisting of three or more injections per day with a long
acting insulin taken once a day and three or more short acting
insulin injections usually given at meal times or for making
corrections for high blood glucose levels; (3) pump therapy (i.e.
continuous subcutaneous insulin infusion) consisting of a basal
dose of insulin as well as bolus dosing of insulin throughout the
day. Thirty percent of the sample was on a pump at the time of the
study with the remaining 70% on a subcutaneous insulin. Sixty-
percent of the sample was prescribed a meal plan technique for
managing blood glucose levels known as carbohydrate counting.
This consists of adhering to a set number of grams of carbohydrate
intake per meal. The remaining 40% were not on a carbohydrate
counting plan because the physicians felt they had yet to master
carbohydrate counting and therefore using a sliding scale to adjust
short acting insulin depending on blood glucose level.
Primary caregivers (84% mothers) completed two HL measures
and two psychosocial measures. Mothers were on average 40 years
old (SD = 7.09) and 73% completed at least some college. Thirty-
five percent of the families who participated were receiving some
type of financial assistance from the government. Participants
were given a small monetary gift card and a parking voucher as
compensation for participating in this study. All study measures
were available in Spanish and English. Families were given the
option to complete measures in the language of their choice. Ten
percent of participants completed the assessment measures in
The Short Test of Functional HL in Adults, or STOFHLA, is a self-
administered test of reading ability that has been validated in
English and Spanish . This measure consists of 36 multiple
choice sentence completion tasks that are to be completed after
reading one of two passages on health related material, which is
preparation for an upper gastrointestinal series and the patient
rights and responsibilities section of a Medicaid application. An
example item is: If you ________ (wash, want, cover, or tape) AFDC
for any family ______ (member, history, weight, or seatbelt) you will
have to _______(relax, break, inhale, or sign) a different application
form. Completion time is estimated to be about 12 min. Total scores
were used in the analyses and range from 0 to 36, with higher
scores indicating greater HL.
The Parental Diabetes Numeracy Test (PDNT)  is a self-
administered test of numeracy and navigational skills. Partici-
pants who self-identified as Spanish being their primary
language (n = 7) were given the DNT-15 Latino , the Spanish
version of the PDNT-14. Both questionnaires consist of multiple
choice responses and free response questions. A sample item is:
You are given the following instructions: ‘‘Take 1 unit of insulin for
every 7 grams of carbohydrate you eat.’’ How much insulin do you
give your child when they eat 98 grams at supper? Participants
were offered a calculator to use if desired when answering
questions. Scores range from 0 to 14 for the English version and
0–15 for the Spanish version. Because of the different number of
items on the scales, percent of items answered correctly was
used in analyses, with higher scores indicating greater numeracy
The Perceived Diabetes Self-Management Scale , (Cron-
bach’s a = .84 in current sample) measures the degree to which
patients with diabetes feel competent in managing their diabetes.
It is a measure of perceived diabetes self-efficacy, not actual
diabetes management skills. This measure was adapted for this
study to apply to parents of children with diabetes and questions
were phrased to measure parents’ perception of their own ability
to complete diabetes related tasks for children . The scale
consists of 8 items such as: I am able to deal with things related to my
child’s diabetes as well as others or I succeed in the projects I undertake
to manage my child’s diabetes. Each item is rated on a 5 point Likert
scale ranging from strongly disagree to strongly agree. Total scores
are utilized, with higher scores indicating greater parental
perceived diabetes self-efficacy.
2.3. Statistical analyses
Spearman correlations were used to determine if there were
relationships between reading skills, numeracy, parental perceived
diabetes self-efficacy, and HbA1c. Significant correlations were
further explored with linear regressions to determine if predictor
variables (numeracy, reading skills) were related to HbA1c. Mean
substitution was used for any missing items in the participant
E.R. Pulgaro ´n et al. / Patient Education and Counseling 94 (2014) 67–70
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Neither reading skills nor numeracy was related to treatment
regimen, diabetes duration, or ethnicity. Parent numeracy and
reading skills were positively correlated, r = .37, p = .02, such that
parents with better numeracy skills also had better reading skills.
However, parent numeracy (r = ?.52, p < 01), but not reading skills
(r = ?.25, p = NS) were negatively correlated with the child’s
HbA1c. Similar to numeracy skills, increased parental perception of
diabetes self-efficacy was associated with lower child HbA1c
(r = ?.47, p < 01), but parental perception of diabetes self-efficacy
and numeracy skills were not correlated with each other (r = .18,
p = NS). When numeracy and parental perceived diabetes self-
efficacy were entered into a linear regression, the model was
significant (F = 12.93, p < .01, R2= .39) with both numeracy
(b = ?.46, p < 01) and parental perception of diabetes self-efficacy
(b = ?.36, p = 01) being independent predictors of HbA1c. When
mother’s education level is entered as a covariate the model
remains significant, F = 5.01, p = .006, R2= .26. Parental perception
of diabetes self-efficacy remains a significant predictor of HbA1c
(b = ?.32, p = 039) but the relationship between numeracy and
HbA1c is attenuated (b = ?1.86, p = 072) (see Table 2).
Data from the current sample was compared to previously
published samples [13,14,16]. In general the current sample
demonstrated greater HL than those in previous studies (see
Table 1). Specifically, the percent of items answered correctly on
the STOFHLA in the current sample was significantly higher than
the norms presented in the administration manual, t(60) = 20.44,
p < 001. Similarly, the mean number of items answered correctly
on the PDNT in the current sample was significantly higher than
those reported in the normative sample for English speakers ,
t(60) = 2.91, p = 005 (no norms were available for Spanish speak-
ers). In contrast, parental perception of diabetes self-efficacy
reported by the current sample were similar to those in previous
research , t(48) = 1.35, p = ns. Due to the small number of
participants in this study who completed measures in Spanish,
comparisons between English respondents and Spanish respon-
dents were not conducted.
4. Discussion and conclusions
This is the first study to assess the role of parental HL in the
health of young children with Type 1 DM. Findings from this study
highlight the importance of considering the role of parental health
literacy, especially numeracy, in creating interventions to improve
the glycemic control of young children with diabetes. Results from
this sample indicated that parental numeracy skills, but not
reading skills, were positively related to young children’s disease
outcomes. Contrary to our hypotheses, parental perception of
diabetes self-efficacy did not mediate the relationship between
numeracy and health outcomes. However, both numeracy and
parental perceived diabetes self-efficacy were found to be
independent predictors of glycemic control. The limitations of
this study include the cross sectional design which limits the
ability to look at predictive relationships between HL of parents
and health outcomes in children over time and a small sample size
which impeded more complex analyses. Additionally, the current
sample scored significantly higher on numeracy and reading skills
than those presented in previous studies, which may have affected
the results. This is especially true regarding the STOHFLA scores
which near ceiling. This may be a result of parents with lower
reading skills self-selecting not to participate in the study or a
function of the literacy measure used in this research. Certainly, in
the area of diabetes management, numeracy is extremely
important, as parents are expected to measure and administer
exact insulin doses and adjust doses of medication depending on
glucose results and carbohydrates consumed as part of a child’s
daily dietary intake. The numeracy measure used in this study was
specific to diabetes, which might explain why it was related to
HbA1c and reading skills were not.
Results from this study highlight the importance of the
numeracy component of health literacy in parents of young
children with diabetes health outcomes. These results suggest that
better glycemic control in children is associated with better
numeracy skills in parents. Future research should consider the use
of multiple assessments over time to ensure the direction of these
relationships and attempt to include participants with a wider
range of HL skills. It will also be important for future studies to
assess whether parental numeracy is the more important predictor
in children’s health outcomes. If so, diabetes-related numeracy
interventions to assist parents in implementing medical recom-
mendations properly, particularly for parents who are charged
with making dosing adjustments would be helpful.
4.3. Practice implications
The results from this study have important potential clinical
implications when treating young children with diabetes. Due to
the relationship between parental diabetes numeracy skills and
Regression models predicting HbA1c.
Sample mean (SD)
Single sample t-test
Reading skills (STOFHLA)
Parental perceived diabetes self-efficacy
t(53) = 2.17, p = ns
t(60) = 2.91, p = 005a
t(60) = 20.44, p < 001
t(48) = 1.35, p = ns
For HbA1c the p = .034.
For Parental perceived diabetes self-efficacy p = .186.
aCompared English speakers in the sample to the English norms of the PDNT.
E.R. Pulgaro ´n et al. / Patient Education and Counseling 94 (2014) 67–70
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glycemic control, it will be important for medical staff to assess for
difficulty with numeracy and not assume all parents have the
necessary mathematical skills to follow treatment recommenda-
tions. Simple and short numeracy screening measures could be
used as part of standard care. If parents are found to have low
numeracy skills or this is suspected, more detailed explanations of
the medication regimen and concrete examples during medical
visits, including written instructions, tailoring messages, partition-
ing information, and making instructions interactive may be
helpful . For patients with diabetes, numeracy screeners could
also assist physicians in deciding which type of insulin regimen
would be most appropriate given the families’ abilities. If specific
numeracy screening is unavailable, educational level could be used
as a proxy. Future studies should continue to assess the
relationship between parental numeracy skills and glycemic
control and the role of interventions that address numeracy to
improve diabetes care and outcomes.
Conflict of interest
The authors would like to acknowledge the pediatric research
team at the University of Miami Miller School of Medicine and the
families who participated in this study. This study was made
possible in part through funding from NIH grant no. 5T32
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