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The Relationship between Compliance and Quality of Life among Adolescents with Diabetes Mellitus Type 1

Samah El Awady Bassam

Pediatric Nursing Department, Faculty of Nursing, Zagazig University, Egypt

Abstract: Background: Puberty is a period of rapid growth and hormonal changes and is often characterized by deterioration in glycemic control, and all of these factors may promote the development of diabetes complications. Type 1 diabetes mellitus (T1DM) is a chronic disease requiring complex management, including blood glucose monitoring, insulin administration along with diet restrictions, which can have a negative impact on the quality of life (QoL) of adolescents. The aim of the study: This study aimed to investigate the relationship between compliance and quality of life among adolescents with diabetes mellitus type 1. Design: A descriptive cross-sectional design was utilized in this study. Setting: This study was conducted at the outpatient clinics in Zagazig University Hospitals at the pediatrics unit and the health insurance clinic for diabetes in Zagazig city. Subjects: A convenient sample of 80 adolescents diagnosed with type 1 diabetes Three tools were used for data collection, namely; A structured interviewing questionnaire, Diabetes self-management profile, and Diabetes quality of life for youths scale. The results: Slightly more than half of adolescent had a moderate knowledge of diabetes mellitus (53.8%), the highest percentage of the study sample had inadequate levels of compliance to diabetes treatment recommendations and perceived their quality of life as low (61.3% & 67.5%, respectively). Conclusion: It was found that there was a statistically significant relation between adolescents' compliance and quality of life score. Recommendations: Conduct educational program for adolescents and their parents to increase the level of their knowledge and compliance for diabetes management to improve QOL for all diabetic adolescents.

Keywords: adolescents, compliance, diabetes mellitus type 1, quality of life

Received September 14, 2019; Revised October 24, 2019; Accepted October 29, 2019

Citation: Samah El Awady Bassam, The Relationship between Compliance and Quality of Life among Adolescents with Diabetes Mellitus Type 1. American Journal of Nursing Research, 7 (6). 1057-1068. January 2019. doi:10.12691/ajnr-7-6-20

1. Introduction

Type 1 diabetes is the 7th major cause of death among adolescents worldwide. Type 1 diabetes is also called juvenile diabetes and occurs in children and adolescents. Blood glucose control is more difficult due to hormonal problems related to puberty, which reduces the insulin’s effectiveness by about 30% to 50% [1]. Type 1 Diabetes Mellitus (T1D) “is an autoimmune disease characterized by progressive loss of pancreatic beta cells, culminating in the cessation of insulin production and, consequently, a severe metabolic imbalance”. Most often occurs in people under 30 years of age [2]. It may be triggered by certain genetic tissue types or viral infections, combined genetic, immunologic, and possibly environmental (eg, toxins, viral) factors are thought to contribute to beta cell destruction [3].

The worldwide geographic variation in type 1 diabetes prevalence is remarkable. The existence of type 1 diabetes within a 20-year period has been doubled. In 2011, about 490,100 children from 0 to14 years have type 1 diabetes. In Egypt, epidemiological studies for childhood type 1 diabetes are scarce. Egypt has a prevalence of about 8/100 000 per year in adolescents under the age of 18 years [4].

The adolescents with type I diabetes suffer from many manifestations such as weight loss, polydipsia, polyuria, polyphagia, hyperglycemia – blood glucose level usually greater than 250 mg/dL, loss of skin turgor, dry mucous membranes, weakness, malaise, rapid weak pulse and hypotension [5]. Diagnostic investigations done to confirm the disease include blood and urine tests for sugar. Urine is obtained and tested for the odor, color, gravity and context reaction. Blood is also tested for postparadial blood glucose and glucose tolerance [6].

Diabetes has become an important public health problem which has reached epidemic proportions worldwide. This issue needs to be dealt with to avoid the rising prevalence of this disease, and prevention seems a reasonable method. Preventive measures such as lifestyle adjustments, including nutritional therapy, weight control and adequate exercise can decrease the incidence of diabetes by more than half in patients with impaired glucose tolerance [7].

Adolescence is a stage of physiological and psychological development between ten to 18 years of age, which is considered challenging. For those with T1D, adolescence is the most likely phase where glycaemic control deteriorates due to non-compliance with treatment [8]. Compliance is defined as the extent to which medical advice is followed to achieve therapeutic goals, but the audit reveals that only 16% of adolescent males and 15% of adolescent females comply with T1D treatment. Compliance helps adolescents to take control of their situations with focus on maintaining emotional and physical health [9].

Maintaining glycaemic control is important to prevent short-term complications of diabetes, such as hypoglycaemia, hyperglycaemia and diabetic ketoacidosis. Long-term complications of uncontrolled diabetes can result in cardiovascular disease, renal disease, diabetic retinopathy and neuropathies [10]. Multiple health complications arise in one fifth of adults with T1D due to inadequately manage diabetes in younger years. Therefore, compliance with treatment in adolescence is essential to reduce complications later in life [11].

According to [12] stated that there are a multiple barriers to adherence in adolescents with T1D exist, including psychosocial (Parents support, communication with health professional providers), cost of care, and regimen-associated barriers. To improve adherence in adolescents with T1D, interventions need to target these barriers with the goal of minimizing barriers and improving adherence behaviors that may enable nurses to understand their reasoning and work with young patients to reduce non-compliant behaviors.

Type 1 diabetes is one of the commonest chronic diseases of childhood. When an adolescent is diagnosed with diabetes, all of a sudden everyday life involves multiple injections or continuous subcutaneous injection. Blood glucose must be monitored several times a day, meals and activities must be planned. The blood glucose imbalance must be quickly rectified. Diabetes management affects the quality life of the adolescent [13]. Quality of Life (QoL), defined as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns [14]. According to [15] reported that the adolescents with T1DM experience a poorer QoL in comparison to healthy peers.

The concept of quality of life can be affected by factors such as the age of onset of diabetes [16]. And the child's age and gender [17]. The parents' views on illness, achieving glycemic control, and the lifestyle of their children is also very important [18]. In this context, diabetic adolescents’ QoL is influenced by factors such as obesity, comorbidities, complications, knowledge regarding DM, type of treatment, and glycemic control and adolescents compliance to diabetes treatment’s such as insulin administration, blood-glucose monitoring, exercise, diet, and follow-up [19,20].

1.1. Significance of the Study

Diabetes Mellitus (DM) has become the most common non-communicable chronic metabolic disease. The incidence of type I diabetes mellitus increasing every year among the adolescent in Egypt. It requires continuing medical care and education to prevent its acute and chronic complications. In Egypt, especially in Zagazig city, however, no study has been conducted to investigate the relationship between compliance to diabetes care recommendations and quality of life among adolescents with diabetes mellitus type 1(DMT1), especially incorporating these five treatment parameters (blood glucose monitoring, insulin regimen, exercise , follow up, and diet). Knowing the determinants of adherence to diabetes care recommendations and understand the different aspects associated with the health-disease process and the impact of this condition on daily activities will contribute to changes in professional practice as well as to health policies. These actions may result in the improvement of service delivery to adolescents with T1DM by taking into account these adolescents' experiences. Therefore, the present study aims to investigate the relationship between compliance and quality of life among adolescents with diabetes mellitus type 1(DMT1).

1.2. Aim of the Study

The aim of this study is to investigate the relationship between compliance and quality of life among adolescents with diabetes mellitus type 1(DMT1) through:

1-Determine the level of knowledge among adolescents with diabetes mellitus type 1 about the disease.

2-Determine the level of compliance and the factors associated with compliance to diabetes care recommendations among adolescent with diabetes mellitus type 1

3- Assess quality of life among adolescents with diabetes mellitus type I.

1.3. Research Question

Is there a relationship between compliance and quality of life among adolescents with diabetes mellitus type 1(DMT1)?

2. Subject and Methods

2.1. Research Design

A descriptive cross-sectional design was used to achieve the aim of this study.

2.2. Setting

The study was conducted at the outpatient clinics in Zagazig University Hospitals at the pediatrics unit and the health insurance clinic for diabetes located in Al-modeer street in Zagazig city. The number of clients visiting the outpatient clinics monthly ranged between 40 to 60 but the number of clients visiting the health insurance clinic monthly ranged between 70 to 90.

2.3. Subject

The study comprised of convenience sample of 80 adolescents diagnosed with type 1 diabetes who fulfilled the following criteria:

2.4. Inclusion Criteria

1- Age : 12-18years

2-. Both Genders (male & female).

3. Diagnosed as diabetes mellitus at least for 6 months.

4. Free from other chronic diseases.

2.5. Exclusion Criteria

1- Adolescents receiving drugs which affect blood glucose level, such as steroids and antipsychotic drugs

2- Adolescents suffering from short- or long-term pain.

2.6. Tools of Data Collection

Three tools were used for data collection

Tool I: A Structured interviewing questionnaire: was developed by the researcher through reviewing related literature Safari et al, [21]; Al-Hussaini and Mustafa, [22] to assess the knowledge of adolescents about diabetes disease. It consists of four parts:

First Part: Adolescents' personal characteristics:

Including age, gender, level of education and residence.

Second Part: Family characteristics:

Including level of education of the father and mother, the job of the father and mother, crowding index and family income level.

Third Part: Medical history:

Which collect data about duration of diabetes, presence of complications , and family history of diabetes.

Fourth Part:

To assess the knowledge of adolescents about diabetes type I. The questionnaire consists of 37 multiple choice questions categorized into 7 domains of diabetes mellitus namely; general knowledge about diabetes (eight questions), knowledge of risk factors of diabetes (four questions), knowledge of symptoms (six questions), knowledge on complications (five questions), knowledge about treatment and available medications (two questions), knowledge about lifestyle and non-medical measures (nine questions), and knowledge of monitoring of diabetic condition (three questions).

The scoring system:

The responses were one score for correct answers, and zero for incorrect answers. The total score for each adolescent were calculated and converted into percent score by dividing the adolescent total score by the maximum possible score. The level of knowledge score was high if the score equal and more than 75%, moderate if the score range from 50% to less than 75%, and low if the score less than 50%.

Tool II: Diabetes Self-management Profile (DSMP)

It was developed by Harris et al [23] and consists of two parts

First part:

It composed of 31 multiple choice questions to assessing adolescents 'compliance with diabetes treatment recommendations regarding self-care that includes five subscales: insulin administration, blood-glucose monitoring, exercise, diet, and follow-up.

Second part

Second part was intended to identify the barriers to the compliance from the opinion of adolescent with diabetes type I. It included four questions to determine the factors (family influence, psycho-logical, or financial,) that the adolescent considered as barriers to compliance to different treatment regimens including diet, exercise, insulin administration, follow up, and monitoring blood glucose level.

Scoring system

The items reported to be done were scored “1” and the items not done were scored “0”. For each area, the scores of the items were summed-up and the total divided by the number of the items, giving a mean score for the part. These scores were converted into a percent score. The compliance was considered adequate if the percent score was 60% or more and inadequate if less than 60%.

Tool III: Diabetes Quality of Life for Youths scale (DQOLY)

It was developed by Ingersol and Marrero [24] to evaluate the quality of life of adolescents with diabetes. The instrument consists of 50 items categorized into three domains; satisfaction with life (17 items), the impact of diabetes (22 items), and worries about diabetes (11 items). Responses are given on a Likert scale. Each question is answered using a scale ranging from 1 to 5 (very satisfied to very unsatisfied, respectively, for the satisfaction domain and never to always for the worries and impact domains). The total QoL was obtained by summing i) the total impact of diabetes, ii) worries about diabetes, and iii) satisfaction with life. The total sum of QoL range was divided into low QoL (< 60%), moderate QoL (60%–80%), and high QoL (> 80%).

Reliability

The internal consistency of the structured interviewing questionnaire was analyzed using Cronbach’s alpha coefficients and the value obtained from questionnaire was. 0.88. Internal consistency in the original version was. 74, for Diabetes Self-management Profile and 0.83 for Diabetes Quality of Life for Youths scale (DQOLY) [23,24].

Validity

The tools were tested for content validity by five experts (two professors of pediatric nursing , Faculty of Nursing, Cairo University, and three professors from Faculty of Nursing, Ain Shams University. The recommended modifications were done and the final form was ready for use.

Preparatory phase:

Based on the review of the current local and international-related literature and theoretical knowledge of various aspects of the study using books, articles and magazines for full understanding and to get acquainted with the research problem and prepare the data collection tools.

Pilot study:

A pilot study was carried out on 8 adolescents with type 1 diabetes, representing about 10% of the study sample to test the clarity and applicability of the tools of data collection and to estimate the length of time needed to fill the tools. No modifications were done and the subjects who shared in the pilot study were included in the main study sample.

Field work:

Once permission was granted to proceed with the study, the researcher started to prepare schedule for collection the data. The researcher introduced herself and explained the aim of the study briefly; the nature of the tools used for data collection. The tools of data collection was filled in 30 to 45 minutes. Each adolescent filled the tools individually at the diabetes clinic either in the out-patient clinics hospital or in the health assurance clinic. Data were collected through three months, starting from June 2018 up to the end of August 2018. Work was done three days per week from 10 am to 1 am.

Administrative Design:

An official permission were being obtained from the dean of the faculty of nursing , Zagazig University to conduct the study and sent to the directors of Out-patient clinics Hospital and health assurance clinic in which the study was conducted to the responsible authorities of the study setting to obtain their permission for data collection.

Ethical Considerations:

The study was approved by the Research Ethics Committee at the Faculty of Nursing, Zagazig University. At the time of data collection, a verbal informed consent for participation was taken from each adolescent and from his parents after full explanation of the aim of the study. They were informed that their participation in the study is voluntary. Adolescents were given the opportunity to refuse participation, and they were notified that they can withdraw at any stage of the study without giving reason. They were also assured that all information they were giving would be confidential and used for the study purpose only.

2.7. Statistical Design

Data entry and statistical analysis were performed using computer software, the statistical package for social sciences (SPSS), version 14. Suitable descriptive statistics were used such as; frequency, percentage for qualitative variables, and means and standard deviations, range, and medians for quantitative variables. The chi – square test was used to detect the relation between the variables. In addition, correlation coefficient (r) test was used to estimate the close association between variables. P-values which were less than 0.05, 0.001 were considered as statistically significant and highly significant respectively.

3. Results

Table 1: Reveals that the study sample involved 80 adolescents whose age ranged 10 to 18 years, with a mean of 14.3±2.0 years. With an equal percentage of males and females (50%) among study sample, and more than half of the study sample (51.25%) belonged to urban areas. Moreover, more than half of the fathers of adolescents (51.25%) had a university education and of mothers (52.5%) had a basic/ intermediate education. More than half of the study sample (51.2%) had sufficient income.

As Table 2 shows that about one-third of the study sample (36.3 %) had type1 diabetes for duration of more than 5 years, and more than one half of the adolescents in the study sample (53.8%) had a family history of type 1 diabetes. Concerning T1D complications, the table revealed that about three -fifths of adolescents' included in the study sample (62.5%) suffer from complications of T1D. Also, this table shows that the highest percentage of adolescents had insulin injection twice a day and never admitted to the hospital in the last 6 months (62.5%& 68.8%, respectively), while the half of adolescents had twice time of hypoglycemic episodes in the last three months (50%).

The mean score of adolescents' knowledge regarding diabetes were showed in Table 3. It was found that the highest mean score of knowledge domains as reported by adolescents was related to general knowledge about diabetes (2.2198±1.14236), while the lowest mean score was related to risk factors and complications domains (1.9655±.59788&1.9544±.53311, respectively). Also, this table showed that slightly more than half of adolescent had a moderate knowledge of diabetes mellitus (53.8%).

Compliance to diabetes management among adolescents in the study sample was illustrated in Table 4. It’s revealed that the highest percentage of adolescent had inadequate levels of compliance to diabetes self-management (61.3%). The highest percentage of compliance as reported by adolescents was related to follow-up and insulin administration (97.5%& 88.8%, respectively). While the lowest percentage of compliance was related to diet (37.5%).

Table 1. Socio-demographic characteristics of adolescents in the study sample (n=80)

Table 2. Characteristics of type I diabetes among adolescents in the study sample (n=80)

Table 3. Mean score of adolescents' knowledge regarding diabetes (n=80)

Table 4. Compliance to diabetes management among adolescents in the study sample (n=80)

A description of the barriers to compliance reported by adolescents is presented in Table 5. It indicates that most barriers were related to Blood-glucose monitoring and diet. The most commonly reported categories of barriers were the family influence ones regarding diet (71.2%%), follow up (55%), exercise (55%), and insulin administration (52.5%). As for blood-glucose monitoring, the most commonly reported barrier was the financial one (75%).

Table 5. Barriers to compliance to diabetes management among adolescents in the study sample (n=80)

Table 6 displays the mean score of quality of life among adolescents with type I diabetes. It can be noticed that the highest mean score of quality of life domains as reported by adolescents was related to satisfaction with life (90.8±10.5), while the lowest mean score was related to the impact of diabetes domain (60.1±9.3). Also, this table showed that the highest percentage of adolescent perceived their quality of life as low (67.5%).

As Table 7 shows that no statistical significant differences were found between male and female adolescents for their level of knowledge. Also, this table shows that a statistically significant differences were found between age of adolescents and their level of knowledge.

Table 6. Mean score of quality of life among adolescents with type I diabetes (n=80)

Table 7. Diabetic adolescent knowledge about diabetes mellitus according to their gender and age (n=80)

Table 8 displays the relation between adolescents' compliance and their socio-demographic characteristics. It can be noticed that the only relation of statistical significance was with family income (p=0.04). It is evident that a higher percentage of the adolescents with insufficient income had adequate compliance (74.4%), compared to 24.4% of those with sufficient income

Table 9 displays the relation between quality of life adolescents' socio-demographic characteristics and knowledge scores. It can be noticed that there is a positive correlation between quality of life score and duration of diabetes and the number of insulin injections (r= 0.332, 0.321; p= 0.001&0.001, respectively), while there is a negative correlation with number of hospital admission, (r= -0.342 &p= 0.001). While this table showed that there is no correlation between quality of life and knowledge scores (r=0.123& p=0.171).

Table 10 points in statistically significant relation between adolescents' compliance and their perception of barriers related to diet (p=0.006), and quality of life score (p=0.003).

Table 8. Relation between adolescents' compliance and their socio-demographic characteristics (n=80)

Table 9. Relation between quality of life, adolescents' socio-demographic characteristics and knowledge scores (n=80)

Table 10. Relation between adolescents' compliance, perception of barriers influence compliance, knowledge, and quality of life scores(n=80)

4. Discussion

Puberty is a period of rapid growth and hormonal changes and is often characterized by deterioration in glycemic control, and all of these factors may promote the development of diabetes complications [11]. Type 1 diabetes mellitus (T1DM) is a chronic disease requiring complex management, including blood glucose monitoring, insulin administration along with diet restrictions, which can have a negative impact on the quality of life (QoL) of adolescents [25]. As well as, diabetes can adversely affect both psychosocial and neurocognitive functioning, thus potentially affecting the life style of adolescent and the entire family [26].

The aim of this study is to investigate the relationship between compliance and quality of life among adolescents with diabetes mellitus type 1(DMT1).

The finding of the current study showed that the number of female participants is equal to the number of males. This reflects the fact that the both gender 's attendance to diabetic center without differences. The highest percentage of adolescents living in the urban areas this may because of the highest percentage of the adolescents visiting the clinic are from the Zagazig city. Furthermore, the sample clarifies that half of the participants had sufficient family income. These findings indicate that the diabetic adolescents are among worse and best economic situation. The highest percentage of adolescents were at age 10 to less than 16 years; this may be due to during this phase there is insulin insensitivity and higher HbA1c levels. More adolescents have long disease duration and the mean duration of type 1 diabetes was four years. Supporting this finding the previous studies of (Berg et al [27] and Hilliard et al [28]). Slightly more than half of fathers of studied adolescents are university educated, while the mothers arebasic/intermediate educated. Supporting this finding the previous study of Salem et al [29].

The finding of the current study showed that slightly more than half of adolescent had a moderate knowledge of diabetes mellitus. This result can be attributed to a lower status and quality education among the family members in Al-Sharkia Governorate. As well as, this may be due to misguiding of community health workers to provide health education about diabetes type I for adolescents whether in the schools and outpatient clinics.

This finding agreed to study conducted in UAE by Safari et al, [21] who assess of diabetes knowledge among adolescents and found that the highest percentage of adolescent had an average level of knowledge regarding diabetes. Also the study conducted in Kuwait by Al-Hussaini and Mustafa [22] who assess the adolescents’ knowledge and awareness of diabetes mellitus and showed that the adolescents had an average level of knowledge of diabetes. While this finding disagreed with the study conducted in Portugal by Flora and Gameiro [30] who identify the knowledge of adolescents with T1DM about the disease and found that the adolescents has a good level of knowledge regarding diabetes.

The finding of the current study showed that the highest mean score of knowledge domains as reported by adolescents was related to general knowledge about diabetes and the lowest mean score of knowledge was related to risk factors and complications domains. The results showed that adolescents had good general knowledge of the disease and knew that there are different types of diabetes affecting different ages. This could be explained by the high percentage of diabetes in Egypt. At the same time the adolescents were unaware that pregnancy is a risk factor and that pregnant women may become diabetic through pregnancy, it is still alarming and effort should be taken toward educating female adolescents regarding pregnancy induced diabetes. Where according to the culture in Egypt and, marriage at this age is common.

As well as the adolescents did not know that diabetes can progress to affect different organs in the body leading to deterioration in their function. Thus, it is very important to educate adolescents at early stages about diabetes complications. This will help them to encourage to comply with treatment in order to avoid some of the complications associated with diabetes.

This finding agreed with the study of Muninarayana et al [31] who identify the prevalence and awareness regarding diabetes mellitus in rural Tamaka and found that the lowest mean score of adolescents knowledge was related to risk factors and complications of diabetes. Also the study carried out in Saudi Arabia by Al-Mutairi et al, [32] who study the health beliefs related to diabetes mellitus prevention among adolescents and found that adolescents were less aware of the risk factors of TIDM. Again the study conducted by Al-Hussaini and Mustafa [22] who found that the highest percentage of adolescent knowledge domains was related to general knowledge about diabetes and the lowest score was related to complications. And the study carried out in Saudi Arabia by Alanazi et al, [33] who assess the knowledge and awareness of diabetes mellitus and its risk factors and found that the lowest mean score of adolescents knowledge was related to diabetes complications.

The finding of the current study revealed that the highest percentage of adolescent had inadequate levels of compliance to diabetes self-management. Cognitive development may contribute to an increase in non-compliance, also, immaturity of thought, in adolescence, based on invulnerability may be one of the main causes of inadequate compliance to diabetes treatment in adolescence. This finding agreed to study conducted in Egypt by Taha, et al [34] who assesses the factors affecting compliance of diabetic patients toward therapeutic management and found that most of subjects showing a low compliance level to diabetes self-management.

While this finding disagreed with study conducted in Egypt by Mahfouz and Awadalla [35] who study the compliance to diabetes self-management in rural El-MinIa and revealed that a good adherence level of diabetes self-management among adolescents. Again the study of the Flora and Gameiro [30] who found that most of adolescents showing a high adherence level to diabetes self-management.

The finding of the current study showed that the compliance of the adolescents in the present study was very variable. It was higher in certain areas as administered insulin and follow up possibly because this is a more technical activity about which the adolescents receive instructions since their diagnosis and are imbued with a sense of responsibility since their short-term well-being depends on the correct performance of this technique. The high compliance to follow-up is certainly attributed to obtaining the medications from the study setting. On the contrary adolescents compliance with self-care activities as diet, exercise, and blood glucose monitoring was low.

The low testing rates among these adolescents could probably be attributed to the lack of testing strips or fear of self-injection among the adolescents. It is also important to note that near from half of the adolescents had insufficient family income, and thus, testing strips could be difficult to access by most of adolescents due to cost. Type 1 diabetes adolescents are reported to have a poor adherence to dietary recommendations as their diets are characterized by high proportions of saturated fat and low fruit, vegetable, and fiber content. The low financial status of families could be one of the limiting factors to the provision of adequate diets to these type 1 diabetes adolescents. Also, this may be a result of children’s improper education by their diabetologist, nurse educators or dietitian and yet dietary education methods remain controversial and poorly evaluated. In addition to, the diabetes self-management behaviors such as diet and exercise involve and depend on guidance from a health care provider, meal preparation in a family context.

The finding of the current study agreed with the study of Miller et al [36] who assess the association between frequency of self-monitoring of blood glucose and hemoglobin A1c levels in T1D and found that the lowest adherence to diabetes care recommendations among adolescents with type 1 diabetes was related to blood glucose monitoring and diet recommendations. Also the study conducted in Saudi by Moawad et al, [11] who assess the knowledge of diabetic children/ adolescent at Riyadh city and found that the a lowest adherence of adolescents to diabetes care recommendations was related to exercise recommendation.

While this finding disagreed with the study conducted in Uganda by Kyokunzire and Matovu [37] who assess the factors associated with adherence to diabetes care recommendations among children and adolescents with type 1 diabetes and found that the a higher adherence of adolescents was related to blood glucose monitoring and diet recommendations.

The factors influence on compliance of adolescents to diabetes management in the current study were mostly family influence and financial ones. The family influence ones were related to diet, exercise, follow up , and insulin administration. These barriers are commensurate with the generally low socioeconomic characteristics of the adolescents in the study sample, They may perceive more difficulties in following dietary and medication regimens for a long-term disease as DM. Meanwhile, the barrier that had the most significant impact on compliance of the patients in the present study was that related to diet.

This finding agreed with the previous studies of Greene [38], Palmer et al, [39] and Mlynarczyk [40] they mentioned that the family influence is a well-established factor contributing to adherence in youth with T1D. Parent-adolescent relationships characterized by warmth and support for diabetes management are associated with better adherence to treatment. Also the study of Valenzuela et al, [12] who found that the cost of care provided was the major barrier that influence on compliance of adolescents to diabetes management. In congruence with these findings, dietary adherence has been consistently viewed as the most difficult aspect of the diabetes regimen Cox and Hunt, [41].

The finding of the present study revealed that the only factor that constituted a financial barrier to adolescents' compliance in the current study was that of investigations. The majority of adolescents perceived this barrier, which might be attributed to the high cost of such investigations that might not be available in the study setting. Supporting this finding Taha, et al., [34].

According to the present study findings, adolescents with insufficient income tended to be more compliant to diabetes management, compared to those with sufficient income. This might be explained by the fact that higher income adolescents have more potential to consume more food, especially sweets and candies; such items may not be available to those with insufficient income. In support of this finding, the study of Ingerski et al, [42] who found that the adolescent with higher socioeconomic levels are more likely to less compliance to diabetic management. Also the study of Palladino and Helgeson [43] who found that the socioeconomic conditions of adolescents with type I diabetes influence on their compliance to diabetic management.

The findings of the present study showed that the highest percentage of adolescents with Type 1 Diabetes perceived their quality of life as low. This may be due to the intensive health care routine they need to follow rigorously, as well as the lower quality of life may be related to stronger beliefs of diabetes consequences and negative emotional representations.

This finding agreed with the study carried at Jordanian by Al-Akour et al, [44] who assess the quality of life and associated factors among adolescents with Type 1 Diabetes mellitus and found that the adolescents perceived their quality of life as low. Again the study of Kalyva et al, [15] who assess the health related quality of life of children and adolescents with Type 1 Diabetes and found that the adolescents perceived their quality of life as poor. Also the study conducted in Kuwait by Abdul-Rasoul et al, [16] who assess the quality of life of children and adolescents with Type 1 Diabetes and found that adolescents perceived their quality of life as low. In the same line, the study conducted at Brazil by Garabeli et al [45] who evaluate the quality of life (QoL) and glycemic control of Type 1 Diabetes patients being treated with insulin analogs and receiving medication review with follow-up and found that the adolescents with Type 1 Diabetes tend to have a lower quality of life. While this finding disagree with Özyazıcıoğlu et al, [46] who found that the quality of life of adolescent with type I diabetes were generally shown to be at a good level.

The present study revealed that the impact of diabetes was readily apparent affecting physical, school functioning of the adolescents. The lowest mean score of quality of life domains was related to impact of diabetes was 76.1±9.3 which was nearly equal to the finding of Abolfotouh et al, [47]. This may be due to the diabetes was impact on physical activity of adolescent as feel physically ill, influence on adolescents miss school because of diabetes, as well as the embarrassment felt by the adolescent. It has been suggested that diabetes may slow psychological development of adolescents. The second domain of quality of life was worry about diabetes, the total mean score of worry was 85.3± 11.3 this may be due to most of diabetic adolescents were worried more about occurrence of complications, their bodies look different because of diabetes. Supporting the finding of Monazea et al., [26].

The highest domain of quality of life was satisfaction with life and management. The study revealed that the total mean score of satisfaction was 90.8±10.5. The diabetes satisfaction items overlap with content in the other scales of worry and impact. This poses challenges about how to manage discrepancies between satisfaction and impact or worry. Satisfaction is a discrepancy measure, the discrepancy between expectation and experience, posing difficult interpretation. This finding means that type 1 diabetes did not affect social life. In Egyptian culture, such factors as the high regard for children and support from the extended family may help the child to face problems from outside the family this gives the explanation for this result. Supporting the finding of Lukacs et al [48].

An additional analysis was also performed to observe if the gender and age variables are associated with the knowledge about the disease. In relation to gender, this association was not confirmed, whereas age seems to be directly associated with the adolescents’ knowledge about the disease, which may be justified by the level of intellectual and cognitive development and maturity. These results agreed with Flora and Gameiro [30] who found that there was significant differences being found between knowledge score and age of adolescent, while no significant differences being found with the gender of adolescent.

Concerning factors associated with QOL, the study found that no significant association between total QOL score and age, gender, residence, and family’s income. This mean the fact that adolescents manage their disease more subjectively and independently without the differences in the age and gender, and the half of adolescents had sufficient family income and there is no difference between care provided to adolescent in urban and rural areas, In addition to the existence of a health insurance system. These findings agreed with the study of [25] Kumar et al, [25] who found that the girls diabetic adolescents had total score QOL less than boys but with no significant difference. Again the study of Lindsay et al [49] who found no correlation between diabetes related QOL and residence among adolescents.

While this finding disagree with the study ofKalyva et al. [15] who found that as the age of the onset of diabetes increased and quality of life was higher than in the younger age group. Also the study of Urzúa, et al, [50] who reported gender-specific differences in the QoL perception, and girls usually score higher when compared to boys. Again the study of Pisimisis [51] who assess the quality of life of people with Diabetes Mellitus in Greece and found that the family income is an identifiable risk factor for poor quality of life among adolescents. In addition to the study of [46] Özyazıcıoğlu et al [46] who found that there was a positive relationship between the adolescent's age and the quality of life.

The finding of the present study demonstrated that there was a significant relationship between total score of QOL and duration of diabetes, and the number of insulin injections/day, also there was a negative significant relationship with the number of hospital admission. While the frequency of hypoglycemic episodes was not significantly associated with the QOL. The explanation for this result frequency and number of admissions to hospital had a negative impact on social, school life and family life of diabetics, longer duration of diabetes was associated with more psychological and behavioral problems and worse QoL.

Supporting the finding Abolfotouh et al [47] who reported that poorer QOL was significantly associated with more hospital admission in the last 6 months. These findings agreed with the studies of Al-Akour et al, [52]; Petersson et al, [18] they found a relationship between quality of life and the duration of the diabetes among adolescents. Also the study of Abdul-Rasoul et al [16] who found that there was a significant relationship between insulin regimen and QoL among adolescents. While these results are disagreed with previous studies of Lopez et al, [53], Orozco-Beltrán et al, [54]); Östenson et al [55] that highlighted the impact of hypoglycemia on quality of life among adolescents.

The finding of the current study showed that there was no a statistically significant difference between adolescents’ knowledge score regarding diabetes disease and their compliance to diabetes management. While there was a statistically significant difference between quality of life score and adolescents' compliance to diabetes management, but there were no differences with the knowledge score. This results indicates that the control of blood glucose levels and decision-making are associated with the parents’ knowledge about the disease but are not correlated with the adolescents’ knowledge. Also, this may be due to lack of knowledge about the disease can affect metabolic control in adolescents. As well as when the adolescent more compliance to diabetes management this influence on their quality of life.

This finding agreed with the study of Malipa and Menon [56] who found that there was no a statistically significant difference between adolescents knowledge score regarding diabetes disease and their compliance to diabetes management. Again the study of Saleh et al, [57] who demonstrated a relationship between adolescents compliance to diabetes management and quality of life. Also the study of Kueh et al [58] who assess the knowledge, attitudes, self-management, and quality of life among Australian adolescent with type I diabetes and found that the diabetes knowledge was not a significant predictor for compliance to diabetic management among adolescents. And the adolescents compliance to diabetic management was a significant predictor of impact on quality of life. The same author found that there was no significant relationship between diabetes knowledge and QoL.

5. Conclusion

Based on the findings of the present study, it can be concluded that there was a statistically significant difference between quality of life score and adolescents' compliance to diabetes management.

6. Recommendations

In the light of the findings of the current study, the following recommendations are suggested:

1- Cooperate with Mass media should have an increasing role in diabetic education.

2-Conduct educational program for adolescents and their parents to increase the level of their knowledge and compliance for diabetes management recommendations to improve QOL for all diabetic adolescents.

3-The Ministry of Education improves the curriculum to include diabetes mellitus education in the curriculum of primary, preparatory and secondary school students; as this would go a long way in educating them about these disease entities which in turn will help in the prevention of modifiable risk factors.

4-World Diabetes Day should be celebrated in all schools and workshops and lectures given by Faculty Nursing Teaching Staff in collaboration with the Ministry of Health on this day are recommended to increase the level of awareness of diabetes.

5-Additionally, the barriers perceived by these adolescents need to be addressed, especially the costs of investigations.

7. Further Researches

-Develop and refine interventions to improve compliance of diabetic adolescents and to assess the effectiveness of removing perceived barriers on their compliance.

-Assess the effectiveness of health education on the quality of life among diabetic adolescents and their compliance for diabetes management.

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