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Journal of Pediatric Psychology logoLink to Journal of Pediatric Psychology
. 2022 Feb 15;47(6):714–722. doi: 10.1093/jpepsy/jsac004

Parental Relationships, Patient-Centered Communication With Healthcare Providers, and Diabetes Management Across Emerging Adulthood

Cynthia A Berg 1,✉, MaryJane Simms Campbell 2, Robert G Kent de Grey 3, Jonathan E Butner 4, Mary Murray 5, Deborah J Wiebe 6
PMCID: PMC9425845  PMID: 35167698

Abstract

Objective

To examine whether yearly fluctuations in acceptance from and disclosure to parents were associated with fluctuations in perceptions of patient-centered communication (PCC) with the healthcare provider and whether fluctuations in PCC were associated with self-efficacy, type 1 diabetes self-care, and HbA1c across four annual assessments during early emerging adulthood (EA).

Methods

A total of 228 high school seniors (M age = 17.76 years at time 1) reported on mothers’ and fathers’ acceptance and diabetes-related disclosure to parents, diabetes self-care, and PCC once per year for 4 years. HbA1c was collected from assay kits.

Results

Multilevel models revealed within-person associations such that in years when individuals reported greater maternal acceptance than their average, they reported higher PCC. In addition, between-person differences indicated that individuals who reported more maternal acceptance on average relative to others also perceived greater PCC. Similar associations were found for EAs’ reports of fathers. No significant effects were found for disclosure to either mother or father. Yearly fluctuations in PCC were associated with self-efficacy such that in years when perceived PCC was higher, self-efficacy was higher. Between person-effects were found for self-efficacy, self-care, and HbA1c such that individuals who reported more PCC on average relative to others reported higher self-efficacy, better self-care, and lower HbA1c.

Conclusions

Aspects of EA’s relationships with parents fluctuate with perceptions of PCC with healthcare providers. Perceived PCC with the healthcare provider may be important in higher self-efficacy, diabetes self-care, and lower HbA1c across the early EA years.

Keywords: emerging adulthood, parent involvement, patient-centered communication, type 1 diabetes

Diabetes management across emerging adulthood (EA) is characterized by many changes including a decline in parental involvement in diabetes-related tasks (Majumder et al., 2017) and the transition from pediatric to adult medical care, which frequently involves a change in one’s healthcare provider. EA is typically characterized as occurring across the ages of 18–30, with the early part of this period most challenging for diabetes management (Peters & Laffel, 2011). These changes may contribute to the increases in HbA1c seen during this time period, making early EA a high-risk time for diabetes management (Miller et al., 2015). Growing evidence indicates that maintaining a warm and accepting relationship with parents, where EAs disclose to their parents about diabetes management, is linked with better self-care and HbA1c during EA (Berg et al., 2019; Helgeson et al., 2018).

The developmental literature indicates that accepting relationships with parents provide the context for EAs to disclose to parents about their activities and may be associated with how EAs interact with others in their network (friends, romantic partners) (see Berg et al., 2017), including with their healthcare provider. Our developmental coordination model suggests that changes across EA in the parent–child relationship may be coordinated (show consistent temporal patterns across time) with changes in relationships with their healthcare provider (Berg et al., 2017). That is, the acceptance developed within the parenting relationship may be coordinated with perceptions that EAs maintain and develop of their healthcare provider (Baker et al., 2019; Berg et al., 2017). A common way to assess the patient–provider relationship is through patient perceptions of patient-centered communication (PCC, see Wiebe et al., 2020). PCC is characterized by patient perceptions of a supportive and autonomy-promoting communication style where patients feel comfortable sharing health information with providers and empowered to collaborate on treatment decision-making (Wiebe et al., 2020; Williams et al., 2005). Such perceptions likely reflect a number of different components including the EA’s perception of what the doctor and what the EA brings to the relationship, as well as what the patient and doctor create in the interaction. We posit that patient perceptions of PCC reflect the lens that the patient brings from their broader interpersonal parental experiences. Evidence for this idea comes from Baker et al. (2019) who found in the present sample that in the first year after high school, an accepting relationship with mother was associated concurrently with greater PCC with the healthcare provider. In a sample of adolescents, Goethals et al. (2020) found that reports of parents’ autonomy-supportive communication were associated with autonomy-supportive communication with the healthcare provider. These findings are consistent with Ciechanowski et al. (2004) who found that adults’ reports of secure attachment with parents were associated with better healthcare provider relationships for adults with type 2 diabetes.

Accepting relationships with parents are also associated with greater disclosure by adolescents to parents (Berg et al., 2017) and could translate into higher PCC with one’s healthcare provider as the young adult may be more experienced in sharing their diabetes management with others. Such disclosure to parents may also translate into greater sharing of information in the healthcare visit when parents still attend the visit with their late adolescents. As relationships with parents are changing across EA (Berg et al., 2019), changes in the parent–child relationship may fluctuate with the EA’s perceptions of PCC with the healthcare provider.

We know very little about the development of PCC with one’s healthcare provider across the EA years. The development of PCC with the healthcare provider may be especially important during EA as individuals become more independent from their parents in their diabetes self-management and establish new relationships with healthcare providers (Baker et al., 2019; Peters & Laffel, 2011). Although most EAs transition to adult care, they often report challenges in establishing this new relationship with adult healthcare providers (Hilliard et al., 2014). In a cross-sectional analysis of the present sample, Baker et al. (2019) found that PCC was more strongly linked to self-efficacy for diabetes management among EAs who had transferred to adult care in the year after high school compared to those who had remained in pediatric care. Thus, PCC may be especially important as EAs transition to new relationships with adult care providers given the challenges that EAs report in establishing this new relationship.

Although perceptions of PCC have traditionally been examined as an individual difference of the perceptions the person with diabetes holds of their healthcare provider, PCC may fluctuate across time together with parental relationships. In the present sample, we have reported previously significant within-person variability in maternal acceptance across time (Berg et al., 2019). Further, parental acceptance may change even across days (Bai et al., 2017). Fluctuations in parental acceptance and disclosure to parents could occur as EAs begin to leave the family home and have less daily exposure to parents (Akın et al., 2020). If parental relationships are coordinated with the perceptions that EAs have of PCC, within-person associations between parental relationships and PCC would be expected. During times when EAs experience an accepting relationship with parents with greater disclosure regarding diabetes management, they may also feel more comfortable being open with their healthcare provider. An important contribution of the present study is to separate between-person individual differences from within-person fluctuations in parental acceptance and disclosure to parents and PCC across the early years of EA. Understanding such fluctuations may open up new avenues for intervention that address the malleable nature of the healthcare relationship and how it exists in the context of other important relationships such as parents.

Understanding fluctuations in perceived PCC across EA is important as PCC is associated with higher perceptions of competence and self-efficacy for diabetes management, as well as better self-care and HbA1c among adults (Wiebe et al., 2020). For example, Williams and colleagues found autonomy support in patient–provider interactions among adults with type 2 diabetes predicted increased perceptions of diabetes-related competence, which mediated improvements in self-care and HbA1c over time (Williams et al., 1998, 2005). Although little longitudinal data exist for individuals with type 1 diabetes, Croom et al. (2011) found that PCC reported by adolescents with type 1 diabetes was associated with higher self-efficacy after the clinic visit, which in turn predicted improvements in self-care and metabolic control 6 months later. Similarly, in analyses using the second time point of the present sample (when early EAs had begun to change to adult care), Baker et al. (2019) found that higher perceived PCC was associated cross-sectionally with higher self-care through higher diabetes-related self-efficacy.

The present study examined perceptions of PCC across the transition into EA. First, we examined whether fluctuations in acceptance and disclosure to mother and father were associated with fluctuations in PCC (within-person effects) over and above between-person associations. We anticipated that at time points when EAs experienced higher acceptance from their parents and were disclosing more to parents they would also report higher PCC above and beyond between-person effects across the years. As mothers are most frequently involved in daily care (Berg et al., 2019) and in attending healthcare visits (Markowitz et al., 2014), we predicted that aspects of the mother–EA relationship might be especially important. Second, we examined whether fluctuations in PCC were associated with self-efficacy and diabetes outcomes across EA over and above between-person associations. We expected that at time points when perceived PCC was higher, EA would report higher self-efficacy, higher self-care, and lower HbA1c.

Methods

Participants

The present study was a secondary analysis of data from a larger multisite longitudinal project examining type 1 diabetes management from late adolescence into early EA (see Berg et al., 2019). Participants were high school seniors with type 1 diabetes and their mothers and fathers who were recruited from outpatient pediatric endocrinology clinics in two southwestern U.S. cities. Participants were eligible if they had been diagnosed with type 1 diabetes for at least 1 year (M time since diagnosis = 7.35 years, SD =3.88), were in their final year of high school, lived with a parent or parent figure at baseline (68.4% lived with both biological parents, 27.1% with one biological parent, 4.5% with adoptive parents or grandparents), would be able to have regular contact with parents throughout the duration of the study, and had English as their primary language. Of the qualifying 507 individuals approached, 301 (59%) agreed to participate, of which 247 (82%) enrolled in the study (see Berg et al., 2019). At baseline, 236 participants had complete survey data, 62% were female, 43% reported using an insulin pump, average HbA1c was 8.27 (SD = 1.62), 75.2% identified as non-Hispanic White, 14.2% as Hispanic, and 4.8% as African American. Participants completed study procedures for 4 years (Time 2 N = 216, Time 3 N = 211, Time 4 N = 179). Eight participants reported that they did not have a father figure to report on at any time point. To maintain consistent samples across mother and father analyses, these participants were dropped from analyses (thus, the analyses include 228 participants, mean age = 17.76, SD = .39 at baseline). The majority of individuals (75.4%) lived outside of the parental home during at least one of the years of the study.

Procedure

Participants ages 18 and older provided written consent and those ages 17 and younger provided assent (and later consent when they turned aged 18) and a parent provided permission. Participants were compensated $50 for the first two assessments and $75 for the last two. All study procedures were approved by the IRB.

Measures

Demographics and Illness Information

Age, gender, ethnic status, length of diagnosis, whether the young adult lived in the parental home, and whether the individual used a pump were gathered from a questionnaire.

Parental Acceptance

Emerging adults’ perceptions of mothers and fathers were measured separately via the five-item acceptance subscale from the Mother-Father-Peer scale (Epstein, 1983). Items (e.g., “My [mother/father] gives me the feeling that she/he likes me as I am, [she/he] doesn’t feel he has to make me over into someone else”) were rated on a 1 (strongly disagree) to 5 (strongly agree) scale. This scale had strong reliability, ranging from α = .81 to .87 for reports of mothers and α =.81 to .90 for reports of fathers across the four time points.

Diabetes Disclosure

Emerging adults completed three diabetes disclosure items developed by Osborn et al. (2013), based on items by Stattin and Kerr (2000) and factor analyzed by Frijns et al. (2010) separately on mothers and fathers (e.g., “I spontaneously tell my [mother/father] about what is going on with my diabetes management,” measured on a 1 (strongly disagree) to 5 (strongly agree) scale). Reliability ranged from α = .83 to .90 for perceptions of mother and .88 to .93 for perceptions of father across the four time points.

Patient-Centered Communication

Emerging adults completed the Modified Health Care Climate Questionnaire (Williams et al., 1998), which includes five items that assess perceptions of PCC with their health provider (e.g., My doctor listens to what I think before setting treatment goals; encourages me to ask questions about managing my diabetes) rated on a 1 (strongly disagree) to 5 (strongly agree) scale, with higher average scores indicating higher PCC. Strong internal consistency has been found among adults (α = .82; Williams et al., 1998) and adolescents with diabetes (α = .77; Croom et al., 2011, supported by factor analysis of the scale). Reliability ranged from α = .91 to .92 across the four time points in the present study.

Self-Efficacy

The Self-Efficacy for Diabetes Management Scale (Iannotti et al., 2006) is a 10-item scale that assesses confidence in managing diabetes across 10 situations (e.g. “How sure are you that you can manage your diabetes even when you feel overwhelmed?”), rated on a 1 (not sure at all) to 10 (completely sure) scale. To capture situations relevant to EAs, four items were added (i.e., How sure are you that you can make doctor’s appointments, deal with insurance, check diabetes supplies, and fill your prescriptions?). These four items correlated highly with the original 10-item scale at baseline (r=.55, p < .01). This scale has strong reliability ranging from α = .88 to .89 across the four time points.

HbA1c

Glycated hemoglobin (HbA1c) was obtained at all time points via mail-in kits (processed by CoreMedica Laboratories, www.coremedica.net). This approach was selected over obtaining HbA1c from medical records to ensure that the same procedures were used across time points, and HbA1c could be obtained from those who were not currently under routine care with a healthcare provider. At baseline, EAs completed the kit after receiving instructions from an assistant who observed test completion. This measure was highly correlated with point-of-care HbA1c assays in medical records at baseline (r = .74, p < .001).

Self-Care

Emerging adults completed the Self-Care Inventory (La Greca et al., 1990) to measure adherence to diabetes tasks over the past month. Items were rated from 1 (never did it) to 5 (always did this as recommended). Scores were averaged for the present analyses. Internal consistency ranged from α.=77 to .83 across the four time points.

Change in Healthcare Provider

At each time point, participants were asked whether they had experienced a change in their healthcare provider from their prior time point and the name of their physician. This information was used to assess whether the person had changed physicians across the time of the study, with 0 reflecting maintaining the same healthcare provider across time (i.e., remaining with their pediatric care provider at all time points) and 1 indicating that they changed their provider across time (i.e., transitioning to an adult provider or a different provider). Although we had intended to capture the time point at which transition to adult care occurred, missing data prevented us from characterizing annual changes in healthcare provider with confidence. One provider allowed EAs to remain in his practice across time and another provider had both a pediatric and adult practice (coded as no change in physician), likely creating inconsistencies in how EAs answered our questions. Eighty percent of EAs reported transitioning to adult care at some point across the 4 years.

Analytic Plan

Missing data ranged from a low of 0% (gender) to a high of 20.8% for report of fathers’ acceptance. To account for missing data, we generated 10 datasets through multiple imputation (MI) (Graham, 2008) via IBM SPSS (Version 25; IBM Corp., 2017), estimating data for those missing a variable at a time point and for those who skipped a time point but remained in the study. MI was chosen over maximum likelihood estimation to be consistent with the systematic data approach in the larger study. MI included variables beyond those in the present analyses to ensure an adequate missing-at-random model. Across all analyses, the lowest efficiency was .92, indicating that the 10 datasets adequately recovered the missing data. All analyses examined effects separately for gender, ethnicity, time since diagnosis, and pump status with three variables showing significant effects for HbA1c only (males had higher HbA1c than females, p < .05, non-Hispanic participants had lower HbA1c than Hispanic participants, p < .05, and those on a pump had lower HbA1c than those not on a pump, p < .01); these variables were included as covariates in analyses for HbA1c. The covariate of whether individuals lived in the parental home across years in all models was included in initial models, but removed as it was nonsignificant in each analysis (p > .27).

All analyses used multilevel models via IBM SPSS Mixed (Version 27; IBM Corp., 2020). All models included both within-person (yearly) and between-person (average across the 4 years) effects (see Hoffman & Stawski, 2009), with person centering at Level 1 and grand centering at Level 2. Random effects were included for within-person variables and the intercept.

For analyses examining whether yearly fluctuations in acceptance and disclosure were associated with changes in perceptions of PCC, analyses included PCC as the dependent variable and person-centered and grand-centered acceptance and disclosure, Year (with time 1 coded as 0) and whether the person changed doctors across years as independent variables. Separate models were performed for individuals’ perceptions of mothers and fathers.

Finally, to examine whether PCC was associated with self-efficacy, self-care, and HbA1c, we estimated similar multilevel models with perceived PCC as the independent variable and self-efficacy, self-care, and HbA1c as separate yearly dependent variables. Covariates on the intercept for HbA1c included gender, ethnicity, and pump status.

Results

Preliminary Analyses

Means and standard deviations of all study variables at time 1 are in Table I. Random intercept models to examine within- and between-person variability to calculate intraclass coefficients, a metric of between-person variance, indicated that for each variable, less than half of the variance was between-persons. The substantial within-person variability in all variables supports the multilevel analyses that were conducted.

Table I.

Descriptive Statistics at Time 1 and Intraclass Correlation Coefficients for Primary Study Variables

Variable Mean (SD) Range ICC
PCC 4.09 (0.84) 1–5 0.19
Mother acceptance 4.34 (0.87) 1–5 0.37
Father acceptance 4.28 (0.91) 1–5 0.45
Mother disclosure 3.22 (0.96) 1–5 0.46
Father disclosure 2.98 (1.03) 1–5 0.49
Self-efficacy 6.84 (1.64) 2.14–9.93 0.44
Self-care 3.98 (0.59) 2–5 0.39
HbA1c 8.27 (1.66) 4.40–14.10 0.45
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Note. ICC = intraclass coefficient; PCC = patient-centered communication.

Fluctuations in Parental Involvement and PCC Across Time

Multilevel models predicting PCC from maternal acceptance and disclosure revealed significant within- and between-person associations of acceptance with PCC (Table II). The within-person effect indicates that in years when EAs reported greater maternal acceptance than their own average, they reported higher PCC. Further, the between-person effect indicates that EAs who reported more maternal acceptance on average relative to others also reported greater PCC. No within- or between-person effects were found for disclosure to mothers. The analyses for fathers revealed similar within- and between-person effects. No significant effects of year or change in healthcare provider were found. The only significant random effect was on the intercept, indicating significant variation in PCC across individuals at time 1.

Table II.

Multilevel Models Predicting Perceived PCC from EAs’ Reports of Parental Acceptance and Disclosure

Mothers
Estimate (SE) Random effects
Intercept 4.10 (.07)** .17**
Year .01 (.03)
Within-person maternal acceptance .15 (.07)* .08
Between-person maternal acceptance .27 (.08)**
Within-person diabetes disclosure .08 (.07) .07
Between-person diabetes disclosure .06 (.05)
Physician change −.15 (.11)
Pseudo R2 19.7%
Fathers
Intercept 4.09 (.07)**
Year .00 (.03) .18**
Within-person paternal acceptance .16 (.07)* .12
Between-person paternal acceptance .29 (.08)**
Within-person diabetes disclosure .10 (.06) .09
Between-person diabetes disclosure −.01 (.05)
Physician change −.14 (.12)
Pseudo R2 21.4%
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Note. Pseudo R2 is the % variance in PCC accounted for by the entire model, calculated as the ratio of the variance in the predicted values divided by the variance in the original variables.

*

p < .05.

**

p < .01; Year (time 1 = 0); Physician change (0 = no change, 1 = change).

Fluctuations in PCC and Self-Efficacy, Self-Care, and HbA1c Across Time

Multilevel models predicting self-efficacy revealed significant within-person and between-person associations of perceptions of PCC with self-efficacy (see Table III). The within-person effect indicates that in years when EAs reported higher PCC than their own average, they also reported greater self-efficacy. The between-person effect indicates that EAs who reported more PCC on average relative to others displayed higher self-efficacy. A significant year effect indicated that self-efficacy increased across years. A significant random effect only existed on the intercept indicating that self-efficacy varied across individuals at time 1.

Table III.

Multilevel Models Predicting Self-Efficacy, Self-Care, and HbA1c From Perceived PCC

Independent variable Self-efficacy
 Self-care
 HbA1c
Estimate (SE) Random effects Estimate (SE) Random effects Estimate (SE) Random effects
Intercept 6.80 (.15)** 1.19** 3.93 (.05)** .14** 9.11 (.42)** 1.35**
Year .23 (.07)** .06 −.01 (.02) .01 .31 (.06)** .24**
Within-person PCC .25 (.08)** .10 .07 (.04) .02 −.11 (.10) .16
Between-person PCC .58 (.16)** .22 (.06)** −.43 (.18)*
Physician change −.09 (.26) .12 (.10) .23 (.32)
Gender .33 (.21)
Ethnicity −.55(29)
Pump status −.43 (.17)*
Pseudo R2 42.7% 35.4% 39.6%
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Note. PCC = patient-centered communication.

Gender (−.5 = females, .5 = males), Ethnicity (−.5 = Hispanic, .5 = Non-Hispanic), Pump (−.5 = no pump, .5 = pump).

*

p < .05.

**

p < 01.

Similar multilevel models predicting self-care and HbA1c revealed only between-person differences such that EAs who reported more PCC on average relative to others reported higher self-care and lower HbA1c. Significant random effects were found on the intercept for both self-care and HbA1c, indicating significant variation across individuals and on year for HbA1c, indicating that individuals varied in how much they increased in HbA1c across time.

Analyses were also conducted to examine the combined effect of parental acceptance and PCC in predicting self-efficacy, self-care, and HbA1c (see Table S1 supplemental analysis). Across outcomes, sometimes PCC only predicted the outcome (predicting self-efficacy from mother acceptance and PCC), sometimes mother or father acceptance only predicted the outcome (e.g., HbA1c), and sometimes both predicted the outcome (e.g., fathers’ acceptance and PCC predicting self-care). The covariation between parental acceptance and PCC revealed in the first set of analyses is likely contributing to this complicated set of findings.

Discussion

In early EA, fluctuations occur in the quality of EAs’ relationships with their parents and their healthcare provider, as well as in their self-efficacy, self-care, and HbA1c. The majority of the variance in these variables across the 4 years was within-person as opposed to between-person, indicating that there is a great deal of change in variables that are often characterized in the literature as individual differences. Very little research has followed aspects of parent–child relationships across EA, with the developmental literature indicating that parent–child warmth declines across EA among healthy individuals, although there is high relative stability across time (Parra et al., 2015). The within-person variability in these variables indicates the value of examining aspects of the parent–child relationship and healthcare provider as well as diabetes management across time, consistent with the view of EA as a period of change (Peters & Laffel, 2011). Variations in the parent–child and healthcare provider relationship across these 4 years may be associated with transitions such as moving out of the parental home, beginning college, the development of committed romantic relationships (Aquilino, 1997), as well as changes in their healthcare.

EAs reported that their healthcare provider displayed high levels of PCC on average, although there was quite a range with some individuals reporting low PCC. Perceptions of PCC did not differ as a function of whether the EA reported changing healthcare providers across the 4-year study period. This was somewhat surprising as the majority of individuals indicated that they experienced a change of providers across time, suggesting that variables other than a change in healthcare provider are affecting how EAs perceive PCC.

Yearly fluctuations in parental acceptance were related to fluctuations in perceptions of PCC over and above individual differences in parental acceptance. The importance of parental acceptance is consistent with work linking PCC to a nonjudgmental and accepting style of communication that deals with a patient’s feelings and concerns (Saha et al., 2008). Simms et al. (2017) in a qualitative study found that young adults value warmth, positivity, and engagement with healthcare providers. A growing literature indicates that the parent–child relationship continues to play an important role in diabetes management across the early years of EA (Berg et al., 2019; Helgeson et al., 2018), and the present results extend that role to developing or maintaining a collaborative relationship with the healthcare provider.

The fact that acceptance was uniquely predictive over disclosure points to the importance of the affective tone of both parent–EA relationships and healthcare provider relationships. It is possible that the unique role of parental acceptance in these relationships is because acceptance is the foundation for disclosure to occur (Berg et al., 2017). Parental acceptance also fosters independence and autonomy and is associated with numerous markers of adulthood such as leaving the family home (Akın et al., 2020) and well-being (Mendoza et al., 2019). When EAs feel accepted by their parents, this likely facilitates autonomy and self-efficacy that sets the EA up to advocate for themselves in the healthcare relationship. Supplemental analyses including EAs’ perceptions of both mother and father acceptance and PCC revealed a complicated set of findings predicting diabetes outcomes, with future research needed to understand when parental acceptance versus PCC or both may predict such outcomes.

The present findings extend previous research demonstrating benefits of PCC for self-efficacy, self-care, and HbA1c in adolescence (Croom et al., 2011) to EA. Baker et al. (2019) found in the present sample that PCC at time 2 was concurrently associated with higher self-efficacy, self-care, and lower HbA1c. The current findings reveal that yearly fluctuations in EAs’ perceptions of PCC are associated with better self-efficacy and that EAs reporting higher PCC on average reported higher self-care and had lower HbA1c. Further, self-efficacy increased across the 4 years, which might be reflective of emerging adults’ increased autonomy and independence for diabetes self-care during this time. The results that the relationships of PCC with self-care and HbA1c only occurred between-persons rather than within-persons suggests that yearly fluctuations in self-care and HbA1c are affected by variables other than PCC. Our prior work with this sample indicated that yearly fluctuations in mothers’ and fathers’ knowledge of the young adults’ diabetes activities were related to lower HbA1c, with such knowledge likely affecting the support that parents may provide (Berg et al., 2019). Fluctuations in other variables, such as self-regulation and attending regular healthcare visits, could be more important for self-care and HbA1c during EA than PCC. The fact that a minority of the variance was accounted for in the dependent variables by all models (i.e., pseudo r-squared) indicates that much of the variance in self-efficacy, self-care, and HbA1c are not explained by PCC.

The present findings should be interpreted in the context of some limitations. First, our measure of PCC was a brief measure and was not able to capture multiple facets of PCC. EAs report that they desire communication that is warm, positive, supportive, and engaging (Simms et al., 2017) as well as autonomy-supportive (Goethals et al., 2020). Although such desired characteristics of healthcare providers are likely correlated with PCC, future research is needed that examines their associations with diabetes outcomes during EA. In addition, the present study focused on the perceptions of PCC by the EA, perceptions that may differ from those of the healthcare providers themselves (Croom et al., 2011; Michaud et al., 2018) or from objective measures. Further, measures of parent–child relationship, PCC, and self-care were self-report measures and would benefit from replication using more objective metrics (e.g., coding of actual interactions between parent–child and patient–provider, self-care). Finally, we were not able to definitively assess whether the EA changed physicians across years as we relied on the EA’s report. Although we asked EAs to indicate if they had transitioned to “adult care” and to indicate their physician’s name, only roughly half responded in a way that was consistent. EAs often experience gaps in clinical care (Garvey et al., 2016) and maintain some connection with the pediatric provider for prescription refills. Such prolonged transitions potentially affected EAs’ consideration of who their doctor was and if they had transitioned to adult care. Although we did try to verify EA’s responses with clinic records, missed clinic appointments that are characteristic of EA prevented us from confidently verifying their responses. Supplementing self-report with medical claims data would be helpful in future research.

The results have potential clinical implications for EAs, their parents, and their healthcare providers. Fluctuations in mother and father acceptance that are coordinated with perceived PCC with one’s healthcare provider indicate that both relationships are changing during EA and malleable. The healthcare provider relationship exists in a broader context of the other relationships of the EA, which may open new ways to intervene to improve the healthcare provider relationship. For instance, teamwork approaches where parents, EA, and the healthcare provider work collaboratively to support diabetes management have worked well during adolescence (Anderson et al., 1999) and have been suggested in family-based approaches to transition of care during EA (Weissberg-Benchell & Shapiro, 2017). Establishing and maintaining accepting parent–EA relationships and a patient-centered patient–provider relationship may provide the foundation that is needed to work through some of the challenges facing EAs, including meeting glycemic targets and preventing complications. Having a parent attend the first adult transition visit with the healthcare provider is reported by nearly one-half of adult physicians (Garvey et al., 2016), which could provide important information about the broader family system and long-standing relationships that may provide opportunities for developing PCC with EAs.

Future research is needed to ascertain mechanisms of action linking parent–EA relationships, perceived PCC, and diabetes management through time. Parent–EA relationships may serve as a foundation for emerging adults’ abilities to develop a strong relationship with their healthcare providers. Such PCC may lead to higher self-efficacy, self-care, and lower HbA1c, consistent with Williams’ et al. (2005) self-determination theory. Alternatively, these variables may be coordinated and change together through time in a more dynamic fashion (Berg et al., 2017). Future research examining parent–EA relationships, the healthcare provider relationship, and diabetes self-care across multiple time points per year with self-report and objective markers will be important in examining these complex relationships.

Supplementary Data

Supplementary data can be found at: https://academic.oup.com/jpepsy.

Funding

The data used in this study was supported by a grant from the National Institutes of Diabetes and Digestive and Kidney Diseases DK092939 awarded to Cynthia A. Berg and Deborah J. Wiebe. Data are available upon request.

Conflicts of Interest

None declared.

Supplementary Material

jsac004_Supplementary_Data
Click here for additional data file. (13.7KB, docx)

Contributor Information

Cynthia A Berg, Department of Psychology, University of Utah, USA.

MaryJane Simms Campbell,  Department of Psychology, University of Utah, USA.

Robert G Kent de Grey, Department  of Psychology, University of Utah, USA.

Jonathan E Butner, Department of Psychology , University of Utah, USA.

Mary Murray, Department of Pediatrics, University of Utah School of Medicine, USA.

Deborah J Wiebe, Psychological Sciences and the Health Sciences Research Institute, University of California, USA.

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