1. Study setting
This cross-sectional study targeted Saudi adolescents aged 12-18 years with type 1 diabetes registered in the King Abdulaziz Medical City, National Guard Health Affairs, Western region (KAMC-NGHA-WR). Also, Adolescents without type 1 diabetes mellitus were reached through Jeddah NGHA affiliated schools and were asked to participate in the study as a comparative (control) sample.
The inclusion criteria for this study includes aged 12-18 years, can independently read and write in Arabic or English, diagnosed with T1DM since at least 12 months (for non-control sample), undergoing diabetes therapy (for non-control sample). Those having cognitive impairment, or learning disability were excluded from the study. Non-control sample criteria, including diabetes diagnosis, were confirmed through the medical records of NGH. All data was kept confidential. Informed consent has been granted prior to the participation in the study. The study was approved by the Institutional Review Board at King Abdullah International Medical Research Center (Project #SP20/064/J.)
2. Questionnaire instrument
This study utilized The Psychosocial Inventory of Ego Strengths (PIES). The instrument is a 32- item (short version) questionnaire with all items having a Likert-type response scale and corresponding to eight different subscales corresponding to the eight stages as described by Erikson’s psychosocial theory of development. The questionnaire was developed in 1988 by Hawely et al. and validated in the context of the US and Canada [9,10]. The questionnaire was later translated and validated by Alghamdi et al. in the context of Saudi Arabia with a spearman coefficient of 0.99 [11]. Participants were given a choice to take the survey in English or Arabic. Furthermore, the PIES questionnaire measures the following variables or Erikson’s psychosocial development theory subscales of the eight ego strengths: hope, will, purpose, competence, fidelity, love, care, and wisdom. In accordance with Hawley, each item was assigned a score from 1 (Does not describe me well) to 5 (Describes me very well) according to the response given on the Likert-type scale [12]. This scoring was reversed for items assessing for the absence of the ego virtue.
3. Questionnaire subscales
Demographic characteristics
Participants were asked for their age, gender, Hb1AC levels (non-control sample), and presence of any co-morbidities.
4. Erikson Theory of psychosocial development
Participants were provided 32-items that assess their psychosocial development subscales and were asked to assign a score for each item, ranging from 1 (Does not describe me well) to 5 (Describes me very well).
4. Data collection
The sampling technique of this study is non-probability convenience sampling. Master lists of phone numbers were requested from the National Guards Hospital in Jeddah, Saudi Arabia for the patients eligible to our inclusion criteria. Similarly, master lists of phone numbers were requested from the administrators in a total of six school contacted (For the control sample). The authors have assigned thirteen well-trained data collectors for this study and were instructed conduct a questionnaire-structured interview via phone call to the phone numbers provided. The data has been directly entered into an excel-sheet designed for the study. The data collection spanned the duration from 1st of November 2020 until the 8th of June 2021.
5. Data analysis
The data were analyzed using Statistical Packages for Social Sciences (SPSS) version 21 Armonk, NY: IBM Corp. Both descriptive and inferential statistics had been conducted. A p- value cut-off point of 0.05 at 95% CI was considered statistical significance while a p-value of 0.01 was considered as highly statistically significant.
The psychological development of the participants has been assessed by using the Psychosocial Inventory Egovirtues Scale (PIES). Normality tests were performed using the Shapiro Wilk test as well as the Kolmogorov-Smirnov test. Furthermore, the comparison between having diabetes among the socio-demographic characteristics and the domains of PIES had been conducted using Chi-square test (categorical variables) and Mann Whitney U-test (continuous variable vs 2 categorical variables) or Kruskal Wallis H-test (continuous variable vs 3 or more categorical variables).
Significant results were then placed in a regression model to determine the independent influence of psychosocial development among patients with diabetes type 1 with corresponding odds ratio and 95% confidence interval.
The overall PIES score and its domains follow the abnormal distribution. Thus, non-parametric tests were applied. Pearson correlation coefficient was also performed to determine the correlation between PIES score and its domains along with HbA1c level.