The Multiple Contexts of Chronic Illness:
and Community Characteristics
Dawn A. Obeidallah
Harvard School of Public Health
Stuart T. Hauser
Judge Baker Childrens' Center, Harvard Medical School, and Josling Diabetes Center
Alan M. Jacobson
Josling Diabetes Center and Harvard Medical School
Adolescents diagnosed with diabetes negotiate at least two worlds of competing demands simultaneously. First, as part of normative adolescent development, they navigate the challenges of individuation, development of behavioral and cognitive autonomy, and intensification of close relationships with friends. In contrast to this push toward independence and greater sense of freedom, successful treatment of diabetes involves changes in diet and exercise habits, monitoring of glucose levels, and administration of insulin (Hauser et al., 1986; Hauser et al., 1997). These paradoxical stressors of adolescence and of disease maintenance contribute to divergent behaviors and somewhat opposing goals for diabetic adolescents and their families.
The diagnosis of diabetes requires a substantial reorganization of families and complicates already nuanced aspects of childrearing (Anderson, 1995; B lechman & Delamater, 1993; Hauser & Solomon, 1985; Reiss, Steinglass, & Howe, 1998). Some families, in response to adolescents' diagnosis of diabetes, step up protection over them by excessively monitoring diet and activities with friends. Such responses may be at odds with the developmental challenges of adolescence and contribute to new tensions between newly diagnosed diabetic adolescents and their parents. In the context of this tension, other social supports, including neighbors and community resources, may take on substantial importance (Powers et al., 1985).
The chronic nature of diabetes, particularly when first occurring during the already complex transition to adulthood, paints a stressful picture for adolescents and their families (Jacobson, et al., 1997; Wertlieb et al., 1990). The burden of these multiple stressors may overtax families' ability to function adaptively. Families that are overtaxed sometimes reach outside the family for assistance, frequently turning to their communities for additional help and support (Powers et al., 1985; Stack & Burton, 1993). The majority of research on diabetic adolescents, however, focuses on the family as the sole social context (Hauser, Jacobson, Benes, & Anderson, 1997), excluding contexts of peers, schools, and most importantly for the purposes of this chapter, communities.
This work is in response to social scientists' calls for further investigations of diabetic individuals with respect to neighborhood and community influences (Glasgow & Anderson, 1995). The basic premise is that families in need, especially those with a child recently diagnosed with diabetes, can draw on the strength of their communities or be undermined by the negative