Parental Quality of Life and Its Influence on Health-Related Quality of Life in Children with Type 1 Diabetes: A Cross-Sectional Dyadic Study in a Multi-ethnic Cohort

Parental Quality of Life and Its Influence on Health-Related Quality of Life in Children with Type 1 Diabetes: A Cross-Sectional Dyadic Study in a Multi-ethnic Cohort | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Parental Quality of Life and Its Influence on Health-Related Quality of Life in Children with Type 1 Diabetes: A Cross-Sectional Dyadic Study in a Multi-ethnic Cohort Jiaying Lin, Daniel Chan, Joyce ST Lim, Wilson Low, Rashida Farhad Vasanwala This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7510461/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jan, 2026 Read the published version in BMC Endocrine Disorders → Version 1 posted 12 You are reading this latest preprint version Abstract Background: Children with type 1 diabetes mellitus (T1DM) rely heavily on caregivers for disease management, particularly in the early years following diagnosis. While child health-related quality of life (HrQOL) is widely recognised as a key outcome in diabetes care, the role of caregiver wellbeing—particularly within diverse sociocultural and economic contexts—has been insufficiently examined. This gap is especially relevant in multi-ethnic Asian settings, where family structures and caregiving expectations may diverge from Western norms. Objectives: To evaluate the sociodemographic determinants of caregiver quality of life (QoL), and examine how these domains of caregiver wellbeing are associated with child-reported HrQOL in paediatric T1DM. Methods: We conducted a cross-sectional study involving 72 parent–child dyads recruited from a tertiary paediatric endocrinology clinic in Singapore. Children (< 18 years) and their primary caregivers independently completed validated QoL instruments (KIDSCREEN-27 and WHOQOL-BREF, respectively). Sociodemographic variables were collected, and multivariable linear regression was performed to evaluate associations between caregiver QoL, socioeconomic indicators, and child-reported HrQOL, adjusting for relevant covariates. Results: Caregiver QoL was significantly influenced by household income, education, spousal support, and family configuration. Financial hardship, absence of spousal or maternal support, and lower educational attainment were associated with poorer caregiver QoL across multiple domains (p < 0.05). In turn, higher caregiver psychological wellbeing, social relationships, and personal beliefs were positively associated with child-reported QoL across physical, emotional, autonomy-related, and school-related domains (p < 0.01). Conclusion: Caregiver wellbeing is a critical determinant of child HrQOL in paediatric T1DM. These findings highlight the importance of incorporating caregiver-focused psychosocial and structural support into family-centred diabetes care models. Proactively addressing caregiver needs—particularly in families experiencing socioeconomic or relational vulnerability—may offer a meaningful pathway to improve outcomes for both children and their caregivers. Introduction Type 1 diabetes mellitus (T1DM) is the most common endocrine disorder in the paediatric population and presents a complex, lifelong condition requiring meticulous self-management and medical oversight ( 1 ). In children, particularly those diagnosed at a young age, disease management falls heavily on parents and caregivers, who must navigate the demands of insulin administration, carbohydrate monitoring, symptom vigilance, and routine healthcare appointments ( 2 ). Beyond these clinical responsibilities, caregivers often encounter significant emotional, logistical, and financial challenges—including anxiety about acute complications, the cost of ongoing medical supplies, and the need to balance caregiving with employment and other familial obligations. These burdens may intensify during adolescence, a developmental period often characterised by diminished treatment adherence, emerging mental health concerns, and increasing child autonomy ( 3 – 5 ). Health-related quality of life (HrQOL)—a multidimensional construct encompassing physical, emotional, and social wellbeing—has been established as an essential patient-reported outcome for both paediatric patients and their caregivers ( 6 , 7 ). In this context, caregiver wellbeing is not only important in its own right, but may also directly influence the child’s own disease outcomes and psychosocial health. While the HrQOL of children and adolescents with T1DM has been extensively studied, considerably less research has explored how caregivers’ quality of life may influence child outcomes. This represents a critical gap in the literature, particularly given the integral role of caregivers in facilitating daily diabetes management, emotional regulation, and treatment adherence. Although caregiver burden has been recognised across various chronic paediatric conditions, few studies have quantitatively examined this dyadic relationship in paediatric diabetes, and even fewer have considered how it may be shaped by social determinants such as household income, educational attainment, marital status, and access to practical support. These factors are especially pertinent in multi-ethnic, urban Asian settings such as Singapore, where cultural expectations around caregiving, healthcare access, and family structure may differ substantially from Western contexts. Failure to account for the caregiver’s experience risks overlooking a significant determinant of the child’s health and wellbeing. Evidence from studies in other chronic illnesses indicates that caregiver distress is associated with poorer child mental health, reduced treatment adherence, and lower self-reported QoL. In the specific context of T1DM—where management is intensive, daily, and home-based—these dynamics may be even more pronounced. A robust understanding of the interplay between socioeconomic context, caregiver wellbeing, and child outcomes is critical for informing timely identification of at-risk families and the development of targeted psychosocial support. Addressing this research gap is not only clinically relevant, but essential for advancing more equitable, sustainable, and family-centred models of chronic disease care. This study aims to evaluate the sociodemographic and psychosocial determinants of caregiver quality of life and to examine their association with the HrQOL of children and adolescents living with T1DM in Singapore. By employing validated instruments in a dyadic framework, this study provides novel insights into the interrelationship between caregiver and child wellbeing in the context of paediatric diabetes. The findings are expected to inform clinical guidelines, healthcare policy, and service delivery models that more explicitly incorporate caregiver support as a component of high-quality diabetes care. Ultimately, this work contributes to a growing recognition that supporting families—rather than focusing solely on the individual patient—is essential for improving outcomes in children with chronic conditions. Methods Study Design This was a cross-sectional, observational study conducted in KK Women’s and Children’s Hospital (KKH), a tertiary paediatric hospital in Singapore. The study was nested in a larger national initiative led by the National Council of Social Service (NCSS) to assess the quality of life (QoL) of children and adolescents with chronic conditions and their caregivers. Participants were recruited from the outpatient paediatric endocrinology clinic between November 2017 and November 2018. The study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the SingHealth Centralised Institutional Review Board (CIRB No. 201709-00077). Participants Eligible participants were parent–child dyads in which the child was aged less than 18 years with a confirmed diagnosis of T1DM. Caregivers were required to be parents or legal guardians aged ≥ 21 years, residing in the same household, and providing regular care for the child (defined as ≥ 5 days of a week). Children with comorbidities that could independently affect QoL assessments (such neurodevelopmental or major psychiatric disorders) were excluded. Dyads were also excluded if either party was unable to complete the survey in English. Data Collection Participants were identified by diabetes nurse educators during scheduled clinic visits and referred to trained research study staff. Written informed consent was obtained from all caregivers. Assent was obtained from children aged 7 and above, as per local ethical guidelines. Participants completed their surveys in private consultation rooms using electronic tablets. Research personnel were available to assist with clarification where necessary. Data were collected using structured, self-administered surveys completed independently by the child and the caregiver. The surveys captured health-related quality of life and sociodemographic information. Average survey completion time was 20 to 30 minutes. Demographic and Socioeconomic Variables Caregiver-reported variables included caregiver age, sex, marital status, education level, employment status, chronic illness status, and household income. Household characteristics included type of housing, per capita income, family composition, and whether the family received any form of financial assistance. Child Quality of Life Children completed the KIDSCREEN-27 8 , a validated, multidimensional instrument assessing generic health-related QoL in children and adolescents. It comprises five domains: physical well-being, psychological well-being, autonomy and parent relationships, social support and peers, and school environment. Scores were transformed according to standard scoring algorithms, with higher scores indicating better QoL. Caregiver Quality of Life Caregivers completed the WHOQOL-BREF 9 , a 26-item instrument developed by the World Health Organization to assess QoL in adults across four domains: physical health, psychological health, social relationships, and environment. Domain scores were linearly transformed to a 0–100 scale, with higher values representing better perceived QoL. Statistical Analysis Descriptive statistics were used to summarize participant characteristics. Continuous variables were reported as means and standard deviations (SD), while categorical variables were reported as frequencies and percentages. Associations between sociodemographic variables and QoL scores were examined using Student’s t-test for categorical predictors, and Pearson correlation coefficient (r) for continuous predicators. Univariate linear regression is further performed to assess the change to the QoL scores for every unit change in the predictor values for each WHOQOL-BREF and KIDSCREEN domain. Only participants with complete data for the variables of interest were included in the final analysis (complete-case analysis). A two-tailed p-value of < 0.05 was considered statistically significant. All analyses were conducted using Stata Version 14.2 (Stata Corp, College Station, Texas, USA). Results Participant Characteristics A total of 72 parent–child dyads were included in the analysis. The sociodemographic and clinical profiles of children and their caregivers are summarised in Table 1 . The mean age of the children was 12.79 years (SD ± 2.88), and 52.8% were male. Ethnically, 68.1% were Chinese, 16.7% Malay, and 13.9% Indian. The average duration of living with T1DM was 4.13 years (SD ± 3.68), with nearly 70% of children having been diagnosed for five years or less. Table 1 Baseline Demographic and Clinical Characteristics of Children with T1DM and Their Caregivers Child Characteristics Age 12.79 ± 2.88 Sex Male 38 (52.8) Female 34 (47.2) Ethnicity Chinese 49 (68.1) Malay 12 (16.7) Indian 10 (13.9) Others 1 (1.4) Years living with DM 4.13 (3.68) Caregiver Characteristics Sex Male 23 (31.9) Female 49 (68.1) Age 44 ± 6.4 Marital status Single/Separated 12 ( 17 ) Married 60 (83) Presence of chronic illness Yes 45 (62.5) No 27 (37.5) Household income per capita 1600.95 (1281.95) Caregiver education level Primary/Secondary School 23 (32) Pre-university 28 (38.9) University Graduate and Above 21 (29.1) Continuous variables are presented as mean ± standard deviation (SD); categorical variables are presented as frequency and percentage. Caregivers were predominantly female (68.1%), with a mean age of 44.0 years (SD ± 6.4). The majority were married (83.0%), and 62.5% reported living with a chronic health condition. Approximately one-third of households (34.8%) were classified as low-income, with an average per capita income of SGD 1,600.95 (SD ± 1,281.95). Regarding educational attainment, 29.1% of caregivers had completed university-level education, while 38.9% had received specialised diploma or polytechnic training, 25.0% completed secondary education, and 7.0% had only primary school education. Sociodemographic Predictors of Caregiver Quality of Life Univariate linear regression identified several significant sociodemographic predictors of caregiver QoL across WHOQOL-BREF domains (see Table 2 ). Caregivers who received government financial assistance reported lower scores in the domains of personal beliefs (mean score of 60.29 (SD 21.76) vs 71.82 (SD 17.38), regression coefficient (β) = − 11.52, 95% confidence interval (CI) -21.75 to -1.30, p = 0.030) and environment (mean score of 62.47 (SD 18.51) vs 73.62 (SD 14.93), β = − 12.85, 95% CI -21.61 to -4.10, p = 0.005). A higher proportion (for every 10%) of household income allocated to the child’s diabetes care was also associated with lower scores in social relationships (β = − 3.04, CI -5.41 to -0.67, p = 0.01) and environmental QoL (β = − 3.09, 95% CI -5.21 to -0.97, p = 0.005), highlighting the psychological and relational burden of financial stress. Educational attainment was associated with differences in QoL outcomes. Compared to caregivers with a university degree, those with only primary education had significantly lower scores in the environmental domain (mean scores of 74.71 (SD = 14.81) vs 51.40 (SD = 22.21), β = − 23.31, 95% CI -39.23 to -7.40, p = 0.01). No significant differences were observed between university education and other non-degree categories. Spousal support emerged as a consistently protective factor. Caregivers who reported receiving help from their spouse scored significantly higher than those who did not across all domains, including physical health (β = 13.72, 95% CI 3.21 to 24.23, p = 0.01), independence (β = 15.84, 95% CI 5.15 to 26.53, p = 0.005), psychological wellbeing (β = 18.19, 95% CI 8.41to 27.96, p = 0.001), personal beliefs (β = 27.20, 95% CI 14.64 to 39.75, p < 0.001), social relationships (β = 19.81, 95% CI 5.29 to 34.34, p = 0.01), and environment (β = 13.82, 95% CI 1.45 to 26.20, p = 0.03). Family structure also had a substantial impact. The absence of a mother was associated with significantly lower scores across all QoL domains, including physical health (β = − 39.48, 95% CI -69.55 to -9.42, p = 0.01), psychological health (β = − 46.97, 95% CI -74.33 to -19.61, p = 0.001), and environmental wellbeing (β = − 53.84, 95% CI -84.08 to -23.61, p = 0.001). The absence of a father was associated with lower scores in independence (β = − 14.65, 95% CI -28.44 to -0.86, p = 0.04) and psychological health (β = − 15.57, 95% CI -28.18 to -2.96, p = 0.02). Non-intact family structures were associated with poorer outcomes in independence (β = − 20.50, 95% CI -31.79 to -9.21, p = 0.001), psychological health (β = − 16.34, 95% CI -26.88 to -5.81, p = 0.003), personal beliefs (β = − 17.97, 95% CI -31.62 to -4.32, p = 0.01), social relationships (β = − 15.98, 95% CI -29.36 to -2.61, p = 0.02), and environmental domains (β = − 20.34, 95% CI -31.90 to -8.78, p = 0.001). Associations Between Caregiver and Child Quality of Life Regression analysis demonstrated significant associations between caregiver psychological wellbeing, personal beliefs, and child-reported QoL outcomes across several KIDSCREEN domains (see Table 3 ). Notably, higher caregiver psychological wellbeing was positively associated with greater child overall QoL (β = 0.37, 95% CI 0.14 to 0.61, p = 0.002), as well as child physical wellbeing (β = 0.24, 95% CI 0.10 to 0.39, p = 0.001), psychological wellbeing (β = 0.27, 95% CI 0.10 to 0.44, p = 0.003), autonomy and parent relations (β = 0.30, 95% CI 0.08 to 0.52, p = 0.01), and social support and peer relationships (β = 0.25, 95% CI 0.09 to 0.41, p = 0.003). Caregiver personal beliefs were also significantly correlated with a broad range of child QoL outcomes. These included autonomy and parent relations (β = 0.49, 95% CI 0.21 to 0.76, p = 0.001), school environment (β = 0.26, 95% CI 0.02 to 0.49, p = 0.03), and financial resources (β = 0.27, 95% CI 0.09 to 0.44, p = 0.004). Caregiver social relationships were associated with child physical wellbeing (β = 0.20, 95% CI 0.01 to 0.39, p = 0.04) and peer support (β = 0.26, 95% CI 0.05 to 0.46, p = 0.02). Overall, these findings underscore the interdependence of caregiver and child wellbeing in the context of chronic disease. Higher caregiver QoL, particularly in the psychological, environmental, and relational domains, was associated with more favourable child-reported outcomes, highlighting the importance of family-centred care approaches in paediatric diabetes management. Discussion This study investigated the associations between sociodemographic characteristics, caregiver quality of life (QoL), and child-reported health-related quality of life (HrQOL) in a cohort of paediatric patients with T1DM in Singapore. Several key findings emerged. First, caregiver QoL was significantly associated with household income, educational attainment, spousal support, and family structure. Second, higher caregiver psychological wellbeing, social relationships, and personal beliefs were consistently associated with better child-reported QoL across multiple KIDSCREEN domains, including physical wellbeing, emotional health, peer relationships, and school environment. These findings support a dyadic, interdependent model of chronic disease management that places caregiver wellbeing at the centre of paediatric diabetes care. These findings reinforce the conceptualisation of paediatric diabetes care as inherently family-centred. The strong associations between caregiver psychological wellbeing and child QoL suggest that addressing caregiver stress, perceived burden, and environmental challenges may indirectly enhance children's functioning and disease management. Spousal involvement and family intactness emerged as especially strong protective factors, reinforcing the importance of social support within the household. Conversely, findings related to financial hardship—both in the form of government assistance and proportion of income spent on care—underscore the social gradient in caregiving burden and its impact on wellbeing. The effects of family structure, particularly the absence of a mother or non-intact family configuration, were especially pronounced. These findings speak to the emotional and logistical toll experienced by single caregivers and suggest that family-based support interventions may be most impactful when targeted at these vulnerable configurations. These observations align with the broader understanding that social context is a key determinant of both caregiver capacity and child outcomes in chronic disease management ( 10 , 13 ). Our findings align with a growing body of literature that demonstrates the reciprocal relationship between caregiver and child wellbeing in chronic paediatric illness ( 10 , 14 – 16 , 23 – 26 ). For example, studies in asthma, cancer, and disability populations have shown that caregiver distress correlates with lower child QoL, reduced treatment adherence, and poorer psychosocial outcomes ( 10 , 11 – 13 ). The observed impact of financial burden and lower education on caregiver QoL corroborates findings from Toledano-Toledano et al. and Bellin et al., who identified socioeconomic gradients in caregiver stress and functioning ( 14 , 15 ). Our results extend this evidence by quantifying associations in the context of T1DM, a condition characterised by daily, high-stakes disease management. Importantly, this study adds a unique perspective by focusing on an underrepresented setting: an urban, multi-ethnic Asian population. Cultural norms regarding caregiving, familial co-dependence, and help-seeking behaviour may modify the caregiving experience in ways not captured in Western-centric research. The strong association between caregiver beliefs and child autonomy and school functioning, for example, may reflect cultural values around educational success and intergenerational responsibility that warrant further exploration. This study possesses several methodological and conceptual strengths. The dyadic design enabled concurrent evaluation of caregiver and child QoL, offering a more holistic understanding of family-level dynamics in paediatric T1DM care. Validated, multidimensional instruments (KIDSCREEN-27 and WHOQOL-BREF) ensured consistent and reliable measurement across emotional, physical, social, and environmental domains ( 6 , 7 ). The inclusion of diverse sociodemographic variables allowed for detailed analysis of structural determinants that are often underexamined in clinical research. Additionally, by situating the study in a non-Western setting, we address a meaningful gap in the global diabetes literature. However, certain limitations must be acknowledged. The cross-sectional design limits causal inference; while significant associations were observed, the directionality of effects remains unclear. The relatively small sample size, drawn from a single public tertiary hospital, limits generalisability, particularly to non-hospitalised or socioeconomically distinct populations. Self-reported data introduce the potential for social desirability bias, and the absence of clinical indicators such as glycated haemoglobin (HbA1c) limits the ability to correlate psychosocial wellbeing with metabolic control. Language-based exclusion criteria may have disproportionately excluded caregivers with lower health literacy or those from marginalised linguistic groups. Finally, the absence of qualitative data limits interpretation of how cultural, emotional, and familial contexts shape the caregiving experience. Future research should expand upon these findings in larger, multi-centre cohorts and explore their applicability to other chronic paediatric conditions. Longitudinal studies are needed to understand how changes in caregiver wellbeing over time influence child QoL and metabolic outcomes ( 10 , 19 – 22 ). Incorporating biomarkers such as HbA1c would allow for a more integrated understanding of the psychosocial–clinical interface. Intervention studies evaluating targeted psychosocial, financial, and educational support for caregivers are warranted. Additionally, qualitative studies could enrich interpretation by capturing nuanced aspects of caregiver burden and resilience, particularly in diverse cultural contexts. In conclusion, this study highlights the significant role of caregiver wellbeing—particularly psychological, social, and environmental domains—in shaping the quality of life of children living with T1DM. Sociodemographic factors such as financial stress, educational attainment, and family structure exert measurable influence on caregiver outcomes, with downstream effects on child functioning. These findings support the integration of caregiver assessment and support into routine diabetes care, reinforcing the need for family-centred, equity-informed, and psychosocially integrated models of chronic disease management. By addressing the needs of caregivers, we not only improve their wellbeing, but also enhance the health and developmental trajectories of the children in their care. Abbreviations T1DM Type 1 Diabetes mellitus HrQOL Health-related quality of life QoL Quality of life WHOQOL-BREF World Health Organization Quality of Life – Brief version NCSS National Council of Social Services SD standard deviation Declarations Ethics approval and consent to participate The research was conducted according to the Declaration of Helsinki. This study was approved by the Singhealth Centralised Institutional Review Board (CIRB No. 201709-00077). Consent for publication Written informed consent was obtained from the parents. Competing interests The authors declare no competing interests. Funding: None Author Contribution JL and DC wrote the original and final manuscript. WL and JL prepared the figures. JL and DC were responsible for writing of the original draft. RFV, JSTL, WL were responsible for conceptualization, and methodology writing, JSTL and WC were responsible for the practical part of the experiment. All authors reviewed the manuscript. Acknowledgements Not applicable Data Availability The authors confirm that the data supporting the findings of this study are available within the article. References Rydén O, Nevander L, Johnsson P, Hansson K, Kronvall P, Sjoblad S, et al. Family therapy in poorly controlled juvenile IDDM: effects on diabetic control, self-evaluation and behavioural symptoms. Acta Paediatr. 1994;83(3):285–91. Wysocki T, Wayne W. Childhood diabetes and the family. Pract Diabetol. 1992;22:29–32. Schafer LC, McCaul KD, Glasgow RE. Supportive and Nonsupportive Family Behaviors: Relationships to Adherence and Metabolic Control in Persons with Type I Diabetes. Diabetes Care. 1986;9(2):179–85. Lawler MK, Volk R, Viviani N, Mengel MB. Individual and family factors impacting diabetic control in the adolescent: a preliminary study. Maternal-child nursing journal [Internet]. 1990;19(4):331–45. Available from: https://pubmed.ncbi.nlm.nih.gov/2136583/ Hanson CL, Henggeler SW, Burghen GA. Model of Associations Between Psychosocial Variables and Health-Outcome Measures of Adolescents with IDDM. Diabetes Care. 1987;10(6):752–8. THE WHOQOL GROUP. Development of the World Health Organization WHOQOL-BREF Quality of Life Assessment. Psychological Medicine [Internet]. 1998;28(3):551–8. Available from: https://www.cambridge.org/core/journals/psychological-medicine/article/abs/development-of-the-world-health-organization-whoqolbref-quality-of-life-assessment/0F50596B33A1ABD59A6605C44A6A8F30 Bullinger M. Quality of life—definition, conceptualization and implications: a methodologist’s view. Theor Surg. 1991;6:143–8. Ravens-Sieberer U, Herdman M, Devine J, Otto C, Bullinger M, Rose M, Klasen F. The European KIDSCREEN approach to measure quality of life and well-being in children: development, current application, and future advances. Qual Life Res. 2014;23(3):791–803. 10.1007/s11136-013-0428-3 . Epub 2013 May 18. PMID: 23686556; PMCID: PMC3953538. Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group. Psychol Med. 1998;28(3):551-8. 10.1017/s0033291798006667 . PMID: 9626712. Boyden JY, Hill DL, Carroll KW, Morrison WE, Miller VA, Feudtner C. The Association of Perceived Social Support with Anxiety over Time in Parents of Children with Serious Illnesses. J Palliat Med. 2020;23(4):527–34. Gallagher S, Phillips AC, Oliver C, Carroll D. Predictors of Psychological Morbidity in Parents of Children with Intellectual Disabilities. J Pediatr Psychol. 2008;33(10):1129–36. Hsieh RL, Huang HY, Lin MI, Wu CW, Lee WC. Quality of life, health satisfaction and family impact on caregivers of children with developmental delays. Child Care Health Dev. 2009;35(2):243–9. Thomas A, Sawhill IV. For Love and Money? The Impact of Family Structure on Family Income. Future Child. 2005;15(2):57–74. Toledano-Toledano F, de la Moral J, Nabors LA, Domínguez-Guedea MT, Salinas Escudero G, Rocha Pérez E, et al. Predictors of Quality of Life among Parents of Children with Chronic Diseases: A Cross-Sectional Study. Healthcare. 2020;8(4):456. Bellin MH, Kub J, Frick KD, Bollinger ME, Tsoukleris M, Walker J, et al. Stress and Quality of Life in Caregivers of Inner-City Minority Children With Poorly Controlled Asthma. J Pediatr Health Care. 2013;27(2):127–34. Vanz AP, Félix TM, da Rocha NS, Schwartz IVD. Quality of life in caregivers of children and adolescents with Osteogenesis Imperfecta. Health and Quality of Life Outcomes [Internet]. 2015 Apr 1 [cited 2019 Mar 21];13(1). Available from: https://hqlo.biomedcentral.com/articles/ 10.1186/s12955-015-0226-4 de la Fernández K, Leon DA. Self-perceived health status and inequalities in use of health services in Spain. International journal of epidemiology [Internet]. 1996;25(3):593–603. Available from: https://pubmed.ncbi.nlm.nih.gov/8671561/ Medway M, Tong A, Craig JC, Kim S, Mackie F, McTaggart S, et al. Parental Perspectives on the Financial Impact of Caring for a Child With CKD. Am J Kidney Dis. 2015;65(3):384–93. Hoekstra-Weebers JEHM, Jaspers JPC, Kamps WA, Klip EC. Psychological Adaptation and Social Support of Parents of Pediatric Cancer Patients: A Prospective Longitudinal Study. Journal of Pediatric Psychology [Internet]. 2001;26(4):225–35. Available from: https://academic.oup.com/jpepsy/article/26/4/225/988760 Rini C, Manne S, DuHamel K, Austin J, Ostroff J, Boulad F, et al. Social support from family and friends as a buffer of low spousal support among mothers of critically ill children: A multilevel modeling approach. Health Psychol. 2008;27(5):593–603. Dahlquist LM, Czyzewski DI, Jones CL. Parents of Children with Cancer: A Longitudinal Study of Emotional Distress, Coping Style, and Marital Adjustment Two and Twenty Months After Diagnosis. J Pediatr Psychol. 1996;21(4):541–54. Wijnberg-Williams BJ, Kamps WA, Klip EC, Hoekstra-Weebers JEHM. Psychological Distress and the Impact of Social Support on Fathers and Mothers of Pediatric Cancer Patients: Long-Term Prospective Results. J Pediatr Psychol. 2005;31(8):785–92. Wertlieb D, American Academy of Pediatrics Task Force on the Family. Converging trends in family research and pediatrics: recent findings for the American Academy of Pediatrics Task Force on the Family. Pediatrics [Internet]. 2003;111(6 Pt 2):1572–87. Available from: https://pubmed.ncbi.nlm.nih.gov/12777596/ Brown RT, Wiener L, Kupst MJ, Brennan T, Behrman R, Compas BE, et al. Single Parents of Children with Chronic Illness: An Understudied Phenomenon. J Pediatr Psychol. 2007;33(4):408–21. Leeman J, Crandell JL, Lee A, Bai J, Sandelowski M, Knafl K. Family Functioning and the Well-Being of Children With Chronic Conditions: A Meta-Analysis. Res Nurs Health. 2016;39(4):229–43. Lewandowski AS, Palermo TM, Stinson J, Handley S, Chambers CT. Systematic Review of Family Functioning in Families of Children and Adolescents with Chronic Pain. The Journal of Pain [Internet]. 2010;11(11):1027–38. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2993004/ Tables Tables 2 and 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table23.docx Cite Share Download PDF Status: Published Journal Publication published 03 Jan, 2026 Read the published version in BMC Endocrine Disorders → Version 1 posted Editorial decision: Revision requested 07 Oct, 2025 Reviews received at journal 02 Oct, 2025 Reviews received at journal 01 Oct, 2025 Reviews received at journal 30 Sep, 2025 Reviewers agreed at journal 19 Sep, 2025 Reviewers agreed at journal 18 Sep, 2025 Reviewers agreed at journal 18 Sep, 2025 Reviewers invited by journal 18 Sep, 2025 Editor assigned by journal 18 Sep, 2025 Editor invited by journal 16 Sep, 2025 Submission checks completed at journal 15 Sep, 2025 First submitted to journal 15 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7510461","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":521832424,"identity":"6824c82b-bf86-49c9-80db-86ea80d39fbe","order_by":0,"name":"Jiaying Lin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYBACPmYgIWHAwMDGwMD44EMFkMfM3IBXCxuSFmbDGWdAWhgJaEFmS/O2gWhCWth5DzBYFNgl9km3X5OcOa82mr8dqOVHxTY8DuNLADosObFN5kyxxcdtx3NnHGZsYOw5cxuPFh4DoBbmxDaJnMSbM7cdy20AamFmbCOopR6kJUGad86x3PlEajkM1JJ+SJq3oSZ3AzFaDkgYHDcG2gIM5GMHcjcCtRzE5xd+/jOGjyX+VMvOn5H+8MGHmrrceecPH3zwowK3FhA4LMHA4NjAAHQhkA0WOYBXPRAwfmBgsGdgYH8AZNcRUjwKRsEoGAUjEAAA3eNUrZEwJLoAAAAASUVORK5CYII=","orcid":"","institution":"KK Women’s and Children’s Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jiaying","middleName":"","lastName":"Lin","suffix":""},{"id":521832425,"identity":"5f8b710a-c128-4ecc-bc56-e5e0764a1ba9","order_by":1,"name":"Daniel Chan","email":"","orcid":"","institution":"KK Women’s and Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Chan","suffix":""},{"id":521832426,"identity":"abf3eb27-032f-463e-913e-9e9da6b28f36","order_by":2,"name":"Joyce ST Lim","email":"","orcid":"","institution":"KK Women’s and Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Joyce","middleName":"ST","lastName":"Lim","suffix":""},{"id":521832427,"identity":"73870479-e88b-40cc-923c-84b54db94bee","order_by":3,"name":"Wilson Low","email":"","orcid":"","institution":"KK Women’s and Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wilson","middleName":"","lastName":"Low","suffix":""},{"id":521832428,"identity":"f1cd57ff-f3a1-4228-bcf2-def19b78d240","order_by":4,"name":"Rashida Farhad Vasanwala","email":"","orcid":"","institution":"KK Women’s and Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Rashida","middleName":"Farhad","lastName":"Vasanwala","suffix":""}],"badges":[],"createdAt":"2025-09-01 16:38:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7510461/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7510461/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12902-025-02127-4","type":"published","date":"2026-01-03T15:58:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":92519568,"identity":"c5516f4b-350b-4026-b026-c0c989a8c81c","added_by":"auto","created_at":"2025-09-30 14:46:08","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":336787,"visible":true,"origin":"","legend":"","description":"","filename":"DMQOLManuscript20junlin24.docx","url":"https://assets-eu.researchsquare.com/files/rs-7510461/v1/7bcf58d21d3a337f04f39548.docx"},{"id":92518101,"identity":"213323dd-033e-4603-997d-5a5bf01ab58c","added_by":"auto","created_at":"2025-09-30 14:30:08","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7481,"visible":true,"origin":"","legend":"","description":"","filename":"ff8ddb6d691149ce973b179517259890.json","url":"https://assets-eu.researchsquare.com/files/rs-7510461/v1/f3b5d887a1f3c6f604383e51.json"},{"id":92518519,"identity":"8cc464d2-c838-4223-9aa9-876ab29c54b4","added_by":"auto","created_at":"2025-09-30 14:38:08","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":76896,"visible":true,"origin":"","legend":"","description":"","filename":"ff8ddb6d691149ce973b1795172598901enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7510461/v1/56aff702d42548507456990a.xml"},{"id":92518111,"identity":"fd18e774-f5a4-4510-a5f1-1d79455d4ade","added_by":"auto","created_at":"2025-09-30 14:30:08","extension":"emf","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4115792,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.emf","url":"https://assets-eu.researchsquare.com/files/rs-7510461/v1/b6f589407aaada04d9fae6dc.emf"},{"id":92518105,"identity":"ed448bb9-bf7d-46b4-b0d2-25aca9af6c00","added_by":"auto","created_at":"2025-09-30 14:30:08","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":592543,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7510461/v1/c78b674606aac1d0970e58cc.jpeg"},{"id":92518516,"identity":"e2b3091e-fc3b-40ae-94e4-fe3bfc78fc43","added_by":"auto","created_at":"2025-09-30 14:38:08","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":37341,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7510461/v1/41566b9fbfb882c2a09cfc45.png"},{"id":92518109,"identity":"16b1b847-e2a1-4592-9d37-2ea5e02df9af","added_by":"auto","created_at":"2025-09-30 14:30:08","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":459304,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7510461/v1/c0a32f68770c63bdc626dd92.png"},{"id":92518522,"identity":"22efab24-fd7e-4811-bfc3-d3a4ad3e1d71","added_by":"auto","created_at":"2025-09-30 14:38:08","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":73645,"visible":true,"origin":"","legend":"","description":"","filename":"ff8ddb6d691149ce973b1795172598901structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7510461/v1/12d1a6f8722589557c07f014.xml"},{"id":92518107,"identity":"dad6cb92-19c2-477a-b72c-2f965cf13976","added_by":"auto","created_at":"2025-09-30 14:30:08","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":82026,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7510461/v1/f0e9861d55fa2b0bea4ec499.html"},{"id":99545402,"identity":"5247d95b-28a4-48a7-b16f-9a1db4885643","added_by":"auto","created_at":"2026-01-05 16:07:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":624089,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7510461/v1/560104e7-6141-45b2-8a77-58e2337f6ad0.pdf"},{"id":92518514,"identity":"1991a918-f189-4330-82bb-8a1d2c9a89e6","added_by":"auto","created_at":"2025-09-30 14:38:08","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":300423,"visible":true,"origin":"","legend":"","description":"","filename":"Table23.docx","url":"https://assets-eu.researchsquare.com/files/rs-7510461/v1/69f53e4ac33d28f6f8a3280a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Parental Quality of Life and Its Influence on Health-Related Quality of Life in Children with Type 1 Diabetes: A Cross-Sectional Dyadic Study in a Multi-ethnic Cohort","fulltext":[{"header":"Introduction","content":"\u003cp\u003eType 1 diabetes mellitus (T1DM) is the most common endocrine disorder in the paediatric population and presents a complex, lifelong condition requiring meticulous self-management and medical oversight (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In children, particularly those diagnosed at a young age, disease management falls heavily on parents and caregivers, who must navigate the demands of insulin administration, carbohydrate monitoring, symptom vigilance, and routine healthcare appointments (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Beyond these clinical responsibilities, caregivers often encounter significant emotional, logistical, and financial challenges\u0026mdash;including anxiety about acute complications, the cost of ongoing medical supplies, and the need to balance caregiving with employment and other familial obligations. These burdens may intensify during adolescence, a developmental period often characterised by diminished treatment adherence, emerging mental health concerns, and increasing child autonomy (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Health-related quality of life (HrQOL)\u0026mdash;a multidimensional construct encompassing physical, emotional, and social wellbeing\u0026mdash;has been established as an essential patient-reported outcome for both paediatric patients and their caregivers (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In this context, caregiver wellbeing is not only important in its own right, but may also directly influence the child\u0026rsquo;s own disease outcomes and psychosocial health.\u003c/p\u003e\u003cp\u003e While the HrQOL of children and adolescents with T1DM has been extensively studied, considerably less research has explored how caregivers\u0026rsquo; quality of life may influence child outcomes. This represents a critical gap in the literature, particularly given the integral role of caregivers in facilitating daily diabetes management, emotional regulation, and treatment adherence. Although caregiver burden has been recognised across various chronic paediatric conditions, few studies have quantitatively examined this dyadic relationship in paediatric diabetes, and even fewer have considered how it may be shaped by social determinants such as household income, educational attainment, marital status, and access to practical support. These factors are especially pertinent in multi-ethnic, urban Asian settings such as Singapore, where cultural expectations around caregiving, healthcare access, and family structure may differ substantially from Western contexts.\u003c/p\u003e\u003cp\u003e Failure to account for the caregiver\u0026rsquo;s experience risks overlooking a significant determinant of the child\u0026rsquo;s health and wellbeing. Evidence from studies in other chronic illnesses indicates that caregiver distress is associated with poorer child mental health, reduced treatment adherence, and lower self-reported QoL. In the specific context of T1DM\u0026mdash;where management is intensive, daily, and home-based\u0026mdash;these dynamics may be even more pronounced. A robust understanding of the interplay between socioeconomic context, caregiver wellbeing, and child outcomes is critical for informing timely identification of at-risk families and the development of targeted psychosocial support. Addressing this research gap is not only clinically relevant, but essential for advancing more equitable, sustainable, and family-centred models of chronic disease care.\u003c/p\u003e\u003cp\u003eThis study aims to evaluate the sociodemographic and psychosocial determinants of caregiver quality of life and to examine their association with the HrQOL of children and adolescents living with T1DM in Singapore. By employing validated instruments in a dyadic framework, this study provides novel insights into the interrelationship between caregiver and child wellbeing in the context of paediatric diabetes. The findings are expected to inform clinical guidelines, healthcare policy, and service delivery models that more explicitly incorporate caregiver support as a component of high-quality diabetes care. Ultimately, this work contributes to a growing recognition that supporting families\u0026mdash;rather than focusing solely on the individual patient\u0026mdash;is essential for improving outcomes in children with chronic conditions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis was a cross-sectional, observational study conducted in KK Women\u0026rsquo;s and Children\u0026rsquo;s Hospital (KKH), a tertiary paediatric hospital in Singapore. The study was nested in a larger national initiative led by the National Council of Social Service (NCSS) to assess the quality of life (QoL) of children and adolescents with chronic conditions and their caregivers. Participants were recruited from the outpatient paediatric endocrinology clinic between November 2017 and November 2018. The study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the SingHealth Centralised Institutional Review Board (CIRB No. 201709-00077).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eEligible participants were parent\u0026ndash;child dyads in which the child was aged less than 18 years with a confirmed diagnosis of T1DM. Caregivers were required to be parents or legal guardians aged\u0026thinsp;\u0026ge;\u0026thinsp;21 years, residing in the same household, and providing regular care for the child (defined as \u0026ge;\u0026thinsp;5 days of a week). Children with comorbidities that could independently affect QoL assessments (such neurodevelopmental or major psychiatric disorders) were excluded. Dyads were also excluded if either party was unable to complete the survey in English.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eParticipants were identified by diabetes nurse educators during scheduled clinic visits and referred to trained research study staff. Written informed consent was obtained from all caregivers. Assent was obtained from children aged 7 and above, as per local ethical guidelines. Participants completed their surveys in private consultation rooms using electronic tablets. Research personnel were available to assist with clarification where necessary.\u003c/p\u003e\u003cp\u003e Data were collected using structured, self-administered surveys completed independently by the child and the caregiver. The surveys captured health-related quality of life and sociodemographic information. Average survey completion time was 20 to 30 minutes.\u003c/p\u003e\n\u003ch3\u003eDemographic and Socioeconomic Variables\u003c/h3\u003e\n\u003cp\u003eCaregiver-reported variables included caregiver age, sex, marital status, education level, employment status, chronic illness status, and household income. Household characteristics included type of housing, per capita income, family composition, and whether the family received any form of financial assistance.\u003c/p\u003e\n\u003ch3\u003eChild Quality of Life\u003c/h3\u003e\n\u003cp\u003eChildren completed the KIDSCREEN-27\u003csup\u003e8\u003c/sup\u003e, a validated, multidimensional instrument assessing generic health-related QoL in children and adolescents. It comprises five domains: physical well-being, psychological well-being, autonomy and parent relationships, social support and peers, and school environment. Scores were transformed according to standard scoring algorithms, with higher scores indicating better QoL.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eCaregiver Quality of Life\u003c/h2\u003e\u003cp\u003eCaregivers completed the WHOQOL-BREF\u003csup\u003e9\u003c/sup\u003e, a 26-item instrument developed by the World Health Organization to assess QoL in adults across four domains: physical health, psychological health, social relationships, and environment. Domain scores were linearly transformed to a 0\u0026ndash;100 scale, with higher values representing better perceived QoL.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics were used to summarize participant characteristics. Continuous variables were reported as means and standard deviations (SD), while categorical variables were reported as frequencies and percentages. Associations between sociodemographic variables and QoL scores were examined using Student\u0026rsquo;s t-test for categorical predictors, and Pearson correlation coefficient (r) for continuous predicators. Univariate linear regression is further performed to assess the change to the QoL scores for every unit change in the predictor values for each WHOQOL-BREF and KIDSCREEN domain. Only participants with complete data for the variables of interest were included in the final analysis (complete-case analysis). A two-tailed p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant. All analyses were conducted using Stata Version 14.2 (Stata Corp, College Station, Texas, USA).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipant Characteristics\u003c/h2\u003e\n \u003cp\u003eA total of 72 parent\u0026ndash;child dyads were included in the analysis. The sociodemographic and clinical profiles of children and their caregivers are summarised in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age of the children was 12.79 years (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;2.88), and 52.8% were male. Ethnically, 68.1% were Chinese, 16.7% Malay, and 13.9% Indian. The average duration of living with T1DM was 4.13 years (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;3.68), with nearly 70% of children having been diagnosed for five years or less.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline Demographic and Clinical Characteristics of Children with T1DM and Their Caregivers\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eChild Characteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.79\u0026thinsp;\u0026plusmn;\u0026thinsp;2.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (52.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (47.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49 (68.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYears living with DM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.13 (3.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCaregiver Characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (31.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49 (68.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 \u0026plusmn; 6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSingle/Separated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 (83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresence of chronic illness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHousehold income per capita\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1600.95 (1281.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCaregiver education level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary/Secondary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre-university\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (38.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUniversity Graduate and Above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (29.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eContinuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD); categorical variables are presented as frequency and percentage.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eCaregivers were predominantly female (68.1%), with a mean age of 44.0 years (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4). The majority were married (83.0%), and 62.5% reported living with a chronic health condition. Approximately one-third of households (34.8%) were classified as low-income, with an average per capita income of SGD 1,600.95 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;1,281.95). Regarding educational attainment, 29.1% of caregivers had completed university-level education, while 38.9% had received specialised diploma or polytechnic training, 25.0% completed secondary education, and 7.0% had only primary school education.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eSociodemographic Predictors of Caregiver Quality of Life\u003c/h2\u003e\n \u003cp\u003eUnivariate linear regression identified several significant sociodemographic predictors of caregiver QoL across WHOQOL-BREF domains (see Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Caregivers who received government financial assistance reported lower scores in the domains of personal beliefs (mean score of 60.29 (SD 21.76) vs 71.82 (SD 17.38), regression coefficient (\u0026beta;) = \u0026minus;\u0026thinsp;11.52, 95% confidence interval (CI) -21.75 to -1.30, p\u0026thinsp;=\u0026thinsp;0.030) and environment (mean score of 62.47 (SD 18.51) vs 73.62 (SD 14.93), \u0026beta; = \u0026minus;\u0026thinsp;12.85, 95% CI -21.61 to -4.10, p\u0026thinsp;=\u0026thinsp;0.005). A higher proportion (for every 10%) of household income allocated to the child\u0026rsquo;s diabetes care was also associated with lower scores in social relationships (\u0026beta; = \u0026minus;\u0026thinsp;3.04, CI -5.41 to -0.67, p\u0026thinsp;=\u0026thinsp;0.01) and environmental QoL (\u0026beta; = \u0026minus;\u0026thinsp;3.09, 95% CI -5.21 to -0.97, p\u0026thinsp;=\u0026thinsp;0.005), highlighting the psychological and relational burden of financial stress.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003eEducational attainment was associated with differences in QoL outcomes. Compared to caregivers with a university degree, those with only primary education had significantly lower scores in the environmental domain (mean scores of 74.71 (SD\u0026thinsp;=\u0026thinsp;14.81) vs 51.40 (SD\u0026thinsp;=\u0026thinsp;22.21), \u0026beta; = \u0026minus;\u0026thinsp;23.31, 95% CI -39.23 to -7.40, p\u0026thinsp;=\u0026thinsp;0.01). No significant differences were observed between university education and other non-degree categories.\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eSpousal support emerged as a consistently protective factor. Caregivers who reported receiving help from their spouse scored significantly higher than those who did not across all domains, including physical health (\u0026beta;\u0026thinsp;=\u0026thinsp;13.72, 95% CI 3.21 to 24.23, p\u0026thinsp;=\u0026thinsp;0.01), independence (\u0026beta;\u0026thinsp;=\u0026thinsp;15.84, 95% CI 5.15 to 26.53, p\u0026thinsp;=\u0026thinsp;0.005), psychological wellbeing (\u0026beta;\u0026thinsp;=\u0026thinsp;18.19, 95% CI 8.41to 27.96, p\u0026thinsp;=\u0026thinsp;0.001), personal beliefs (\u0026beta;\u0026thinsp;=\u0026thinsp;27.20, 95% CI 14.64 to 39.75, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), social relationships (\u0026beta;\u0026thinsp;=\u0026thinsp;19.81, 95% CI 5.29 to 34.34, p\u0026thinsp;=\u0026thinsp;0.01), and environment (\u0026beta;\u0026thinsp;=\u0026thinsp;13.82, 95% CI 1.45 to 26.20, p\u0026thinsp;=\u0026thinsp;0.03). Family structure also had a substantial impact. The absence of a mother was associated with significantly lower scores across all QoL domains, including physical health (\u0026beta; = \u0026minus;\u0026thinsp;39.48, 95% CI -69.55 to -9.42, p\u0026thinsp;=\u0026thinsp;0.01), psychological health (\u0026beta; = \u0026minus;\u0026thinsp;46.97, 95% CI -74.33 to -19.61, p\u0026thinsp;=\u0026thinsp;0.001), and environmental wellbeing (\u0026beta; = \u0026minus;\u0026thinsp;53.84, 95% CI -84.08 to -23.61, p\u0026thinsp;=\u0026thinsp;0.001). The absence of a father was associated with lower scores in independence (\u0026beta; = \u0026minus;\u0026thinsp;14.65, 95% CI -28.44 to -0.86, p\u0026thinsp;=\u0026thinsp;0.04) and psychological health (\u0026beta; = \u0026minus;\u0026thinsp;15.57, 95% CI -28.18 to -2.96, p\u0026thinsp;=\u0026thinsp;0.02). Non-intact family structures were associated with poorer outcomes in independence (\u0026beta; = \u0026minus;\u0026thinsp;20.50, 95% CI -31.79 to -9.21, p\u0026thinsp;=\u0026thinsp;0.001), psychological health (\u0026beta; = \u0026minus;\u0026thinsp;16.34, 95% CI -26.88 to -5.81, p\u0026thinsp;=\u0026thinsp;0.003), personal beliefs (\u0026beta; = \u0026minus;\u0026thinsp;17.97, 95% CI -31.62 to -4.32, p\u0026thinsp;=\u0026thinsp;0.01), social relationships (\u0026beta; = \u0026minus;\u0026thinsp;15.98, 95% CI -29.36 to -2.61, p\u0026thinsp;=\u0026thinsp;0.02), and environmental domains (\u0026beta; = \u0026minus;\u0026thinsp;20.34, 95% CI -31.90 to -8.78, p\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eAssociations Between Caregiver and Child Quality of Life\u003c/h2\u003e\n \u003cp\u003eRegression analysis demonstrated significant associations between caregiver psychological wellbeing, personal beliefs, and child-reported QoL outcomes across several KIDSCREEN domains (see Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Notably, higher caregiver psychological wellbeing was positively associated with greater child overall QoL (\u0026beta;\u0026thinsp;=\u0026thinsp;0.37, 95% CI 0.14 to 0.61, p\u0026thinsp;=\u0026thinsp;0.002), as well as child physical wellbeing (\u0026beta;\u0026thinsp;=\u0026thinsp;0.24, 95% CI 0.10 to 0.39, p\u0026thinsp;=\u0026thinsp;0.001), psychological wellbeing (\u0026beta;\u0026thinsp;=\u0026thinsp;0.27, 95% CI 0.10 to 0.44, p\u0026thinsp;=\u0026thinsp;0.003), autonomy and parent relations (\u0026beta;\u0026thinsp;=\u0026thinsp;0.30, 95% CI 0.08 to 0.52, p\u0026thinsp;=\u0026thinsp;0.01), and social support and peer relationships (\u0026beta;\u0026thinsp;=\u0026thinsp;0.25, 95% CI 0.09 to 0.41, p\u0026thinsp;=\u0026thinsp;0.003).\u003c/p\u003e\n \u003cp\u003eCaregiver personal beliefs were also significantly correlated with a broad range of child QoL outcomes. These included autonomy and parent relations (\u0026beta;\u0026thinsp;=\u0026thinsp;0.49, 95% CI 0.21 to 0.76, p\u0026thinsp;=\u0026thinsp;0.001), school environment (\u0026beta;\u0026thinsp;=\u0026thinsp;0.26, 95% CI 0.02 to 0.49, p\u0026thinsp;=\u0026thinsp;0.03), and financial resources (\u0026beta;\u0026thinsp;=\u0026thinsp;0.27, 95% CI 0.09 to 0.44, p\u0026thinsp;=\u0026thinsp;0.004). Caregiver social relationships were associated with child physical wellbeing (\u0026beta;\u0026thinsp;=\u0026thinsp;0.20, 95% CI 0.01 to 0.39, p\u0026thinsp;=\u0026thinsp;0.04) and peer support (\u0026beta;\u0026thinsp;=\u0026thinsp;0.26, 95% CI 0.05 to 0.46, p\u0026thinsp;=\u0026thinsp;0.02).\u003c/p\u003e\n \u003cp\u003eOverall, these findings underscore the interdependence of caregiver and child wellbeing in the context of chronic disease. Higher caregiver QoL, particularly in the psychological, environmental, and relational domains, was associated with more favourable child-reported outcomes, highlighting the importance of family-centred care approaches in paediatric diabetes management.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the associations between sociodemographic characteristics, caregiver quality of life (QoL), and child-reported health-related quality of life (HrQOL) in a cohort of paediatric patients with T1DM in Singapore. Several key findings emerged. First, caregiver QoL was significantly associated with household income, educational attainment, spousal support, and family structure. Second, higher caregiver psychological wellbeing, social relationships, and personal beliefs were consistently associated with better child-reported QoL across multiple KIDSCREEN domains, including physical wellbeing, emotional health, peer relationships, and school environment. These findings support a dyadic, interdependent model of chronic disease management that places caregiver wellbeing at the centre of paediatric diabetes care.\u003c/p\u003e\u003cp\u003eThese findings reinforce the conceptualisation of paediatric diabetes care as inherently family-centred. The strong associations between caregiver psychological wellbeing and child QoL suggest that addressing caregiver stress, perceived burden, and environmental challenges may indirectly enhance children's functioning and disease management. Spousal involvement and family intactness emerged as especially strong protective factors, reinforcing the importance of social support within the household. Conversely, findings related to financial hardship\u0026mdash;both in the form of government assistance and proportion of income spent on care\u0026mdash;underscore the social gradient in caregiving burden and its impact on wellbeing.\u003c/p\u003e\u003cp\u003eThe effects of family structure, particularly the absence of a mother or non-intact family configuration, were especially pronounced. These findings speak to the emotional and logistical toll experienced by single caregivers and suggest that family-based support interventions may be most impactful when targeted at these vulnerable configurations. These observations align with the broader understanding that social context is a key determinant of both caregiver capacity and child outcomes in chronic disease management (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Our findings align with a growing body of literature that demonstrates the reciprocal relationship between caregiver and child wellbeing in chronic paediatric illness (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). For example, studies in asthma, cancer, and disability populations have shown that caregiver distress correlates with lower child QoL, reduced treatment adherence, and poorer psychosocial outcomes (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The observed impact of financial burden and lower education on caregiver QoL corroborates findings from Toledano-Toledano et al. and Bellin et al., who identified socioeconomic gradients in caregiver stress and functioning (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Our results extend this evidence by quantifying associations in the context of T1DM, a condition characterised by daily, high-stakes disease management. Importantly, this study adds a unique perspective by focusing on an underrepresented setting: an urban, multi-ethnic Asian population. Cultural norms regarding caregiving, familial co-dependence, and help-seeking behaviour may modify the caregiving experience in ways not captured in Western-centric research. The strong association between caregiver beliefs and child autonomy and school functioning, for example, may reflect cultural values around educational success and intergenerational responsibility that warrant further exploration.\u003c/p\u003e\u003cp\u003eThis study possesses several methodological and conceptual strengths. The dyadic design enabled concurrent evaluation of caregiver and child QoL, offering a more holistic understanding of family-level dynamics in paediatric T1DM care. Validated, multidimensional instruments (KIDSCREEN-27 and WHOQOL-BREF) ensured consistent and reliable measurement across emotional, physical, social, and environmental domains (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The inclusion of diverse sociodemographic variables allowed for detailed analysis of structural determinants that are often underexamined in clinical research. Additionally, by situating the study in a non-Western setting, we address a meaningful gap in the global diabetes literature. However, certain limitations must be acknowledged. The cross-sectional design limits causal inference; while significant associations were observed, the directionality of effects remains unclear. The relatively small sample size, drawn from a single public tertiary hospital, limits generalisability, particularly to non-hospitalised or socioeconomically distinct populations. Self-reported data introduce the potential for social desirability bias, and the absence of clinical indicators such as glycated haemoglobin (HbA1c) limits the ability to correlate psychosocial wellbeing with metabolic control. Language-based exclusion criteria may have disproportionately excluded caregivers with lower health literacy or those from marginalised linguistic groups. Finally, the absence of qualitative data limits interpretation of how cultural, emotional, and familial contexts shape the caregiving experience.\u003c/p\u003e\u003cp\u003eFuture research should expand upon these findings in larger, multi-centre cohorts and explore their applicability to other chronic paediatric conditions. Longitudinal studies are needed to understand how changes in caregiver wellbeing over time influence child QoL and metabolic outcomes (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Incorporating biomarkers such as HbA1c would allow for a more integrated understanding of the psychosocial\u0026ndash;clinical interface. Intervention studies evaluating targeted psychosocial, financial, and educational support for caregivers are warranted. Additionally, qualitative studies could enrich interpretation by capturing nuanced aspects of caregiver burden and resilience, particularly in diverse cultural contexts.\u003c/p\u003e\u003cp\u003eIn conclusion, this study highlights the significant role of caregiver wellbeing\u0026mdash;particularly psychological, social, and environmental domains\u0026mdash;in shaping the quality of life of children living with T1DM. Sociodemographic factors such as financial stress, educational attainment, and family structure exert measurable influence on caregiver outcomes, with downstream effects on child functioning. These findings support the integration of caregiver assessment and support into routine diabetes care, reinforcing the need for family-centred, equity-informed, and psychosocially integrated models of chronic disease management. By addressing the needs of caregivers, we not only improve their wellbeing, but also enhance the health and developmental trajectories of the children in their care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eT1DM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eType 1 Diabetes mellitus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHrQOL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth-related quality of life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQoL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality of life\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHOQOL-BREF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization Quality of Life \u0026ndash; Brief version\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNCSS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational Council of Social Services\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003estandard deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\u003cp\u003e The research was conducted according to the Declaration of Helsinki. This study was approved by the Singhealth Centralised Institutional Review Board (CIRB No. 201709-00077).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003e Written informed consent was obtained from the parents.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJL and DC wrote the original and final manuscript. WL and JL prepared the figures. JL and DC were responsible for writing of the original draft. RFV, JSTL, WL were responsible for conceptualization, and methodology writing, JSTL and WC were responsible for the practical part of the experiment. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe authors confirm that the data supporting the findings of this study are available within the article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRyd\u0026eacute;n O, Nevander L, Johnsson P, Hansson K, Kronvall P, Sjoblad S, et al. Family therapy in poorly controlled juvenile IDDM: effects on diabetic control, self-evaluation and behavioural symptoms. Acta Paediatr. 1994;83(3):285\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWysocki T, Wayne W. Childhood diabetes and the family. Pract Diabetol. 1992;22:29\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchafer LC, McCaul KD, Glasgow RE. Supportive and Nonsupportive Family Behaviors: Relationships to Adherence and Metabolic Control in Persons with Type I Diabetes. Diabetes Care. 1986;9(2):179\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLawler MK, Volk R, Viviani N, Mengel MB. Individual and family factors impacting diabetic control in the adolescent: a preliminary study. Maternal-child nursing journal [Internet]. 1990;19(4):331\u0026ndash;45. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/2136583/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/2136583/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHanson CL, Henggeler SW, Burghen GA. Model of Associations Between Psychosocial Variables and Health-Outcome Measures of Adolescents with IDDM. Diabetes Care. 1987;10(6):752\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTHE WHOQOL GROUP. Development of the World Health Organization WHOQOL-BREF Quality of Life Assessment. Psychological Medicine [Internet]. 1998;28(3):551\u0026ndash;8. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cambridge.org/core/journals/psychological-medicine/article/abs/development-of-the-world-health-organization-whoqolbref-quality-of-life-assessment/0F50596B33A1ABD59A6605C44A6A8F30\u003c/span\u003e\u003cspan address=\"https://www.cambridge.org/core/journals/psychological-medicine/article/abs/development-of-the-world-health-organization-whoqolbref-quality-of-life-assessment/0F50596B33A1ABD59A6605C44A6A8F30\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBullinger M. Quality of life\u0026mdash;definition, conceptualization and implications: a methodologist\u0026rsquo;s view. Theor Surg. 1991;6:143\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRavens-Sieberer U, Herdman M, Devine J, Otto C, Bullinger M, Rose M, Klasen F. The European KIDSCREEN approach to measure quality of life and well-being in children: development, current application, and future advances. Qual Life Res. 2014;23(3):791\u0026ndash;803. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11136-013-0428-3\u003c/span\u003e\u003cspan address=\"10.1007/s11136-013-0428-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2013 May 18. PMID: 23686556; PMCID: PMC3953538.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDevelopment of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group. Psychol Med. 1998;28(3):551-8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/s0033291798006667\u003c/span\u003e\u003cspan address=\"10.1017/s0033291798006667\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 9626712.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoyden JY, Hill DL, Carroll KW, Morrison WE, Miller VA, Feudtner C. The Association of Perceived Social Support with Anxiety over Time in Parents of Children with Serious Illnesses. J Palliat Med. 2020;23(4):527\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGallagher S, Phillips AC, Oliver C, Carroll D. Predictors of Psychological Morbidity in Parents of Children with Intellectual Disabilities. J Pediatr Psychol. 2008;33(10):1129\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHsieh RL, Huang HY, Lin MI, Wu CW, Lee WC. Quality of life, health satisfaction and family impact on caregivers of children with developmental delays. Child Care Health Dev. 2009;35(2):243\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThomas A, Sawhill IV. For Love and Money? The Impact of Family Structure on Family Income. Future Child. 2005;15(2):57\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eToledano-Toledano F, de la Moral J, Nabors LA, Dom\u0026iacute;nguez-Guedea MT, Salinas Escudero G, Rocha P\u0026eacute;rez E, et al. Predictors of Quality of Life among Parents of Children with Chronic Diseases: A Cross-Sectional Study. Healthcare. 2020;8(4):456.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBellin MH, Kub J, Frick KD, Bollinger ME, Tsoukleris M, Walker J, et al. Stress and Quality of Life in Caregivers of Inner-City Minority Children With Poorly Controlled Asthma. J Pediatr Health Care. 2013;27(2):127\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVanz AP, F\u0026eacute;lix TM, da Rocha NS, Schwartz IVD. Quality of life in caregivers of children and adolescents with Osteogenesis Imperfecta. Health and Quality of Life Outcomes [Internet]. 2015 Apr 1 [cited 2019 Mar 21];13(1). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://hqlo.biomedcentral.com/articles/\u003c/span\u003e\u003cspan address=\"https://hqlo.biomedcentral.com/articles/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12955-015-0226-4\u003c/span\u003e\u003cspan address=\"10.1186/s12955-015-0226-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ede la Fern\u0026aacute;ndez K, Leon DA. Self-perceived health status and inequalities in use of health services in Spain. International journal of epidemiology [Internet]. 1996;25(3):593\u0026ndash;603. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/8671561/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/8671561/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMedway M, Tong A, Craig JC, Kim S, Mackie F, McTaggart S, et al. Parental Perspectives on the Financial Impact of Caring for a Child With CKD. Am J Kidney Dis. 2015;65(3):384\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoekstra-Weebers JEHM, Jaspers JPC, Kamps WA, Klip EC. Psychological Adaptation and Social Support of Parents of Pediatric Cancer Patients: A Prospective Longitudinal Study. Journal of Pediatric Psychology [Internet]. 2001;26(4):225\u0026ndash;35. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://academic.oup.com/jpepsy/article/26/4/225/988760\u003c/span\u003e\u003cspan address=\"https://academic.oup.com/jpepsy/article/26/4/225/988760\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRini C, Manne S, DuHamel K, Austin J, Ostroff J, Boulad F, et al. Social support from family and friends as a buffer of low spousal support among mothers of critically ill children: A multilevel modeling approach. Health Psychol. 2008;27(5):593\u0026ndash;603.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDahlquist LM, Czyzewski DI, Jones CL. Parents of Children with Cancer: A Longitudinal Study of Emotional Distress, Coping Style, and Marital Adjustment Two and Twenty Months After Diagnosis. J Pediatr Psychol. 1996;21(4):541\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWijnberg-Williams BJ, Kamps WA, Klip EC, Hoekstra-Weebers JEHM. Psychological Distress and the Impact of Social Support on Fathers and Mothers of Pediatric Cancer Patients: Long-Term Prospective Results. J Pediatr Psychol. 2005;31(8):785\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWertlieb D, American Academy of Pediatrics Task Force on the Family. Converging trends in family research and pediatrics: recent findings for the American Academy of Pediatrics Task Force on the Family. Pediatrics [Internet]. 2003;111(6 Pt 2):1572\u0026ndash;87. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/12777596/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/12777596/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrown RT, Wiener L, Kupst MJ, Brennan T, Behrman R, Compas BE, et al. Single Parents of Children with Chronic Illness: An Understudied Phenomenon. J Pediatr Psychol. 2007;33(4):408\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeeman J, Crandell JL, Lee A, Bai J, Sandelowski M, Knafl K. Family Functioning and the Well-Being of Children With Chronic Conditions: A Meta-Analysis. Res Nurs Health. 2016;39(4):229\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLewandowski AS, Palermo TM, Stinson J, Handley S, Chambers CT. Systematic Review of Family Functioning in Families of Children and Adolescents with Chronic Pain. The Journal of Pain [Internet]. 2010;11(11):1027\u0026ndash;38. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC2993004/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2993004/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 2 and 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-endocrine-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bend","sideBox":"Learn more about [BMC Endocrine Disorders](http://bmcendocrdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bend/default.aspx","title":"BMC Endocrine Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7510461/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7510461/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eChildren with type 1 diabetes mellitus (T1DM) rely heavily on caregivers for disease management, particularly in the early years following diagnosis. While child health-related quality of life (HrQOL) is widely recognised as a key outcome in diabetes care, the role of caregiver wellbeing\u0026mdash;particularly within diverse sociocultural and economic contexts\u0026mdash;has been insufficiently examined. This gap is especially relevant in multi-ethnic Asian settings, where family structures and caregiving expectations may diverge from Western norms.\u003c/p\u003e\u003ch2\u003eObjectives:\u003c/h2\u003e\u003cp\u003eTo evaluate the sociodemographic determinants of caregiver quality of life (QoL), and examine how these domains of caregiver wellbeing are associated with child-reported HrQOL in paediatric T1DM.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eWe conducted a cross-sectional study involving 72 parent\u0026ndash;child dyads recruited from a tertiary paediatric endocrinology clinic in Singapore. Children (\u0026lt;\u0026thinsp;18 years) and their primary caregivers independently completed validated QoL instruments (KIDSCREEN-27 and WHOQOL-BREF, respectively). Sociodemographic variables were collected, and multivariable linear regression was performed to evaluate associations between caregiver QoL, socioeconomic indicators, and child-reported HrQOL, adjusting for relevant covariates.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eCaregiver QoL was significantly influenced by household income, education, spousal support, and family configuration. Financial hardship, absence of spousal or maternal support, and lower educational attainment were associated with poorer caregiver QoL across multiple domains (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In turn, higher caregiver psychological wellbeing, social relationships, and personal beliefs were positively associated with child-reported QoL across physical, emotional, autonomy-related, and school-related domains (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eCaregiver wellbeing is a critical determinant of child HrQOL in paediatric T1DM. These findings highlight the importance of incorporating caregiver-focused psychosocial and structural support into family-centred diabetes care models. Proactively addressing caregiver needs\u0026mdash;particularly in families experiencing socioeconomic or relational vulnerability\u0026mdash;may offer a meaningful pathway to improve outcomes for both children and their caregivers.\u003c/p\u003e","manuscriptTitle":"Parental Quality of Life and Its Influence on Health-Related Quality of Life in Children with Type 1 Diabetes: A Cross-Sectional Dyadic Study in a Multi-ethnic Cohort","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-30 14:30:03","doi":"10.21203/rs.3.rs-7510461/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-07T05:16:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-03T01:55:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-01T15:44:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-01T02:28:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319878152130770513847246482159098351883","date":"2025-09-19T12:36:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212809781591167488788037235906152391207","date":"2025-09-19T02:33:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123263140731359313596299104929294513467","date":"2025-09-19T00:17:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-18T18:56:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-18T18:49:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-16T11:37:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-15T23:48:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Endocrine Disorders","date":"2025-09-15T23:45:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-endocrine-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bend","sideBox":"Learn more about [BMC Endocrine Disorders](http://bmcendocrdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bend/default.aspx","title":"BMC Endocrine Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"89da58c6-2f24-46a6-bce6-b570e536511d","owner":[],"postedDate":"September 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T16:03:25+00:00","versionOfRecord":{"articleIdentity":"rs-7510461","link":"https://doi.org/10.1186/s12902-025-02127-4","journal":{"identity":"bmc-endocrine-disorders","isVorOnly":false,"title":"BMC Endocrine Disorders"},"publishedOn":"2026-01-03 15:58:09","publishedOnDateReadable":"January 3rd, 2026"},"versionCreatedAt":"2025-09-30 14:30:03","video":"","vorDoi":"10.1186/s12902-025-02127-4","vorDoiUrl":"https://doi.org/10.1186/s12902-025-02127-4","workflowStages":[]},"version":"v1","identity":"rs-7510461","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7510461","identity":"rs-7510461","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}