behavior may vary with the differences in culture

behavior may vary with the differences in culture. Ethnicity is one of the factors which influence self-care and metabolic control. Therefore, studies based on populations from different cultures are required to address this issue. (Guo et al, 2011) The link between the self-care sharing process and the socio cultural diversity is not completely identified (Helgeson et al, 2007). The current study focuses on the self-care behavior and the sharing of responsibilities among the adolescents with T1DM within the Sri Lankan socio- cultural context. Socio-demographic characteristics, characteristics related to the illness and the perceptions on the illness are considered to be vital aspects in the Sri Lankan culture. A gap exists in the available researches related to the perceptions of children and adolescents on behaviour related to diabetes (Herman, 2006). The identification of the impact of each component towards self-care behaviour is vital to provide effective care for the adolescents with T1DM.
Economic, educational, and cultural influences play important roles in the self-management of diabetes (Abdulrehman et al, 2016). Cultural beliefs influence the perceptions of the illness and the understanding of the management of the disease. Family and social relationships and the symbolism of food were identified as cultural themes in relation to self-care of diabetes among Filipino Americans in Hawaii (Finucane and McMullen, 2015). No one has still examined the role of cultural attitudes, beliefs, and practices in the management of diabetes among the adolescents with T1DM.

1:2 The Adolescents with T1 DM in Sri Lanka and the nursing aspect
The collective incidences of the adolescents’ withT1 DM are an ongoing process of certain health institutions in Sri Lanka. The pediatric endocrine clinic at the Lady Ridgeway Hospital (LRH) and the National Diabetic Center (NDC) in Sri Lanka are maintaining registries of the children and adolescents with T1 DM. The Insulin Bank (IB) of NDC consists of 597 T1 DM children and young adults (Diabetes Association, 2013). There are a few institutes in Sri Lanka which provide facilities to specialized clinical follow up care for children and adolescents. Many patients have to attend general diabetes clinics which function mostly for adults. Only one pediatric endocrinologist was available in Sri Lanka for the treatment of diabetes in the initial period of the study. The accurate incidence of T1 DM in Sri Lanka has not been identified. However, the clinical evidence shows an increment of incidences in the past few years.
Pediatricians provide care for pediatric patients up to 12 years of age. The transitional care is mostly neglected in the current practices in Sri Lanka. It is recently initiated to establish a provision of transition and care for adolescents and also to extend the age limit cared by the pediatricians up to 16 years similar to developed countries. The establishment of multi consultant facilities, transition and adolescent clinics, reform of the infrastructure of pediatric wards to accommodate adolescents, provision of trained human resources including physicians for adolescents, psychologists, counselors and nurses are the pivotal strategies required to be implemented in Sri Lanka for the provision of a sound adolescent care. It is important to bridge the gap of knowledge among health care providers towards the care for adolescents. The revision of nursing training incorporated with nursing care of adolescents and emphasizing on adolescent medicine in the undergraduate curriculum and increasing the training exposure in this field are considered vital within the practice (Perera, 2016).
Promoting an active, lifelong self-care process in disease management for the patients with the chronic disease is a fundamental function in nursing. Providing education on diabetes care is the frontline strategy to assist patients in adapting a self-care management under this chronic condition. Nevertheless, the consideration made on this behalf within the Sri Lankan nursing education system is not adequate. The Sri Lankan education system extends from diploma level to degree level at present. A very few nursing personals are engaging in post graduate studies. The Post Basic College of nursing is a recognized higher education institute which provides diploma level nursing education from 1960 (Pathiranage ; Mori, 2014). It conducts post graduate diploma causes such as ward management, teaching and supervision, pediatric training, nursing in operating theatre etc. Nevertheless, it does not offer any special training in diabetes care or the care of Non-Communicable Diseases (NCDs). Almost all nursing officers are working in tertiary care units rather than primary health care sector in Sri Lanka. The public health nursing sisters are involved in primary health care activities as middle level managers. However, community health nurses are not available all the time (Jayasekara, 2009). The public health midwives who involve in child and maternity care are the main community health workers in the community health sector in Sri Lanka at present. However, midwives are not recognized to be involved in the care of NCDs such as diabetes and assisting self-care practices among children and adolescents with T1 DM. The health care delivery system in Sri Lanka is not well designed to implement in continuing care and behavioral modification strategies in the prevention and control of NCDs (Weerasinghe ; Siriwardana, 2013). The American Diabetes Association and Australian clinical practice guideline highly recommended the necessity of accessing care by multidisciplinary teams who are trained for the care of childhood diabetes. A nurse educated in the field of diabetes has a vital role in the team. Unavailability of the active role of a specialized nurse educator for childhood diabetes in Sri Lankan health care system is considered to be a draw back.

The role of nurse educators on diabetes cannot be neglected when assisting the self-care processes in the management of diabetes. Upgrading nursing education in this specialized field and establishing a nursing service in the community health setup is highly recommended. The availability of a diabetic nurse educator who can be easily approached in both community and hospital setting is an important strategy to achieve goals of having a quality self-care practice among children and adolescents with T1 DM. The trained nurses who are available for 24 hours are recommended to assist patients and their families in Sri Lanka (Atapattu ; De Silva, 2012). Furthermore, qualified and trained nurse educators on diabetes should be utilized effectively within the Sri Lankan health care system for assisting self-care activities of the children and adolescents with T1 DM.

Specific scientific studies related to the process of self-care among Sri Lankan children and adolescents with T1 DM are difficult to be found. An island wide standard method is not available to evaluate the progress of the self-care practices among children and adolescents. It depends on several institutions which facilitate follow-up care for the adolescents with diabetes. A national guideline for the investigation and management of T1 DM is recommended to overcome the challenges in the management of T1 DM in children (Atapattu ; De Silva, 2012). The availability of well-organized sub specialized clinics for adolescents with diabetes may help to address specific problems encountered by them.

The systematic literature review (Pathirange et al, 2015) pointed out the nonexistence of scientific literature on several areas in relation to T1 DM in Sri Lanka. There is a lack of relevant studies related to the ‘Type 1 diabetes’ within a specific ‘sociocultural context’. Behavioral modification is the frontline strategy to control this lifelong chronic illness. Cultural beliefs, values, attitudes, confidence, habits, functional and cognitive abilities are some factors affecting self-care in the management of diabetes (Zimmet et al, 2001). Culturally appropriate behavioral modifications should be followed in order to receive an effective outcome. Articles which contain information related to both ‘Type 1 diabetes’ and