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A MODEL OF ADHERENCE IN TYPE 2 DIABETES MELLITUS
i
THE ROLE OF PSYCHOSOCIAL FACTORS
Dissertation
Presented to
The Faculty o f the School o f Health Professions
MCP Hahnemann University
In Partial Fulfillment
of the Requirements for the Degree
Doctor o f Philosophy
by
David J. Kutz
Department o f Clinical and Health Psychology
May 1999
UMI Number: 9943603
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THESIS.APP
Abstract
Type 2 diabetes is identified by insulin resistance and beta cell dysfunction.
Commonly, an individual with Type 2 diabetes will produce insulin, but it is ineffective
in controlling blood glucose levels within the normal range. Epidemiological studies
have indicated that Type 2 diabetes affects approximately 5 million people in the United
States alone.
The treatment o f Type 2 diabetes involves a number o f factors that invariably
compel the patient to make life-long behavioral changes. These include following strict
dietary and exercise regimens, as well as checking one’s blood glucose levels and taking
insulin. Through extensive research, it has been determined that many patients do not
follow their prescribed treatment plans. Previous studies have alluded to varying
psychosocial factors in explaining why certain individuals adhere more to their doctors’
recommendations than others.
The current study examined the role that a number o f psychosocial variables may
have played in affecting adherence behaviors in two populations o f patients with Type 2
diabetes mellitus. The studies’ psychosocial variables included the patient-practitioner
relationship (PPR), coping style, social support, psychological distress, perceived stress,
and SES.
Ultimately, it was discovered that when individuals were satisfied with
interpersonal aspects o f their medical care they were receiving in their endocrinology
clinics, they were more likely to adhere to treatment recommendations. Furthermore, it
was discovered that when patients were less likely to utilize avoidance as a means by
which to cope with their illness, they tended to adhere more to prescribed treatment
regimens. It was also indicated that general satisfaction with medical care, as well as the
perceived level of social support the patients felt they obtained, contributed to adherence
practices.
Dedication
I would like to dedicate this paper to my parents, Alan and Nancy Kutz. Without
their help, love, and support, I would have never been able to complete this task.
Acknowledgments
I would first like to thank the endocrinology clinics that offered their help and
patient populations. These include Dr. Hasinski’s clinic at MCP Hahnemann Hospital,
and Dr. Pendergrass’ clinic at the Tulane University Medical Center. Furthermore, I
would like to acknowledge all of the guidance provided to me by my research mentor,
Dr. Julie Landel. Throughout our entire working relationship, she has always extended a
helping hand and pointed me in the right direction. Finally, I would like to thank all of
my friends and family for their understanding and support as I made it through the
arduous process o f completing my dissertation.
vi
Table o f Contents
I. Introduction to Diabetes 3
n. Psychosocial Factors Related to Adherence 34
m. Rationale for Present Study 52
IV. Working Model 55
V. Method 60
VI. Results 72
VII. Main Analyses 76
VIII. Supplementary Analyses 80
IX. Discussion 83
X. Main Analyses 83
XI. Supplementary Analyses 95
XII. Clinical Considerations 97
XIII. Limitations 99
XIV. Conclusions 103
XV. References 106
XVI. Tables 117
XVII. Figures 120
XVIII. Appendix 123
List of Tables
T ab let: Sample Characteristics
Table 2: Descriptive Statistics for the Psychosocial Scales and Metabolic Control
Table 3: Correlational Matrix
List o f Figures
Figure 1: Hypothesized Path Model
Figure 2: Path Model
Figure 3: Correlation o f Adherence and Metabolic Control
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Type 2 Diabetes 3
A Model o f Adherence in Type 2 Diabetes Mellitus:
The Role o f Psychosocial Factors
The present paper addresses the formulation, results, and conclusions of a
working model that conceptualizes the roles that certain psychosocial variables may play
in affecting adherence behaviors and health outcomes in patients with Type 2 diabetes
mellitus. A literature review indicating relevant clinical and theoretical issues is
presented first. Following this, a description of the present study is outlined, and the
results of the data are presented and explained. Finally, clinical considerations,
limitations, and conclusions associated with the present research endeavor are illustrated.
Introduction to Diabetes
“Diabetes” is a term used to describe a number of different disorders that reflect
problems o f glucose metabolism. In an individual without diabetes, glucose metabolism
is predominantly controlled by a feedback system that monitors concentrations o f blood
glucose (BG), and allows beta cells o f the pancreas to produce and release the hormone
insulin to metabolize glucose if levels of BG become too high. In persons with diabetes,
there is a problem within this system regarding insulin production or utilization.
Therefore, people with diabetes often have abnormally elevated levels o f glucose in their
bloodstream. The accumulation of glucose in the blood stream is referred to as
hyperglycemia. The hyperglycemic condition can be caused by a number o f different
variables. Among them are: insufficient insulin, insulin resistance, excess food intake,
Type 2 Diabetes 4
fever or infection, stress or emotional changes, and other factors that are not yet known
(Cox, Gonder-Frederick, & Saunders, 1991).
Diagnosis and Classification
Diagnosis. Diagnostic criteria for diabetes mellitus and impaired glucose
tolerance can be found in a report published in Diabetes Care (The Expert Committee on
the Diagnosis and Classification o f Diabetes Mellitus; ECDCDM, 1998). The report
states that for a diagnosis o f diabetes mellitus, a patient must have one o f the following:
(1) a casual plasma glucose level o f 200 mg/dl or greater plus classic signs and symptoms
o f diabetes mellitus including polydypsia, polyuria, polyphagia, and weight loss, (2) a
fasting plasma glucose level o f 126 mg/dl or greater, or (3) a two-hour plasma glucose
level greater than or equal to 200 mg/dl. (The 2-hour sample and at least one other
between 0 and 2 hours after the 75-gram anhydrous glucose dose should be 200 mg/dl or
greater.) For a diagnosis o f impaired glucose tolerance, the committee stated that a
patient must present a fasting plasma glucose level greater than or equal to 110 mg/dl,
but less than 126 mg/dl (ECDCDM, 1998).
Classification. There are numerous classifications o f diabetes, all with the
common etiological determinant o f glucose intolerance. However, there are two major
types o f diabetes: Type 1 and Type 2 (ECDCDM, 1998). Although Type 2 diabetes will
be the focus on the present study, a background of Type 1 diabetes will be given to
distinguish the closely related disorders.
Type 1 diabetes is characterized by a destruction of pancreatic beta cells and thus
an inability to produce an adequate amount of insulin. As a result, individuals with Type
Type 2 Diabetes 5
1 diabetes must administer daily injections o f insulin to survive (Cox et al., 1991). The
most common etiological explanation for Type 1 diabetes is that it is caused by a
combination o f genetic and autoimmunological processes (Cox & Gonder-Frederick,
1992). An individual who may be genetically predisposed towards diabetes may
encounter a stressful situation, such as a viral infection, and this may trigger an
autoimmunological reaction that destroys pancreatic beta cells (Raskin, Beebe, Davidson,
Nathan, Rizza, & Sherwin, 1994). Although Type 1 diabetes can occur at any age, it is
most often diagnosed during childhood or adolescence, between the ages o f 5-6 and 10-
12. Approximately 500,000-600,000 persons in the United States suffer from Type 1
diabetes (Cox et al., 1991), and it is most evident in Caucasian populations (Raskin et al.,
1994).
Type 2 diabetes is identified by insulin resistance and beta cell dysfunction, rather
than insufficient insulin production (ECDCDM, 1998). Commonly, an individual will
produce insulin, but it is ineffective in controlling BG levels within the normal range
(Johnson, 1992). Most patients with Type 2 diabetes are obese (approximately 80%), or
have a history o f obesity at the time o f diagnosis. However, nonobese individuals may
also develop Type 2 diabetes, particularly the elderly. It is believed that obesity is a main
contributor to insulin resistance (Cox & Gonder-Frederick, 1992).
Unlike Type 1 diabetes, which is often diagnosed in childhood, Type 2 diabetes is
usually diagnosed after the age o f 30 (Raskin et al., 1994). Type 2 diabetes is also
considered to be 7-10 times more prevalent than Type 1 diabetes (Polonsky, 1994).
Type 2 Diabetes 6
Furthermore, Type 2 diabetes is more often diagnosed in nonwhite populations (Raskin et
al., 1994).
Persons with Type 2 diabetes may not present the classic symptoms o f Type 1
diabetes, such as polydipsia, polyuria, polyphagia, and weight loss. In addition, Type 2
patients are not likely to develop other complications often seen with patients with Type
1 diabetes, such as ketoacidosis, except during periods o f traumatic stress (Raskin et al.,
1994).
Pathogenesis o f Type 2 Diabetes
Type 2 diabetes is known as a heterogeneous disease that is characterized by
“diminished tissue (liver and muscle) sensitivity to insulin and impaired beta cell
function.” (Rifkin et al., 1984). Although research has debated whether it is impaired
insulin secretion or impaired insulin action that is the initial marker in the pathogenesis
of Type 2 diabetes, it is clear that both insulin secretion and insulin action become
significantly impaired in persons who have had the disorder for a long time. Currently,
studies have found that defects in insulin secretion can lead to insulin resistance and vice
versa (Raskin et al., 1994).
Impaired Insulin Secretion. In non-diabetic persons, there are two phases o f
insulin release. There is an early phase that occurs within the first 10 minutes after
glucose ingestion which represents the release o f insulin stored within the beta cell, and a
following phase o f insulin secretion that represents newly synthesized insulin. In
individuals with diminished glucose tolerance and fasting plasma glucose levels o f less
than 115 mg/dl, the plasma insulin response after oral or intravenous glucose
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Type 2 Diabetes 7
administration can be either normal or, more often, elevated. However, if the fasting
plasma glucose concentration surpasses 115 mg/dl in a person with impaired glucose
tolerance, the early phase o f insulin secretion is lost or becomes significantly impaired,
and the later phase remains normal or, more often is increased (Rifkin et al., 1984).
Essentially, the plasma insulin response to glucose is often inversely correlated with the
degree of fasting hyperglycemia. So that patients with Type 2 diabetes with moderate to
severe hyperglycemia (>180-200 mg/dl) will tend to have all phases o f insulin secretion
impaired, and those with intermediate fasting plasma glucose levels (120-180 mg/dl) may
have increased, normal, or decreased plasma insulin responses (Cambell, Mandarino,
Gerich, 1988).
There are a number of physiological consequences to impaired insulin secretion.
When insulin release is initially inhibited, the portal vein insulin concentration remains
low and hepatic glucose production is not suppressed. Ancillary output o f glucose by the
liver, in addition to glucose entering circulation through the gastrointestinal tract, can
lead to excessive hyperglycemia. In addition, glucose uptake by surrounding tissues
tends not to be adequate for the level of glucose and insulin concentrations. Early in the
development o f diabetes, this leads to increased secretion o f insulin during the hours
following the ingestion o f glucose. Although the plasma glucose level eventually returns
to normal, it is at the expense o f late hyperglycemia and hyperinsulinemia. Furthermore,
as the beta-cell secretion defect worsens with prolonged marked fasting hyperglycemia,
the later phase o f insulin secretion is diminished. As this occurs, fasting hyperglycemia
and diabetes develop (Raskin et al., 1994).
Type 2 Diabetes 8
Insulin Resistance. Insulin resistance is an early defect. It is common in
individuals with impaired glucose tolerance, and fundamentally resides in all Type 2
diabetes patients who have fasting plasma glucose levels greater than or equal to 140
mg/dl. Insulin resistance has been found to be positively correlated with elevations in
fasting plasma glucose concentrations. Therefore, those with greater glucose intolerance
become more insulin resistant than those who are less glucose intolerant (Moller & Flier,
1991).
The process of insulin resistance can be best explained by first examining the
basic action o f insulin in nondiabetic persons at a cellular level. This occurs in two
phases. Initially, insulin binds to a specific receptor located on the surface of a cell.
Then, this interaction begins a series of intracellular sequences which result in enhanced
glucose transport and stimulation o f a number o f intracellular enzymatic pathways
(Moller & Flier, 1991).
Binding abnormalities (defects in the first stage o f insulin action) refer to a
reduction in insulin binding. This is followed by a reduction in insulin action. Such an
occurrence can be found in patients with mutations in the insulin gene or insulin receptor
gene. However, such abnormalities account for less than 1% of the those with Type 2
diabetes. This may be because most o f those with Type 2 diabetes are obese and
hyperinsulinemic, and a decrease in binding may be secondary to these conditions
(DeFronzo & Bonadonna, 1992).
Postbinding abnormalities, which occur after the insulin has bound to the cell, are
fundamentally responsible for insulin resistance in those with Type 2 diabetes and
Type 2 Diabetes 9
significant fasting hyperglycemia. These defects involve a decrease in glucose transport
and other intracellular processes involved in glucose metabolism; notably insulin-
stimulated glycogen synthesis (DeFronzo & Bonadonna, 1992).
As it has been mentioned, it is unclear whether impaired insulin secretion or
impaired insulin action explains the pathogenesis for Type 2 diabetes. Therefore, it
should be noted that by the time Type 2 diabetes is diagnosed in a specific individual, it
is often difficult to determine the primary etiological process for that particular patient
(Raskin et al., 1994).
Pathogenetic Sequences Leading to Type 2 Diabetes. Although it is still difficult
to determine if impaired insulin action or defects in insulin secretion occur first in
individuals with Type 2 diabetes, current trends in research have pointed to abnormalities
in insulin secretion as being a more common etiological starting point for this disease.
Recent studies have described a dual process by which impaired insulin secretion leads to
the development o f insulin resistance, while defects in glucose uptake by peripheral
tissues may secondarily result in beta-cell failure (Raskin et al., 1994; Rifkin et al.,
1984).
As it has been briefly discussed, the insulin secretory response to glucose is
delayed or diminished in almost all patients with Type 2 diabetes. This impaired insulin
secretory response leads to an inadequate suppression o f hepatic glucose production and
a decrease in the uptake o f glucose by peripheral tissues during the time immediately
following the ingestion o f glucose. The resulting hyperglycemia provides a continuous
stimulus to insulin secretion, and this will eventually return plasma glucose
Type 2 Diabetes 10
concentrations to normal. However, while fasting euglycemia is maintained, increased
plasma insulin concentrations result from this process. This is important because insulin
is involved in the regulation o f its own receptor. So, when chronic hyperinsulinemia
exists, a downregulation in the number o f insulin receptors may occur. This may lead to
insulin resistance (Campbell et al., 1988).
An insulin secretory abnormality may result from several factors: (1) the natural
history o f the beta-cell defect (which may be genetically determined), (2) persistent
hyperglycemia, which may have deleterious effects on the beta-cell and can cause
impairment in insulin secretion, or (3) a yet to be understood metabolic disturbance
(Rifkin et al., 1984).
Taken together, the etiological process o f Type 2 diabetes may be viewed in the
following manner: Both early and late phases o f insulin secretion become impaired,
while insulin resistance is also often seen in peripheral tissues (i.e. muscle). In addition,
postbinding abnormalities tend to be responsible for diminished insulin action. These
patients tend to have elevated hepatic glucose production both prior to, and after, food
consumption. Finally, the ability o f insulin to suppress hepatic glucose output and
elevated glucose utilization is also impaired (DeFronzo & Bonadonna, 1992).
Complications o f Type 2 Diabetes
Although Type 2 diabetes has been referred to as a “milder” form o f diabetes
when compared to Type 1, patients with Type 2 diabetes can be affected by the same
spectrum o f diabetes-specific complications as persons with Type 1 diabetes.
Furthermore, because Type 2 often occurs in an older population than Type 1, it is
Type 2 Diabetes 11
accompanied by a higher rate o f premature cardiac and cerebral and peripheral vascular
disease than Type 1 and nondiabetic populations. In addition, because Type 2 diabetes
makes up approximately 90% o f the cases o f diabetes in the United States, these
complications afflict a large number o f people (over 13 million), and place an immense
responsibility on our health care system (Raskin et al., 1994).
Major Chronic Complications. Studies have found accelerated macrovascular
disease, namely atherosclerosis involving the coronary, cerebrovascular, and peripheral
vessels, to be responsible for approximately 80% o f the mortality in adults with diabetes.
Hence, macrovascular disease presents the most serious threat to the health o f diabetes
patients (Raskin et al., 1994). Furthermore, these disorders tend to occur at an earlier age
and at a greater frequency in diabetic patients than in the general population. In fact,
Type 2 diabetes is viewed as an independent risk factor for macrovascular disease (Cox
etal., 1991). In addition, many common coexistent conditions seen in diabetic patients,
such as hypertension, dyslipidemia, and obesity, are also risk factors for macrovascular
disease (Raskin et al., 1994).
Diabetes also targets other areas of the body; including the eyes, kidneys, feet,
blood vessels, and nervous system. Retinopathy, a degenerative disorder that affects
blood vessels in the retina and can cause visual impairment and blindness, is the most
common long-term complication o f diabetes (Cox et al., 1991).
There are three types of diabetic retinopathy: nonproliferative, preproliferative,
and proliferative. Nonproliferative diabetic retinopathy (NPDR) occurs in most patients
who have long-term Type 2 diabetes. In its earliest phase, NPDR is characterized by
Type 2 Diabetes 12
microaneurysms and intraretinal “dot and blot” hemorrhages. Fortunately, in many
cases, this complication does not progress and visual acuity is not affected (Rosenstock
& Raskin, 1986).
Preproliferative diabetic retinopathies (PPDR) are retinal lesions that represent an
advanced form o f NPDR. PPDR lesions include “cotton-wool spots” (ischemic infarcts
in the inner retinal layers), “beading” o f the retinal veins, and intraretinal microvascular
abnormalities. If these lesions are found together, the risk o f progression to the final,
most visually-threatening stage, proliferative diabetic retinopathy (PDR), is increased
The PDR stage is characterized by the introduction o f new vessels
(neovascularization) on the surface o f the retina. PDR becomes a threat to vision
because the new vessels are prone to bleed. If bleeding infuses into the preretinal space
or vitreous, patients may report “floaters” or “cobwebs” in their field o f vision. Patients
who have major retinal hemorrhages will experience sudden, painless loss of vision. The
prevalence o f PDR among those with Type 2 diabetes who have had the disease for more
than or equal to 20 years is approximately 30% (Raskin et al., 1994).
Research has shown that by 15 years after the diagnosis o f diabetes, 97% of Type
1 and 80% o f Type 2 patients display indications o f retinopathy. Furthermore,
approximately 12% of those who have had diabetes for more than 30 years are legally
blind (Cox et al., 1991).
Another long-term complication that many with diabetes may contend with is
diabetes renal disease (nephropathy). Studies have shown that, in the United States,
Type 2 Diabetes 13
diabetes accounts for 20-30% o f all cases o f nephropathy. Furthermore, by the 15th year
following the diagnosis of diabetes, approximately 33% o f Type 1 and 20% o f Type 2
patients will have developed some sign of renal disease (Cox et al., 1991). Raskin et al.
(1994) put forth a number o f conditions that may precipitate and/or maintain renal
dysfunction. These conditions include: hypertension, neurogenic bladder, infection and
urinary obstruction, and nephrotoxic drugs.
In addition to the aforementioned long-term complications o f diabetes,
neuropathic conditions are also viewed as a common problem within the diabetic
population. Specifically, there a two forms of diabetic neuropathy: sensorimotor
neuropathy and autonomic neuropathy (Raskin et al., 1994).
Sensorimotor neuropathies include symmetric distal neuropathies,
mononeuropathy, and diabetic amyotrophy. Symmetric neuropathy generally occurs in
the lower extremities, and is often described by patients as being mildly annoying, rather
than severely painful. Persons often initially feel “pins and needles” paresthesias during
the nighttime hours. However, hypesthesia can develop as neuropathy progresses, and
this can put an individual at risk for trauma and foot ulcers (Nathan, 1993).
Mononeuropathy is commonly seen via extraocular muscle motor paralysis.
Patients may develop peroneal (foot drop) and median or ulnar palsies, or they may
experience compression neuropathies, such as carpal tunnel syndrome. Typically,
patients will spontaneously recover within 3 to 6 months (Raskin et al., 1994).
Diabetic amyotrophy is characterized by severe pain and wasting of the proximal
muscles (pelvic girdle and thigh). Well-known features of this disorder include
Type 2 Diabetes 14
quadriceps involvement, atrophy o f the thigh muscles, and absent patellar tendon
reflexes. Complete recovery often occurs within several months to a year (Rifkin et al.,
1984).
Autonomic neuropathies form the second classification of diabetic neuropathies.
They tend to appear late in the course o f diabetes, and they include gastroparesis, diabetic
diarrhea, neurogenetic bladder, impaired cardiovascular reflexes, and impotence in men
(Nathan, 1993).
A person with gastroparesis may experience “early satiety, nausea, vomiting, or
abdominal discomfort secondary to delayed emptying or retention o f gastric contents.”
(Raskin, et al., 1994) A similar problem, diabetic diarrhea, may cause a patient to pass
loose stools, especially following meals and at night. This may alternate with periods of
constipation (Raskin et al., 1994).
Another autonomic neuropathy, the neurogenic bladder, can cause a diabetic
patient to experience frequent small voidings and incontinence. This can progress
toward a state o f urinary retention, which at times may lead to an infection. Cystometric
abnormalities and a large residual urine volume are necessary for an individual to be
diagnosed with this condition (Rifkin et al., 1984).
Impaired cardiovascular reflexes and impotence in men are two other autonomic
neuropathies often seen in diabetic patients. Impaired cardiovascular reflexes can result
in orthostatic hypotension and increased heart rates for some individuals. Impotence in
men is usually characterized by lack of a firm, sustained erection. However, in many
Type 2 Diabetes 15
cases, libido and ejaculatory function are not affected, although retrograde ejaculation
may occur (Keen, 1982).
Finally, research has also shown that both Type 1 and Type 2 diabetes can
significantly increase the risk o f a myocardial infarction. Furthermore, diabetic patients
present a two to six times higher prevalence rate o f stroke than the nondiabetic
population (Cox et al., 1991).
Among many diabetes patients, foot problems present yet another difficulty that
must be addressed. Research has shown that more than 50% of the cases of nontraumatic
amputations in the United States occur in persons with diabetes. Foot lesions often result
from a combination of peripheral neuropathy, peripheral vascular disease, and an
infection (Levin, O’Neil, & Bowker, 1993). Typically, peripheral neuropathy becomes
noticed when the patient experiences abnormal sensations or severe pain in the lower
limbs and feet. In many instances, total loss of sensation eventually occurs, and the
diabetic patient may become unaware o f injuries to these regions. This loss of sensation
is often accompanied by peripheral vascular disease, which together, tends to impair the
healing process in many diabetic patients. As a result o f these complications, lower limb
amputations are often an inevitable consequence to prevent more serious health risks
such as ulcerations, infections, or gangrene (Scardina, 1983).
Major Acute Complications. There are two major acute diabetes-specific
complications: (1) metabolic problems, and (2) infection. Furthermore, within the
category o f metabolic problems, there are two syndromes; hyperosmolar hyperglycemic
nonketotic syndrome and hypoglycemia (Raskin et al., 1994).
Type 2 Diabetes 16
Hyperosmolar hyperglycemic nonketotic syndrome, a hyperglycemic condition
that typically occurs in older Type 2 patients, encompasses four major clinical features.
They include severe hyperglycemia (BG >600mg/dl), absence o f or slight ketosis, plasma
or serum hyperosmoladity, and profound dehydration. This life threatening condition
often exposes itself by way o f excessive thirst, altered sensorium (coma or confusion),
and physical signs of severe dehydration. In addition, there are almost always
precipitating factors that precipitate this condition. They may include the use of drugs, or
may involve acute or chronic diseases (especially infections) that increase glucose levels.
Limited access to water may also initiate this syndrome (Raskin et al., 1994).
Hypoglycemia, another metabolic problem that may occur in diabetes
populations, involves an imbalance between the amount o f food one digests and the
dosage o f drug therapy (e.g. insulin) one administers (Raskin et al., 1994). Essentially, it
occurs when BG levels become too low to provide the body with the necessary metabolic
fuel to maintain normal body (particularly brain) functions. Symptoms are usually
presented when BG levels are approximately 50-70 mg/dl or lower (Cox et al., 1991).
Patients who are hypoglycemic may have altered mental and/or neurologic functions,
such as changes in sensorium and behavior, comas, or seizures, as well as adrenergic
responses. These include tachycardia, palpitations, increased sweating, and hunger.
Exercise, intake o f alcohol, or other drugs, and decreased liver or kidney function can
initiate or worsen this condition (Raskin et al., 1994).
Infections, another acute diabetic complication, are the leading cause of
metabolic abnormalities that can lead to a diabetic coma. Common infections include
Type 2 Diabetes 17
cutaneous infections, urinary tract infections, pulmonary infections, and ear infections. It
is imperative that these problems are diagnosed and treated as quickly as possible to
avoid severe hyperglycemia and its complications (Keen. 1982).
As it has been demonstrated, Type 2 diabetes can pose a serious threat to a
patient’s health, in that it can potentially adversely affect any part of the body. In
addition, the risk factors may be viewed as both acute and chronic. The next section will
be dedicated to the management o f Type 2 diabetes, and will focus on current treatment
recommendations that are utilized to stave off the previously mentioned complications.
Management o f Type 2 Diabetes
There are two principle goals in the management o f Type 2 diabetes: (1) to avoid
hyperglycemia by maintaining BG levels as close to the normal range as possible (80-120
mg/dl), and (2) to prevent microvascular and macrovascular complications (Polonsky,
1994;
Raskin et al., 1994). Treatment plans should be geared towards reversing the pathogenic
metabolic mechanisms of diabetes that result in hyperglycemia; namely insulin resistance and
impaired beta-cell function (Raskin et al., 1994). Plans should include at least the following
variables: (1) diabetes education, (2) dietary modification, (3) an exercise regimen, (4) self
testing of BG or urine, and (5) medication or insulin injections (for some Type 2 patients). It is
important to remember that all treatment plans should presented in an idiographic manner, and
will most likely differ from patient to patient. In addition, it may be useful to note that the
management o f diabetes is typically the patient’s responsibility because they must follow this
complex set o f self-care behaviors on a daily basis for the rest o f their lives (Cox et al., 1991).
Type 2 Diabetes 18
Education. It is critical that a patient becomes knowledgeable o f the self-care
skills needed to manage their diabetes (Raskin et al., 1994). National standards exist
regarding the proper manner with which physicians should educate their patients
(American Diabetes Association, 1996). Often, patients are asked to leam a large
amount o f information and acquire a number o f skills. From the time o f diagnosis,
patients should grasp such critical skills as self-testing one’s BG, administering one’s
insulin (if necessary), and techniques to treat possible bouts of hypoglycemia.
Furthermore, continuing education and skill building is often necessary as a patient’s
disease progresses, and as new methods of treatment are introduced (Cox et al., 1991).
Diet. Medical nutrition therapy is believed to be the most important element in
the treatment of Type 2 diabetes. There are four fundamental goals o f nutrition therapy:
(1) maintaining near-normal blood glucose levels, (2) normalizing serum lipid levels, (3)
attaining and maintaining a reasonable body weight, and (4) promoting overall health
(Raskin et al., 1994; Franz et al., 1994).
As it has been mentioned, approximately 80-90% of Type 2 patients are obese
(>25 Body Mass Index), and thus caloric restriction is usually the primary treatment
component utilized to improve glucose tolerance (Raskin et al., 1994). The loss o f as
little as 5-10% of one’s body weight can improve glucose uptake, reduce insulin
secretion, and decrease hepatic glucose production. Furthermore, there are some
indications that weight loss may be most effective in the early stages of Type 2 diabetes
when insulin secretion is greatest (Henry, Wallace, & Olefsky, 1986).
Type 2 Diabetes 19
A specific dietary plan for Type 2 patients typically includes the moderation o f
protein consumption, limiting the intake o f simple carbohydrates (sugar), increasing the
intake o f complex carbohydrates, and reducing fat intake. Furthermore, for individuals
using insulin therapy as well, the timing o f food consumption is as important as the
amount and types o f food consumed (C oxetal., 1991).
The recommendation for protein intake for Type 2 patients is the United States
recommended dietary allowance (RDA) of 0.8 g/kg daily. If possible, it is important to
keep protein intake within the bounds of 0.8-1.0 g/kg daily because excessive protein
consumption may aggravate renal insufficiency, a common problem among individuals
with diabetes. On such a diet, protein will account for about 10-20% of the total calories
a patient consumes. Also, common sources o f protein such as meat, fish, and poultry are
limited to approximately 3-5 oz/day (Franz et al., 1994).
The remaining 80-90% of a Type 2 patient’s diet should be divided between
carbohydrates and fat. Specifically, saturated fats should make up <10% of one’s total
caloric intake because these products contain more than twice as many calories as either
carbohydrates or protein, and help develop and maintain obesity. Coconut and palm oil,
both highly saturated, should be completely avoided. In addition, limiting the intake of
red meat to 3-4 oz/day, drinking skim milk (as opposed to whole or 1% milk), and
substituting margarine for butter, may further aid a patient in limiting their saturated fat
intake below the 10% guideline. Forms of unsaturated fat should not exceed 20% of
one’s total caloric intake (Franz et al., 1994).
Type 2 Diabetes 20
The Food Guide Pyramid (US Department o f Agriculture, 1992) provides a good
recommended model for carbohydrate intake among Type 2 patients. The emphasis in
the pyramid is on whole grains, starches, fruits, vegetables, vitamins, and minerals.
Although a small portion o f the carbohydrate makeup o f a Type 2 patient’s diet may
allow for simple carbohydrates such as sucrose, the majority of the dietary carbohydrate
makeup should be dedicated to complex carbohydrates such as starches. Carbohydrates,
therefore, make up approximately 50-60% o f the total caloric intake in patients with
Type 2 diabetes (Raskin et al., 1994; Franz et al., 1994).
Exercise. Exercise can enhance insulin sensitivity and increase skeletal muscle
glucose uptake both during and after significant physical activity (American Diabetes
Association, 1993). Thus, exercising in regular intervals (i.e. every other day) can help
aid in the reduction in glucose intolerance. In addition, exercise has been purported as a
significant aid in reducing one’s weight, a problem with which most Type 2 patients must
contend. This is important because a reduction in weight can increase insulin action and
decrease insulin resistance. Furthermore, a consistent regimen o f exercise has also been
shown to reduce risk factors associated with cardiovascular disease. This may be a
function o f exercise being correlated with an increase in HDL cholesterol, a decrease in
LDL cholesterol, and a decrease in triglycerides and insulin; all of which have been
shown to provide protection against cardiovascular disease. Other benefits o f exercise
include decreases in blood pressure and heart rate, increases in maximum oxygen uptake,
and numerous psychological benefits such as decreased anxiety and improved mood and
self-esteem (ADA, 1993).
Type 2 Diabetes 21
In instating an exercise regimen for a patient, a physician must take a number of
precautions into consideration. Type 2 patients may have insensitive feet or peripheral
vascular insufficiency, untreated or newly treated retinopathy, or hypertension.
Therefore, plans for activity, including the intensity, duration, and frequency o f the
exercise, should be carefully monitored by both the physician and the patient (Raskin et
al., 1994).
While walking is generally a safe form o f exercise for most patients, some
patients with diabetes may be able to undertake more rigorous forms o f exercise such as
biking, swimming, or running. Lifting light weights may also be beneficial for some
patients. Generally, a session of aerobic exercise should last anywhere from 20-40
minutes, and should sustain a patient’s heart rate at approximately 60-80% o f their
maximal heart rate. Furthermore, maximal benefits o f exercise are seen when a patient
participates in sessions that are less than or equal to 48 hours apart from each other
Self-Monitoring BG Levels. Another important aspect o f a Type 2 patient’s
treatment may include self-testing one’s blood. The purpose of this is threefold: (1) it
prevents unacceptable BG levels, (2) it monitors overall diabetes control, and (3) it
evaluates the effectiveness o f self-treatment (Schiffrin & Belmonte, 1982; Skyler,
1981b). Daily urine tests are often used to detect the presence of ketones, which are a
marker for hyperglycemia. In addition, blood tests are performed, via finger pricks, and
blood drops are placed on reagent strips to be examined either visually or by meters. The
frequency o f blood tests vary, depending on the number o f injections of insulin a patient
Type 2 Diabetes 22
is administering. They can range anywhere from three or four tests daily to only a few
tests per week (ADA, 1987).
Insulin and Other Medications. Pharmacological interventions for patients with
Type 2 diabetes are typically utilized when normal levels of plasma glucose cannot be
achieved through nutrition therapy and exercise. There are two forms of
pharmacological treatment for this population. They include oral hypoglycemic agents
and insulin (Raskin et al., 1994).
Oral hypoglycemic agents (sulfonylureas) are only used with individuals with
Type 2 diabetes because they rely on endogenous insulin secretion, which individuals
with Type 1 diabetes inherently lack. In effect, they aid beta-cell insulin secretion, may
reduce accelerated rates o f hepatic glucose production, and may partially reverse defects
in insulin action (Raskin et al., 1994). Additional information, such as an in depth
review o f oral agents utilized with Type 2 diabetes patients, can be found in Diabetes
Care. Volume 20(11) (Bloomgarden, 1997).
Insulin treatment has been shown to be very effective in restoring BG levels to
their normal range in Type 2 patients. It lowers BG levels by increasing glucose uptake
and metabolism o f insulin-sensitive peripheral tissues (i.e. muscle), and by suppressing
hepatic glucose production. This form o f therapy may be highly recommended for
patients with symptoms typical o f Type 1 diabetes, such as rapid uncontrolled weight loss
(unexplained by diet) and severe hyperglycemia with ketonemia and/or ketonuria. Other
indications for the use of insulin therapy include: (1) hyperglycemia despite maximal use
Type 2 Diabetes 23
o f sulfonylureas, (2) pregnancy, (3) renal disease, (4) periods o f acute stress or infection,
and (5) allergy or serious reaction to sulfa drugs (Raskin et al., 1994).
Adherence to Treatment
The treatment of diabetes is often viewed by the patient as an arduous and
complex task because it involves a number o f lifestyle changes that must be completed
on a daily basis for the rest o f the patient’s life (Cox et al., 1991). In addition, many
patients must also face the emotional stress o f having to take personal responsibility for a
chronic, life threatening illness that could result in long-term complications- regardless o f
how strict they are in adhering to their treatment regimen (Polonsky, 1994).
Many studies have reported low levels o f adherence within this population. Kurtz
(1990) reported that among their sample o f Type 1 patients, 80% failed to administer
insulin regularly in an acceptable manner, 35-75% failed to abide by their dietary
restrictions, and 43% failed to test their urine glucose regularly. Other studies have seen
similar results. Polonsky (1991) reported that, in a sample o f 456 women with diabetes,
83% found it impossible to follow a certain meal plan. Similarly, Christensen, Terry,
Wyatt, Pichert, & Lorenz (1983) found 78% of their sample to be significantly
nonadherent with their dietary regimens on a weekly basis.
Past research (Fairbum, Peveler, Davies, Mann, & Mayou, 1991; Rodin, Craven,
Littlefield, Murray, & Daneman, 1991) has further pointed out that 10-40% of women
with Type 1 diabetes intentionally omit insulin doses on a regular basis. Additionally, in
regard to BG testing, Wilson & Endres (1986) found that patients reported and recorded
30-40% more BG tests than were recorded by their glucometers when they were unaware
Type 2 Diabetes 24
o f the machine’s capacity to store such information. Plus, Mazze et al. (1984) reported
that between 40% and 80% o f their subjects underreported their blood sugar levels on at
least half o f their recordings.
Interestingly, some studies have reported that, although nonadherence is
widespread, patients often have the most difficulty adhering to the diet and exercise
components of treatment (Glasgow, McCaul, & Schafer, 1986, 1987). This is important
to recognize because these variables are viewed as the most vital components o f
treatment in the management o f Type 2 diabetes (Raskin et al., 1994). This also further
emphasizes the challenge that Type 2 diabetes patients must face on a daily basis.
Adherence: Defined and Assessed
Adherence versus Compliance. Many medical treatment studies use the terms
“compliance” and “adherence” interchangeably, and it may be helpful to explain why the
current study will examine patient adherence, rather than patient compliance. The term
compliance refers to the extent to which a patient is obeying a physician’s treatment
orders, and implies that the patient is taking on a passive role in their disease
management. Most noteworthy o f this term, is that when a patient is unable to comply, it
is inherently assumed that the noncompliance is their fault because the physician has
already done his/her job in recommending the treatment protocol (Turk & Meichenbaum,
1988). Adherence, on the other hand, connotes a dual relationship between the physician
and the patient (Turk & Meichenbaum, 1988). It has been described as a “mutually
acceptable course o f behavior that produces a desired preventive or therapeutic result.”
(Meichenbaum & Turk, 1987) Therefore, both parties have an obligation to formulate
Type 2 Diabetes 25
and modify the treatment plan, and a failure to follow management suggestions may
highlight difficulties within the patient-physician relationship, rather than sole problems
with the patient (Turk & Meichenbaum, 1988). Thus, the term adherence will be used in
the present study because it contains a less negatively- biased perspective on who must
take responsibility for nonadherence to treatment and connotes a more impartial view of
the patient.
What Constitutes Adherence. Turk and Meichenbaum (1988) stated that,
“Adherence should reflect the minimum standards necessary to achieve desired health
benefits.” However, regarding the treatment of many chronic diseases, it has yet to be
determined what specifically constitutes an adequate level o f adherence (Epstein &
Cluss, 1982). This may be because physicians often find that less than perfect adherence
rates still result in positive health outcomes (Turk & Meichenbaum, 1988). For example,
in one study (Luscher, Vetter, Seigenthaler, & Vetter, 1985) researchers found that 80%
adherence rates to a medication regimen for hypertensives resulted in the normalization
of subjects’ blood pressure. Likewise, in another study (Olson, Zimmerman, & Reyes de
la Rocha, 1985), it was determined that children taking oral penicillin as a prophylactic
for rheumatic fever needed only 33% of their medication to reduce the rate of
streptococcal infection.
For some research endeavors that deal with long-standing illnesses, a model has
been applied to operationalize the term adherence. This model, the Transtheoretical
Model of behavior change, focuses on the extent to which a given patient has ceased
high-risk behaviors and acquired health-enhancing behaviors. The model contains five
Type 2 Diabetes 26
separate stages: precontemplation, contemplation, preparation, action, and maintenance.
Behaviors described by the model range from (1) patients not planning to make any
behavior changes in the foreseeable future (precontemplation stage) to (5) individuals
that have overtly changed their behavior as recommended, and have done so for at least
six months (maintenance stage) (Ruggiero & Prochaska, 1993). Interestingly, even
within this model, which has attempted to give the term adherence more o f an empirical
basis, actual percentages o f what constitutes adherence do not exist. Those that adhere
are simply described as patients who closely follow their prescribed treatment regimens
most o f the time (Ruggiero & Prochaska, 1993). Thus, adherence remains an amorphous
term that has different applications in varying fields o f medicine.
General Assessment of Adherence. The most frequently used tool for assessing
adherence behaviors is the patient self-report method (McNabb, 1997). Typically, the
patient is asked questions regarding their treatment behavior, or may be required to
record the frequency, duration, and number of specific treatment behaviors they
completed. Following this, the patient’s answers to the questions are often scaled and
averaged together to make an overall “adherence score” (Turk & Meichenbaum, 1988).
It is recommended, however, that for diseases that have multiple aspects o f treatment,
such as diabetes, adherence rating should be made separately for the various components
of the regimen (i.e. diet, exercise, etc.). This is because patients tend to adhere
differently to particular aspects of treatment In this manner, a self-report measure can
be more sensitive to the complexities of managing the disorder (Johnson, Kelly, Henretta,
Cunningham, Tomer, & Silverstein, 1992).
Type 2 Diabetes 27
Self-report measures have been shown to be a relatively valid and cost-efficient
method to gather adherence information (McNabb, 1997; Hanson, Cigrang, Harris, Carle,
Relyea, & Burghen, 1989; Morisky, Green, & Levine, 1986). In one study (Hanson et al.,
1989), researchers utilized a selt-report measure to assess adherence behaviors across
five areas that had been deemed important in the treatment o f diabetes. They found the
test-retest (3 month) reliability o f the composite index, as well as the interrater reliability
o f the total adherence scale, to be significant. They also discovered that the adherence
measure was significantly associated with the health outcome, metabolic control.
In another study (Morisky et al., 1986), a self-report scale measuring adherence to
a hypertension management protocol was able to significantly predict health outcomes.
Individuals in the study who scored high on the adherence scale were more likely to have
their blood pressure under control than those who scored low on the scale. Based on
these outcomes, it was concluded that the self-report measure accurately predicted actual
adherence behaviors.
Although the practical uses of self-report scales appear evident, there are a
number of limitations related to the use o f this method o f data collection (McNabb, 1997;
Turk & Meichenbaum, 1988). First, falsification o f the data by the patient may occur for
a number of reasons: (1) the patient may simply not be able to recall the information
accurately, (2) they may not want to look unfavorable to the clinician, or (3) the patient
may deny that they are struggling with the self-management o f their disorder. Second,
even when examiners can be assured that the patient is attempting to answer the measure
accurately, data may be difficult to interpret because patients may have not received
with permission of the copyright owner. Further reproduction prohibited without permission.
Type 2 Diabetes 28
explicit treatment instructions from their physicians, and what patients may consider
“adherent” may not actually be sufficient (Polonsky, 1994). As a result o f its limitations,
many authors suggest that it is most appropriate to combine self-report measures with
other, more objective tools o f assessment (Turk & Meichenbaum, 1988).
Other methods o f assessing adherence behaviors include physiological and
biochemical monitoring and clinical outcome measurements. Physiological and
biochemical monitoring describes a process by which researchers incorporate chemical
tracers into their subjects’ medication, and then subsequently attempt to detect these
tracers in tracers in the patients’ urine or blood. This may also be done through the use
of bioassay o f medication or its metabolites in urine or blood.
Although this process is less subjective than self-report measures, it tends to
involve a high cost and may be less practical for research purposes. In addition, research
has shown that methods such as biological assays may produce misleading results due to
such factors as individual variations in serum levels o f absorbed drugs and difficulty in
specifying the optimum serum levels. Also, because the marker or drug is often excreted
quickly, the method may only provide information about recent doses, and therefore may
not be capable of measuring adherence over long periods o f time (Turk & Meichenbaum,
1988). Furthermore, in regard to the present study, this method is not feasible for use
with insulin doses and other diabetes treatment behaviors.
Clinical outcome measures can also be used to assess adherence behaviors.
Essentially, researchers will look at an outcome variable, such as metabolic control, and
determine the rate of adherence behaviors based on this physiological measure. If the
Type 2 Diabetes 29
variable has significantly changed for the better, it is believed that adherence is indicated.
If the variable has changed for the worse, nonadherence is presumed to have occurred
(Turk & Meichenbaum,1988). For example, in a study performed with a child and
adolescent diabetes population (Hanson et al., 1989), a measure indicative o f metabolic
control, hemoglobin A le (HbAlc), was examined Higher levels o f HbAlc, which
typically reflects a poor clinical outcome, indicated lower levels of adherence.
Conversely, lower levels o f HbAlc pointed to higher levels o f adherence.
Unfortunately, the link between rates o f adherence and clinical outcomes appear
to be questionable (Johnson et al., 1992; Polonsky, 1994). In fact, some studies have
shown that patients may get better regardless o f low rates o f adherence, and may get
worse despite high levels o f adherence (Turk & Meichenbaum, 1988). This issue will be
discussed at greater length in forthcoming pages of the present literature review.
Assessment o f Type 2 Diabetes Treatment Adherence. Generally, research
examining adherence behaviors in Type 2 populations use various combinations of four
assessment methods: self-reports, collateral reports, indirect clinical observations, and
clinical outcomes (metabolic control) (Sherboume, Hays, Ordway, DiMatteo, & Kravitz,
1992). However, because of the expense and inconvenience o f many indirect clinical
observation tools, it is common for studies to rely on self-report measures, such as the
Self Care Inventory (SCI; LaGreca et al., 1990), collateral reports; and/or metabolic
control measures, such as glycosylated hemoglobin assays, rather than all four
assessment methods. In addition, for those that utilize self-report scales, it has been
further recommended that multiple measures be used so that adherence to various
Type 2 Diabetes 30
regimen components can be measured separately (Sherboume et al., 1992). This may be
helpful because, as it has been mentioned, patients tend to be differentially adherent, in
that they may adhere well to one aspect o f their treatment while adhering to a lesser
degree to others (Polonsky, 1994; Orme & Binik, 1989).
Metabolic Control: Defined and Assessed
Metabolic control refers to a patient’s ability to control BG levels that accumulate
in the bloodstream (Raskin et al., 1994). Often, a glycosylated hemoglobin assay (HbAl
or HbAlc, depending on the assay method used) is assessed because it is an accurate
biological marker of glucose control (Polonsky, 1994). The glycosylated hemoglobin
assay indicates the percentage of total hemoglobin to which glucose is attached. Thus, it
provides an index of the average glucose levels to which tissues have been exposed in the
4-8 weeks prior to measurement. However, it should be noted that although this index
provides a moderately convenient and accurate assessment of metabolic control, the
HbAlc marker does not reflect changes in metabolic control, which may, in itself, affect
a patient’s health (Rifkin et al., 1984).
Researchers typically assess the average BG level for a specified period o f time
(often 1-2 months) by examining a glycosylated hemoglobin assay to determine whether
the concentration of BG has increased or decreased during that duration. (Rost, Flavin,
Cole, & McGill, 1991; Hanson et al., 1989). Glycated hemoglobin is considered to
indicate good glycemic control if the percentage of total hemoglobin to which glucose is
attached is less than 6%. Furthermore, a recommended goal for most Type 2 patients is
Type 2 Diabetes 31
less than 7%, and treatment is recommended if levels rise above 8%. It is at this elevated
level that an individual is at risk for hyperglycemic conditions (Raskin et al., 1994).
Metabolic control can also be assessed through an analysis o f blood, fasting blood
glucose levels, and post-prandial records o f self-monitored blood glucose levels (Raskin
et al., 1994). However, it is more common for studies to utilize glysosylated hemoglobin
assays to assess metabolic control because o f accuracy and convenience considerations.
In regard to the relationship between metabolic control and health outcomes, a
recently completed study, the Diabetes Control and Complications Trial (DCCT), found
positive correlations between glycemic control and a slowing of the development and
progression o f diabetes-related complications. The 10-year study conducted with 1,441
adolescent and adult Type 1 diabetes patients, observed that long-term glycemic control
significantly prevented or ameliorated many o f the microvascular and neuropathic
complications of diabetes. Although none o f the subjects in the DCCT study had Type 2
diabetes, it has been mentioned that one could extrapolate these findings to non-insulin-
dependent diabetes populations (Raskin et al., 1994).
Adherence and Metabolic Control
As it has been alluded to, the link between adherence to Type 2 diabetes
treatment and metabolic control has not been definitively determined (Johnson et al.,
1992). Some studies have found the marker, HbAlc, to be a good indicator o f adherence
behaviors (Hanson et al., 1989; Brownlee-Duffeck, Peterson, Simonds, Goldstein, Kito,
& Hoette, 1987; Hanson, Henggeler, & Burghen, 1987a), while other studies have found
nonsignificant relationships between the two variables (Cox, Taylor, Nowacek, Holley-
Type 2 Diabetes 32
Wilcox, & Pohl, 1984; Glasgow, McCaul, & Shafer, 1987; Hanson, Henggeler, &
Burghen, 1987b).
Regarding this issue, Hanson et al. (1987a) utilized a self-report measure to
record adherence behaviors, while metabolic control was assessed through an HbAlc
index. Researchers found that HbAlc was significantly correlated (r = -.30) with
adherence, in that high adherence was associated with good metabolic control Gower
HbAlc levels). It should be recognized, however, that adherence behaviors did not cause
better metabolic control, but were simply correlated with better control. In other words,
good adherence rates explained a significant amount o f the variability in levels of
metabolic control, but did not fully explain physiological outcomes.
Similar results were found in a study conducted by Schafer et al. (1983). Once
again, a self-report measure was used to record adherence behaviors, and an HbAlc
index was utilized to determine metabolic control. However, unlike many other studies,
adherence behaviors were analyzed separately in regard to their relationship to BG
control. It was found that three of seven adherence behaviors were significantly
associated with HbAlc levels. These behaviors included diet, insulin, and BG
monitoring factors. Together, the Hanson et al. (1987a) and Schafer et al. (1983) studies
provide modest support for the relationship between adherence and metabolic control.
On the other hand, Hanson et al. (1987b) did not find support for this relationship.
In this study, African American adolescents were compared to Caucasian adolescents
concerning adherence behaviors and metabolic control. It was found that African
American females displayed poorer BG control than their male counterparts and
Type 2 Diabetes 33
Caucasians. However, the poorer control that characterized these subjects was not
predicted by lower adherence to treatment, for the groups did not significantly differ on
this variable. It was concluded that other factors, such as dietary intake or amount of
exercise, may have played a role in effecting HbAlc levels.
These conflicting results may be partially explained by the fact that many studies
have operationalized adherence as a single global index. When such composites were
used, some variables that may have had little to do with glycemic control, such as foot
care, were included in the single measurement of adherence, thus weakening the
relationship between the two variables (Goodall & Halford, 1991). Goodall and Halford
(1991) proposed that when individual adherence behaviors that are more directly related
to metabolic control are examined separately in regard to their relationship to HbAlc, a
stronger association may be found between the two variables.
However, some researchers (Polonsky, 1994; Peyrot & McMurray, 1985) have
carefully pointed out that, although metabolic control is often viewed as the final
indicator o f adherence behaviors, HbAlc can also be influenced by other factors. They
include: insulin sensitivity (e.g. changes due to hormonal influences during puberty or
pregnancy), illness severity, and the effectiveness of the recommended regimen. Thus, at
times, adherence behaviors may be forced to play a secondary role in effecting levels of
HbAlc. This may provide an explanation for the non-significant relationships that have
been found regarding the two variables.
Type 2 Diabetes 34
Psychosocial Factors Related to Adherence and Metabolic Control: Intrapersonal.
Interpersonal, and Environmental Determinants
There are a number o f psychosocial variables that are associated with the self
management and glycemic control o f diabetes (Polonsky, 1994; Cox & Gonder-
Frederick, 1992; Cox et al., 1991; La Greca & Spetter, 1992; Johnson, 1992). These
variables may be categorized as intrapersonal, interpersonal, and environmental factors.
Furthermore, they appear to effect a patient’s ability to adhere to their treatment and
manage their BG levels in varying ways (Polonsky, 1994).
Intrapersonal Determinants
Demographic Variables. Demographic variables are among a number o f
intrapersonal psychosocial variables that have been examined in relation to adherence
behaviors and glycemic control. Demographic variables such as gender, race,
socioeconomic status (SES), and age, have been investigated. Regarding gender,
Ericksson & Rosenqvist (1993) examined differences between men and women with high
and low social support. They found that highly supported men had better fasting blood
glucose (fB>- values than highly supported women. This is interesting because the social
support scores for the two genders did not differ in this study. Likewise, Hanson et al.
(1987b) used an adolescent population to examine both gender and racial factors in their
relation to patient adherence and metabolic control. They found that African American
girls displayed significantly less metabolic control than their male counterparts and
Caucasian adolescents. However, they were not able to definitively conclude why this
occurred.
Type 2 Diabetes 35
In regard to adherence, the role o f socioeconomic status has also been
investigated- Padgett (1993) found that subjects who were at lower educational and
occupational levels adhered less to treatment than those o f higher SES status.
Specifically, they found that those o f lower SES status were less likely to monitor their
medication and insulin intake and follow their prescribed diet.
There are very few studies that have employed adult diabetes populations to
examine associations between age, adherence, and metabolic control. This may be
because much o f the research exploring the impact o f age on adherence tends to focus on
adolescent populations, who have historically had the lowest adherence rates of any age
group (Hanson et al., 1987a, Johnson et al., 1992). However, some interesting findings
have been found with adolescent populations. In one paper, Hanson et al. (1989) found
that, with a sample o f 10-20 year old children, age was negatively associated with
adherence to treatment- in that the older the children became, the less they adhered to
their treatment protocol. The researchers stated that the adolescent subjects may have
adhered less because o f factors related to the developmental stage they were in. This
would be one in which they often strive for acceptance in a peer group and search for
independence from their parents. Such developmental behaviors are seemingly
noncondusive to the treatment of diabetes (Hanson et al., 1989).
Psychological Illness. It has been reported that prevalence rates of psychiatric
disorders, such as depression, in Type 1 and Type 2 patients have been anywhere from
18-38% (Wilkinson, Borsey, Leslie, Newton, Lind, & Ballinger, 1988; Lustman, Griffith,
Clouse, & Cryer, 1986), and that this is a higher rate than what is evident in the general
Type 2 Diabetes 36
population (Lloyd, Matthews, Wing, & Orchard, 1992). For this reason, a great deal o f
research has been dedicated to diabetes populations who suffer from comorbid
psychological difficulties. The presence o f a psychological illness is believed to be
another intrapersonal psychosocial factor that moderates adherence behaviors and
glycemic control (Kovacs, Iyengar, Mukeiji, & Drash, 1996; Lustman, Griffith, Gavard,
& Clouse, 1992; Lustman, Griffith, & Clouse, 1988).
While some of the research on this topic has found an association between
psychiatric illness, adherence behaviors and metabolic control, other studies have failed
to show such a relationship (Kovacs et al., 1996). In support o f such a relationship,
Lustman et al. (1988) compared a control group of psychiatrically well diabetes patients
to those with a history o f an affective illness. At a five year follow-up point, well
subjects were found to have a mean HbAlc of 9.2%, while those with an affective
illnesses had a mean HbAlc of 12.5%. Thus, at follow-up, the control group had
significantly better glycemic control than the depressed group.
Wilkinson, Borsey, Leslie, Newton, Lind, & Ballinger (1988) also investigated the
relationship of psychiatric morbidity, metabolic control, and diabetes-specific
complications. In a sample of 194 subjects, they found that psychiatric morbidity was
not significantly associated with elevated HbAlc or the presence of complications.
Similarly, Jacobson, Adler, Wolfsdork, Anderson, & Derby (1990) examined differences
between those with poor versus good glycemic control in regard to psychiatric
symptomology. It was found that, once again, there appeared to be no differences
between those with poor versus good glycemic control.
Type 2 Diabetes 37
Although the apparent impact o f psychiatric comorbidity in diabetic populations
has yet to be conclusively determined, it is widely agreed that illnesses such as
depression should be sincerely addressed in clinical and research settings. It is evident
that psychiatric problems can pose a serious threat to a patient’s daily functioning, and
may at times dramatically threaten their ability to cope with the daily demands of
managing a chronic medical disorder (Lustman et al., 1992).
Coping Styles. Another important intrapersonal psychosocial variable that may
play a role in influencing adherence behaviors and metabolic control is the manner in
which patients cope with their diabetes. Coping refers to the cognitive and behavioral
efforts individuals use in response to stressful situations (Lazarus & Folkman, 1984).
These strategies have been described as mediators o f the relation between difficult
circumstances and the adjustment to those situations (Reid, Dubow, Carey, Dura, 1994).
Two general types o f coping have been established in much of the research on
this topic. They are problem-focused coping, which refers to problem solving or doing
something to alter the source of stress, and emotion-focused coping, which is aimed at
reducing or managing the emotional distress that is associated with the situation.
Although a stressor may elicit both forms o f coping, problem-focused tends to dominate
when the individual feels something actively can be done, while emotion-focused coping
tends to be more evident when the individual concludes that the stressor is something that
must be endured (Folkman & Lazarus, 1980). Although current research has concluded
that this distinction of coping styles may be too simplistic, it is still viewed as being
important (Carver, Scheier, & Weintraub, 1989).
Type 2 Diabetes 38
While the issue o f coping styles has been examined at great length with child and
adolescent diabetes populations (Reid et al., 1994; Delamater, Kurtz, Bubb, White, &
Santiago, 1987; Hanson et al., 1989), little research has been completed with adult
populations. Regarding studies with adult subjects, Sachs, Moser, Pietschmann,
Schemthaner, & Prager (1994) examined the effects o f four internal and two external
categories o f coping on metabolic control using an adult diabetes population. The four
internal categories included: fatalism, anxious coping behavior, degree o f internal and
external control, and fatalistic control by the subject. The two external factors included:
social integration and familial adherence as a coping support. All six categon'es were
then summarized into a global coping index that indicated the degree o f coping quality.
Interestingly, no correlations were found between the coping variable and metabolic
control at the 8- and 16-month follow-ups. However, at the 24-month follow-up, a
significant decrease in HbAlc was found in patients who had better global coping, higher
coping control, and lower non-control. In addition, it was determined that poor global
coping quality was significantly correlated with poor metabolic control at the 24-month
follow-up.
Sherboume, Hays, Ordway, DiMatteo, and Kravitz (1992) used an adult
population (ages 19 to 97) to investigate the effects o f coping strategies on adherence to
treatment. Their most significant finding was that avoidance coping strategies (i.e.
hoping for a miracle, rather than dealing directly with the problem) were found to be
important predictors o f poor adherence. Specifically, those that reported avoidant coping
Type 2 Diabetes 39
behaviors were less likely to adhere to their doctor’s advice and management
recommendations.
Kvam and Lyons (1991) also utilized an adult population (17 to 78 years of age)
to examine the intrapersonal psychosocial variable, coping style. However, researchers
in this study simply explored the effects o f coping on the patient’s view o f their general
well-being and didn’t relate coping to actual health behaviors or status. The Folkman-
Lazarus Ways o f Coping Checklist-Revised (Folkman & Lazarus, 1980) was used to
assess coping strategies, and The Rand Health Insurance Study- General Well-being
Schedule (Brook et al., 1979) was used to measure perceived health status. Patients were
asked to answer the coping checklist with respect to their diabetes condition. The
checklist measures seven coping variables: (1) problem-focus (problem solving), (2)
wishful thinking, (3) detachment, (4) seeks social support, (5) positive/growth, (6)
blamed self, and (7) tense/minimize threat. Results indicated that o f the seven factors,
problem solving coping had the most significant impact on general perceived well-being.
In addition, a negative correlation was found between wish-fuifillment coping and
general well-being scores. Other correlations in the study did not reach significance.
Amir, Rabin, and Galatzer (1990) used a sample of adult diabetes patients to
investigate the impact o f coping styles on adherence behaviors. However, rather than
assessing how patients cope with their disease condition, they looked at another stressful
situation with which patients may have to contend. They hypothesized that (1) the
patient-practitioner relationship is often another stressor for many diabetes patients
because they are often criticized by the medical team when they do not adhere properly,
Type 2 Diabetes 40
and (2) the manner in which the patient copes with this stressor may mediate adherence
rates. After teaching patients certain constructive and active coping skills, they found
that these cognitive and behavioral coping skills correlated significantly with various
adherence variables. Specifically, the following skills were found to be significant
predictors o f adherence behaviors: maintenance o f positive self-esteem and efficacy
during criticism, positive acceptance o f criticism, avoidance of conflict by offering
compromising solutions, and assertive request for follow-up with a specific doctor.
On the other hand, Reid et al. (1994) used a child and adolescent population (8 to
18 years o f age) to examine how coping strategies affected the medical adjustment o f it’s
subjects. They investigated the manner in which their subjects responded to three
stressful situations: (1) a diabetes-related social problem, (2) a diabetes-management
problem related to diet, and (3) a diabetes-management problem related to fingerpricks.
Coping styles were assessed by a self-report measure and included the following styles:
(1) seeking social support, (2) problem solving, (3) distancing, (4) internalizing, and (5)
externalizing. Results indicated that higher levels o f approach-coping strategies (e.g.
problem solving) related to better adherence to diet, and higher levels of avoidance-
coping strategies (e.g. distancing) related to poorer metabolic control and adherence to
fingerpricks.
In a similar fashion, Hanson et al. (1989) used subjects 10 to 20 years of age to
investigate coping styles and adherence and metabolic control outcomes. Coping was
measured with the Adolescent-Coping Orientation for Problem Experiences (A-COPE;
McCubbin, Needle, & Wilson, 1985), and metabolic control was assessed with an HbAlc
Type 2 Diabetes 41
index. It was found that ventilation and avoidance coping strategies were negatively
related to adherence behaviors, whereas utilizing personal and interpersonal resources
were not associated with adherence to the treatment regimen. No coping factors were
related to metabolic control. Therefore, it appears from these results that “negative”
coping strategies impeded adherence behaviors, while “positive” coping styles had no
effect on adherence behaviors. Furthermore, regarding the absence o f a relationship
between coping styles and metabolic control, Hanson et al. (1989) mentioned that
significant results may have been found if the stressors and coping behaviors described in
the study had been diabetes-specific.
From both the adult and child and adolescent studies, it appears that a patient’s
coping style may be an important moderator o f adherence behaviors and metabolic
control. Specifically, certain coping strategies, such as problem solving, may
significantly increase treatment adherence and metabolic control, while coping strategies
such as avoidance may decrease treatment adherence and metabolic control. Further
research on this subject has been deemed necessary by several researchers (Hanson et al.,
1989; Kvam & Lyons, 1991).
Interpersonal Determinants
Social Support. In the 1970’s, a growing interest evolved as to which social
factors could protect some individuals from disease and death. The factors that were
identified as having a buffering or protective function were labeled “social support”
(Cassel, 1976; Kaplan, Cassel, & Gore, 1977). At that time, it was found that a lack of
social support was associated with increased morbidity and mortality (Berkman & Syme,
Type 2 Diabetes 42
1979), and that social support helped persons deal with life stress (Cobb, 1976). More
recent studies (Anderson & Auslander, 1980; Kaplan & Hartwell, 1987; Eriksson &
Rosenqvist, 1993), using diabetes populations, have found similar results.
Regarding the self-management o f diabetes in child and adolescent samples,
social support has been shown to be an important determinant. Adolescents who report
the presence of supportive environments have often been found to have better control o f
their diabetes (Anderson & Auslander, 1980) and tend to report more efficient self
management skills (Hanson et al., 1987d; Marteau, Bloch, & Baum, 1987). In should be
noted that in child and adolescent social support studies, the term social support typically
refers to familial, rather than peer, support.
Studies on the effects o f social support in the management o f diabetes in adult
populations have found results comparable to what was indicated in younger samples.
Kaplan and Hartwell (1987) found that satisfaction with social support was correlated
with better glycemic control for the female group o f their sample. However, surprisingly,
social support satisfaction was associated with poorer glycemic control for the male
group. Authors hypothesized that, for women, social support may facilitate adherence
behaviors by providing an environment conducive to such self-care actions. On the other
hand, male satisfaction with social support may indicate an environment that reinforces
behaviors not prescribed in diabetic treatment plans, such as eating and drinking certain
goods.
In a similar study, Eriksson and Rosenqvist (1993) studied the influence o f social
support on health outcomes in 76 adult Type 2 patients. Social support referred to three
Type 2 Diabetes 43
functional elements: emotional, informative, and practical support. It was measured
through the use o f a self-report questionnaire, and health outcomes were determined by a
fasting BG index o f glycemic control. Following the dichotomization o f social support
into high and low indices, it was found that social support scores after one year with
Type 2 diabetes were correlated with fasting BG values. The study indicated that higher
reported social support was associated with lower fBG-values, while lower reported
social support was associated with higher fBG-values.
Research on this topic has yet to definitively determine which element(s) o f social
support represent(s) the protective or buffering component that has been shown to
mediate health outcomes (Eriksson & Rosenqvist, 1993). Furthermore, additional
research is needed to clarify whether it is the continuous access to social support that is
important, or whether a patient can simply mobilize support on an as-needed basis to
facilitate health benefits (Goodall & Halford, 1991).
Patient-Practitioner Relationship. Another important, but often neglected,
psychosocial mediator o f adherence behaviors and metabolic control is the patient’s
satisfaction with the patient-practitioner relationship (PPR) (Golin, DiMatteo, & Gelberg,
1996). Regarding this relationship, a number of elements have been hypothesized to
influence patient satisfaction, and thus adherence and metabolic control (Golin et al.,
1996; DiMatteo et al., 1993; Johnson, 1992; Cox & Gonder-Frederick, 1992; Viinamaki,
Niskanen, Korhonen, & Tahka, 1993; Dinicola & DiMatteo, 1982; Garrity, 1981). Those
that have been empirically studied will be discussed in this paper.
Type 2 Diabetes 44
One o f the earlier elements of the PPR to be studied was the degree to which the
physician imparted medical recommendations clearly and unequivocally, and how this
affected a patient’s ability to understand and recall medical advice. An early study (Ley,
Jain, & Skilbeck, 1976a) found that when treatment instructions were simplified,
subjects made fewer errors in taking their medication, and thus adhered better to their
treatment. In another study (Ley et al., 1976b), researchers found that when the clarity of
a physician’s communication was increased by, for example, emphasizing the important
aspects o f treatment or giving medical advice early in the interview, adherence also
increased. Recall o f treatment information on the part o f the patient, which is correlated
with understanding treatment information, has been shown to affect adherence rates as
well (Garrity, 1981).
Another element o f the PPR that has been examined in relation to satisfaction and
adherence behaviors is the extent to which the patient and the physician share
expectations about appropriate behaviors in clinical sessions and what is considered
“good” patient adherence. For example, if a patient expects to spend about 50% of their
office visits asking questions about their disease, and the physician expects to spend no
more than 25% of this time answering such questions, tension within the PPR may arise,
and both the patient and the physician may be dissatisfied with the relationship. This
may, in turn, detrimentally affect future adherence rates (Garrity, 1981). In his review of
the literature on this topic, Garrity (1981) concluded that research findings have
consistently pointed to a significant relationship between complementary expectations,
patient satisfaction, and increased adherence behaviors.
Type 2 Diabetes 45
An additionally important mediating factor o f the PPR relates to the degree to
which the physician is capable o f communicating with the patient in a positive and
supportive manner. Regarding this issue, studies often measure the physician’s ability to
convey sympathy, understanding, and encouragement to the patient (Garrity, 1981).
Interestingly, these elements have been described as being closely related to the
previously mentioned factor, social support, in that it characterizes the “material,
intellectual, and emotional resources [patients] find through the agency o f others.”
(Dimsdale et al., 1979) However, this aspect o f the PPR should be considered a separate
entity from familial or peer-related social support because research has supported the
notion that the PPR, and specifically the emotionally supportive aspect o f the PPR,
represents an important mediating factor in patient adherence behaviors, apart from other
psychosocial variables (DiMatteo et al., 1993).
In studying the supportive nature of the physician, a number o f researchers have
investigated the “affective tone” o f the physician and its relationship to patient
adherence. In an early study, Freemon et al. (1971) found that the greater the friendliness
and solidarity expressed by the physician, the better the adherence exhibited by the
patient. In addition, it was conversely found that the greater the antagonism displayed by
the doctor, the poorer the patient performed in their disease management.
Svarstad (1974) found similar results. The study measured the relationship
between three physician characteristics and rates o f adherence. The physician
characteristic were: (1) physician approachability, (2) signs of friendliness, and (3)
Type 2 Diabetes 46
interest and respect for the patient. It was concluded that the physician’s characteristics
were directly associated with levels o f patient adherence.
More recent studies have also investigated the relationship between patient
satisfaction with the physician and adherence behaviors and metabolic control. However,
they have often done this in a more general manner by examining a number o f different
PPR elements in the same study, rather than looking at one specific factor. For example,
Viinamaki et al. (1993) examined four PPR factors using a self-report questionnaire.
They were as follows: (1) a general estimation of the PPR, (2) the degree o f satisfaction
with the site o f office visits, (3) the PPR in its ability to provide self-esteem enhancement
for the patient, and (4) the PPR as a source o f safety for the patient. It was found that the
third factor, regarding the PPR as a source o f self-esteem, was significantly associated
with metabolic control. When sufficient support for the patient’s self-esteem was
provided by the physician, metabolic control increased. Conversely, when insufficient
support was evidenced, patients tended to display poor metabolic control. The authors
suggested from these results that metabolic control may therefore be closely related to
the patient’s judgment o f his doctor’s way of treating him.
In another study, DiMatteo, Hays, & Prince (1986) examined a physician’s ability
to encode and decode nonverbal emotions, and its relationship to patient satisfaction and
adherence to clinical appointments. A physician’s ability to decode emotions was
measured by having doctors match correct emotional labels with brief nonverbal patient
expressions. The ability to encode emotions was demonstrated by having doctors
communicate verbally neutral sentences to a patient while expressing four different
Type 2 Diabetes 47
emotions (happiness, sadness, anger, and surprise). Overall scores were given by
averaging the accuracy of the communications. It was found that both a physician’s
encoding and decoding skills were positively correlated with patient satisfaction.
Furthermore, it was concluded that a physician’s sensitivity to voice-tone nonverbal
communication (accuracy at decoding) was significantly related to their patients’
adherence to scheduled appointments. In other words, the more “sensitive” physicians
had more satisfied patients, and less canceled appointments.
Likewise, DiMatteo et al. (1993) studied physician attributes that were
hypothesized to be associated with patient satisfaction and medical adherence. Using
subjects with one or more o f four chronic diseases (hypertension, diabetes, heart disease,
and depression), they investigated a number o f physician characteristics that included
demographic variables, practice specialties, and provider-style-of-practice variables. It
was found that when physicians made definite future appointments for follow-ups,
patients achieved better medication adherence. In addition, results also indicated that
when physicians reported that they answered all o f their patients’ questions no matter
how long it took, patients adhered better to their exercise regimens.
Also, in a longitudinal medical outcomes study looking at antecedents o f
adherence to medical recommendations, Sherboume et al. (1992) found that patients who
reported that they were satisfied with the interpersonal quality o f their medical care also
reported higher levels of adherence to treatment recommendations. Understandably,
results also indicated that lower levels o f satisfaction with the interpersonal quality o f
Type 2 Diabetes 48
medical care were correlated with lower levels o f adherence to recommendations in
general.
Finally, similar findings were found in a study investigating the impact o f PPR
satisfaction on adherence to diabetes treatment protocols in women with Gestational
Diabetes Mellitus (GDM). Specifically, Landel (1995) found that increased satisfaction
was correlated with increased appointment keeping, increased diet adherence, and
normalization o f infant birth weight.
Overall, a substantial amount of evidence has accumulated in support of a
relationship between the PPR and patient treatment behaviors. Specifically, studies have
concluded that patient satisfaction with physician interpersonal and communication
styles is often associated with increased levels of adherence to treatment. In addition,
some of the research has pointed to the physician’s role as an element o f social support
for the patient in explaining the relationship between the PPR and adherence outcomes.
Furthermore, in regard to diabetes, metabolic control has also been associated with
satisfaction with the PPR. Unfortunately, research in this area, especially with diabetes
populations, is scarce, and further studies are needed to establish a more definitive link
between the PPR and health behaviors and outcomes (Golin et al., 1996; Cox & Gonder-
Frederick, 1992).
Environmental Factors
Barriers to Adherence. Often, persons suffering from diabetes find themselves
confronting a number o f barriers that may thwart efforts to manage their condition.
These may include cost or time restrictions, as well as limitations in regard to resource
Type 2 Diabetes 49
availabilities (Cox & Gonder-Frederick, 1992). When an individual is unable to
overcome a significant proportion o f these obstacles, a lower rate o f adherence is often
expected (Glasgow, McCaul, & Schafer, 1986).
The barriers that diabetes patients face tend to be related to the complexities and
intrusiveness o f being asked to adopt certain lifelong behaviors. As it has been
mentioned, these may include administering medication (i.e. insulin), exercising
regularly, and controlling one’s eating, among others (Cox et al., 1991). Faced with such
daily tasks, persons may find it difficult to find the time or place to follow treatment
recommendations carefully.
In a study conducted by Glasgow and colleagues (1986), an effort was made to
assess the frequency o f different barriers within a diabetes population. To assess these
barriers, the Barriers to Adherence Questionnaire was formulated. It measures barriers
such as the inconvenience o f having to inject insulin away from one’s home and the
embarrassment o f having to test one’s blood at school or at work. The barriers reported
as occurring most frequently were as follows: (1) not having glucose testing materials
available at the appropriate times, (2) making mistakes on food exchanges, (3) feeling
out o f place testing glucose levels away from home, and (4) having bad weather interfere
with exercise plans. Furthermore, results from the study indicated that subjects reported
the highest frequency o f barriers to the dietary and exercise components o f treatment, and
the fewest barriers to taking insulin injections. In addition, the frequency o f reported
barriers was significantly related to self-report measures o f adherence for all o f the
Type 2 Diabetes 50
treatment components investigated in the study; in that higher barrier scores were
associated with lower levels o f adherence.
Other Environmental Factors. In addition to the aforementioned barriers that may
affect one’s ability to adhere to treatment recommendations, persons suffering from
diabetes may cope with other variables that negatively effect their disease management.
Included among these variables are a fear o f hypoglycemia and weight gain (Cox &
Gonder-Frederick, 1992), environmental stressors such as unemployment (Cohen,
Kamarck, & Mermelstein, 1983), and feeling better during periods of elevated glucose
levels (Polonsky, 1994).
Hypoglycemia refers to a condition in which there is an imbalance between food
intake and the appropriate dosage o f drug therapy. As a result, levels of glucose exist at
lower levels than desired. The hypoglycemic patient may experience increased hunger,
or feel tachycardic symptoms, as well as changes in sensorium and behavior. For many
individuals, this condition is often initiated by an injection o f insulin, which may give
this aspect o f treatment a negative connotation, and thus affect it’s maintenance (Raskin,
1994).
In addition to a fear of hypoglycemia, patients may become concerned with
gaining weight as a result o f their treatment, and may decide that they actually feel better
during periods o f elevated BG levels. Both of these factors may serve to negatively
reinforce treatment-associated contingencies (Polonsky, 1994). Wing, Klein, and Moss
(1990) found that improved glycemic control was associated with significant weight gain,
and that this was an area o f serious concern, especially for women. The weight gain
Type 2 Diabetes 51
observed in this sample may be contributed to the meal schedules that are often set up for
patients with diabetes, which may serve to increase a patient’s daily caloric intake.
Another environmental factor that may contribute to poor disease management is
the level o f stress perceived by the individual coping with diabetes. Mendez & Belendez
(1997) investigated the impact o f stress management on treatment adherence in
adolescents with Type 1 diabetes. They found that individuals who received a behavioral
program that included stress management techniques tended to adhere significantly more
to treatment protocols than individuals who did not receive such techniques. However,
the researchers limited their investigation to the relationship between adherence and
diabetes-related stress, rather than assessing adherence and general forms of stress.
In a related study utilizing children and adolescents with Type 1 diabetes, Viner,
McGrath, & Trudunger (1996) found that an increase in family life-related stress had a
deleterious effect on metabolic control. Furthermore, Boardway, Delamater,
Tomakowsky, & Gutai (1993) found that stress management training significantly
reduced diabetes-specific stress, but failed to affect regimen adherence in adolescents
with Type I diabetes. They concluded that additional procedures, aside from simply
providing stress management techniques, may be necessary to improve adherence.
In reviewing the literature that has been conducted on the effects o f stress on
individuals with diabetes it is important to note certain limitations. First, studies have
seemingly focused their examinations o f the effects o f stress on adolescent, Type 1
diabetes, populations. In addition, in assessing stress, many o f the studies have examined
diabetes-related stress, but appear to have not often considered the impact that general
Type 2 Diabetes 52
life-related stress may have on adherence practices. Finally, it seems that literature that
has examined stress and diabetes has often investigated stress’ relationship with
metabolic control, and has not examined stress’ impact on behavioral (adherence)
outcomes. Thus, it appears that research has only infrequently investigated the impact o f
life-related stress on adherence in Type 2 diabetes populations, and that there is a need
for such an inquiry.
Polonsky (1994) also referred to a large ratio o f patients who reported feeling
better when their BG levels were elevated above what was recommended. Therefore, for
this group, it appears that hyperglycemic-like BG levels are often not negatively
reinforced by distressing symptoms. As a result, it is possible to assume that these
patients will not actively strive to lower their BG levels, even though their behavior (or
lack thereof) is contraindicated for health reasons.
Present Study
Rationale
As indicated in the preceding literature review, a number o f studies have
examined the roles that psychosocial variables play in the mediation o f adherence
behaviors and metabolic control. In addition, previous research has often found
significant relationships between these psychosocial variables and patient practices and
health outcomes. However, research studies have typically limited their assessments to
univariate, correlational approaches, as opposed to examining multiple variables
Type 2 Diabetes 53
concurrently (Glasgow, 1995; Cox & Gonder-Frederick, 1992; La Greca & Spetter,
1992).
Some researchers have theorized that such a limited analysis of diabetes-related
psychosocial variables fails to take into account the complexity o f the patient’s treatment
regimen, and the possible interactions o f factors that may facilitate or hinder the patient’s
ability to follow that regimen (La Greca & Spetter, 1992). Thus, a multivariate
framework has been postulated to be the most efficient means by which one should
investigate the roles that psychosocial variables play in diabetes care. Such a framework
would include a number of pertinent variables, and in assessing these variables,
researchers would not only examine how they affect adherence and metabolic control,
but how the variables affect one another. In this manner, the investigator could formulate
an integrative picture for the conceptualization of diabetes management, which may, in
turn, aid the clinician in designating patient problem areas in a more precise manner.
This follows from recommendations made by Glasgow (1995), who stated that, “A good
model can be very practical and provide important guidelines for treatment [and] clinical
use.”
Unfortunately, little has been done to formulate and test a multivariate model to
explain psychosocial mediators of diabetes treatment. Furthermore, although persons
with Type 2 diabetes make up approximately 80% of the diabetes population, it is even
more difficult to find a model dedicated to this group (Cox & Gonder-Frederick, 1992).
The production o f such a model would address the apparent paucity of multivariate
research within this population.
Type 2 Diabetes 54
In a related article, La Greca and Spetter (1992) conceived a multivariate
framework for the role of psychosocial and family factors in children with Type 1
diabetes. Specifically, it outlines pathways between psychosocial variables (i.e.
psychological adjustment), diabetes specific variables (i.e. adherence), and glycemic
control. It also hypothesizes that certain variables may act as mediators between other
variables. So that, instead o f simply stating that psychological stress may affect glycemic
control, for example, the model holds that other factors, such as physiological variables,
may intercede this relationship. It also implies that different psychosocial variables may
mediate one another in affecting adherence behaviors and glycemic control.
The present research endeavor attempted to formulate a similar multivariate
model by utilizing an adult, Type 2 diabetes population. Variables believed to be
relevant to such a population were chosen from empirically driven studies, and were
conceptualized within the working framework so that each variable was represented by
(1) the manner in which it was believed to affect adherence, and (2) the manner in which
it was hypothesized to interact with other psychosocial variables. Furthermore, the
relationship between adherence and metabolic control was investigated separately. This
was done because the study was not able to obtain the necessary amount of subject
metabolic control data to allow this measures’ inclusion in a path analysis. This seemed
to be an unfortunate result o f the current state o f the health care system. Apparently,
many o f the subjects were asked by their insurance providers to have their glycosylated
hemoglobin assays drawn by their primary care physicians (PCPs) rather than their
endocrinologists. As a result, circumstances arose whereby either: (1) patients did not
Type 2 Diabetes 55
follow through in obtaining their HbAlc measures, (2) the labs analyzing the HbAlc data
only reported back to the PCPs and did not report this information to the
endocrinologists, or (3) the present researcher was unable to obtain this information from
the PCPs. Therefore, the researcher was often unable to obtain metabolic control levels
that encapsulated the time period in which the subjects completed their psychosocial
questionnaires. Thus, it became difficult to obtain relevant physiological measurements
of BG control.
The purpose of the study was to formulate a model that can lead to better disease
management and metabolic control for patients suffering from Type 2 diabetes. Below,
the proposed model and associated hypotheses are presented.
Working Model for Psychosocial Factors. Adherence, and Metabolic Control
The study was designed to test a multivariate model hypothesized to explain the
impact selected psychosocial variables have on adherence behaviors. The psychosocial
variables that were included in the framework were as follows: current level of
psychological distress, patient coping style, satisfaction with the patient-practitioner
relationship, social support, and perceived environmental stress. The following
demographic variables were also investigated within the model: gender, ethnicity, age,
elapsed time since receiving diagnosis of Type 2 diabetes, and socioeconomic status.
Theoretical Model. The theoretical model o f adherence behavior and metabolic
control outcomes in Type 2 diabetes was based on empirical findings from literature that
utilized both Type 2 and Type 1 populations. All variables included in the present study
Type 2 Diabetes 56
have displayed an effect on patient adherence behaviors and/or metabolic control in
previously described studies. Furthermore, these variables have been chosen because,
although they have been proposed to be important, conclusive findings have yet to be
determined regarding their effects on health and behavior outcomes in Type 2
populations. Below, each factor o f the present model will be described, followed by an
explanation o f the working model and specific hypotheses.
First, psychological distress was selected because its effects on adherence rates
and metabolic control have been demonstrated in Type 1 diabetes populations. It is
believed that those who have been diagnosed with Type 2 diabetes have to cope with
similar feelings o f distress, and this distress may manifest itself as anxiety or depression,
as it can with Type 1 patients. Thus, psychological distress may also affect health and
behavior outcomes in a Type 2 population.
Patient coping styles was also included in the model because, as with the other
psychosocial variables, its role in affecting adherence behaviors and metabolic control
has been demonstrated in previous research. However, little has been done to examine
the role coping styles play in Type 2 populations.
In addition, the patient’s satisfaction with the patient-practitioner relationship was
also included in the model. This variable, which has been largely neglected in diabetes
research, may affect adherence behaviors by way o f providing the patient with accurate
and essential care information, as well as by contributing a sense o f interpersonal support
for the patient. Previous studies, although rare, have shown a relationship between these
aspects o f the PPR and adherence to treatment recommendations. The present study
Type 2 Diabetes 57
included both a measurement o f general patient satisfaction, as well as a measurement of
satisfaction with the interpersonal aspects of care, because the latter variable has been
alluded to as being a particularly important aspect o f the PPR.
One’s level o f social support was also included in the study because this factor
has previously been linked to the facilitation o f adherence behaviors in those with
diabetes by providing an environment that reinforces behaviors conducive to diabetes
care, such as maintaining a healthy diet and exercising. Plus, previous research has
called for additional empirical support regarding this factors’ relationship to adherence
behaviors.
Finally, the patients’ level o f perceived stress was included in the model because
it was recognized that having a chronic, long-term illness must be quite trying for
individuals with diabetes, and research has shown that additional stress can often become
very overwhelming for patients. So, this additional factor was believed to be an
important one in which to investigate.
Demographic variables were included because a number of past studies have
suggested that these factors may be possibly correlated with health and behavior
outcomes in diabetes populations. Once again, little has been done to study such group
differences in Type 2 diabetes samples, and it would be interesting to assess how strong
o f a role these demographic variables play in affecting rates o f adherence.
By including an adherence measure in the multivariate model, one may view the
paths by which certain psychosocial variables affect health outcomes. This could lead to
Type 2 Diabetes 58
a more precise understanding o f what a patient must do in a behavioral sense to maintain
stronger metabolic control, and thus better health.
Finally, the relationship between metabolic control and adherence was
investigated because, for patients with diabetes, metabolic control has been determined
to be the most important factor related to one’s health and preventing diabetes-associated
complications. Metabolic control will be viewed as the physiological outcome measure
through which the effects o f the behavioral outcome measure, adherence, will be
assessed. Given certain aforementioned limitations that arose during the collection of the
data, the relationship between adherence and metabolic control was assessed separately
firom the model that included the other psychosocial variables.
Specific Hypotheses
Hypothesis 1. Psychological distress will have direct effects on adherence
behaviors. Specifically, increased distress will be associated with decreased adherence.
Psychological distress will also indirectly affect adherence behaviors, with increased
distress being correlated with higher levels o f perceived stress and coping strategies
associated with behavioral avoidance.
Hypothesis 2. Maladaptive coping strategies, namely behavioral avoidance, will
be directly associated with decreased adherence behaviors. This coping strategy will also
be indirectly related to lower adherence rates through its association with higher levels of
psychological distress and perceived stress.
Hypothesis 3. The patient-practitioner relationship (PPR) will have direct effects
on adherence behaviors, with increased satisfaction with both interpersonal aspects of
Type 2 Diabetes 59
care and overall care independently being associated with increased adherence. In
addition, satisfaction with overall care will be indirectly related to adherence with
satisfaction with the interpersonal aspects o f care acting as a mediator for this
relationship.
Hypothesis 4. The patients’ level of social support will be directly related to
adherence rates, in that higher levels o f social support will be correlated with better
levels o f adherence. Furthermore, it is believed that social support may indirectly affect
adherence rates through its relationship with both satisfaction with diabetes-specific care
and general medical care. In that, individuals who have generally been successful in
making use of social networks in their lives will more effectively utilize the care that
their health workers provide, thus affecting adherence behaviors.
Hypothesis 5. It is believed that increased levels o f perceived stress will be
directly associated with poorer adherence levels. In addition, it is hypothesized that
perceived stress may have indirect relationships with adherence levels through possible
associations with levels o f psychological distress and poor coping strategies (e.g.
behavioral disengagement).
Hypothesis 6. Regarding the demographic variables, it is believed that subjects of
higher socioeconomic status will have better adherence rates. This falls under the
theoretical idea that those of higher SES generally have better access to educational
materials related to their health care. It is difficult to formulate hypotheses regarding
other demographic variables such as age, gender, and race, as conclusive empirical
findings have yet to be determined in previous studies.
Type 2 Diabetes 60
Hypothesis 7. Adherence behaviors will be directly associated with levels o f
metabolic control, with increased rates o f adherence will be correlated with better
metabolic control.
A model displaying these hypothesized relationships can be found in Figure 1.
This model was theoretically-derived from previous empirical studies, and was used in
the path analysis to examine the psychosocial precursors for adherence behaviors.
Method
Subjects
Subjects included ninety two individuals who had a medical chart documented
diagnosis o f Type 2 diabetes. They were recruited from two outpatient endocrinology
clinics during regular clinic visits. One o f the clinics was affiliated with the Allegheny
University Hospital, located in Philadelphia, Pennsylvania. This endocrinology clinic
served patients of all racial and financial backgrounds, but typically served patients who
were racial minorities and/or o f mid- to lower socioeconomic status. The other clinic
utilized in the study was affiliated with the Tulane University Medical Center, in New
Orleans, Louisiana. Similarly, it served a wide variety of patients, but tended to care for
racial minorities and/or those utilizing Medicare or Medicaid.
Upon being presented with the opportunity to be included in the study, the
subjects were told that their participation (or nonparticipation) would have no bearing
upon the quality o f their medical care. Furthermore, it was stated that their participation
in the study was on a voluntary basis, and that they could exclude themselves from the
Type 2 Diabetes 61
study at any time. After prospective subjects had been given a brief introduction to the
study, those who met the following criteria were asked to participate:
Inclusion/Exclusion Criteria. To be included in the study, subjects had to be at
least 18 years old and have had a diagnosis o f diabetes for at least 1 year. Female
subjects who were currently pregnant, as well as subjects who had a history of psychiatric
hospitalizations and/or those who were taking psychotropic medications at the time o f the
study, were excluded from the subject pool. Finally, subjects were excluded if they had
been diagnosed with other serious medical conditions that were unrelated to their
diagnosis of diabetes. These conditions included both AIDS/HIV and cancer. Much of
this information was retrieved from the patients’ medical charts. Both male and female
subjects, as well as subjects o f all ethnicities, were welcomed to participate.
Measures
Psychological Distress. A short form of the Profile of Mood States (POMS;
McNair, Lorr, & Droppleman, 1981), the POMS-SF (Shacham, 1983), was used to assess
levels o f psychological distress in the study’s subjects. Both the original POMS and
POMS-SF self-report scales impart information regarding the type and severity of any
recent or current psychological distress experienced by an individual. The POMS is
accepted as a valid and reliable indicator of psychological distress in a variety o f medical
and nonmedical populations (Curran, Andrykowski, & Studts, 1995). It is composed of
65 items, rated on a 5-point scale that ranges from (1) not at all to (5) extremely.
Repeated factor analytic studies o f the POMS (McNair, Lorr, & Droppleman, 1971) have
derived six separate factors; Tension-Anxiety, Depression-Dejection, Anger-Hostility,
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Fatigue- Inertia, Vigor-Activity, and Confusion-Bewilderment. Scoring can provide six
separate subscores, as well as a “global distress score” referred to as Total Mood
Disturbance.
The POMS-SF, which continues to maintain all o f the subscales o f the original
POMS, was developed through the use o f the Reliability program from the Statistical
Package for Social Science (Hull & Nie, 1979). The elimination of POMS items were
made according to the following criteria: (1) the contribution to internal consistency
(coefficient alpha) of the scale, and (2) the face validity o f the items in relation to the
scales (Shacham, 1983). The POMS-SF was formulated to facilitate the POMS’ use with
physically ill patients who may not have the energy to complete the longer scale.
The POMS-SF contains 37 items, rather than the 65 items contained in the
POMS. Internal consistency estimates of the POMS-SF subscales, using coefficient
alpha, ranged from .80 to .91, while coefficients for the POMS subscales ranged from .74
to .91. Thus, the POMS-SF appears to preserve subscale information available in the
original model, while remaining less time consuming (Curran et al., 1995). In the present
study, only the Total Mood Disturbance Score from the POMS-SF was utilized as a
measure of distress.
Coping. Coping style was assessed with the self-report COPE-SF (Short Form)
scale. The COPE-SF is an abbreviated version of the original COPE scale (Carver,
Scheier, & Weintraub, 1989), and was created because patient samples were reportedly
becoming impatient with the length and redundancy o f the COPE scale (Personal
Communication, Carver, 1997). The COPE-SF was closely based on the original COPE
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scale, and Carver (1997) reported that its evolution was guided by strong loadings from
previous factor and reliability analyses. The COPE-SF measures 13 distinct aspects o f
coping, including subscales reflective o f both problem-focused coping and emotion-
focused coping. It was theoretically derived from both functional and empirically
determined properties o f coping strategies. Specifically, it is based on: (1) Folkman and
Lazarus’ (1980, 1985) Ways o f Coping scale, (2) a model o f behavioral regulation that
has been studied extensively (Carver & Scheirer, 1981, 1983, 1985; Scheier & Carver,
1988), and (3) preexisting studies pertaining to coping measures.
Given that research using the COPE-SF has yet to be published, statistical
information regarding the original COPE scale will be presented below. The scale can be
used to measure relatively stable dispositional coping strategies or strategies that reflect
coping with a specific situation. Regarding dispositional tendencies, internal consistency
estimates computed with Cronbach’s alpha reliability coefficients found that, overall,
values were high, with only one subscale (mental disengagement) falling below .60. In
addition, when the COPE was utilized to assess situational or time-limited coping efforts,
Cronbach’s alpha reliability coefficients were even higher, suggesting that people’s
ratings may have greater internal consistency when they are asked to appraise their
coping styles to specific circumstances, rather than rate their general coping tendencies
(Carver et al., 1989).
Furthermore, a principal-factors factor analysis o f the COPE scale, using an
oblique rotation, yielded 12 factors with eigenvalues greater than 1.0. It was also
determined that intercorrelations between subscales were weak. It has therefore been
Type 2 Diabetes 64
concluded that the coping styles measured by the COPE scale can be distinguished
empirically from one another, and their effects can be assessed separately (Carver et al.,
1989).
Due to the COPE’s utility in measuring situationally-specific coping (Carver et
al., 1989), it was used in the present study to assess how subjects were coping with
problems related to diabetes and its management. Furthermore, because it had been
mentioned that the effects o f each subscale could be measured separately, the present
study included the COPE subscale that best exemplified the type o f coping that had been
explored in past literature with populations suffering from diabetes. Research (Carver,
1997; Carver et al., 1989) has verified the utilization o f the COPE in this manner.
Therefore, the entire COPE was administered, but only the “Behavioral Disengagement”
subscale was utilized in the statistical analysis. This subscale is composed of two
questions, that was assessed on a Likert scale that ranged from (1)1 usually don’t do this
at all to (4) I usually do this a lot.
General Patient Satisfaction A revised edition o f the Patient Satisfaction
Questionnaire (PSQ; Ware, Snyder, & Wright, 1976a, 1976b), the PSQ-III (Wilkin,
Hallem, & Duggett, 1992), was used to measure overall patient satisfaction with medical
care. The PSQ is an 80-item self-report questionnaire and is one o f the most widely used
assessments o f satisfaction with medical care (Marshall, Hays, Sherboume, & Wells,
1993). It has demonstrated good convergent and discriminant validity (Ware, Snyder,
Wright, & Davies, 1983).
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The PSQ-III contains 44 items, that are broken into 6 subscales which assess
different aspects of satisfaction with care. They include the following subscales:
interpersonal manner (7 items), communication (5 items), technical competence (10
items), time spent with the doctor (2 items), financial aspects (8 items), and access to
care (12 items). The PSQ-III also includes a subscale (6 items) that measures a summary
index o f general satisfaction with medical care. Patients are asked to indicate how they
feel about their care, and responses are measured on a 5-point scale ranging from
strongly agree (1) to strongly disagree (5) (Marshall, et al., 1993). Subscale items are
summed to yield composite scores.
Internal consistency reliability estimates for the PSQ-III subscales are as follows:
Time, .87; Technical, .85; Interpersonal, .82; Communication, .82; Financial, .89;
Access, .86; and General Satisfaction, .88. In addition, fit indexes and chi-square
difference tests indicated that the six-factor model was statistically superior to all
previously considered models, in that it revealed six empirically distinct dimensions of
satisfaction. Furthermore, a structural equation model indicated that scores from the set
o f six discrete dimensions correlated significantly with the general satisfaction subscale
score. Thus, researchers may chose to utilize the PSQ-III to examine overall satisfaction
ratings, or they may assess various aspects of patient satisfaction on an individual basis
(Marshall etal., 1993).
In the present study, only the general satisfaction subscale of the PSQ-III was
utilized, because it had been shown to be empirically sound, and because it’s brevity was
more conducive to this populations’ needs. However, in order to obtain a more specific
Type 2 Diabetes 66
account of the subjects’ feelings about the interpersonal aspects o f their diabetes care
with their individual doctor and medical staff, another scale was utilized in addition to
the PSQ-m subscale.
Patient Satisfaction with Interpersonal Aspects o f Medical Care. The Patient-
Practitioner Relationship Questionnaire (PPRQ; Landel et al., 1998) was used to assess
the degree to which subjects were satisfied with the interpersonal aspects o f their
diabetes care. Statements in the PPRQ were devised to address several areas of patient-
practitioner interactions. These include: perceived availability o f the medical staff and
attending physician, as well as the amount of involvement the patient feels they have in
their own medical care. Statements include: “I feel that the doctor is often too busy to
see me,” and “I feel I’m ‘part o f the team’ in my diabetes care.” Subjects were asked to
rate how they felt about such statements on a Likert scale ranging from (1) not at all true
to (5) extremely true. Statements on the PPRQ are broken up into two subscales. Ten
items address patient satisfaction with the adjunct medical staff, and 10 items (the same
exact statements) address patient satisfaction with the attending physician. A total PPRQ
score was used in the present study because an analysis revealed that the subscales were
highly intercorrelated (r_= .86, p < .05), and utilizing separate scores for the subscales
would have violated the assumption o f independence of variables. A total score was
made by summing all of the responses for both of the subscales, after appropriate
reversals were made. Therefore, higher scores reflect greater satisfaction with the
interpersonal aspects o f one’s medical care.
Type 2 Diabetes 67
Initial item-total correlations indicated that the items on the PPRQ displayed
adequate item-total correlations. In addition, the scale demonstrated good reliability
(Cronbach’s alpha = .79) (Landel et al., 1998). Furthermore, evidence has been provided
for both criterion-related validity as well as concurrent validity for the PPRQ (Landel et
al., 1998; Landel, 1995; Landel, Habboushe, Ross, Kaplan, & Faust, 1997).
Social Support. Social support was measured with the Social Provisions Scale
(SPS; Russell & Cutrona, 1984). The scale was designed to measure six dimensions of
interpersonal support; attachment, social integration, reliable alliance, guidance,
reassurance o f worth, and opportunity for nurturance. Weiss (1974) identified these
factors as being important aspects in adult relationships, especially in individuals who
have had a major disruption in their lives (e.g. change in health status). Subjects
administered the SPS were asked to rate the degree to which they agreed with certain
statements about their relationships with other people. Ratings were on a 4-point Likert
scale and ranged from (1) Strongly Disagree to (4) Strongly Agree. Examples of
statements include, “There are people I can depend on to help me if I really need it,” and
“I feel that I do not have any close personal relationships with other people.” When
taken together, the ratings for each statement were summed and provided a total score of
one’s social provisions, with higher scores indicating more social support and lower
scores indicating less social support (Mancini & Blieszner, 1992).
Studies (Cutrona & Russell, 1987; Constable & Russell, 1986) have indicated that
the SPS is both and valid and reliable measure o f social provisions. Furthermore, in one
study (Mancini & Blieszner, 1992), researchers indicated that all of the items on the SPS
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had reliable standardized factor loadings (e.g. >.45), and that all o f the loadings were
statistically significant. Therefore, it was concluded that the SPS would provide the
present study with an adequate measurement of social support, especially with a
population that had faced the common stressor of dealing with a chronic illness.
Perceived Stress. The subjects’ perceived level of stress that they felt they were
facing at the time o f the study was measured using the Perceived Stress Scale (PSS;
Cohen, Kamarck, & Mermelstein, 1983). This 14-item measure was designed to assess
the degree to which situations in one’s life are appraised as stressful. It can also be used
to determine whether appraised stress is a risk factor in behavioral health outcomes, as
well as a means by which to investigate the extent to which social support protects one
from the negative effects o f an illness. Items on the scale include questions such as,
“How often have you been upset because of something that happened unexpectantly?”
and “How often have you felt that you were unable to control the important things in your
life?” Subjects were asked to indicate how often they had felt or thought a certain way
on a 5-point Likert scale ranging from (1) never to (5) very often. The PSS then yielded a
total score indicating the amount o f stress one perceived they were experiencing (Cohen
et al., 1983).
Regarding validity and reliability estimates for the PSS, Cohen et al. (1983)
reported coefficient alpha reliability estimates between .84 and .86 for the three samples
given the PSS in their study. Test-retest correlations calculated for one o f their samples
resulted in a correlation of .85. The PSS also demonstrated its validity in that it was
found to be highly correlated with other scales measuring both depressive
Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.
Type 2 Diabetes 69
symptomotology and health-related outcomes (.52 to .76). In fact, it appeared to be a
better predictor of depressive symptoms and health outcomes than certain previously
established scales (Cohen et al., 1983).
SES. Socioeconomic status was calculated through the utilization of a four-factor
analysis established by Holingshead (1975). Holingshead (1975) posited that an
empirical estimation of social status could be formulated by assessing four separate
factors; education, occupation, sex, and marital status. Following recommendations set
forth by Holingshead (1975), the status score for each individual was estimated by
combining information on the four factors. To calculate the status score, the scale value
for both the subjects’ occupation and education levels was attributed. Higher scaled
scores were given for higher education levels, and for professions that resulted in larger
salaries for the individual. Holingshead (1975) categorized the salaried positions by
surveying the average earnings of different occupational positions (e.g. unskilled vs.
skilled vs. professional positions), and giving each position a particular scaled score.
These scale value scores were then multiplied by a weight o f five for one’s occupation,
and three for one’s education. Those were then added together to achieve a total SES
score. Furthermore, if a subject had a spouse who was gainfully employed, an estimation
was made for both the subject and their spouse, and their scores were then added together
and divided by two (averaged).
Adherence. Patient adherence to medical recommendations was assessed with
the Self Care Inventory (SCI; Greco et al., 1990). The SCI is a 13-item self-report scale
that was developed to investigate the frequency o f adherence to recommended treatment
Type 2 Diabetes 70
behaviors in children, adolescents, and adults with Type 1 diabetes. The SCI measures
various aspects of self-care, including: maintaining a regular meal plan, administering
insulin, glucose testing and recording, and attending dim e appointments. Components
such as these have been emphasized as being important by the American Diabetes
Association (Davidson, 1986) and have been used in other measures o f diabetes
adherence (Hanson et al., 1987; Wing et al., 1986). Subjects are asked to rate how often
they have adhered to certain self-care behaviors within the past month. Respondents are
asked to rate each item on a 5-point scale ranging from (1) “Never do it” to (5) “Always
do this as recommended without fail”. Subjects may also indicate if a particular aspect
o f the treatment regimen is not applicable to their treatment protocol. The SCI can yield
an overall adherence index, or may be used to assess adherence to individual treatment
components.
The SCI was chosen as a measure o f adherence for this study because o f it’s
brevity, clear instructions, and flexibility in assessing adherence behaviors in an
idiographic manner. Furthermore, satisfactory internal consistency estimates
(Cronbach’s alpha = .87) have been demonstrated (Greco et al., 1990).
Validity of the SCI is proposed by findings of significant correlation with scores
on a 24-hour recall instrument designed to measure regimen adherence in a sample of
adults with Type I diabetes (Greco et al., 1990). In addition, scores on the SCI have been
found to be correlated with measurements of metabolic control (Greco et al., 1990;
Ireland et al., 1989; La Greca et al., 1990).
Type 2 Diabetes 71
The present study initially examined the intercorrelations among the SCI
subscales. In light o f the fact that the subscales were highly intercorrelated, an overall
adherence score was utilized to assess rates of subject adherence behaviors. The use of
an overall score was supported by the scale’s authors (La Greca personal communication,
1995). Following previous recommendations, the overall score was calculated by
averaging all o f the responses from all of the items applicable to each particular
individual. More specifically, scores were calculated by taking each subject’s total score,
and dividing it by the total number o f questions that were applicable for each individual.
Metabolic Control. Metabolic control was estimated from glycosylated
hemoglobin levels (HbAlc), which describes blood glucose levels that have accumulated
in the subjects’ bloodstream over a specific period of time (generally 1-2 months).
Analysis of metabolic control only utilized the glycosylated hemoglobin measures that
had been drawn so that the indications of blood glucose levels encompassed the time in
which the psychosocial information was obtained. Therefore, measures taken before, or
more than 2 months after the subjects filled out their questionnaires, were not used in the
data analysis.
Procedure
As it has been mentioned, participants were approached by research associates
not affiliated with the medical clinic during their regularly scheduled clinic visits. They
were given a brief overview of the study, and asked if they had any questions. Eligible
subjects signed an informed consent form indicating their willingness to answer the
study’s questionnaires and allowed the researchers to review their medical charts.
Type 2 Diabetes 72
Patients were reminded that their responses to the self-report scales would be kept
confidential, and that the clinic and medical staff would not have access to their
responses.
Participants were given a demographic form and a self-report scale packet. The
demographic form included questions regarding subjects’ gender, age, employment
status, and education level. The self-report packet contained the POMS-SF, COPE-SF,
PSQ-III (General Subscale), PPRQ, SPS, PSS, and SCI scales. Both the demographic
form and the self-report scale packet was presented to the subjects at their clinics by
trained research assistants not affiliated with the clinic staff. Patients were asked to fill
out the packet at the clinic during normal scheduled appointments or were given self-
addressed stamped envelopes so that they could complete the packet at home and return
it in a timely fashion (within a week or two). In addition, all of the patients’ questions
and concerns were addressed. Once this information was obtained, the subjects’
glycosylated hemoglobic indexes were recorded. O f all of the subjects enlisted in the
study, 64% returned their questionnaire packets.
Results
Prior to conducting the statistical analyses, the data set was reviewed for accuracy
o f data entry, inflated and deflated correlations, and the possibility o f outliers. Close
inspection o f the data revealed that the means, standard deviations, and ranges for each
o f the variables were plausible, and that there were no significant outliers in the data set.
Furthermore, the coefficients o f variation indicated that the correlations were neither
inflated or deflated. Missing data was addressed by normalizing each of the scales for
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the number of questions not answered. For each of the scales, certain thresholds were
determined in proportion to the number of items in the scales, and if the number o f
missing items extended beyond the predetermined threshold, the scale for that particular
individual was deemed invalid and not used in the statistical analyses. When the number
o f missing items were below the threshold, however, mean substitutions were made for
the subjects’ missing data. Statistics regarding the characteristics o f the sample are
presented below, followed by preliminary, main, and supplementary analyses.
Sample Characteristics
The sample was made up of a total o f 92 subjects. Fifty seven of the subjects
were recruited from the Philadelphia clinic, and 35 of the subjects were recruited from
the New Orleans clinic. Demographic information regarding the subjects can be found in
Table 1, and is summarized below. T-tests for equality of means were conducted to
compare the descriptive statistics of the sample gathered in Philadelphia and the
descriptive information of the sample from New Orleans. Results indicated that the
mean scores of the two samples did not statistically differ on any o f the variables.
The participants included 42 males and 50 females. They tended to be of an
ethnic minority, middle aged, unemployed, and single (never married, separated,
divorced, or widowed). Furthermore, most o f the subjects tended to have an education
level at or below the high school level.
Preliminary Analyses
The results of the preliminary analyses, including descriptive values for the scales
regarding psychological distress, coping style, satisfaction with one’s physician, social
Type 2 Diabetes 74
support, perceived stress, and adherence are displayed in Table 2, and are summarized
below.
Psychological Distress
The subjects’ levels o f psychological distress, as measured by the Profile of Mood
States- Short Form’s (POMS-SF) “Total Score” scale evidenced a mean score of 43.13
(SD = 25.97, range = 3.0 - 123.0). The POMS-SF scale contains a possible range o f 0 (no
psychological distress) to 148 (highest level of psychological distress).
Coping
The subjects’ use of behavioral avoidance as a means to cope with difficulties
associated with diabetes was measured with the COPE scale’s “behavioral
disengagement” subscale. The subscale contains a possible range o f 2 (minimum amount
o f avoidance) to 8 (maximum amount o f avoidance). The mean score for this population
was 2.83 (SD = 1.30, range = 2.0 - 8.0).
Patient Satisfaction
One o f the measures used to assess the subjects’ satisfaction with their medical
care was the Patient Satisfaction Questionnaire- Third Revision (PSQ-III) General
Satisfaction subscale. This subscale contains a possible range o f 6 (completely
dissatisfied with medical care) to 30 (completely satisfied with medical care). This
population evidenced a mean score o f 22.30 (SD = 5.41, range = 6.0 - 30.0).
The other measure of patient satisfaction was the Patient-Practitioner
Relationship Questionnaire (PPRQ). The PPRQ was broken up into two separate
subscales; one assessing satisfaction with the interpersonal care o f the attending
Type 2 Diabetes 75
physician, and one indicating satisfaction with the interpersonal care o f the adjunct
medical staff. Scores for each subscale had a possible range o f 10 (completely
dissatisfied with medical care) to 50 (completely satisfied with medical care). The mean
PPRQ score for the attending physician was 42.94 (SD = 7.38, range = 14.0 - 50.0), while
the mean PPRQ score for the medical staff was 42.05 (SD = 7.18, range = 23.0 - 50.0).
Social Support
Social support was measured with the Social Provisions Scale (SPS), which has a
possible range of scores o f 24 (minimum amount o f perceived social support) to 96
(maximum amount of perceived social support). The mean score for this population was
82.1 (SD = 11.3, range = 48.0 - 96.0).
Perceived Stress
The amount o f environmental stress experienced by the subjects was measured
with the Perceived Stress Scale (PSS). The scales scores range from 14 (minimum
amount of perceived stress) to 70 (maximum amount of perceived stress). The mean
score evidenced in the study was 23.4 (SD = 7.7, range = 14.0 - 43.0).
Adherence
The Self-Care Inventory (SCI) was utilized to assess the extent to which the
subjects followed their prescribed diabetes treatment protocols. Because it is
characteristic o f patients with Type 2 diabetes to have varying treatment regimens, scores
o f all of the applicable SCI items were averaged to form a mean adherence score for each
patient. The possible range for the scales’ score is 1.0 (minimum amount of adherence)
Type 2 Diabetes 76
to 5.0 (maximum amount o f adherence). The mean adherence score for this population
was 3.79 (SD = .779, range = 2.19 - 5.00).
Overall, the subjects in the study tended to report moderately low levels of
psychological distress, as well as tended to report utilizing only minimal amounts of
behavioral avoidance when attempting to cope with their chronic illness. Furthermore,
the subjects appeared to generally report being satisfied with the care they were receiving
for their diabetes, and that this was consistent for both their overall treatment, as well as
the interpersonal aspects o f this care. The subjects also tended to report that they had
moderately high levels of perceived social support, and low levels o f perceived stress.
Finally, the subjects tended to report moderately high levels o f adherence to their
treatment protocols.
Main Analyses
Correlational Matrix
The hypothesized relationships between the variables that were derived from
previous research findings and theoretical constructs were initially tested with a
correllational matrix. This was constructed so that plausible linkages between univariate
relationships could be further explored. The results o f the correlational matrix can be
found in Table 3.
Path Model
Once the correlational matrix was formulated, a path model was configured as a
rigorous test to determine the relationships between each o f the variables and adherence
ratings, as well as how each variable was related to one another in explaining adherence
Type 2 Diabetes 77
scores. Prior to conducting the path analysis, the four assumptions o f multivariate
analysis were assessed. They were: (1) multivariate normality, (2) homoscedasticity, (3)
linearity, and (4) multicollinearity. As violations o f normality in distinct variables may
affect the assumption o f multivariate normality, the distributions for the individual
variables were examined, as were skewness and kurtosis. Furthermore, analyses were
completed to determine if univariate extreme scores, if any, were significant outliers.
Results o f the examination revealed that one o f the variables, the COPE scales’
“behavioral disengagement” subscale, had a significant Kolmogorov-Smimov Z value o f
3.3 (p<.05), pointing to a violation o f the univariate normality assumption. However,
when one considers that this subscale is made up o f only two questions, it is reasonable
to assume that one would need an excessively large number of subjects to avoid violating
the assumption o f normality. In addition, the subscale was extracted from results of the
whole COPE scale, which has been determined to be both a valid and reliable assessment
o f coping in health research populations. It has also been determined that one can utilize
individual COPE subscales in empirical research. Therefore, given these considerations,
as well as the fact that this subscale has previously been empirically shown to be a
pertinent variable in predicting health behaviors, it was felt that the behavioral
disengagement subscale should still be included in the model.
Scatterplots of residuals were examined to further test the assumptions of
homoscedasticity and linearity. Examination revealed that the data set met these two
assumptions. Finally, because there were no correlations between the independent
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variables greater than .90, there was no multicollinearity among the variables under
consideration.
Once the assumptions for multivariate analyses were assessed, an initial path
model was tested. The process o f testing the model was based on recommendations for
structural equation modeling established by Joreskog (1973). This was conducted by
examining the multitude o f theoretical relationships that were initially hypothesized to
explain variability in adherence behaviors. Again, these were derived from previous
research findings. While a correlational matrix was used as a confirmatory measure for
univariate relationships, multiple regression analyses were used as preliminary steps to
examine the hypothesized multivariate relationships. By examining which relationships
succeeded or failed to be statistically significant through the multiple regressions, one
was able to derive which equations merited further investigation through a path analysis.
This initial path model that was assessed could be best described as a “full”
model. This was because all o f the hypothesized paths that proved to be significant
through the previously examined regression equations were investigated simultaneously.
The model was tested using forced entry regression equations, and modified based on
whether the paths violated the assumptions o f a path model. More specifically; all paths
had to be statistically significant, and all variables in the path had to be statistically
independent of each other (and thus measuring distinct phenomenon). The latter
assumption was tested using a Cross Model Correlational Matrix (CMCM) of the
regression equations. In assessing the relationships between the regression equations to
see if they exceeded the absolute value threshold o f +/- .15, one had an accurate method
Type 2 Diabetes 79
by which to investigate whether a dependency between the regression equations existed
that was not specified in the model.
Finally, after a number o f attempts, a model emerged that was consistent with the
aforementioned criteria. This model can be seen in Figure 2. It consists of three distinct
relationships (shown as separate regression equations) that are simultaneously related
through intervening variables. Together, they ultimately help to explain the variance that
exists on the adherence measure in the present study. In order, they are the following:
(A) Social support (SPS) significantly predicted general patient satisfaction with
medical care (PSQ-III) £ ( 1,80) = 5.43, g < .05], so that social support explained 5% o f
the variance in general medical care satisfaction (B = 0.122, g < .05).
(B) General satisfaction with medical care (PSQ-III) significantly predicted level
o f satisfaction with interpersonal aspects of medical care (PPRQ) [F(l,80) = 63.77, g <
.0001], in that general satisfaction explained 44% o f the variance o f satisfaction with
interpersonal aspects o f the subjects’ diabetes care (B = 1.72, p < .0001).
(C) The subjects’ satisfaction with the interpersonal aspects o f their diabetes care
(PPRQ), as well as the extent to which they utilized avoidance as a means to cope with
their chronic illness (COPE, bd) significantly predicted levels of adherence to diabetes
treatment protocols (SCI) £(2,79) = 14.63, g < .0001]. The combination of the two
variables accounted for 25% of the variance of adherence. Both patient satisfaction with
interpersonal variants o f diabetes care (B = .482, p < .0001) and avoidance coping (B =
-.257, p < .05) independently contributed to the explanation o f variance on the diabetes
adherence measure.
Type 2 Diabetes 80
The resultant path model supported the following hypotheses: (1) One’s
satisfaction with interpersonal aspects of their diabetes care (PPRQ), as well as (2) one’s
tendency to utilize behavioral avoidance as a means to cope with difficult situations
related to having diabetes (COPE,bd) directly affected the extent to which one adhered to
their diabetes treatment protocol (SCI).
Furthermore, the model displayed that (3) the extent to which one was satisfied
with their medical care in general (PSQ) was directly related to one’s satisfaction with
interpersonal variants o f their diabetes care (PPRQ), and (4) indirectly related to
adherence variability (SCI), with the PPRQ acting as a mediator between the two
variables.
In addition, the path model indicated that (5) one’s assessment o f their social
support (SPS) directly affected the extent to which one was satisfied with their medical
care in general (PSQ), and (6) was indirectly related to one’s satisfaction with the
interpersonal aspects of diabetes care (PPRQ), with the PSQ acting as the mediator
between these variables.
Finally, the model displayed that (7) variability in one’s assessment of their social
support (SPS) was indirectly related to the extent to which one adhered to their diabetes
treatment (SCI), with both general satisfaction with medical care (PSQ) and satisfaction
with interpersonal variants of diabetes care (PPRQ) acting as mediators for this
relationship.
Type 2 Diabetes 81
Supplementary Analyses
As previously described, circumstances arose that did not allow for the necessary
amount of metabolic control data to be collected- Therefore this variable was not
included in the path analysis. Rather, it was solely investigated in terms o f its
relationship to self-reported adherence outcomes for the subset o f subjects with
completed data. Values were obtained for a total of 43 subjects. The mean HbAlc value
was 8.72 (SD = 2.63, range = 5.4 - 15.0). This relationship was investigated with a
bivariate correlational analysis (Pearson Product-Moment). Results indicated that there
was no statistically significant correlation between adherence and levels of metabolic
control (r = .063, g > .05). This can be seen in Figure 3.
Demographic Variables
Although the demographic variables were insignificant predictors of the
adherence measure in respect to the other psychosocial variables, further data was
collected to investigate group differences within the demographic measures in regard to
adherence outcomes, as well as their predictive value upon adherence independent o f the
other psychosocial variables. This was conducted because the lack o f findings was
surprising, as past research had noted significant results, and the present researcher
wanted to attempt to replicate previous findings. Analyses of variance (ANOVAs) as
well as t-tests were conducted to assess group differences for each o f the demographic
Type 2 Diabetes 82
variables, and standard regressions were conducted to investigate the predictive value o f
each o f the demographic variables.
Subjects’ Age
An assessment of the relationship between the subjects’ age and their adherence
practices revealed that the older subjects tended to adhere more to their prescribed
regimens than the younger subjects. This trend, with age measured as a continuous
variable, proved to be moderately statistically significant [F(l,80) = 3.64,j ) = .06].
Therefore, age was a moderately significant predictor of adherence (B = .209, g = .06).
Gender
Regarding associations between gender and adherence, it was found that the mean
SCI score for males (M = 62.47) was slightly higher than the mean score for females (M
= 59.03). However, no significant differences were found between the male and female
subjects in the study [t(80) = 1.25, g = .215] in regard to reported adherence practices.
Ethnicity
As it has been mentioned, the pool o f subjects was made up o f four different
ethnic groups: Whites, Blacks, Hispanics, and “Others”. However, it was revealed that
there were only 2 subjects in this “Other” category. A bar graph depicting group
differences displayed that those subjects classified as “Other” also appeared to
significantly adhere less to their treatment regimens than those of other ethnicities. Thus,
these subjects were deemed “outliers”. Therefore, an ANOVA was conducted without
the 2 “Other” subjects, and displayed insignificant differences between ethnic groups
(7(2,78) = 2.16, g = .122] in regard to adherence.
Type 2 Diabetes 83
Duration o f Diabetes Diagnosis
The time that had elapsed since each subject had received the diagnosis of Type 2
diabetes was also investigated in regard to its relationship to adherence. This variable
was not significantly related with the adherence variable (r = .009, p > .05).
Socioeconomic Status
All of the subjects were given SES ratings derived from an equation prescribed by
Hollingshead (1975). Ratings were based on the education level and occupation o f each
subject (and their partner when applicable). A regression analysis revealed that SES was
not a significant predictor of adherence ratings OE(1,80) = .078, p = .781].
Discussion
The results of the main analyses will be addressed first. Each o f the six
psychosocial variables will be considered for their value in predicting adherence to Type
2 diabetes treatment. They will be presented in the following order: (1) the patient-
practitioner relationship (PPR), (2) coping style, (3) social support, (4) psychological
distress, (5) perceived stress, and (6) SES. Next, the supplementary analyses will be
reviewed and discussed. Finally, the clinical implications, limitations, and possible
future investigations will be considered.
Main Analyses
The primary purpose o f this investigation was to formulate a multivariate model
that explained the role that certain psychosocial variables played in predicting Type 2
diabetes treatment adherence. The psychosocial variables hypothesized to be related to
Type 2 Diabetes 84
treatment adherence included the PPR, coping style, social support, psychological
distress, perceived stress, and SES. The direct relationship of each variable with
adherence, as well as the mediating roles that some variables played in predicting
adherence, will be discussed below.
First, prior to examining the predictor variables, the accuracy o f the dependent
variable, adherence, will be addressed. This is important to discuss because it has been
mentioned that adherence ratings, especially to behavioral treatment protocols, can
sometimes be difficult to assess accurately (McNabb, 1997; Turk & Meichenbaum,
1988). For example, McNabb (1997) pointed out that “common strategies for measuring
adherence can be difficult because there may be substantial variability among patients
and across situations that must be accounted for in a measure of diabetes self-care.” In
the present study, variability among subjects’ treatment protocols was addressed
statistically. This was done by taking each subject’s total score, and dividing it by the
number of applicable items each subject endorsed on the adherence measure.
Furthermore, difficulties in adherence assessment can be particularly evident
when self-report methods are utilized to collect data- as they may be susceptible to
certain reporting biases. These can include inaccurate recall of information, a desire to
look favorable to the researcher, or a denial that one may be struggling with a chronic
illness, among others (Turk & Meichenbaum, 1988). However, steps were taken to
minimize the occurrence of such biases. For example, subjects were informed that all of
their answers would be kept confidential, and that their responses would in no way affect
the treatment they would receive in their respective clinics. Evidence for the utility o f
Type 2 Diabetes 85
such procedures was displayed by the fact that the subjects’ SCI scores were evenly
distributed throughout the curve, and failed to violate the test o f univariate normality.
Therefore, there appeared to be no ceiling effects within the results o f this particular
scale. However, one must always use caution when assessing the results o f a self-report
scale. This will be discussed further in the limitations section.
The Patient-Practitioner Relationship
The patient-practitioner relationship (PPR) proved to be the single most important
predictive factor associated with the adherence measure. More specifically, when
subjects were more satisfied with the care they were receiving in their diabetes clinic,
they tended to adhere more to their prescribed treatments. However, when subjects were
less satisfied with their care, they tended to demonstrate poorer adherence. This is
consistent with the limited amount o f research that has been conducted in this area (Galin
et al., 1996; DiMatteo et al., 1993; Cox & Gonder-Frederick, 1992; Sherboume et al.,
1992).
It was not surprising to find that this variable resulted in being a significant
determinant of adherence variability, especially when one considers the fact that the
subjects received their information regarding specific treatment behaviors from their
health care providers. Furthermore, because it has been mentioned that satisfaction with
health care, and more specifically, the doctor’s care, is commonly associated with crucial
factors that contribute to a patient’s ability to follow their recommended treatments,
dissatisfaction with this relationship could prohibit a patient from being acutely aware of
their responsibilities regarding their own care. For example, Ley et al. (1976a) reported
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that when patients were satisfied with the extent to which their physicians simplified
treatment instructions, patients made fewer errors in taking medications. In addition, Ley
et al. (1976b) reported that adherence increased when patients reported that their doctors
emphasized the important aspects of treatment. Finally, Garrity (1981) found that recall
o f treatment information, which increased as patients reported being more satisfied with
the care they were receiving, significantly affected adherence rates.
Aside from the previously mentioned aspects o f the PPR that could have
contributed to its significant relationship with adherence ratings, another issue associated
with PPR has demonstrated its applicability in previous studies. This refers to the nature
o f the interpersonal relationship that the medical care providers have with their patients
(Sherboume et al. 1992). Sherboume et al. (1992) reported that when patients felt that
their expectations o f care have been fulfilled, and physicians have respected their
concerns and provided responsive information about their condition and progress,
adherence has been greater. Interestingly, a number o f aspects o f this interpersonal
relationship were examined with one of the self-report scales utilized in the present
study. Among those mentioned as being important that were also assessed in this study
included: (1) the physician’s ability to impart medical information clearly and
unequivocally, (2) the physician’s ability to communicate with the patient in a positive
and supportive manner (e.g., conveying sympathy, understanding, and encouragement),
(3) the physician’s accessibility to the patients, and (4) the physician’s tendency to
encourage the patient to take an active role in their own diabetes care.
Type 2 Diabetes 87
Taken together, it may be difficult to assess which of these particular properties
o f the PPR proved to be most important in explaining variability of the adherence
measure. However, it can be assumed that they may have all contributed to predicting
adherence outcomes.
Another interesting finding was that it was the subjects’ opinion regarding the
interpersonal aspects o f their health care (the PPRQ measure) that was most relevant in
predicting variability on the adherence measure, while their general feelings about their
medical care (the PSQ-III general subscale measure) was only related to the adherence
measure indirectly in the path analysis, with the PPRQ providing mediation for that
relationship. However, upon investigating the univariate relationships in the
correlational matrix, one could see that the PSQ-HI general subscale was significantly
correlated with the adherence measure (SCI). Therefore, it appears that the relationship
that the PSQ-III general subscale may have had with the SCI was better explained by the
constructs contained within the PPRQ measure when entered into a multiple regression
equation that accounted for shared variance. In other words, the superior predictive
power of the PPRQ over the PSQ-III general subscale may have resulted from the
PPRQ’s ability to assess more pertinent aspects o f the patient’s satisfaction of care
related to adherence behaviors (namely, their interpersonal relationship with their
medical team). As it had been mentioned that previous literature (Sherboume et al.,
1992) has pointed to the importance of one’s satisfaction with interpersonal aspects of
one’s diabetes care, this finding was not surprising.
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Although the predictive value o f the measure assessing the subjects’ general
feelings toward their health care was overshadowed by the predictive strength of the
measure assessing satisfaction with interpersonal care, it is noteworthy to mention that
the PSQ-EH general subscale resulted in being the only variable significantly related to
the PPRQ scale in the path analysis. Therefore, it appears that when subjects were
satisfied with the overall level of care they were receiving, they tended to be more
satisfied with the interpersonal relationship they had with their medical team. In other
words, the subjects’ general satisfaction with their diabetes care resulted in being a
significant predictor o f their satisfaction with more specific aspects o f their diabetes
treatment.
Coping Style
The subjects’ coping style, namely the tendency to utilize behavioral avoidance,
significantly predicted adherence behaviors. As subjects chose to cope with their chronic
illness by giving up attempts to cope with their situation, or saying things to themselves
like, “This isn’t real,” they tended to adhere less to their prescribed treatment protocols.
By the same virtue, those that eschewed such means o f coping tended to adhere more to
their diabetes treatment recommendations. In fact, it should be noted that, aside from the
patient-practitioner relationship, behavioral avoidance coping resulted in being the only
variable that directly explained adherence variability in the model.
This finding is consistent with previous research findings. For example,
Sherboume et al. (1992) found, in a similar adult population, that subjects reporting
avoidant coping strategies were less likely to adhere to their doctor’s advice and
Type 2 Diabetes 89
management recommendations. Similarly, Reid et al. (1994) found that avoidance
coping strategies were associated with poorer adherence to the self-monitoring o f blood
glucose, as well as poorer health outcomes.
These results make theoretical sense as well. Given that most o f the activities
associated with diabetes treatment adherence involves the patient taking a physically
active role in numerous behaviors (e.g., BG testing, exercising, etc.), it appears that
adherence to diabetes treatment inherently involves an active style o f coping. A passive
or avoidant style o f coping would therefore tend to involve the patient often neglecting to
take part in these physically active behaviors, which is not conducive to the promotion of
health outcomes in this population.
Social Support
One’s perception of their social provisions resulted in being a significant
predictor of the degree to which subjects were satisfied with the general level o f medical
care they were receiving. More specifically, when subjects tended to perceive that they
had others in which they could depend, or that they had close interpersonal relationships
with others, they tended to be more satisfied with the general level medical care they
were receiving.
The relationship evidenced in this study between the subjects’ perception o f their
social provisions and the degree to which they were satisfied with their medical care
makes theoretical sense. If one’s perception of their social support is a reflection o f their
overall ability to maintain healthy interpersonal relationships, those who reported having
more social support may exhibit a greater ability to initiate, maintain, and take advantage
Type 2 Diabetes 90
of the social networks provided to them in various settings. Since previous research has
indicated that one o f the most important aspects o f the PPR is the degree to which health
care professionals impart encouragement and support (DiMatteo et al., 1993), it follows
that the patient should also possess the ability to utilize this particular form of care being
imparted to them. If they lack such skills, the empathy and support being communicated
by those involved in the medical care may be squandered, or misappropriated in some
manner.
When closely examined, it is interesting to see the similarities between how
researchers have defined “social support” in regard to chronically ill populations, and
what have been deemed crucial aspects o f the PPR. For example, the scale used in the
current study to measure social provisions was initially formulated to assess six
dimensions of social support; attachment, social integration, reliable alliance, guidance,
reassurance o f worth, and opportunity for nurturance (Weiss, 1974). One could posit that
a majority o f these dimensions are closely related to important aspects o f the PPR. These
could include the degree to which patients are satisfied with their medical team’s ability
to impart positive interpersonal communication, technical competence, and proper access
to care, as well as sympathy, understanding, and encouragement.
Results also indicated that, while the measure assessing perceived social support
displayed a direct relationship with the measure assessing general satisfaction with
medical care, it was not directly related with the measure indicating satisfaction with the
interpersonal aspects o f the medical care. Rather, it was only indirectly related to one’s
satisfaction with their interpersonal relationship with the medical staff, with general
Type 2 Diabetes 91
medical care satisfaction acting as a mediator for this relationship. In light o f the fact
that the PPRQ appeared to be assessing more specific aspects o f the PPR than the PSQ-
in general subscale (namely, the interpersonal relationship), this surprisingly conflicted
with the originally hypothesized relationships between social support and the PPR. One
possible explanation is that the general subscale o f the PSQ-IU has been shown to be
highly correlated with the other subscales of the PSQ-m (Wilkin et al., 1992). These five
additional PSQ-in subscales provide an in depth assessment of one’s satisfaction with the
PPR through it’s examination of interpersonal, communicative, and supportive aspects of
one’s care- which were apparently well represented by the general PSQ-III subscale.
Therefore, the PSQ-III general subscale, by virtue o f it’s close association with the other
PSQ-III subscales, may actually be measuring more specific constructs o f the PPR than
the PPRQ. Following this logic, the general subscale o f the PSQ-III may have better been
able to capture the aspects o f the PPR that were related to the social support variable than
the PPRQ.
Finally, it should be mentioned that social support was not directly related to
adherence. Rather, it was indirectly related to adherence, with both satisfaction with
general medical care and interpersonal aspects of care acting as mediators for this
relationship. The lack o f a direct association between social support and adherence
appears to be inconsistent with previous findings. For example, research (Kaplan &
Hartwell, 1987) has found that social support can affect a patient’s tendency to adhere to
their diabetes treatment protocol by providing an environment for the patient that is
conducive to following their particular regimen. More specifically, support systems may
Type 2 Diabetes 92
aid the patient by actively reminding them to take their insulin, exercise, and follow their
diet. However, it should be noted that findings on this matter have typically limited their
assessment o f social provisions to the kind o f support that is specifically related to
guiding the patient through their particular regimen, rather than assessing general types
of interpersonal support that may not necessarily be directly associated with one’s
treatment plan. This may help to explain the lack o f direct findings regarding this issue.
Psychological Distress
Psychological distress was not a significant predictor o f adherence. While the
initial correlational matrix determined that this variable had a significant univariate
relationship with both coping strategies (behavioral disengagement) and perceived stress,
as hypothesized, the correlational matrix determined that it’s relationship with adherence
was insignificant. However, this is inconsistent with previous research that has reported
a significant relationship between psychological factors and adherence variability
(Kovacs et al., 1996; Lloyd et al., 1992).
Interestingly, much o f the research that has found such an association tended to
assess the relationship between diagnosable psychiatric illnesses (e.g. depression) and
behavioral and health outcomes (Wilkinson et al., 1988; Lustman et al., 1986). In
contrast, potential subjects with a history o f psychiatric illnesses were excluded from this
project, and only variations of psychological distress that remained within the “non-
disruptive” (non-diagnosable) range were investigated. Furthermore, within the possible
range of psychological distress allowed for the study, the subjects tended to report
moderately low levels o f distress. Thus, in assessing for psychological distress in a
Type 2 Diabetes 93
presumably “non-psychiatric” population, the study may have limited the potential effect
that this variable may have had on the outcome variable. In other words, it may be that in
order for psychological distress to significantly affect adherence, it may also generally
have to reach a clinically significant level- and be disruptive in other aspects of the
subjects’ lives. However, it should be noted that, while including individuals with a
history of a psychiatric illness could have resulted in displaying this variables’ predictive
power in regard to adherence, it was felt that this would have confounded the validity of
the other variables being measured.
Perceived Stress
Perceived level o f stress was not a significant predictor of adherence. While it
was significantly correlated with numerous other variables; such as coping style,
psychological distress, social provisions, and adherence, it’s univariate relationship with
adherence was not maintained when placed in a regression equation with other variables.
In other words, it was apparent that there was indeed a significant relationship
between perceived stress and adherence, as well as perceived stress and other
psychosocial variables when correlation equations were utilized as a statistical measure.
However, it appears that the predictive value o f perceived stress in explaining variability
o f the adherence measure was better accounted for by variables such as the PPR when its
impact was measured within a multivariate analysis.
The lack o f a direct relationship between adherence and stress appears to
contradict some o f the research on this issue (Mendez & Belendez, 1997; Viner et al.,
1996; & Boardway et al., 1993). For example, when Mendez & Belendez (1997)
Type 2 Diabetes 94
investigated the impact o f stress management on treatment adherence in adolescents with
Type 1 diabetes, they found that individuals who received behavioral programs that
included stress management techniques tended to adhere significantly more to treatment
protocols than individuals who did not receive such techniques.
However, it should be noted that many o f the previous studies that have
investigated the impact of stress in diabetes populations have limited their assessments to
Type 1, child and adolescent, populations. Furthermore, much o f the previous literature
has also tended to solely investigate diabetes-related stress and its impact on health
outcomes, rather than consider associations between general forms o f life-related stress
and adherence, as was done in the present study.
Socioeconomic Status
Socioeconomic status also did not demonstrate a significant relationship with
adherence within the model. This finding was inconsistent with previous studies
reporting associations between the two variables. For example, Padgett (1993) found
that subjects with Type 2 diabetes of lower educational and occupational levels adhered
less to treatment than those of higher SES status. More specifically, he found that those
o f lower SES were less likely to monitor their medication and insulin intake and follow
their prescribed diet. However, like many previous studies utilizing a Type 2 diabetes
population, Padgett’s (1993) investigation o f psychosocial variables was univariate in
nature, and, unlike the present study, failed to account for variables that may better
explain variation of adherence practices.
Type 2 Diabetes 95
The insignificance o f the SES variable did not appear to simply be a result o f
shared variance with another psychosocial variable. Rather, it did not even display a
significant correlation with the adherence measure. This could possibly be explained by
the fact that most of the subjects in the study fell into the lower end o f SES, rather than
being evenly distributed throughout the SES spectrum. Had the sample been more
varied, the present researcher may have better been able to examine the impact o f this
demographic variable on adherence practices.
Supplementary Analyses
As it has been mentioned, the present researcher had unforeseen difficulties in
collecting the necessary amount o f metabolic control data. Once again, this seemed to
result from many o f the subjects being asked by their insurance providers to have their
glycosylated hemoglobin assays drawn by their primary care physicians (PCPs) rather
than their endocrinologists. This brought about circumstances whereby either: (1)
patients did not follow through in obtaining their HbAlc measures, (2) the labs analyzing
the HbAlc data only reported back to the PCPs and did not report this information to the
endocrinologists, and/or (3) the present researcher was unable to obtain this information
from the PCPs. Given that the study would only include HbAlc measures that
encompassed that time period in which the subjects filled out their psychosocial
questionnaires, it became apparent that many o f the subjects’ metabolic control data was
“outdated” in regard to exclusion criteria. Therefore, metabolic control data collected
outside o f the time frame was considered invalid.
Type 2 Diabetes 96
However, the study was able to obtain measures for a subset o f the subjects (n =
43), and a separate correlational analysis was conducted to examine the hypothesized
relationship between behavioral and health outcomes. Results indicated that HbAlc
values were not significantly related with the adherence measure. This was not entirely
surprising, given the discrepancies found in previous studies on this topic. Johnson et al.
(1992) alluded to the fact that the link between metabolic control and adherence to
treatment for individuals with Type 2 diabetes has yet to be definitively determined.
Furthermore, while some studies have found the marker, HbAlc, to be a good indicator
o f adherence practices (Hanson et al., 1989; Brownlee-Duffeck et al., 1987; Hanson et
al., 1987a), other studies have failed to find significant relationships between the two
variables (Cox et al., 1984; Glasgow et al., 1987).
It has been posited that other factors can influence health outcomes in diabetes
populations. These include insulin sensitivity, illness severity, and the effectiveness of
the recommended regimen (Peyrot & McMurray, 1985). Therefore, actual adherence
practices on the part of the patient may not prove to be as significant in affecting HbAlc
values as one may believe.
Regarding the effectiveness o f the recommended treatment plan, it was
anecdotally noted that health care professionals tended to not follow a particular protocol
when they communicated proper adherence practices to their patients. In other words,
some patients received more specific adherence instructions than others. In addition,
patients tended to vary in their interest in what they needed to do to care for their illness,
and when asked, were diverse in their ability to repeat the instructions given to them.
Type 2 Diabetes 97
Therefore, discrepancies appeared to be related to both the nature o f the
recommendations given to the patients, as well as the amount o f information encoded
into memory by the individual patients. As a result, some patients could have followed
treatment recommendations very well, but may have received insubstantial information
from their providers. Subjects could have also reported that they were following
recommendations on the SCI measure, but may not have actually understood what they
were specifically supposed to do in regard to individual treatment items (e.g., BG testing,
diet, exercise). Therefore, if this occurred, metabolic control outcomes could have been
associated with factors other than what was measured with the SCI.
Demographic Variables
None o f the demographic variables were significantly related to adherence.
While this was moderately surprising, as past research had noted significant results in this
area, these variables lacked both multivariate, as well as univariate, relationships with the
adherence measure. Considerations o f these results are explored in the limitation section
o f the discussion section.
Clinical Considerations o f the Current Investigation
The current study is significant in its documentation of the roles that psychosocial
variables may play in affecting adherence behaviors in individuals suffering from Type 2
diabetes. Furthermore, it was notable in that it attempted to investigate these roles
concurrently; by taking into account both the direct relationships that the variables had
with adherence, as well as how the variables interacted with one another to affect
Type 2 Diabetes 98
adherence. This apparently addressed the paucity o f multivariate research regarding this
issue (Glasgow, 1995; Cox & Gonder-Frederick, 1992; LaGreca & Spetter, 1992).
The present research endeavor was most noteworthy in its examination o f the
psychosocial variables most commonly associated with diabetes treatment adherence; the
patient-practitioner relationship, coping styles, social support, psychological distress,
perceived stress, and various demographic variables. It supported numerous
hypothesized univariate relationships that have been established through previous
research. Furthermore, it enhanced previous efforts by attempting to account for
mediating relationships. This was conducted so that an integrative picture o f the
conceptualization of diabetes management could be formulated. The need for such a
model has been proposed as being crucial to understanding the complexities o f a typical
diabetes treatment regimen, as well as understanding what factors may facilitate or
hinder a patient’s ability to follow their regimen (LaGreca & Spetter, 1992).
The model that was derived in the present study explained a significant portion of
the variance of diabetes treatment adherence practices. It was discovered that when
individuals were satisfied with interpersonal aspects of their medical care they were
receiving in their endocrinology clinics, they were more likely to adhere to treatment
recommendations. Furthermore, it was discovered that when patients were less likely to
utilize avoidance as a means by which to cope with their illness, they tended to adhere
more to prescribed treatment regimens. It was also indicated that general satisfaction
with medical care, as well as the perceived level o f social support the patients felt they
obtained, contributed to adherence practices. This occurred because the latter variables
Type 2 Diabetes 99
significantly determined how satisfied patients were with the interpersonal aspects o f
their diabetes care, which in turn directly affected whether they were more or less likely
to adhere to their health care providers’ recommendations.
Thus, the current study has taken an important step in furthering our
understanding of the complexities o f the roles that psychosocial variables may play in
regard to Type 2 diabetes treatment. It is believed that, in formulating a multivariate
model such as this, progress has been made in the realm of behavioral medicine; in that
this may eventually lead to better disease management for patients suffering from Type 2
diabetes.
Limitations o f the Current Investigation
Despite the steps that were taken to insure that the present study was carefully
designed, there were certain limitations inherent in its implementation. First, the
dependent variable, adherence, was assessed using a self-report scale. As it has been
mentioned, such a method of gathering data can be susceptible to certain reporting
biases; such as inaccurate recall o f information, a tendency to over-report adherence to
look favorable to the researcher, or a denial that one may be dealing with a chronic
illness. However, steps were taken to minimize biased reporting. For instance, subjects
were informed that all reported information would be kept confidential, and that their
responses would not affect their treatment in the clinic. Furthermore, subjects were
specifically encouraged to answer all questions honestly.
Another limitation o f the study was associated with how the present researcher
utilized particular scales. Many of the psychosocial scales were made up of numerous
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subscales- each measuring separate constructs o f the variable. For example, the scale
assessing psychological distress (POMS) possessed subscales measuring six factors,
including “Tension-Anxiety”, “Depression-Dejection”, and “Anger-Hostility”, among
others. However, most scales were scored using an overall score, rather than examining
each individual subscale. It can be assumed that this method may have limited the
study’s ability to draw more specific conclusions from the results. However, the
utilization o f general scores was done for a number of reasons. First, in all o f the cases,
an overall score was recognized because previous research had concluded that this was a
valid and reliable method in which to assess the particular construct (e.g., psychological
distress, adherence, etc.). Furthermore, in most cases, the utilization o f the scales in this
manner was actually recommended in studies associated with the measurements. O f
course, proper guidelines were followed to determine whether an overall score would be
used, or whether the subscales would be investigated separately. For example, the scale
measuring adherence to treatment (SCI) consisted o f distinct components related to
diabetes care, and each of these could have been assessed independently in a statistical
analysis. However, following previously determined guidelines, it was determined that
an overall adherence score should be utilized because the individual subscales were
highly intercorrelated.
In attempting to properly apply the psychosocial scales within a statistical
analysis, the measurement assessing coping style (COPE) proved to be the greatest
challenge, and presented an additional limitation. While utilizing a general score rather
than individual subscales did not appear to detract from the utility o f the other scales, this
Type 2 Diabetes 101
researcher found that the COPE conferred special difficulties. Specifically, the COPE
scale was made up o f 13 distinct subscales, each measuring different coping styles.
Interestingly, the COPE did not offer a total score, but only provided 13 separate
constructs, which had to be measured as if they were 13 distinct variables within the path
analysis- should they all be included in the investigation. As this would have resulted in
a complicated and confusing model, the researcher was forced to follow previous
recommendations and chose to analyze the particular subscale that was o f most interest
for this population. Therefore, while the entire COPE was administered, the behavioral
disengagement subscale was the sole construct utilized, and the study dismissed the other
COPE subscales from the model. While this was consistent with previously determined
recommendations, and managed to provide the study with important information
regarding the dependent variable, it would have been interesting to see how other coping
styles contributed to variability of adherence.
Another limitation of the study was that it was significantly limited in its ability to
draw conclusions regarding the relationship between behavioral and health outcomes. As
it had been mentioned, this resulted from an inability to gather the necessary amount of
metabolic control data for its inclusion in the path analysis. Therefore, while the study
initially proposed to examine relationships between psychosocial variables, adherence,
and metabolic control concurrently, the present researcher was forced to dichotomize the
study into two parts; one assessing associations between the psychosocial variables and
adherence (the behavioral outcome), and one examining the relationship between
adherence and metabolic control (the health outcome). As previous research had alluded
Type 2 Diabetes 102
to the possibility that psychosocial variables could impact variability in metabolic control
in Type 2 diabetes populations, it appears that a previously hypothesized relationship
could not be examined.
An additional problem that arose during the study’s implementation was
associated with how adherence behaviors were assessed. While the current study utilized
a valid scale to measure adherence, difficulties surfaced because individual subjects had
treatment recommendations that varied from one another. While the adherence scale
used in the present research was developed to measure common diabetes treatment
behaviors, it was often found that some o f the behaviors were not applicable for some of
the subjects, and that this finding varied from individual to individual. As a result, these
differences had to be addressed statistically, so that scores were not effected by the
subjects’ lack o f adherence to other, inapplicable, behaviors. Furthermore, the adherence
scale was not designed to assess specific reports o f adherence- such as dietary caloric
information or the duration o f exercise regimens. Rather, it simply asked subjects to
indicate the extent to which they were adhering to general descriptions of treatment items
(e.g., “1 exercise regularly.”) Had more specific adherence data been collected, accounts
of adherence practices would have been more accurately represented. Therefore, in a
general sense, if an alternative scale was used that could have assessed adherence in a
more idiographic and detailed manner, the study may have better been able to provide a
more accurate picture of treatment adherence.
Finally, inconclusive findings associated with the demographic variables exposed
another possible limitation o f the study. A lack of significant findings probably resulted
Type 2 Diabetes 103
from the limited variability of the sample chosen for the study. As it had been
mentioned, most o f the subjects recruited for the project tended to be racial minorities, of
lower SES, and single. This was related to the fact that the two clinics used as collection
sites serviced similar populations- both providing medical care for individuals who
tended to fit this profile. It can be assumed that, had the sample generally consisted of
subjects o f a greater variety o f race, SES, and marital status, significant findings would
have been more likely to occur.
Conclusions
In conclusion, this investigation successfully developed a path model for
predicting adherence behaviors in individuals with Type 2 diabetes. Three o f the six
hypothesized variables were related to adherence. These included perceived social
support, satisfaction with the patient-practitioner relationship, and coping style. In other
words, those who (1) perceived that they had greater social support, (2) reported being
more satisfied with their PPR, and (3) tended to not utilize avoidance to cope with their
illness, reported higher adherence rates.
Based on these results, several recommendations may be useful for future
research on diabetes treatment adherence. First, current findings should be replicated
with an additional Type 2 diabetes population, as most previous research has focused on
a Type 1 diabetes population. Next, researchers should explore whether the results
generalize to different populations, such as those o f different ethnic and SES
backgrounds. Furthermore, future research should attempt to better account for
individual differences in recommended treatment protocols when measuring adherence,
Type 2 Diabetes 104
as well as aim to more specifically measure adherence practices. This could be done by
investigating the impact that psychosocial variables may have on adherence to particular
treatment components (which could be assessed quantitatively), rather than overall
adherence practices. In addition, future research should attempt to measure the impact
o f psychosocial variables on adherence longitudinally. This would allow researchers to
more definitively indicate the directionality of the relationships o f variables within the
model. Finally, further research should aim to explore whether there is a relationship
between behavioral and health outcomes, as this study was unable to satisfactorily
resolve this issue.
Additional studies should also continue to address the issue of satisfaction with
the PPR. This should be done for a number o f reasons. First, o f all of the psychosocial
variables included in the present study, this appeared to be the most significant variable
in predicting adherence. Second, little has been done to explore this seemingly crucial
aspect, and its importance can be further emphasized if research can replicate the current
findings. This should also include a more careful description o f what particular aspects
o f the PPR may contribute to increased adherence. Together, this would aid health
professionals in pinpointing what specifically helps to explain why certain individuals
adhere to recommended diabetes treatments, and why others tend not to follow medical
advice.
Several o f the predicted hypotheses were not supported during this investigation.
In certain instances, some psychosocial variables did not share a univariate relationship
with adherence. However, in other cases, variables that may have initially displayed a
Type 2 Diabetes 105
correlation with adherence, resulted in having a relationship with adherence that was
better accounted for by its relationship with the PPR. Thus, in many instances, previous
univariate findings were replicated, but did not hold up under the predictive strength of
the PPR variable when they were entered into a path model that accounted for shared
variance.
Future investigations should attempt to replicate the current findings in this and
other populations, to explore additional correlates of adherence, and to develop further
models for predicting adherence. Researchers should also continue to examine the
nature of adherence, and its relationship with metabolic control- the most commonly
used marker for health outcomes. Then, if it is discovered that poorer adherence is more
definitively explained by psychosocial variables such as satisfaction with the PPR, and
poorer adherence actually results in poorer blood glucose control, potential problems in a
given patient’s psychosocial environment could be more readily identified and addressed
clinically.
Type 2 Diabetes 106
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Wilkin, D., Hallem, L., & Duggett, M. (1992). Measures of need and outcome for
primary health care. New York: Oxford University Press.
Wilkinson, G., Borsey, D.Q., Leslie, P., Newton, R.W., Lind, C., Ballinger, C.B. (1988).
Psychiatric morbidity and social problems in patients with insulin-dependent diabetes
mellitus. British Journal o f Psychiatry. 153,38-43.
Wilson, D.P., & Endres, R.K. (1986). Compliance with blood glucose monitoring in
children with Type I diabetes mellitus. Journal o f Pediatrics. 108. 1022-1024.
Winefield, H., Murrell, T., & Clifford, J. (1995). Process and outcomes in general
practice consultations: Problems in defining high quality care. Social Science in
Medicine. 41(71. 969-975.
Wing, R.R., Klein, R., & Moss, S.E. (1990). Weight gain associated with improved
glycemic control on population-based sample o f subjects with Type I diabetes. Diabetes
Care. 13. 1106-1109.
Type 2 Diabetesl 17
Table 1
Sample Characteristics
Total N = 92
(1) Gender: Males = 42

Females = 50
(2) Race: White = 22.80% (n = 21)

Black = 70.70% (n = 65)
Hispanic = 4.30% (n = 4)
Other = 2.20% (n = 2)
(3) Age: Mean = 52 (SD = 11.04)

Range = 25 to 77
(4) Socioeconomic Status: Mean = 23.02 (SD = 11.92)

Range = 8.00 to 56.00
(5) Employment Status: Employed = 34.80% (n = 32)

Unemployed = 65.20% (n = 60)
(6) Education Level: Less than High School = 30.40% (n = 28)

High School = 37.00% (n = 34)
Part College = 14.10% (n = 13)
College = 6.50% (n = 6)
Post-College = 5.40% (n = 5)
(7) M arital Status: Married = 37.00% (n = 34)

Engaged = 2.20% (n = 2)
Single = 31.50% (n_= 29)
Separated = 15.20% (n = 14)
Divorced = 10.90% (n = 10)
Widowed = 3.30% (n_= 3)
Type 2 Diabetes 118
Table 2
Descriptive Statistics for the Psychosocial Scales and Metabolic Control
MEAN SD RANGE POSS. RANGE

POMS-SF 43.13 25.97 3.00 - 123.00 0 (Low) - 148 (High)
COPE-bd 2.83 1.30 2.00 - 8.00 2 (Min) - 8 (Max)
PSQ-m gs 22.30 5.41 6.00 - 30.00 6 (Disat) - 30 (Sat)
PPRQ-MD 42.94 7.38 14.00 - 50.00 10 (Disat) - 50 (Sat)
PPRO-Staff 42.05 7.18 23.00 - 50.00 10 (Disat) - 50 (Sat)
SPS 82.10 11.30 48.00 - 96.00 24 (Min) - 96 (Max)
PSS 23.40 7.70 14.00 - 43.00 14 (Min) - 70 (Max)
SCI 3.79 .779 2.19-5.00 1 (Min) - 5 (Max)
HbAlc 8.72 2.63 5.40- 15.00 N/A
Note. POMS-SF = Profile o f Mood States- Short Form; COPE-bd = Coping Scale-
behavioral disengagement; PSQ-IIIgs = Patient Satisfaction Questionnaire- Third Edition
(General Subscale); PPRQ MD/Staff = Patient-Practitioner Relationship Questionnaire
(Attending/Staff); SPS = Social Provisions Scale; PSS = Perceived Stress Scale; SCI =
Self-Care Inventory; HbAlc = Metabolic Control
Type 2 Diabetes 119
Table 3
Correlational Matrix
COPE- POMS- PPRQ PSQ -m PSS SPS

bd SF gs
SCI -.257* -.059 .482** .372** -.269* .150
COPE- .355** -.129 .046 .442** -.272*
bd
POMS- -.136 -.120 .588** -.167
SF
PPRQ .666** -.193 .224*
PSQ -m -.166 .252*
gs
PSS -.422**
Note. COPE-bd = Coping Scale- behavioral disengagement; POMS-SF = Profile of

Mood States- Short Form; PPRQ = Patient-Practitioner Relationship Questionnaire; PSQ-
nigs = Patient Satisfaction Questionnaire- Third Edition (General Subscale); PSS =
Perceived Stress Scale; SPS = Social Provisions Scale; SCI = Self-Care Inventory
* Correlation is significant at the 0.05 level
** Correlation is significant at the 0.01 level
Type 2 Diabetesl20
POMS SES
SPS PPRQ SCI
PSS I COPEbd )
Note. POMS ^Psychological Distress; PSS = Perceived Environmental Stress;

SPS = Social Provisions; PSQ-in = Overall Satisfaction with Medial Care;
PPRQ = Satisfaction with Interpersonal Aspects o f Medical Care; SES = Socioeconomic
Status; COPEbd = Behavioral Disengagement Coping (Avoidance); SCI = Adherence.
Figure 1. Hypothesized path model: Influence o f psychosocial factors on adherence.
Type 2 Diabetes 121
PSQ -m PPRQ
SCI
COPEbd
Note. SPS = Social Provisions; PSQ-DI = Overall Satisfaction with Medical Care;
PPRQ = Satisfaction with Interpersonal Aspects o f Medical Care; COPEbd = Behavioral
Disengagement Coping (Avoidance); SCI = Adherence.
(A) Beta = 0.122

Significance = p < .05
Adjusted R = .05
(B) Beta =1.72

Adjusted R = .44
(C) Beta = .482

Adjusted R = .22
(D) Beta = -.257

Adjusted R = .06
Figure 2. Path model: Psychosocial variables predicting adherence behaviors.
Type 2 Diabetes 122
r = .063*
j sci | <------------------ H b A lc
Note. SCI = Adherence. H bA lc = Metabolic Control
*g > .05
Figure 3. Correlation: The relationship between adherence and metabolic control.
Broad & Vine
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Phiiaceionia. PA 1 9 )2 9
ALLEGHENY 2 15-991-8100
UNIVERSITY
OF THE HEALTH SCIENCES
M E M O R A N D U M
TO: JU L IE L. L A N D E L . P H .D . M a ils c o p 626

C lin ic a l a n d H e a lc h P s y c h o lo g y
FROM :
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Jan C. K o rro w , M .D .. C o -C h a ir
C o m s ic c e e fo r che P ro c e c c io n o f H itm a n S u b j e c c s (IR B )
1 -1 4 0 N ew C o l l e g e B u ild in g , K a il S cop 444 (T e l. 2 1 5 -7 6 2 -3 4 5 3 . FAX 2 1 5 - 7 5 2 - 3 7 2 2 )
S U B JE C T : P ro c o c o l A M ODEL O F ADHERENCE AND M E T A B O L IC CO NTROL I N N O N -IN S U L IN -D E P E N D E N T

(T Y P E I I ) D IA B E T E S M E L L IT U S : T H E R O LE O F P S Y C H O S O C IA L FACTORS
N oce: A D -H O C A PPRO VED 0 3 / 1 1 / 9 7 BY D R . HORROH - E X P E D IT E D 1 8
SPO N SOR: IN T E R N A L
U N IV . P R O JE C T * : 970289 U N IV . PROTOCOL N O . 7 0 2 8 1 -0 1
A PP R O V A L D A T E : 0 3 /1 1 /9 7 E X P IR E S : 0 3 /1 0 /9 8
O A TS: M arch IS . 1997
On b e h a lf o f C he C o m m itc e e fo r C he P ro te c tio n of H um an S u b j e c c s (IR B ) . I am p l e a s e d co in fo rm you chac che s u b je c t

p ro c o c o l haa been re v ie w e d and A PPRO VED AS SU B M ITT ED fo r C he p e r i o d in d ic a c e d above. Me o p e r a c e u n d e r m any G o v ern m rn c
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c h la conaenc fo rm ; p re fe ra b ly , che s ig n a c u re e a re w ic n e e a e d o r a c lc a o w le d g e d . T ou m uac g iv e each s u b je c t
a copy o f che conaenc fo rm and y o u m uac r e c a i n a ll a ig n e d conaenc fo n n a fo r c h re e y e a rs afce r p ro je c c
c e rm in a c io n . P le a a e keep chaae fo rm a re a d ily a v a ila b le (H O T i n p a c ie n c s ' c h a rts ) . •
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haa re c e iv e d BOTH a fu lly e x e c u te d sp o n so re d ag re e m e n c AND a p p r o p r i a c e le c c e r(s ) o f in d e m n ific a c io n by che
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id e n tif ie d jn rt a coac cencer d e s ig n a c e d . P le a a e c a ll 2 1 5 -7 5 2 -3 4 5 3 if you have any q u e s tio n s re g a rd in g ch ese
p ro c e d u re s.
3 . Y ou m u se a d v ise che IR B o f cha a c c iv a c io n dace. U se che accached fo rm fo r c h ia p u rp o se .
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5. A ny a d v e rs e re a c tio n m use b e re p o rte d co che IR B in a tim e ly fa s h io n .
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in w ith d ra w a l o f c h is ap p ro v al and n o c ific a c io n of che sp o n so r a n d /o r F ed e ra l a g e n c ie s . S p e c ific in fo rm a tio n
re g a rd in g m o n ito rin g a p p e a rs in cha book: G U ID E L IN E S - B IO M E D IC A L R ESEA R C H IN V O L V IN G HUMAN S U B JE C T S o b t a i n a b l e
th ro u g h th is o ffic e .
7 . w hecher o r noc c h is p ro c o c o l is a c c iv a c e d . che IR B w ill re v ie w ic s p ro g ress on o r abouc 0 3 /1 0 /9 8 . u s in g che

accached s a m p le p e rio d ic re p o rt fo rm . S h o u ld you fa il co re sp o n d co c h is F e d e ra lly -re q u ire d p ro g re ss rep o rc.
che p ro je c c m ay b eco m e in e lig ib le fo r re -a p p ro v a l and cha IR B m a y c h o o s e noc Co c o n s i d e r o ch e r p ro je c ts fo r
a p p ro v a l.
8. A fin a l p ro g re ss re p o rc m uac b e s u b m itte d co cha IR B in fo rm a c s im ila r co chac of a p e rio d ic re p o rc .
T h e IR B w e l c o m e s y o u r r e s e a r c h p r o j e c c i n c o C h e U s e o f a p p ro v e d p r o to c o ls . Y o u r c o m p lia n c e w ic h c h e above
c o n d itio n s w ill h e lp co p r o c e c c ch a c o n c in u a e io n o f a ll re se arc h a c tiv ity a c c h e U n i v e r s i t y . M ic h y o u rp ro je c c an d
o th e rs lik e ic . we lo o k f o r w a r d Co a d d i t i o n s co k n o w le d g e of hum an h e a lc h and b e n e fic s co s c ie n c e , o u rp a c ie n c s a n d
s o c ie ty .
A tta c h .
cc. O epc C h a ir.
Allegheny Health. Education and Research Foundation

A llegheny G e n eral n a s o ita i • AHegr.env in te g ra te d H ealth G rouo • Attegnenv U niversity o l th e H ealth S c ie n c e s • A llegheny U niversity H ospitals • St C h n sto o n e r's H osoitai for C hildren
Allegheny University of the Health Sciences
Consent to Take Part
In a Research Study
CONSENT FORM:
A Model of Adherence and Metabolic Control
in Non-Insulin-Dependent (Type II) Diabetes Mellitus:
The Role of Psychosocial Factors
1. Participant’s N am e:________________________________________
2. Title of Research: A Model o f Adherence and Metabolic Control in Non-Insulin-

Dependent (Type II) Diabetes Mellitus:
The Role o f Psychosocial Factors
3. Purpose of Research: You have been asked to participate in a research project,

involving approximately 100 people, that has the following purpose:
To understand how different ways o f coping, and different relationships with

doctors affect treatment adherence and blood sugar levels in individuals with Type H
Diabetes.
You have been asked to participate in this study because:

a) You have a diagnosis o f Type II Diabetes, which has been made at least 1 year
prior to entering the study.
b) You are currently an outpatient at the Endocrinology Unit at Allegheny

University o f the Health Sciences.
c) You are over the age o f 18.
4. Procedures and Duration: You understand that you will be asked to engage in the
following activities:
•To provide information about vourself. such as age, race, gender, and socioeconomic
status. Your name will not be on any materials retained in the study, and this personal
information will onlv be known to the research team.
•To complete questionnaires asking about how you feel, how you cope with different
situations, vour relationship with vour doctor, and how you adhere to vour treatment
regimen.
►
You will be asked to spend approximately 45 minutes completing the questionnaires.
ALLEGHENY UNIVERSITY OF THE
HEALTH SCIENCES
COMMITTEE FOR PROTECTION OF
HUMAN SUBJECTS ^ . - < 7 ,
STUDY NO-------------
DATE APPROVED — i - / { - Y 7 . -----
HHS ASSURANCE NO. M l 532
•Your medical chart will be reviewed to eather information regarding vour blood sugar
levels.
5. Risks and Discomforts/Constraints: You have been told that the risks and/or
discomforts o f being in this study include:
a) You may worry about who will have information about you. Because
information about you is private, when the researchers talk about the results of this
project, all information about you will be put together with everyone else’s information.
Your name is not on any information, only an identification number is used. Only the
people with this study will see any of your questionnaire answers or other information
that is part o f this study.
b) Answering these questions may cause you to feel frustrated or upset, [f you do
feel worse, you can discuss these feelings with any member o f the project. They will try
to understand these feelings and be o f help to you.
6. Benefits: You understand that the following benefits may occur as a result of your
participation in the study:
a) There may be no benefit to you from participating in this study.
b) Filling out the questionnaires may provide you with an opportunity to learn
things about yourself that you did not know before.
c) Your participation may help to identify factors which are related to adherence
levels and medical status o f individuals with Type II Diabetes. Then, it may be possible
to use these factors to identify patients that have difficulties following similar treatment
regimens. Additionally, interventions may be designed to change these factors and help
people to have better adherence and metabolic control.
7. A lternate Treatm ents: N/A

HEALTH SCIENCES
COMMITTEE FOR PROTECTION OF
HUMAN SUBJECTS , ^
STUDY NO________________ a %
DATE APPROVED — / -
HHS ASSURANCE NO. M 1S32
I
I
8. Reasons For Removal From Study: Your participation may be stopped before the
end o f the study for any o f the following reasons:
a) If ail or part o f the study is discontinued for any reason.
b) Other reasons, including new information available to the investigator or

harmful reactions experienced by others in the study.
9. Voluntary Participation: You understand that being in this study is voluntary. Your
health care will not be affected in any way if you decline to be in or later withdraw from
this study.
10. In Case of Inquiry: You have been told that if you have any questions or believe
you have been injured in any way by being in this research project, you should contact Dr.
- Julie Landei af telephone (215) 762- 3872. If you are injured by this research activity,
which includes only those things that are being done to you which are underlined in
paragraph 4 above, you can obtain treatment at no cost to you, but only at one o f the
hospitals 'affiliated with the Allegheny University o f the Health Sciences. The agreement
to provide free treatment does not include treatment for any complication or illness that
might occur during the course o f the study if that complication or illness is not a result of
the research activity. No other payment will be made. I f you are injured or have an
adverse reaction, you should also contact the Allegheny University o f the Health Sciences
Research Administration Office at (215) 762-3453.
11. Confidentiality: As a participant in this research project, you have given your
permission to the Allegheny University of the Health Sciences to keep, preserve, publish,
use or dispose o f the results o f the research study. In any publication, your identity will be
kept confidential but there is a possibility that records which identify you may be inspected
by authorized individuals such as representatives o f the Food and Drug Administration,
C o m m i t t e e for the P r o t e c t i o n of Human Subjects (IRB), and
agencies required by lav. L •
12. O th er Considerations: I f new information becomes known that will affect you or
might change your decision to be in this study, you will be informed by the investigator. If .
you have any questions at any time about this study or your rights as a research subject -
you may contact the Office o f Research Administration at (215) 762-3453.

HEALTH SCIENCES
COMMITTEE FOR PROTECTION O F.,
HUMAN SUBJECTS r/.n ff-
STUDY NO------------- ^ K r7/a% f - '
OATE APPROVED —
HHS ASSURANCE NO. M l532
13. Consent:
•I have been informed o f the reasons for this study.

• [ have had the study explained to me.
•[ have had all of my questions answered.
•t have carefully read this consent form, have initialed each page, and have
received a signed copy.
•I give consent voluntarily.
I HAVE READ OR HAD READ TO ME THE CONTENTS OF THE CONSENT

FORM. I HAVE ALSO RECEIVED A COPY OF THE CONSENT FORM. I
AGREE TO PARTICIPATE IN THIS RESEARCH STUDY.
Participant/ Authorized Representative Date Relationship, if applicable
Investigator or Individual obtaining this consent* Date
Witness to Signature Date
•List of Individuals Authorized to Obtain Consent
Name Title Davtime Phone#

David Kutz Researcher (215) 587-0448
Julie Landel, Ph.D. Assistant Professor (215) 762-3872

or
M E M O R A N D U M
TO: COMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS (IRB)

MAILSTOP 444
FROM: JULIE L. LANDEL, PH.D.
SUBJECT: ACTIVATION OF HUMAN RESEARCH PROTOCOL ENTITLED

A MODEL OF ADHERENCE AND METABOLIC CONTROL
IN NON-INSULIN-DEPENDENT (TYPE II) DIABETES
MELLITUS: THE ROLE OF PSYCHOSOCIAL FACTORS
Univ. Project #: 970289

Univ. Protocol #: 70281-01
Date of Approval: 03/11/97 Expires: 03/10/98
DATE:
This is to inform the IRB that the subject protocol was
*
activated on ______________________________ . I understand that a
periodic report on this protocol is due on or before 03/10/98.
(Signed) JULIE L. LANDEL, PH.D.
’Activated" means that a new human subject was accrued or an

experimental procedure under this protocol was performed on or
after 03/11/97.
nr t h e h e a l t h s c ie n c e s
Psychosocial Factors
and
Type II Diabetes Care
Instructions
This packet has several forms in it. Please read all

o f the questions carefully and answer them honestly.
If you have any questions, please ask the researcher w ho handed
you the packet. Remember that all o f your answers are kept
confidential.
When you finish, please return the packet to the researcher either
by (1) handing it to him/her before you leave, (2) by using the self-
addressed stamped envelope once y o u ’ve gone home, or (3) by
bringing the packet back with you during your next clinic visit.
If found, please return to:

J. Landel, Ph.D.
Mail Stop 626
Philadelphia. PA 19102
(215) 762- 3872
A llegheny H ealth . E ducation a n d R e search F oundation

.: • •* •* : ' • . .• *. *' • • • ? •- ••• - ♦:c**on*f - j r . v e 'S *v m s • •* ' v r h
d e m o g r a p h ic in f o r m a t io n
Today's D ate:__‘___ '___
Age: _______
Date o f Birth: / /
Gender ZMale ZFemale
Ethnicity: ZWhite ZBIack “ Hispanic ZOther
Age at diagnosis of Type II Diabetes:_______
Marital Status: ZMamed ZEngaged/Living with partner

ZSingle ZSeparated ZDivorced
Including trade and business school or college, what is the highest grade o f school that
you have completed? ___________________
Are vou currently employed? ZYes ZNo

If yes.
What is your job? __________________________
ZPart-tune ZFull-nme
If you are married, is your spouse employed? Yes No

If yes.
What is his'her job? __________________________
ZPan-nme ZFull-ume
If vou are mamed, what is the highest grade of school that your spouse completed?
If you or your spouse are not the heads o f your household:
What is the highest grade of school of the head of your household?
VMtat is the employment status o f the head o f your household?
What is the occupation o f the head of your household? _____
POMS
Below is a list o f words thar describe feelings people have. Please read each one carefully. Then
circle O N E answer to the right which best describes HOW YOU HAVE BEEN FEELING
DURING TH E PAST WEEK INCLUDING TODAY.
The numbers refer to these:
0 = Not at all
1 = A litrle
2 = Moderately
3 = Quite a bit
4 = Extremely
I. Tense 0 1 3 4 20. Discouraged 0 I 2 j 4

2. Angry 0 I 3 4 21. Resentful 0 I 2 3 4
3. Worn out 0 I 3 4 22 Nervous 0 I 2 3 4
4 Unhappy 0 I 3 4 23. Miserable 0 1 2 3 4
5 Lively 0 1 3 4 24 Cheerful 0 -I 2 3 4
6. Confused 0 I 3 4 25 Bitter 0 I 2 j 4
7 Peeved 0 1 3 4 26 Exhausted 0 1 2 j 4
a Sad 0 1 3 4 27. Anxious 0 I 2 3 4
9. Active 0 I 3 4 28. Helpless 0 1 2 4
10. On edge 0 I 3 4 29. Weary' 0 1 2 j 4
II. Grouchy 0 1 3 4 30. Bewildered 0 1 2 3 4
12. Blue 0 I 3 4 31. Furious 0 I 2 4
! 3 Energetic 0 1 3 4 32. Full of pep 0 1 2 j 4
A
U Hopeless 0 1 3 4 33. Worthless 0 1 2 J 4
15 Uneasy 0 1 3 4 34. Forgetful 0 1 2 3 4
16 Restless 0 1 3 4 35. Vigorous 0 I 2 3 4
17 Unable to 0 I 3 4 36. Uncertain about 0 1 2 3 4
concentrate things
18 Fatigued Q 1 2 3 4 37 Bushed 0 1 2 3 4
19 .Annoyed 0 I 2 3 4
COPE
Directions:
We are interested in how people respond when they confront difficult or stressful events related to
diabetes. There are lots o f ways to attempt to deal with stress. This questionnaire asks you to indicate what
vou generally do and feel, when vou experience stressful events reg a rd in g the management of diabetes.
Obviously, different events bring out somewhat different respomses, but think about what you usually do whei
you are under a lot of stress.
Then respond to each of the following items by choosing one of the answers listed below. Please try tc
respond to each item separately in vour mind from each other item.Choose answers thoughtfully, and make
your answers as true FOR YOU as you can. Please answer every item. There are no “right” or “wrong”
answers, so choose the most accurate answer for YOU—not what you think “most people” would say or do.
Indicate what YOU usually do when YOU experience stress related to diabetes.
1 » I usually don’t do this at all.

2 * 1 usually do this a little bit.
3 » I usually do this a medium amount
4 * 1 usually do this a lot.
1. I rum to work or other activities to take my mind off things. 2 4
2. Tconcentrate my efforts on doing something about the situation I am in. 2 4
3. I say to myself “this isn’t real.” 2 4
4. I use alcohol or other drugs to make myself feel better. 2 4
5. I get emotional support from others. i 4
6. I give up trying to deal with it 4
7 I take action to try to make the situation better. 4
8 I refuse to do anything about it. 4
9 I say things to let my unpleasant feelings escape. 4
10 I get help and advice from other people. 4
I l l use alcohol or other drugs to help me get through it. 2 4
12. I try to see it in a different light, to make it seem more positive. 7 4
! 3 I cnticne myself. 4
14 I try to come up with a strategy about what to do. 3 4
15 I get comfort and understanding from someone. 5 4
1 ■ I usually don’t do this at all.
2 - 1 usually do this a little bip
3 - 1 usually do this a medium amount:
4 - 1 usually do this a lot.
16.1 give up the attempt to cope. 2 3 4
17.1 look for something good in what is happening. 2 3 4
18. I make jokes about it 2 3 4
19.1 do something to think about it less, such as going to the movies,
watching TV, reading, daydreaming, sleeping or shopping. 2 3 4
2 0 .1accept the reality of the fact that it has happened. 2 3 4
21.1 express m y negative feelings. 2 3 4
2 2 .1 try to find comfort in my religion or spiritual beliefs. 2 3 4
2 3 .1 try to get advice or help from.other people about what to do. 2 3 4
2 4 .1 learn to live with it 2 3 4
25. I think hard about what steps to take. 2 3 4
2 6 .1 blame m yself for things that happened. 2 3 4
27 I pray or meditating. 2 3 4
28. I make fun o f the situation. 2 3 4
Patient Satisfaction Questionnaire (General)
We would like to get an idea of how you feel about the care you are receiving
from your physician. This scale will ask you to rate how you feel about a number of
statements that refer to different aspects o f this care. Please understand that neither your
physician, nor anyone on the medical staff will have access to your ratings of these
statements, and your care will not be effected by your answers. If you have any
additional questions, please feel free to ask.
1» strongly disagree
2* disagree
3» feeling neutral
4- agree
5* strongly agree -
1 .1 am very satisfied with the medical care I receive. 1 2 3 4 5
2. There are some things about the medical care I

receive that could be better. *1 2 3 4 5
3. Ail things considered, the medical care I receive

is excellent. 1 2 3 4 5
4. There are things about the medical system I receive

my care from that need to be improved. 1 2 3 4 5
5. The medical care I have been receiving is just about

perfect. 1 2 3 4 5
6 . 1 am dissatisfied with some things about the medial

care I receive. 1 2 3 4 5
p a tie n t- p r a c titio n e r r e la tio n s h ip q u e s tio n n a ire
We are interested in how you feel about your relationship with the medical team at this clinic. There
are two sets of questions on this form. The first group asks about your feelings about your relationship to
the doctor and the second group of asks about your relationship to other members of the sraff Remember
that your responses to ail questions are kept confidential: the doctors and staff won’t see your answers.
Please read the following sentences carefully. Keeping in mind vo u r rela tio n sh ip w ith the doctor
select a number to show how wefl the statement describes your feelings from 1 (not at all) to 5 (extremeiy).
Write this number at the end of each sentence.
not at all true extremely true

1 2 3 4 5
1. I feel comfortable talking with the doctor about my problems with

my diabetes care._______________________________________________________________ ____
2. I feel that the doctor does a good job explaining my diabetes care to me. ____
3 I feel that it is difficult to get in touch with a doctor if I have

problems or questions about my diabetes._________________________________________________
4. I feel that the doctor is happy to see me during my appointments.________________________ ____
5 I feel that the doctor is often too busy to listen to me._______________________________________
6 I feel that I can trust the doctor’s opinions on my health.
7 I'm happy with the amount of involvement I have in setting goals in my

diabetes care.
S I feel that I’m "pan of the team" in my diabetes care. ____
9 I do not like to attend my clinic appointments. ____
10 1 have a good relationship with the doctor. ____
Now. think about your relationship with other members o f the medical staff (ex.: nurses,
nutritionists, social workers, etc.). With these relationships in mind, select a number to show how
w ell the statement describes vour feelings about the m edical staff.
not at all true extrem ely true

1 2 3 4 5
1 I feel comfortable talking with the clinic staff about my problems with
my diabetes care. ____
2 I feel that the staff does a good job explaining my diabetes care to me. ____
not at all true extrem ely true
1 2 4 5
3. I feel that it is difficult to get in touch with a staff m em ber if I have

problems or questions about my diabetes.
4 .1 feel that the staff is happy to see me during my appointments.
5 I feel that the staff is often too busy to listen to me.
6 I feel that I can trust the staffs opinions on my health.
7 Tm happy with the amount of involvement I have in setting goals in my

diabetes care.
8. I feel that I'm "part of the team" in my diabetes care.
9 I do not like to attend my clinic appointments
10 I have a good relationship with the clinic staff.
of the copyright owner. Further reproduction prohibited without permission.

Reproduced with permission
s o c ia l novzaxams soom
a*iow are s ta c n ta c s about your relationships with ocher people. Please read each on* .
carefully and. decide how much you agree wish i t . MarJc your aasw«s on a seal* o1 1
i s z r o a g l y disagree) co 4 (strongly agree) .
Scronoly Disagree disagree Agree Strongly Agree

1 2 3 4
1 . t h e r e a r e p e o p l e I c a n d ep en d on t o h e lp me i f I r e a l l y n e e d i c . ____________ ______
2 . I f e e l c h a c I do n o c h a v e any d o s e p e r s o n a l r e l a t i o n s h i p s w ic h o c h e r ______
p e o p le .
3 . T h ere i s no o n e I c a n cu rn Co f o r g u id a n c e i n c im e s o f s c r e e s .
4 . T h ere a r e p e o p l e who d ep en d on me f o r h e l p . '
5. T h e r e a r e p e o p l e who e n j o y c h e same s o c i a l a c c i v i t i e s I d o . ___________________ ______
6. o c h e r p e o p l e do n o c v i e w me a s cc m p e c e n c .__________________________________________ ______
7. I f e e l p e r s o n a l l y r e s p o n s i b l e f o r c h e w e l l - b e i n g o f a n o t h e r p e r s o n . _________ ______
3. I f e e l p a r e o f a g r o u p o f p e o p l e who s h a r e my a c c i c u d e s "and b e l i e f s . ______________
9 . I do n o c c h i n k o c h e r p e o p l e r e s p e c c my s k i l l s and a b i l i t i e s . ________________________
13. I f s o m e c h in g w e n t w ron g, no o n e w o u ld come c o my a s s i s t a n c e . ________________ ______
11. I h a v e c l o s e r e l a t i o n s h i p s c h a c p r o v i d e me w i t h a s e n s e o f e m o t i o n a l ______
s e c u r i t y and w e l l - b e i n g .
12. T h ere i s so m eo n e I c o u l d c a l k co a b o u t i m p o r t a n t d e c i s i o n s i n my l i f e . ______
13. I h a v e r e l a t i o n s h i p s wr.tr* my c o m p e te n c e an d s k i l l a r e r e c o g n i z e d . _________ ______
14. T h e r e i s no on e who s h a r e s my i n t e r e s t s an d c o n c e r n s . __________________________ ______
15. T h e r e . s no o n e who r e a l l y r e l i e s on me f o r t h e i r w e l l - b e i n g . _______________ ______
15. T h e r e i s a t r u s t w o r t h y p e r s o n I c o u l d t u r n t o fo r a d v ic e i f I w e r e _______________
h a v in g p ro b le m s.
17. I f e e l a s t r o n g e m o t io n a l bond w ith a t l e a s t one o c h e r p e r s o n . ______
13. T h e r e i s no o n e I c a n d e p e n d o n f o r any a i d i f I r e a lly need i t . ______
13. T h e r e i s no o n e I f e e l c o m f o r t a b l e c a l k i n g a b o u t p r o b le m s w it f a . ______
2 0 . T h e r e a r e p e o p l e who a d m ir e my t a l e n t s an d a b i l i t i e s . ______
21. I la c k a f e e l i n g o f in tim a c y w ith an oth er p e r s o n . ______
22. T h ere i s no o n e who l i k e s c c do c h e t h i n g s I do. ______
23. T h ere a r e p e o p le I can c c u n t cn m an e m e r g e n c y . ______
* 4 . No o n e n e e d s me c o c a r e f o r th e m a n y m o r e . ______
Perceived Stress Scale
These questions ask you about your feelings and thoughts during the last month.
In each case; you will be asked to indicate how often you felt or thought a certain way.
Although some of the questions are similar, there are differences between them and you
should treat each one as a separate question. Try to answer each question quickly and
remember, answer these only for the last month.
1» never
2* almost never
3- sometimes
4- fairly often
5 » very often
1. How often have you been upset because of something

that happened unexpectantiy? 1 2 3 4 5
2. How often have you felt that you were unable to control
the important things in your life? 1 23 4 5
3. How often have you felt nervous and “stressed”? 1 23 4 5
4. How often have you dealt successfully with imtaring

life hassles? 1 23 4 5
5. How often have you felt that you were effectively coping
with important changes that were occurring in your life? 12 3 4 5
6. How often have you felt confident about your ability

to handle your personal problems? 1 23 4 5
7 How often have you felt that things were going your
way? 1 23 4 5
8 How often have you found that you could not cope
with all the changes that you had to do? 12 3 4 5
9 How often have you been able to control irritations

m your life? 1 23 4 5
10. How often have you felt that you were on top o f
things? 1 23 4 5
11. How often have you been angered because of things

that happened that were outside o f your control? 123-45
1 “ never
2 * almost never
3 “ sometimes
4 - fairly often
5 “ very often
In the past month...
12. How often have you found yourself thinking about

things that you have to accomplish? 1 23 4 5
13. How often have you been able to control the way
you spend your time? 1 23 4 5
14. How often have you felt that difficulties were

piling up so high that you could not overcome them? 1 23 4 5
SCI I
SELF CARE INVENTORY
Please rate each of the items according to HOW WELL YOU FOLLOWED YOUR
PRESCRIBED REGIMEN FOR DIABETES CARE in the oast m onth Use the following
scale:
1 ■ Never do it
2 * Sometimes follow recommendations; mostly not
3 * Follow recommendations about 50% of the time
4 * Usually do this as recommended; occasional lapses
5 * Always do this as recommended without fail
NA mCannot rate this item/Not applicable
1. Glucose testing 1 2 .3 4 5 NA
2. Glucose recording 1 2 3 4 5 NA
3. Ketone testing 1 2 4 5 NA
4. Administering correct insulin dose 1 . 2 3 4 5 NA
5. Administering insulin at right time 1 2 3 4 5 NA
6. Adjusting insulin intake based on

2 *
blood glucose values 1 3 4 5 NA
7. Taking blood sugar medications (pills) 1 2 j 4 5 NA
S. Taking right dose of blood sugar pills 1 2 3 4 5 NA
9. Taking blood sugar pills at right time 1 2 3 4 5 NA
10. Eating the proper foods; sticking to

meal plan I 2 3 4 5 NA
11. Eating meals on time I 2 j 4 5 NA
12. Eating regular snacks I 2 3 4 5 NA
13. Carrying quick-acting sugar to

treat reactions I 2 3 4 5 NA
14. Coming in for appointments 1 2 3 •4 5 NA
SCI 2
1 “ Never do it
2 ~ Sometimes follow recommendations; mostly not
3 * Follow recommendations about 50% of the time
4 =■Usually do this as recommended; occasional lapses
5 » Always do this as recommended without fail
NA = Cannot rate this item/Not applicable
15. Wearing a medic alert ED 1 2 3 4 5 NA
16. Exercising regularly 1 2 3 4 5 NA

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INFORMATION TO USERS

Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning

Photographs included in the original manuscript have been reproduced

Bell & Howell Information and Learning

This reproduction is the best copy available.

The Faculty o f the School o f Health Professions

MCP Hahnemann University

of the Requirements for the Degree

Department o f Clinical and Health Psychology

UMI Microform 9943603

This microform edition is protected against unauthorized

This is to certify that the thesis presented to us by T V ^aA K u ~ f 7 , ______________

on the day o f ,n xu_______ . 19 ° f \ . in partial fulfillment o f the

requirements fo r the degree o f PIa.T>._______ in the 0 1 Lr\\ 1 JnfA ogy Program

x o ~ C ~^2° < T N j€-----

ORIGINAL FORM: F irst Page of Thesis

Type 2 diabetes is identified by insulin resistance and beta cell dysfunction.

The treatment o f Type 2 diabetes involves a number o f factors that invariably

recommendations than others.

diabetes mellitus. The studies’ psychosocial variables included the patient-practitioner

Ultimately, it was discovered that when individuals were satisfied with

clinics, they were more likely to adhere to treatment recommendations. Furthermore, it

would like to acknowledge all of the guidance provided to me by my research mentor,

arduous process o f completing my dissertation.

n. Psychosocial Factors Related to Adherence 34

m. Rationale for Present Study 52

IV. Working Model 55

VII. Main Analyses 76

VIII. Supplementary Analyses 80

XI. Supplementary Analyses 95

XII. Clinical Considerations 97

XIV. Conclusions 103

XV. References 106

XVI. Tables 117

XVII. Figures 120

XVIII. Appendix 123

T ab let: Sample Characteristics

Table 3: Correlational Matrix

Figure 1: Hypothesized Path Model

Figure 2: Path Model

Figure 3: Correlation o f Adherence and Metabolic Control

Page(s) missing in number only; text follows.

This reproduction is the best copy available.

A Model o f Adherence in Type 2 Diabetes Mellitus:

The Role o f Psychosocial Factors

The present paper addresses the formulation, results, and conclusions of a

mellitus. A literature review indicating relevant clinical and theoretical issues is

“Diabetes” is a term used to describe a number of different disorders that reflect

problems o f glucose metabolism. In an individual without diabetes, glucose metabolism

is predominantly controlled by a feedback system that monitors concentrations o f blood

there is a problem within this system regarding insulin production or utilization.

bloodstream. The accumulation of glucose in the blood stream is referred to as

hyperglycemia. The hyperglycemic condition can be caused by a number o f different

(Cox, Gonder-Frederick, & Saunders, 1991).

Diagnosis and Classification

Diagnosis. Diagnostic criteria for diabetes mellitus and impaired glucose

but less than 126 mg/dl (ECDCDM, 1998).

Classification. There are numerous classifications o f diabetes, all with the

distinguish the closely related disorders.

Type 1 diabetes is characterized by a destruction of pancreatic beta cells and thus

an inability to produce an adequate amount of insulin. As a result, individuals with Type

most common etiological explanation for Type 1 diabetes is that it is caused by a

combination o f genetic and autoimmunological processes (Cox & Gonder-Frederick,

1992). An individual who may be genetically predisposed towards diabetes may