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Aim. The present study examined the factors related to self-care behaviour in type 2 diabetic patients aged ‡65 years. In
addition, this study tested the effect of the important explanatory factors on self-care behaviour.
Background. Along with the development of an ageing society, diabetes occurs frequently among older people. Diabetes
requires continual medical treatment, with patients responsible for self-care. Although the relationships among social support,
depression and self-care have been widely studied, little is know about older diabetic patients, especially in Taiwan.
Design. A correlational design was adopted. In total, 165 patients recruited using convenience sampling were diabetic outpa-
tients at three hospitals in southern Taiwan from January–March 2005.
Methods. The participants were interviewed using the Personal Resource Questionnaire 2000 (PRQ 2000), Diabetes Self-Care
Scale and Taiwan Geriatric Depression Scale (TGDS). Data were analysed using descriptive statistics and multiple regression
analysis.
Result. Self-care behaviour scores were significantly influenced by different gender, education level, economic status and
religious beliefs of older diabetic patients. Depression and self-care behaviour were negatively correlated. Social support,
education and duration of diabetes significantly affected self-care behaviour, accounting for 35Æ6% of total variance.
Conclusions. Social support plays a vital factor in contributing to the facilitation of self-care behaviour. These analytical
findings demonstrate the importance of social support, education and duration of diabetes in determining self-care behaviour for
diabetic older diabetic patients and serve as references for future studies of self-care behaviour in type 2 older diabetic patients.
Relevance to clinical practice. Implication for nurses highlights the significance of providing patients with social support that
will enable them to have good support systems during their disease treatment to enhance self-care abilities and improve quality
of life.
Key words: depression, elderly, self-care behaviour, social support, type 2 diabetes
Authors: Yu-Ling Bai, MSN, RN, Instructor, Department of Correspondence: Chou-Ping Chiou, I-Shou University, No. 8, E-Da
Nursing, Chung Hwa Univerisity of Medical Technology, Tainan Road, Jiau-shu Tsuen, Yan-chau Shiang, Kaohsiung County 824,
County, Taiwan; Chou-Ping Chiou, PhD, RN, Associate Professor, Taiwan. Telephone: +886 9212 99091.
School of Nursing, I-Shou University, Kaohsiung County, Taiwan; E-mail: chouping@isu.edu.tw
Yong-Yuan Chang, ScD, Associate Professor, Institute & Department
of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
3308 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315
doi: 10.1111/j.1365-2702.2009.02992.x
Older people Self-care in diabetic elderly
of all medical costs and diabetes patients, on average, cost 4Æ3 Murata et al. (2003) demonstrated that the clinical, psycho-
times that of for treating non-diabetic patients (Lin et al. logical and social factors affected diabetes knowledge of
2001). These statistics indicated a high mortality rate for veterans with established Type 2 diabetes. They found that
diabetics among the aged population and that treatment costs age, years of schooling, duration of treatment, cognitive
and economic burden to the health care system and families function, sex and level of depression were independent
will increase. determinants of the knowledge score. Hopper and Schecht-
Current literature has emphasised the importance of self- man (1985) found that the factors associated with poor
management of diabetes. McCollum et al. (2005) emphasised control include being older, lack of belief in control over
that effective self-care is an essential component of diabetes health, lack of belief in the efficacy of treatment, a belief that
care. Diabetic individuals must manage diet, exercise, med- diabetes is less serious than three curable illnesses, reported
ication, blood glucose monitoring and routine visits to health lack of social support in a crisis with diabetes, reported low
care professionals. Diabetes is a complex chronic metabolic satisfaction with the clinic and finally, higher levels of
disorder that requires continual medical treatment with reported problems with the self-care regimen, particularly
patients responsible for self-care (American Diabetes Associ- diet.
ation 2003). Ninety-five percent of diabetes treatment relies Social support is suggested as a vital factor contributing to
on self-care behaviours (Anderson 1995) and effective treat- facilitate self-care behaviour in managing chronic illness.
ment for diabetics aged ‡65 years depends on the success of Gallant (2003) analysed 29 studies of chronic patients and
self-care (Polly 1992). Regardless of the diabetes type, proposed that a moderate correlation exists between support
diabetic patients must adjust their behaviour and follow and self-care behaviours (in particular for diabetic patients).
prescribed treatments to control their metabolism and Wang and Lee (1999) noted that social support has a
prevent diabetic complications which may be potentially significant impact on self-care behaviour and that without
deadly especially for older people (Toljamo & Hentinen adequate social support, patients may be unmotivated to
2001a). Little is know about self-care behaviour among adopt self-care behaviour and lack the ability to care for
diabetics aged ‡65 years in Taiwan. Therefore, this study themselves properly. Albright et al. (2001) also reported that
examines self-care behaviour and related factors in diabetic social context was significantly associated with three out of
patients aged ‡65 years in Taiwan. the four self-care behaviours for diabetic patients: attention
to medicines, exercise and diet. Wen et al. (2004) suggested
that as family support for diet increased, perceived barriers to
Background
diet self-care decreased. Scollan-Koliopoulos et al. (2007)
Diabetes mellitus as a chronic disease requires active patient suggested that explorations of patients’ recollections of a
participation in self-care. Ruggiero et al. (1997), who family member’s experiences with diabetes can affect their
examined self-care behaviour among diabetics, concluded illness perceptions and behaviour.
that most diabetic patients regularly take prescribed medicine Depression also affects self-care behaviour. Jacobson and
according to instructions, however, few controlled their diet Weinger (1998) suggested that depressed patients commonly
and exercised and up to 42% failed to monitor their blood deny their abilities to perform and complete daily living
sugar levels. Polly (1992) showed that older patients with goals; this negative and pessimistic mindset further hinders
type 2 diabetes are likely to follow medical instructions for their ability to make self-management decisions. DiMatteo
regular diet times, oral administration of medication and et al. (2000) preformed a meta-analysis of the relationship
control caloric intake and less likely to exercise, reduce intake between self-care instructions and depression and concluded
of sweets, monitor blood levels and carry medical that non-depressed patients are three times more likely than
identification card. While surveying diabetic patients ranging depressed patients to follow self-care instructions. Ciecha-
from 40–70 years old, Clark and Hampson (2001) found that nowski et al. (2000), who studied diabetic patients with
type 2 diabetic patients follow diet instruction better than depression, determined patients in the medium- and high-
they do physical activities instruction. severity tertiles were significantly less adherent to dietary
It is important to be aware of the factors associated with recommendations and had a higher percentage of days in
self-care behaviour in diabetic patients. Based on recent nonadherence to oral hypoglycemic regimens than patients in
studies on self-care behaviour, age (Albright et al. 2001, the low-severity depression symptom tertile. Ciechanowski
Toljamo & Hentinen 2001a), gender and education (Aljasem et al. (2003) evaluated 276 type 1 diabetic patients and 199
et al. 2001, Toljamo & Hentinen 2001a) were identified as type 2 diabetics and demonstrated that high levels of
factors associated with self-care behaviour. In addition, depression are associated with ignoring instructions for
2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315 3309
Y-L Bai et al.
dietary intake, diet type and exercise. Lin et al. (2004), who Weinert conducted reliability and validity testing on the
studied diabetic patients, determined that a high percentage PRQ2000 and identified a Cronbach’s a of 0Æ90–0Æ91.
of diabetic patients with depression fail to exercise (62Æ1%), The Diabetes Self-Care Scale (DSC) was developed by
eat more fat and less vegetables and fruit and more days of Hurley and Shea (1992) and revised by Wang et al. (1998)
ignoring medication instructions (24Æ5%) compared with Factor analysis identified five factors that are: exercise, diet,
those with no depression (18Æ8%). Gonzalez et al. (2007) medication and blood sugar monitoring, foot care and
found that major depression was significantly associated with prevention of unstable blood sugar levels. The scale has 27
poorer adherence to general dietary recommendations, con- items; responses are graded using a five-point Likert scale
suming less fruit and vegetables, less frequent spacing of ranging from 1 (not following instructions) –7 (following
carbohydrates over the course of the day, poorer adherence to instructions). Wang et al., who used the DSC to analyse of
exercise recommendations and less frequent SMBG (self- self care for type 2 diabetic patients, identified a Cronbach’s a
monitoring of blood glucose). In summary, passive behaviour of 0Æ82. In this study, Cronbach’s a was 0Æ88 and ICC was
related to depression result in unwillingness to follow 0Æ91 after a two week interval.
prescribed medical care and low levels of performing self- The Taiwan Geriatric Depression Scale (TGDS), contain-
care behaviour, such as controlling dietary intake, remaining ing 30 items, was developed by Liao et al. (2004). People
active and taking medication. were asked to evaluate their physical and emotional feelings
The objective of the study was to identify the important over the past week; each ‘yes’ answer is scored as 1 and each
explanatory factors of self-care behaviour among type 2 older ‘no’ answer is scored as 0. Those with ‡15 points are
diabetic patients. To that end, the following research ques- suspected of having depression. Kuder-Richardson (KR-20)
tions were posed for investigation as follows: of this scale is 0Æ94 and test-retest reliability is 0Æ82. The area
1 Are there significant relationships among socio-demo- under the Receiver Operating Characteristic Curve (ROC) in
graphic characteristics, disease condition, social support, the TGDS equals 0Æ97, indicating that the scale is a very
depression level and self-care behaviour? effective screening tool. The optimal cutoff point of 15 has a
2 Do socio-demographic characteristics, disease condition, sensitivity of 93Æ3% and a specificity of 92Æ3%. In this study,
social support and depression level affect self-care behav- the KR-20 value was 0Æ89 and the ICC was 0Æ90 after a two-
iour among type 2 older diabetic patients? week interval.
Methods Procedure
This correlational study used convenience sampling at three Permission to conduct this study was granted by the Ethics
hospitals in southern Taiwan. Face-to-face interviews were committee at the University. Each participant enrolled
used to collect data between January–March 2005. Inclusion provided written informed consent. Participants were
criteria were as follows: (1) aged ‡65 years; (2) diagnosed informed of the purpose of the research and allowed to
with type 2 diabetic patients; (3) ability to communicate; (4) withdraw from the study at will. Anonymity and confi-
no other significant dysfunction caused by another disease; dentiality of participants were assured. The Statistical
and (5) no dementia or significant mental disease. Based on a Package for the Social Sciences (SPSS) 12.0 for Windows
power analysis using a moderate effect size and probability was used for statistical analysis. Differences and correla-
level of 0Æ05 and 0Æ80 power, a sample size of 145 tions between variables were analysed by independent-
participants deemed adequate (Cohen 1988). During clinical sample t-tests, one-way ANOVA and Pearson’s product
visits, physicians identified patients who met the inclusion moment correlation. Multiple regression analysis was
criteria. Of the 193 participants referred five did not meet applied to identify the factors that significantly affect self-
inclusion criteria, 19 chose not to participate and four were care behaviour in this population. Colinearity diagnostics
unable to complete the questionnaires. In total, 165 partic- and correlation matrix were examined to exclude multico-
ipants were enrolled. linearity. Multicolinearity of independent variables was
examined by calculating the variance inflation factor (VIF).
To avoid multicolinearity bias in linear regression, variables
Instruments
with small tolerance (<0Æ01) and VIF exceeding 10 have to
The Personal Resource Questionnaire 2000 (Weinert 2003) be discard (Schroder 1990). In this study, the tolerance of
has 15 items; responses are graded using a seven-point Likert each independent variable was close to 1Æ0 and VIF less
scale ranging from 1 (strongly disagree) –7 (strongly agree). than 10.
3310 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315
Older people Self-care in diabetic elderly
2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315 3311
Y-L Bai et al.
(1998) noted that treatment cost for many diabetic patients is Wang et al. (1998) determined that no significant differ-
a significant burden. During interviews, some participants ence existed for self-care between religious and non-religious
stated that blood sugar test strips, preparation of special patients; however, this study determined that non-religious
diets, use of sports facilities, medical treatments and expenses patients had better self-care behaviour than religious patients.
for frequent hospital visits were a burden. They who tend to attach their health to religious beliefs may
3312 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315
Older people Self-care in diabetic elderly
Table 2 Pearson’s correlation of self-care behaviour (N = 165) support and self-care behaviour are positively correlated,
Self-care behaviour
implying that social support has a positive impact on self-care
behaviour.
Variables r p-value
2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315 3313
Y-L Bai et al.
Conclusion Aljasem LI, Peyrot M, Wissow L & Rubin RR (2001) The impact of
barriers and self-efficiency on self-care behaviors in type 2 diabetes.
This study enrolled patients from three hospitals. Due to the Diabetes Educator 27, 393–404.
non-probability sampling, conclusions and suggestions in this American Diabetes Association (2003) Standard of medical care for
study results are limited and cannot be generalised to all older patients with diabetes mellitus. Diabetes Care 26(Suppl. 1), S33–
S50.
diabetic patients. This study demonstrated significant differ-
Anderson RM (1995) Patient empowerment and the traditional
ences in self-care behaviour scores when participants were medical model: a case of irreconcilable. Diabetes Care 18, 412–
groups according to gender, education level and economic 415.
status. Depression was negatively correlated with self-care Chen ZT, Chang M & Lin YC (1998) The relationship between self-
behaviour. Social support and self-care behaviour were posi- efficacy, social support and self-care behaviors in diabetes mellitus
patients. Journal of Nursing Research 6, 31–42.
tively correlated. Social support, education level and disease
Chen YM, Liao KM, Shu YH, Wu MH, Wang SH & Tsai HC (2001)
duration are significant predictors of self-care behaviour. Our Relationships between personal perceptions and healthy behaviors
results are limited by the cross-sectional nature of our data. of middle-aged diabetic patients. Journal of Chinese Medical
Therefore, a discussion of changes over time is not possible. Sciences 2, 315–324.
This study only focused on correlations among socio-demo- Chiang FW (2003) Family support, life satisfaction, self-care behav-
graphic characteristics, disease condition, social support, iors and diabetic control for patients with non-insulin-dependent
diabetes mellitus. Journal of Chang Gung Institute of Technology
depression and self-care behaviour. Other lifestyle variables,
2, 27–50.
such as personality and smoking, require further study. Ciechanowski PS, Katon WJ & Russo JE (2000) Depression
and diabetes: impact of depressive symptoms on adherence,
function and costs. Archives of Internal Medicine 160, 3278–
Relevance to clinical practice 3285.
Ciechanowski PS, Katon WJ, Russo JE & Hirsch IB (2003) The
This study found that among older diabetics, special attention
relationship of depressive symptoms to symptom reporting, self-
needs to be paid to influential factors such as gender, care and glucose control in diabetes. General Hospital Psychiatry
education level, social and economic status, disease duration 25, 246–252.
and religious belief on self-care behaviour. Different nursing Clark M & Hampson SE (2001) Implementing a psychological
techniques must be used with patients according to individual intervention to improve lifestyle self-management in patient with
conditions and based on respect and caring. When caring for type 2 diabetes. Patient Education and Counselling, 42, 247–256.
Cohen J (1988) Statistical Power Analysis for the Behavioral Science,
older diabetics, psychological evaluations should be con-
3rd edn. Academic Press, New York.
ducted from time to time during disease treatment and in Department of Health (2006) Statistics of Causes of Death. Taiwan
particular, when caring for groups with a high risk of Government, Taipei.
depression. The psychological impact of complications, DiMatteo MR, Lepper HS & Croghan TW (2000) Depression is a
disease duration and different treatment methods should be risk factor for noncompliance with medical treatment: meta-
analysis of the effects of anxiety and depression on patient
taken into consideration for early detection of psychological
adherence. Archives of Internal Medicine 54, 403–425.
problems. Psychological support or suggestions for solutions Gallant MP (2003) The influence of social support on chronic illness
to health problems should also be offered. Furthermore, self-management: a review and directions for research. Health
nurses should also provide patients with social support that Education and Behavior 30, 170–195.
will enable them to have good support systems during their Gonzalez JS, Safren SA, Cagliero E, Wexler DJ, Delahanty L,
disease treatment to enhance self-care abilities and improve Wittenberg E, Blais MA, Meiggs JB & Grant RW (2007) Depres-
sion, self-care and medication adherence in type 2 diabetes: rela-
quality of life.
tionships across the full range of symptom severity. Diabetes Care
30, 2222–2227.
Hopper SV & Schechtman KB (1985) Factor associated with diabetic
Contributions
control and use patterns in a low-income, older adult population.
Study design: C-PC, Y-LB; data collection and analysis: Y-LB, Patient Education and Counseling 7, 275–288.
Hunt LM, Pugh J & Valenzuela M (1998) How patients adapt
C-PC, Y-YC and manuscript preparation: C-PC, Y-LB.
diabetes self-care recommendations in everyday life. Journal of
Family Practice 46, 207–215.
Hurley CC & Shea CA (1992) Self-efficay: strategy for enhancing
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