effectiveness of self-management for persons with type 2 diabetes
TRANSCRIPT
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SCHOOL OF NURSING
CENTRE FOR HEALTH RESEARCH (NURSING)
Effectiveness of self-management for persons with type 2 diabetes following the implementation of a self-
efficacy enhancing intervention program in Taiwan
Shu-Fang (Vivienne) Wu
RN, BN, MSc (Nursing)
This dissertation is submitted to fulfil the requirement for the award of the doctor of
Philosophy of Nursing at Queensland university of Technology
November 2007
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STATEMENT OF ORIGINALITY
This work contained in this dissertation has not been previously submitted for a
degree at any other tertiary education institution. To the best of my knowledge and
belief, the dissertation contains no material previously published or written by another
person, except where due reference is made.
Name: Shu Fang Vivienne Wu
Signed:
Date :
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ACKNOWLEDGEMENTS
I wish to gratefully acknowledge all the people who assisted me in varied ways during
my doctorate. Completion of this thesis would have been impossible without the
assistance and guidance of the following people.
The person who was primarily instrumental throughout the entire course of this thesis
in bringing it to a successful conclusion was Prof. Mary Courtney, my principal
supervisor and someone I consider a great mentor. I would like also to express my
gratitude to each member of my supervisory team- Prof. Helen Edwards, Dr. Jan
McDowell, Prof. Lillie M. Shortridge-Baggett and Associate Prof. Pei-Jean Chang,
for their guidance, caring support, encouragement and instruction throughout my
academic career.
Thanks also to the faculty and my nursing colleagues at the National College of
Nursing who always encouraged me to keep going. I am grateful to the Queensland
University of Technology for the two-year scholarship, the QIDS which has been
extremely helpful to my financial situation. I am deeply indebted to the people,
research team members and participants who were involved in my research project.
Without their joint, support and cooperation, my thesis would not have been possible.
A big thank you to my PhD colleagues at QUT campus. We have laughed, cried,
provoked and debated with one another. Our shared experiences made this journey
easier.
Finally, it is very difficult to imagine how I would have completed this thesis without
the love and support of my family; especially my husband, Ming-I Venson. He has
given me his complete support, patience, acceptance and love. My family all have
made my life more meaningful by sustaining me during my PhD journey.
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KEYWORDS
Type 2 diabetes, Randomised controlled trial, Self-management, Self-efficacy, Outcome expectations, Self-efficacy enhancing intervention program (SEEIP), Self-care, Health-related quality of life, Psychosocial well-being, Social support, Depression, Health care utilisation
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ABSTRACT
Objective The aim of this study firstly, was to translate and test the validity and reliability of two diabetes-specific self-efficacy instruments (the Diabetes Management Self-Efficacy Scale; DMSES and the Perceived Therapeutic Efficacy Scale; PTES) in a Taiwanese population. The main aim of this study was then to develop an intervention based on self-efficacy theory that was appropriate for the Taiwanese population and to examine the effects of a self-efficacy enhancing intervention program (SEEIP). Background In Taiwan, the prevalence, mortality rate and healthcare cost of diabetes has dramatically increased. People with diabetes have low participation rates in performing self-care activities, with some two-thirds of diabetic patients not controlling their disease appropriately. Moreover, few studies in Taiwan have conducted randomised controlled trials or had improvement in patient self-care or self-management as their primary goal and no instruments that measure self-efficacy related to the management of diabetes (especially for outcome expectations) have yet been found and appropriately used to measure the effectiveness of self-management. Therefore, there is a particular need for research on self-efficacy enhancing intervention programs for people with type 2 diabetes. Design A convenience sample survey (n=230) was used in order to test the validity and reliability of C-DMSES and C-PTES in a Taiwanese population. Moreover, a randomised controlled trial (RCT) (n=145; the intervention group (72); the control group (73)) design was conducted in the main study with pre (baseline) and post-testing (undertaken at 3 months and 6 months following baseline collection). Intervention Both the control group and intervention group received the standard diabetic educational program in the outpatient clinic. The intervention group participants received the standard diabetic educational program and the following additional interventions: (1) viewed a 10-minute DVD (2) received a “Diabetes Self-Care” booklet (3) participated in four efficacy- enhancing counselling intervention sessions, and (4) participated in telephone follow-up. The self-efficacy model was adapted from
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Shortridge-Baggett & van der Bijl (1996). Diabetes self-management principles were used in program development and evaluation. Main outcome measures Instruments used in data collection included 1) Self-efficacy towards management of type 2 diabetes (as measured by the Chinese version of the Diabetes Management Self-Efficacy Scale; C-DMSES and the Chinese version of the Perceived Therapeutic Efficacy Scale; C-PTES); 2) self management behavior (as measured by the Summary of Diabetes Self-Care Activities; SDSCA); 3) health-related quality of life for diabetes (as measured by the Short Form-12; SF-12); 4) psychosocial well-being (as measured by the Medical Outcomes Study (MOS), Social Support Survey (SSS) tool and the Center for Epidemiology Studies Short Depression Scale; CES-D) and 5) health care utilisation (as measured by health care utilisation self report instrument). Data analysis
Data were double-entered for verification using SPSS® statistical software. Study I:
Descriptive statistics, regression analysis, Pearson’s correlation, Cronbach’s alpha-coefficients, factor analysis and Bland-Altman plots with 95% limits of agreement (LOA) were performed to evaluate validity and reliability of C-DMSES and C-PTES.
Study II: Descriptive analysis was used to examine demographic variables and outcome variables. T-tests were used to analyse differences on continuous data between mean scores for the intervention and control groups. Categorical data were analysed using Chi-square statistics to test the significance of different proportions. To assess the group differences of dependent variable changes, repeated measures ANOVA/ ANCOVA were used.
Results Study I: Convergent validity showed that C-DMSES correlated well with the validated measure of the General Self-Efficacy Scale (GSE) in measuring self-efficacy. Criterion-related validity showed that the C-DMSES was a significant predictor of the Summary of Diabetes Self-Care Activities (SDSCA) scores. Factor analysis supported the C-DMSES being composed of four subscales with good internal consistency (Cronbach’s alpha=.77 to .93) and stability (ICC=.82). Similarly, significant criterion-related validity was demonstrated between the C-PTES and SDSCA scores. Convergent validity was confirmed as the C-PTES converged well with the GSE Scale in measuring self-efficacy. Construct validity of the C-PTES was confirmed through factor analysis and a single subscale formed. Internal
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consistency with a Cronbach’s alpha was .95 and the test-retest reliability (ICC) was .77 and a Bland-Altman plot showed 97% of the subjects were within 2 standard deviations of the mean. Study II: The 3- and 6-month benefits of the intervention over usual care were increases in self-efficacy, outcome expectation, self-care activities, and social support. However, the results of the health-related quality of life and depression scores indicated that the change over time was not different in the two groups. A smaller proportion of the participants significantly in the intervention group, had been hospitalised and visited the emergency room than participants who were in the control group at the 6-month period. However, health-related quality of life and depression were not significantly increased in the intervention group at the 3- and 6-month compared to the control group.
Conclusion Results of Study I support the psychometric properties of C-DMSES and C-PTES in providing a measure for self-efficacy specific to persons with type 2diabetes in Taiwan. The main study revealed that the SEEIP for type 2 diabetes based on self-efficacy theory was culturally acceptable to Taiwanese people with diabetes and that the SEEIP was effective in the self-management of people with type 2 diabetes.
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List of publications related to this thesis Title Status
TAIWANESE JOURNALS
Wu, S. F., Li, Y. C., Chang, J. R., & Courtney, M (2007). The Application of Self-Efficacy Counselling Skills in Health Education for Patients with Diabetes, The Journal of Nursing (Taiwan), 54(1), 70-77 .
Published
Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, J. R. (2006). Application of the Self-Efficacy Model in Nursing Practice, VGH Nursing Journal (Taiwan), 23(2), 181 -186.
Published
Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, J. R. Hong, S. T. (2006). Self-efficacy-enhancing intervention training and application for patients with diabetes mellitus. Formosan Journal of Medicine (Taiwan), 10(1), 115-122.
Published
Wu, S. F. (2006). A two-stage translation and test the validity and reliability of a foreign instrument. The Journal of Nursing (Taiwan), 53 (1), 65-71.
Published
INTERNATIONAL JOURNALS (WITH SCI IMPACT FACTOR)
Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, J. R. (2006). Development and validation of the Chinese version Diabetes Management Self-Efficacy Scale, International Journal of Nursing Studies, doi:10.1016/j.ijnurstu.2006.08.020 (SCI, Impact Factor=0.692).
Accepted &
In press
Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, J. R. (2006). Psychometric properties of the Chinese version of the Perceived Therapeutic Efficacy Scale, Journal of the Formosan Medical Association, (SCI, Impact Factor= 0.453).
Accepted
Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, J. R. (2006). Self-efficacy, outcome expectations, and self-care behavior in people with type 2 diabetes in Taiwan, Journal of Clinical Nursing, (SCI, Impact Factor=0.867 )
Accepted &
In press
CONFERENCE PRESENTATIONS (PEER-REVIEWED) *denotes presenter
*Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, P.J. (20-22 July 2006). Evaluation of a Self-Efficacy Enhancing Intervention for Taiwanese Persons' Self-Management of Type 2 Diabetes. in The Sigma Theta Tau International 17th International Nursing Research Congress: Advancing Knowledge and Community
Published
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Globally Through Collaboration, Le Centre Sheraton Montréal, Québec, Canada: Sigma Theta Tau International Honor Society of Nursing
*Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M.,
Chang, P.J. (2005, Nov.).Understanding diabetes mellitus in Taiwan: Evaluation of the validity and reliability of a diabetes-specific self-efficacy instrument in a Taiwanese population. in The 3rd Pan-Pacific Nursing Conference & The 5th Hong Kong Nursing Symposium on Cancer Care. Shatin, N.T., Hong Kong: The Nethersole School of Nursing
Published
*Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, P. J. (2005, May). Translation and validation of a diabetes-specific self-efficacy instrument in a Taiwanese population. in ICN 23rd Quadrennial Congress, Nursing on the move: Knowledge, innovation and vitality. Taipei, Taiwan: Taiwan International Conference Centre (TICC)
Published
CONFERENCE POSTERS (PEER-REVIEWED) *denotes presenter
*Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, P. J. (2005, May). Improving Taiwanese persons’ self-efficacy towards self-management of type 2 diabetes. in International Network for Doctoral Education in Nursing, A global agenda for nursing doctoral education. Taipei, Taiwan: The Howard Plaza Hotel Taipei.
Published
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TABLE OF CONTENTS Contents page ABSTRACT.................................................................................................................i LIST OF PUBLICATIONS RELATED TO THIS THESIS..........................................iv TABLE OF CONTENTS.............................................................................................vi LIST OF APPENDICES..........................................................................................xvi LIST OF TABLES ....................................................................................................xviii LIST OF FIGURE ...................................................................................................xxi
Chapter 1 Introduction ........................................................................ 1
1.1 Introduction .........................................................................................................1 1.2 Background and significance of the study ...........................................................2 1.3 The aim, objectives, and research questions, hypotheses, and definitions .........10
1.3.1 Two research studies in three phases ....................................................10 1.3.2 The aim ................................................................................................11 1.3.3 Objectives .............................................................................................12 1.3.4 Research questions................................................................................12 1.3.5 Research Hypotheses ............................................................................13 1.3.6 Definitions of terms ..............................................................................14
1.4 Assumptions ........................................................................................................18 1.5 Expected outcomes ..............................................................................................18
1.5.1 Study I...................................................................................................18 1.5.2 Study II outcome...................................................................................18
1.6 Summary .........................................................................................................20
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Chapter 2 Review of literature on the burden of diabetes mellitus and on current health care in Taiwan ............................. 21
2.1 Introduction..........................................................................................................21 2.2 Population profile of Taiwan including its health characteristics ........................21
2.2.1 A profile of Taiwan ...............................................................................21 2.2.2 Health care expenditure ........................................................................22 2.2.3 National Health Insurance in Taiwan....................................................23 2.2.4 Core health policies in Taiwan..............................................................23 2.2.5 Chronic diseases in Taiwan...................................................................24
2.3 The prevalence, mortality rate and cost burden of diabetes mellitus in Taiwan ..25
2.3.1 High prevalence rate of diabetes mellitus in Taiwan ............................26 2.3.2 High mortality rate of diabetes mellitus in Taiwan...............................28 2.3.3 The high proportion of health expenditure for the treatment
of diabetes mellitus ...............................................................................29 2.3.4 Conclusions...........................................................................................31
2.4 Current situation for diabetes health care services in Taiwan..............................31
2.4.1 Community-base approach ...................................................................31 2.4.2 Hospital-base approach.........................................................................33
2.5 Diabetes in Taiwan: self management issues.......................................................35 2.6 Literature on diabetes care interventions in Taiwan ............................................37 2.7 International cooperation .....................................................................................40 2.8 Summary ..............................................................................................................40
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Chapter 3 Review of literature on diabetes, self-care, quality of life, and psychosocial issues ............................. 46
3.1 Introduction .........................................................................................................46 3.2 Diabetes Mellitus .................................................................................................46
3.2.1 Diagnosis and definition ......................................................................46 3.2.2 Classifying diabetes .............................................................................48 3.2.3 Complications .....................................................................................50
3.3 Self-care of diabetes ............................................................................................53
3.3.1 Blood glucose monitoring.....................................................................55 3.3.2 Nutrition................................................................................................57 3.3.3 Exercise ................................................................................................59 3.3.4 Medication ............................................................................................61 3.3.5 Foot care................................................................................................64
3.4 Quality of life and diabetes ..................................................................................68
3.5 Psychosocial issues and diabetes .........................................................................71
3.5.1 Diabetes and social support ....................................................................72 3.5.2 Diabetes and depression..........................................................................74
3.6 Summary…. .........................................................................................................78
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Chapter 4 Framework ......................................................................... 81 4.1 Introduction .........................................................................................................81 4.2 Self-efficacy model .............................................................................................81
4.2.1 Self-efficacy (efficacy expectations) ....................................................84 4.2.2 Outcome expectations...........................................................................87 4.2.3 Information sources ..............................................................................90
4.2.3.1 Performance accomplishments .................................................90 4.2.3.2 Vicarious experience.................................................................91 4.2.3.3 Verbal persuasion......................................................................92 4.2.3.4 Self-appraisal ............................................................................93
4.2.4 Behaviour..............................................................................................94
4.3 Self-efficacy and diabetes self-management .......................................................95 4.4 Self-efficacy and health outcome variables .........................................................102
4.4.1 Self-efficacy and quality of life ............................................................102 4.4.2 Self-efficacy and psychosocial-well-being ...........................................105
4.4.2.1 Self-efficacy and social support................................................105 4.4.2.2 Self-efficacy and depression .....................................................108
4.4.3 Self-efficacy and health care expenditure.............................................110
4.5 An intervention program based on self-efficacy theory ................................113 4.5.1 The rationale for developing SEEIP .....................................................113
4.5.1.1 To test the self-efficacy model requires establishing a comprehensive intervention program.....................................114
4.5.1.2 A new conceptual framework: the empowerment approach.....117 4.5.1.3 Traditional patient educational programs in Taiwan
are insufficient for people’s diabetic control.............................118 4.5.2 Development of self-efficacy for people with diabetes ........................121
4.5.2.1 Counselling skills to develop self-efficacy ..............................121 4.5.2.2 Self-efficacy enhancing strategies according to
Bandura’s information sources .................................................128
4.6 Summary ..............................................................................................................138
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Chapter 5 Methods .............................................................................. 140 5.1 Introduction..........................................................................................................140 5.2 Study I: Translation, testing of validity and reliability of two diabetes-specific
self-efficacy instruments in a Taiwanese population .......................141 5.2.1 Research design ....................................................................................141
5.2.1.1 Stage one: translation and instruments development................142 5.2.1.2 Stage two: validation and reliability of instruments .................146
5.2.2 Population and sample ..........................................................................149 5.2.3 Setting and procedure ...........................................................................149 5.2.4 Research concept and instruments/measurement strategies .................150 5.2.5 Data Analysis ........................................................................................154 5.2.6 Ethical considerations ...........................................................................155
5.3 Study II (Pilot Study): Development of an intervention based on self-efficacy
theory and piloting of the intervention ..........................................156 5.3.1 Research design ....................................................................................158 5.3.2 Population and sample ..........................................................................158 5.3.3 Setting and procedure ...........................................................................159 5.3.4 Ethics considerations ............................................................................159 5.3.5 Results: Study II (Pilot Study) ..............................................................160
5.3.5.1 Viewing a 10-minute DVD .......................................................162 5.3.5.2 Receiving the “Diabetes Self-Care” booklet.............................163 5.3.5.3 Participating in four efficacy- enhancing counseling
intervention sessions .................................................................164 5.3.5.4 Participating in telephone follow-up.........................................165
5.4 Study II (Main Study): Randomised controlled trial to evaluate the
efficacy of an intervention ..........................................167 5.4.1 Research design ....................................................................................167 5.4.2 Population and sample ..........................................................................167 5.4.3 Sample size ...........................................................................................168 5.4.4 Setting and procedure ...........................................................................170 5.4.5 Research concept and instruments/measurement strategies .................173 5.4.6 Data management and analysis.............................................................178
5.4.6.1 Data management......................................................................179 5.4.6.2 Data analysis .............................................................................180
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5.4.7 Ethical considerations ...........................................................................181 5.5 Summary ..............................................................................................................182 Chapter 6 Results ................................................................................. 184 6.1 Introduction..........................................................................................................184 Result of Study I.......................................................................................................184 6.2 Description of sample ..........................................................................................184 6.3 Result of the Chinese version of the DMSES (C-DMSES).................................187
6.3.1 Result of Stage one: translation and development of the C-DMSES .............................................................................................187
6.3.2 Result of Stage two: validation and reliability of the C-DMSES .............................................................................................188 6.3.2.1 The content validity of the C-DMSES............................................189 6.3.2.2 The criterion validity of the C-DMSES..........................................191 6.3.2.3 The convergent validity of the C-DMSES......................................193 6.3.2.4 The construct validity of the C-DMSES.........................................193 6.3.2.5 Internal consistency of the C-DMSES............................................196 6.3.2.6 Stability of the C-DMSES ..............................................................197
6.4 Result of the Chinese version of the PTES (C-PTES).........................................199
6.4.1 Result of Stage one: translation and development of the C-PTES ................................................................................................199
6.4.2 Result of Stage two: validation and reliability of the C-PTES ................................................................................................199 6.4.2.1 The content validity of the C-PTES................................................199 6.4.2.2 The criterion validity of the C-PTES..............................................201 6.4.2.3 The convergent validity of the C-PTES..........................................203 6.4.2.4 The construct validity of the C-PTES.............................................203 6.4.2.5 Internal consistency of the C-PTES................................................205 6.4.2.6 Stability of the C-PTES ..................................................................205
6.5 Summary result of Study I ...................................................................................207
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Result of Study II (Main study) .............................................................................208 6.6 Introduction..........................................................................................................208 6.7 Description of sample ..........................................................................................209 6.8 Checking differences between groups .................................................................212
6.8.1 Sociodemographics and illness history...................................................212 6.8.2 Key variables of participants ...................................................................214
6.9 Question 2: Can an intervention (SEEIP) based on self-efficacy theory improve
self-management in people with type 2 diabetes in Taiwan? .............................216 6.9.1 Question 2.1: Is there a difference in the self-efficacy of people
with type 2 diabetes following implementation of the SEEIP? .................217 6.9.2 Question 2.2: Is there a difference in the self-care activities of people
with type 2 diabetes following implementation of the SEEIP? .................221 6.9.3 Question 2.3: Is there a difference in health-related quality of life of
people with type 2 diabetes following implementation of the SEEIP? ......223 6.9.4 Question 2.4: Is there a difference in the psychosocial well-being of
people with type 2 diabetes following implementation of the SEEIP? ......226 6.9.5 Question 2.5: Is there a difference in health care utilisation of people
with type 2 diabetes following implementation of the SEEIP? ..................233
6.10 Summary result of Study II................................................................................237
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Chapter 7 Discussion ........................................................................... 239 7.1 Introduction..........................................................................................................239 Discussion of Study I................................................................................................240 7.2 Discussion of the Chinese version of the DMSES (C-DMSES)..........................240
7.2.1 Discussion of Stage one: translation and development of the C-DMSES .............................................................................................240
7.2.2 Discussion of Stage two: validation and reliability of the C-DMSES ............................................................................................242 7.2.2.1 The content validity of the C-DMSES............................................242 7.2.2.2 The criterion validity of the C-DMSES..........................................244 7.2.2.3 The convergent validity of the C-DMSES......................................244 7.2.2.4 The construct validity of the C-DMSES.........................................245 7.2.2.5 Internal consistency of the C-DMSES............................................248 7.2.2.6 Stability of the C-DMSES ..............................................................249
7.3 Discussion of the Chinese version of the PTES (C-PTES) .................................250
7.3.1 Discussion of Stage one: translation and development of the C-PTES .................................................................................................250
7.3.2 Discussion of Stage two: validation and reliability of the C-PTES ................................................................................................251 7.3.2.1 The content validity of the C-PTES................................................251 7.3.2.2 The criterion validity of the C-PTES..............................................252 7.3.2.3 The convergent validity of the C-PTES..........................................253 7.3.2.4 The construct validity of the C-PTES.............................................254 7.3.2.5 Internal consistency of the C-PTES................................................254 7.3.2.6 Stability of the C-PTES ..................................................................255
7.4 Summary discussion of Study I ...........................................................................256
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Discussion of Study II (Main Study) ......................................................................258 7.5 Description of sample, sociodemographics, and illness history
of participants......................................................................................................258
7.6 Research Question 2: Can an intervention (SEEIP) based on self-efficacy theory improve self-management in people with type 2 diabetes in Taiwan?.....259 7.6.1 Hypothesis 1: People who receive the intervention will have
greater self-efficacy towards managing their type 2 diabetes than people who do not receive the intervention .......................................259
7.6.2 Hypotesis 2: People who receive the intervention will undertake diabetes self-care activities more frequently than people who do not receive the intervention ................................................263
7.6.3 Hypothesis 3: People who receive the intervention will have better HRQOL than people who do not receive the intervention ...............266
7.6.4 Hypothesis 4: People who receive the intervention will have better psychosocial well-being than people who do not receive the intervention...................................................................268
7.6.5 Hypothesis 5: People who receive the intervention will have a lower usage of health services than people who do not receive the intervention....................................................................273
7.7 Summary discussion of Study II (Main Study) ...................................................275
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Chapter 8 Conclusions and Recommendations ................................. 277 8.1 Introduction..........................................................................................................277 8.2 Conclusion and significance of Study I ...............................................................279 8.3 Conclusion and significance of Study II..............................................................280 8.4 Implications..........................................................................................................283 8.5 Limitations ...........................................................................................................286 8.6 Recommendations................................................................................................287 8.7 Summary ..............................................................................................................289
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LIST OF APPENDICES Contents page Appendix 1. REFERENCES ................................................................................ A1 Appendix 2. The letter of approval from University Human Ethics Committee,
Queensland University of Technology............................................ A21
Appendix 3. The letter of approval from the Research Degree Committee,
Queensland University of Technology ............................................ A22 Appendix 4. A study consent form from Tri-Service general Hospital
in Taipei city, Taiwan ...................................................................... A23 Appendix 5. Study information sheet (Study I) ................................................... A24 Appendix 6. Study information sheet (Study II) (Intervention group) ................. A27 Appendix 7. Study information sheet (Study II) (Control group)......................... A30 Appendix 8. Study consent form (Study I & II) .................................................. A33 Appendix 9. The questionnaire in English .......................................................... A34 Appendix 10. The questionnaire in Chinese ......................................................... A47 Appendix 11. The approval of DMSES scale ..................................................... A59 Appendix 12. The approval of PTES scale ......................................................... A60 Appendix 13. The approval of SDSCA scale........................................................ A61 Appendix 14. The approval of SF-12 scale ......................................................... A62 Appendix 15. The approval of MOS-SSS scale .................................................. A63
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Appendix 16. The approval of GSE scale ........................................................... A64 Appendix 17. The approval of CES-D scale ........................................................ A65 Appendix 18. A certificate of participation for 10 sessions of the “get to
know your blood glucose level” program .................................... A66
Appendix 19. A certificate of participation for 24-hour chronic disease counseling skills program ........................................................... A67
Appendix 20. Intervention suite of the SEEIP .................................................... A68
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LIST OF TABLES Contents page Table 2.1 Ten leading causes of death in Taiwan in 2004..................................... 24 Table 2.2: Total Diabetes Population .................................................................... 27 Table 2.3 Results of diabetes care ........................................................................ 35 Table 2.4 Publications related to self-efficacy or interventions for diabetes
care in Taiwan ........................................................................................ 44 Table 3.1Diagnostic criteria for diabetes based on the fasting plasma
glucose (venous) .................................................................................... 47
Table 4.1 Goals, strategies and targets: from the general to the specific .............. 126 Table 5.1 Instrument/ measurement strategies (Study I) ...................................... 150 Table 5.2 Comparison of traditional patient education in Taiwan and
the SEEIP............................................................................................... 156 Table 5.3 Intervention suite of the SEEIP ............................................................ 161 Table 5.4 Instrument/ measurement strategies (Study II: Main Study) ................ 173 Table 6.1 Characteristics of participants (Study I) ............................................... 185
Table 6.2 Characteristics of participants of the total and retest sample (Study I) ................................................................................................................ 186 Table 6.3 Results of the translation and the back-translation of the C-DMSES .. 188 Table 6.4 Expert panel for content validity .......................................................... 189
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Table 6.5 Content validity score of C-DMSES .................................................... 190 Table 6.6 A regression analysis summary for the C-DMSES predicting
the SDSCA ............................................................................................ 193 Table 6.7 The result of the principal-component factor analysis for C-DMSES.. 194 Table 6.8 Rotated factor matrix of the C- DMSES. Principal-component
method with Varimax rotation ........................................................... 195 Table 6.9 Cronbach’s α value of C-DMSES ........................................................ 197 Table 6.10 The C-PTES after modification based on the experts’ comments ..... 200 Table 6.11 Content validity score for C-PTES...................................................... 200 Table 6.12 Rotated factor matrix of the C-PTES. Principal-component
method with Varimax rotation ............................................................ 204 Table 6.13 Pearson item-total coefficient of correlation of the C-PTES.............. 205 Table 6.14 Comparisons of sociodemographics and illness history between
intervention and control groups .......................................................... 212 Table 6.15 Differences between groups on the key variables of baseline ............ 215
Table 6.16 Differences between groups on health care utilisation of baseline .... 216 Table 6.17 The mean (SD) for the efficacy-expectation and
outcome-expectation scores ................................................................ 218 Table 6.18 The mean (SD) for the self-care activities scores ............................... 221 Table 6.19 The mean (SD) for the physical health and mental health scores....... 224 Table 6.20 The mean (SD) for the social support and depression scores ............. 226
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Table 6.21 Repeated measure analysis of variance for the outcome variables ..... 230 Table 6.22 Comparisons of outcome variables by time of groups
(Paired-t Test) ..................................................................................... 231 Table 6.23 Comparisons of outcome variables by time of groups
(Independent-t Test)............................................................................ 232 Table 6.24 Comparison of visits to emergency room between intervention
and control groups .............................................................................. 236 Table 7.1 Comparison of subscales in the Dutch and Chinese versions of DMSES
............................................................................................................. 247
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LIST OF FIGURES Contents page Figure1.1 The two research studies ...................................................................... 11 Figure 2.1 Total of People with Diabetes in the world ......................................... 26 Figure 2.2 The Prevalence of Diabetes in Taiwan ................................................ 28
Figure 2.3 Mortality Rate for Diabetes in Taiwan ................................................ 29 Figure 4.1 Self-efficacy Model adapted from Shortridge-Baggett
and van der Bijl (1996) ....................................................................... 83 Figure 4.2 Modified self-efficacy model for evaluation of the
self-efficacy enhancing intervention program (SEEIP) for persons with type 2 diabetes......................................................... 116
Figure 5.1 Two studies (or three phases) of the research ..................................... 141 Figure 5.2 Stage one of the development processes of the C-DMSES
& C-PTES .......................................................................................... 145
Figure 5.3 Stage two of the validation and reliability of instruments of
the C-DMSES & C-PTES.................................................................. 148
Figure 5.4 Sampling strategy and procedures to collect the study sample
in Study II (Main Study) .................................................................... 168 Figure 5.5 The result of repeated measures ANOVA power analysis................... 169 Figure 5.6 Research design- experimental study .................................................. 172 Figure 6.1 Scatter plot between SDSCA and C-DMSES for individual
observations ........................................................................................ 192
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Figure 6.2 Scree plot of the C-DMSES ................................................................ 195
Figure 6.3 Bland-Altman plot for reproducibility of C-DMSES scores............... 198 Figure 6.4 Scatter plot between SDSCA and C-PTES for individual
Observations ....................................................................................... 202
Figure 6.5 Scree plot of the C-PTES .................................................................... 204
Figure 6.6 Bland-Altman plot for reproducibility of C-PTES scores................... 206
Figure 6.7 Sample of the main study .................................................................... 211 Figure 6.8 Graph of the interaction between time and group for the
efficacy expectations........................................................................... 219
Figure 6.9 Graph of the interaction between time and group for the outcome expectations................................................................... 221
Figure 6.10 Graph of the interaction between time and group for the self-care activities ........................................................................ 223
Figure 6.11 Graph of the interaction between time and group for the
physical health-related quality of life .............................................. 224
Figure 6.12 Graph of the interaction between time and group for the mental health-related quality of life................................................. 225
Figure 6.13 Graph of the interaction between time and group for the
social support ................................................................................... 228
Figure 6.14 Graph of the interaction between time and group for the depression ........................................................................................... 229
Figure 6.15 The percentage of the hospitalisation between the intervention and control groups at Time 1, Time 2 and Time 3........................... 234
Figure 6.16 The percentage of visits to emergency room between the intervention
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and control groups at Time 1, Time 2 and Time 3........................... 235
Figure 6.17 The percentage of visits to OPD between the intervention and control groups at Time 1, Time 2 and Time 3........................... 235
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Student number: n4513282 Shu-Fang Wu Chapter 1 Introduction
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Chapter 1
1.1 Introduction
Diabetes Mellitus (diabetes) is a prevalent and costly condition with substantial
morbidity and mortality. Enhancing self-efficacy for persons with diabetes, improving
their self-management and quality of life, and reducing their utilisation of health
services is an ongoing challenge for health-care providers and the government. In
Taiwan, the prevalence, mortality rate and health care costs of diabetes have increased
dramatically. Previous research has shown that people with diabetes may lack
education or skills or have low participation rates in performing self-care activities
(Chuang et al., 2001; Lin et al., 2001). In addition, only a few studies have used
randomised trials and only a few studies have examined the improvement in patient
self-care or self-management as their primary goal in Taiwan. There is a particular
need for research on an intervention program to enhance the self-efficacy of people
with type 2 diabetes. The approach used for this study was to develop an intervention
that would be responsive to the needs of people with type 2 diabetes, and would
improve their self-efficacy and their self-management ability. This intervention was
evaluated in a randomised controlled trial (RCT) that included multiple measures of
outcomes, such as self-efficacy in managing type 2 diabetes, diabetes self-care
activities, health-related quality of life, psychosocial well-being and health service
utilisation. A 6-month follow-up and a pre- and post-test design was used to evaluate
the effectiveness of the intervention. This chapter will discuss the background and
significance of this study, and its purpose, objectives, research questions and
definitions and expected outcomes.
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1.2 Background and significance of the study
Diabetes in adults is a global health problem. Diabetes mellitus is a disorder of the
endocrine system characterised by abnormal fluctuations in blood glucose levels,
usually related to a defect in insulin production and glucose metabolism (Dunning,
2003). Although its prevalence varies widely between different populations, the rate
has generally increased worldwide (Chang et al., 2000). The global number of
diabetes patients is estimated to rise significantly from 176 to 370 million between
2000 and 2030, with more than 80% of them living in developing countries (Aubert,
1997; King, Aubert & Herman, 1998; World Health Organization (WHO), 2003). In
Taiwan, the overall 5-year incidences for men and women were 187.1 and 218.4 per
100,000 populations, respectively (Tseng et al., 2006), of these 96.7% had type 2
diabetes (Tasi, Wong, Lin & Chang, 2002). It is estimated that there are about
540,000 patients with drug-treated diabetes, affecting around 1 million people (Tseng,
2003), out of a total population of 23 million people in Taiwan. Moreover, diabetes
mellitus has been ranked as the fourth leading cause of death in Taiwan (Taiwan
Department Of Health (DOH), 2006). It is associated with long-term complications,
including heart disease, peripheral vascular disease, neuropathy, retinopathy, renal
disease and poor health-related quality of life (Guthrie & Guthrie, 2002). In addition,
the mortality rate of diabetes has dramatically increased from 7.9 per 100,000
population in 1980, to 16.8 per 100,000 in 1985 and to 34.49 per 100,000 in 1998 (Lu,
Yang, Wu, Wu & Chang, 1998; Tseng, Chong & Heng, 2000). In 2002, there were
8,818 cases of mortality from diabetes mellitus. These statistics reflect the
considerable impact the disease has on the health care system; health care costs for
diabetic patients amount to 11.5% of the total health care expenditure in Taiwan
(Tseng, 2003). Diabetes, therefore, is not only a serious health problem but also has a
major impact on the National Health Insurance budget of Taiwan.
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In Taiwan, several factors contribute to the poor control of diabetes. Firstly, lack of
education for diabetic patients, due to issues such as pressure of time; lack of
communication skills; lack of familiarity and confidence with appropriate education
strategies; and lack of counselling skills among health professionals. Secondly, people
who live in Taiwan typically do not obtain sufficiently comprehensive medical
information. Finally, while some people have poor control of their disease due to
shortfalls in self-care knowledge or skills, a large proportion of diabetic people do not
have the motivation to make any changes. Two epidemiological surveys showed that
only 30% of people with diabetes had performed self-monitoring of blood sugar or
urine sugar, indicating that people with diabetes may lack skills or have low
involvement in self-care activities (Chuang, Tsai, Huang & Tai, 2001; Lin, Chou, Lai,
Tsai & Tai, 2001). A recent Taiwanese study found that still only 9.4 % of patients <
65 years and 14.0 % > 65 years had HbA1c values within the optimal range (HbA1c
< 6.5 %) (Tai, Chuang, Tsai & Huang, 2006). Alarmingly, Tseng (2003) also stated
that 30% of people with diabetes were found to have an HbA1C level >10%. This
means more than two-thirds of diabetic patients do not control their disease
appropriately (Tasi et al., 2002) because it is difficult for them to change their
lifestyles.
In general, diabetes patient education programs can be found in some hospitals and
community health services in Taiwan. These traditional patient educational programs
may be conducted either by individuals or groups. Individual patient educational
program means one patient receives one professional’s health education. Group
patient educational program means many patients receive one professional’s health
education at one time. Normally nurses or diabetes educators will be involved in
delivering these patient education programs (either by individuals or groups), with a
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few nutritionists or dieticians also contributing. In 2001, the Bureau of National
Health Insurance (BNHI) started some “quality-based payment programs” to improve
quality of care, including diabetes care. This reimburses medical care providers with
extra payments if they provide nutrition consulting and individual diabetic education.
It is estimated that, currently, there are about 139 diabetes educational promotion
institutions in Taiwan. Even though patient education is being widely promoted, there
remains a lingering doubt about how effective it is in achieving the desired
improvement in diabetic care. Previous studies have shown that, unfortunately, most
diabetic patients in Taiwan do not control their disease appropriately. Consequently,
assisting people with diabetes to change their behaviour is significant in implementing
self-management and reaching the highest possible level of health
(Shortridge-Baggett, 2001). For diabetes care to succeed, patients must be able to
make informed decisions about how they will live with their illness (Funnell &
Anderson, 2000).
It has been recognised for at least a decade that the treatment of diabetes and illness in
industrialised countries has moved from reliance on medical interventions alone to
involving also the development of personal skills to adapt to the process of illness
(Connelly, 1987). Management of diabetes is aimed at keeping blood sugar levels
within the normal range (Drury, 1979; Expert Committee on the Diagnosis and
Classification of Diabetes Mellitus, 1997); effective management depends on the
individual with diabetics undertaking a range of self-care behaviours that may include
insulin injections several times daily, oral hypoglycemics, a strict calorie-controlled
diet that is low in fat and high in fibre, and regular exercise (Wing, Epstein, Nowalk
& Lamparski, 1986). Diabetes is a disease for which treatment and prevention of
complications largely depends on the patient’s willingness to self-manage most of
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Student number: n4513282 Shu-Fang Wu Chapter 1 Introduction
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their own care on a daily basis (Fitzgerald et al., 2000). Maintaining long-term
motivation and concordance are major issues; lowering blood sugar level requires
changes to lifelong behaviours related to diet and physical activities, a very difficult
and complex process (Prochaska & DiClemente, 1983). Patients’ self-management
depends heavily on their education and empowerment, and their self-monitoring of
the outcomes of self-care (Pasavic, 1980). However, Clement (1995) stated that more
than 50% of patients with diabetes receive limited education on diabetes
self-management, or none. Only through education and empowerment can people’s
awareness of their self-care abilities be improved, leading to a better quality of life
(Chuang et al., 2001).
Self-efficacy is a cognitive resource that enables an individual to adapt to and cope
with chronic illness; efficacious individuals are able to cope under diverse conditions
and are willing to meet new challenges (Bandura, 1997). Over the last 30 years,
Bandura’s social cognitive theory has been increasingly applied, both as a model of
health behaviour and as a framework for developing effective health interventions
(Bandura, 1977b; 1986). Self-efficacy is an important element of social cognitive
theory. Bandura has defined self-efficacy as “people’s judgment of their capabilities to
organise and execute the course of action which require designated types of
performances” (Bandura, 1986, p.391). WHO (1986) advocated the use of strategies
to enable people to make healthy lifestyle choices. Self-efficacy theory provides the
scientific rationale for strategies that have the potential to enhance people’s
self-confidence in their ability to undertake behaviour change.
Self-efficacy also offers a basis for improving the effectiveness of diabetes education
because it focuses on behavioural change (van der Bijl & Shortridge-Baggett, 2001).
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Student number: n4513282 Shu-Fang Wu Chapter 1 Introduction
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Johnson (1996) suggested that it is important to develop educational programs based
on self-efficacy theory for the self-management of diabetes. These can improve upon
traditional diabetes education that focuses only on the transmission of information or
skills (Moens, Grypdonck & van der Bijl, 2001; van de Laa & van der Bijl, 2001).
Health care professionals view the facilitation of personal self-efficacy, in the
individuals’ ability to manage self-care regimens, as a primary health resource and an
effective solution for diabetes management. So, in order for individuals to take an
active role in their own health, people need an increased understanding of their illness
condition and of self-care regimens. Intervention strategies must involve building up
their personal self-efficacy in individual’s ability to manage self-care activities, as
well as the development of positive expectations about their health outcomes (Bradley,
1989).
A comprehensive literature review has revealed that there have been 92 Taiwanese
studies related to self-efficacy, in areas such as education, social learning, job
satisfaction, information management and exercise behaviours. However, few
researchers have engaged in self-efficacy research in relation to health period.
Nevertheless those who did so have demonstrated that self-efficacy is an important
predictor of health improvement (Chang, Huang & Lee, 1996; Wang & Chiou, 1996;
Hung & Kao, 1997; Chen, Chang & Lin, 1998; Wang, Wang & Lin, 1998; Guo, Tsay
& Yen, 2002). At the time of writing, only three correlational research studies that
relate to self-efficacy and diabetes were located (Chang & Lin, 1997; Chen, Chang &
Lin, 1998; Wang, Wang & Lin, 1998), and only two intervention studies relating to
empowerment and diabetes (Lai & Liu, 2003; Guo, Tsay & Yen, 2002). There are
other studies that have evaluated interventions to improve dietary behaviour, exercise
and glucose testing, but none was found that addressed all of these in one study.
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No Taiwanese studies have used randomised trials as a methodology to trial new
interventions for diabetes; instead they have focused on how to produce
improvements in diabetes knowledge rather than on measures of self-management or
behaviour change (Chuang, Lin, Wu, Chen & Tai, 1989). Also, many studies lack a
comprehensive model and theory (Chang & Lin, 1997; Chen, Chang & Lin, 1998;
Wang, Wang & Lin, 1998). The present study made use of an intervention that
focussed on the effects on self-efficacy of relying on four sources of information that
have been adopted from Bandura (1977a) and the aim of this study was to develop,
trial and evaluate a theory-based nursing intervention program suitable for people
with type 2 diabetes in Taiwan. In Taiwan, no researchers have engaged in
self-efficacy studies on diabetes that incorporate interventions, and hence there is a
lack of results that could relate changes in self-efficacy for diabetics to their reliance
upon these sources. Furthermore, no instruments that measure self-efficacy related to
the management of diabetes (especially for outcome expectations) have yet been
found and appropriately used to measure the effectiveness of self-management. Since
there is such a lack of literature on self-efficacy interventions in diabetes education in
Taiwan, further studies on nursing interventions to improve self-management of
diabetes are particularly crucial in the future.
At the same time, this study presented a great opportunity to link up with international
research teams to develop and test the self-efficacy model in Taiwan. The
International Partnership in Self-management and Empowerment (IPSE) is a
collaborative group of researchers conducting studies on the role of self-efficacy in
the management of chronic disease, including diabetes. The IPSE is also involved in
constructing theory-based instruments that can measure the effectiveness of an
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intervention intended to improve self-efficacy, and demonstrating their reliability and
validity. Such instruments include the Diabetes Management Self-Efficacy Scale
(DMSES) and the Perceived Therapeutic Efficacy Scale (PTES). The DMSES and
PTES have been translated into several languages and psychometrically tested with
diabetes populations in various countries, such as Netherlands, Switzerland, Belgium,
UK, USA and Australia.
Bolstering patient’s confidence in their ability to successfully care for themselves is a
critical step in promoting active self-management (Fu et al., 2003; Ismail, Winkley &
Rabe-Hesketh, 2004). The rationale for developing the intervention program based on
self-efficacy theory (Self-Efficacy Enhancing Intervention Program; SEEIP) included
the following:
• Firstly, to test the self-efficacy model adapted from Shortridge-Baggett & van
der Bijl (1996) in an experimental design required a comprehensive
intervention program to be established and then its effectiveness to be
evaluated.
• Secondly, patient empowerment has recently become an alternative to the
compliance-orientated approach to diabetes management. The intervention of
this study based on self-efficacy theory. Self-efficacy is a major component of
the empowerment approach and it plays an important role in behaviour
change.
• Finally, existing traditional patient educational programs in Taiwan are
insufficient to control people’s diabetes; a new diabetes service program needs
to be introduced into the Taiwanese healthcare system.
The SEEIP emphasises confidence enhancing and goal-setting skills in order to
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increase self-efficacy and change people’s behaviours. Four sources of information
adopted from Shortridge-Baggett and van der Bijl (1996) and Bandura (1977a) were
applied in this intervention. The SEEIP given to diabetic people included: (1) viewing
a 10-minute DVD, (2) receiving a “Diabetes Self-Care” booklet, (3) participating in
four efficacy-enhancing counselling intervention sessions at weekly intervals, and (4)
participating in telephone follow-up. The SEEIP guided people in identifying their
problems and provided techniques to help people make decisions and take actions, as
they encountered changes in circumstances or disease and improve their health
outcomes.
This study proposed that educating people with type 2 diabetes, within a framework
that enhances self-efficacy, would improve self-management of this disease,
health-related quality of life and psychosocial well-being and would lower health care
costs. This study was divided into three phases. The first phase of this study, was to
translate the two instruments into Chinese, and then to test the validity and reliability
of the Chinese versions of each of them in a Taiwanese population. An intervention
based on self-efficacy theory was then developed. Finally, a randomised controlled
trial was conducted to evaluate the efficacy of the intervention. If significant
differences in the outcome variables were found between the intervention and control
groups, this would demonstrate that the intervention program was effective.
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1.3 The aim, objectives, and research questions, hypotheses, and definitions
1.3.1 Two research studies in three phases
The study was divided into two research studies. Study I (Phase 1) translated two
diabetes-specific self-efficacy instruments (DMSES & PTES: the Diabetes
Management Self-Efficacy Scale and the Perceived Therapeutic Efficacy Scale) into
Chinese for use in a Taiwanese population, and tested their reliability and validity.
Study II covered two phases: Phase 2 consisted of development of an intervention
based on self-efficacy theory, and then Phase 3 was a randomised controlled trial to
evaluate the efficacy of the intervention in a Taiwanese population (see Figure 1.1).
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Figure 1.1 The two research studies
1.3.2 The aim
The aim of this study was to develop, trial and evaluate a theory-based nursing
intervention program suitable for people with type 2 diabetes in Taiwan. The
evaluation focussed on the effects of enhancing self-management, health-related
quality of life, and psychosocial well-being for people, to determine if there was any
reduction in health service usage.
Study I (Phase 1)
Translation, testing of
validity and reliability of
two diabetes-specific
self-efficacy instruments in
a Taiwanese population
Translate DMSES and
PTES scales (English to
Chinese; Chinese to
English)
Content validity (CVI)
Construct validation: factor
analysis
Internal consistency:
Cronbach’s alpha
Stability: test-retest (after
2-4 weeks): ICC; a
Bland-Altman plot
Study II (Phase 2:
Pilot study) Development of an
intervention based on
self-efficacy theory &
piloting of the intervention
Developing a suitable
intervention in
Taiwanese: included
videotape (DVD),
“Diabetes Self-Care ”
booklet, efficacy-
enhancing counselling
intervention sessions and
telephone follow-up
•Validation of the
intervention: patient and
provider experts
• Pilot the intervention
Study II (Phase 3:
Main study) Randomised controlled trial
(RCT) to evaluate the
efficacy of the intervention
Pre-test / post-test/
experimental study
Baseline- 3months- 6 months
Outcome measure:
C-DMSES
C-PTES
SDSCA
SF-12
MOS-SSS
CES-D
Health Service utilisation
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1.3.3 Objectives
The objectives of this research study were to:
• Translate and test the validity and reliability of two diabetes-specific
self-efficacy instruments (DMSES scale & PTES scale) in a Taiwanese
population.
• Develop an intervention based on self-efficacy theory that is appropriate for
the Taiwanese population; and
• Use a randomised controlled trial to evaluate the efficacy of the intervention in
a Taiwanese population in improving:
1. Self-efficacy towards management of type 2 diabetes;
2. Diabetes self-care activities, i.e., adherence to medication regime;
blood glucose testing; foot care;
3. HRQOL (health-related quality of life);
4. Psychosocial well-being; and
5. Health service utilisation.
1.3.4 Research Questions
Study I
Research Question 1: Are the two diabetes-specific self-efficacy instruments, the
DMSES and PTES, valid and reliable for a Taiwanese population?
Study II
Research Question 2: Can an intervention based on self-efficacy theory improve
self-management in people with type 2 diabetes in Taiwan?
Within Research Question 2, the following further questions were examined.
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For people with type 2 diabetes, following implementation of the SEEIP, is there a
difference in their:
2.1: Self-efficacy?
2.2: Self-care activities?
2.3: Health-related quality of life?
2.4: Psychosocial well-being?
2.5: Health care utilisation?
1.3.5 Research Hypotheses
The following hypotheses were tested during Study II (Main study):
1. People who receive the intervention would have greater self-efficacy in managing
their type 2 diabetes than those who do not;
2. People who receive the intervention would undertake diabetes self-care activities
more frequently than those who do not;
3. People who receive the intervention would have better HRQOL than those who do
not;
4. People who receive the intervention would have better psychosocial well-being
than those who do not; and
5. People who receive the intervention would have a lower usage of health services
than those who do not.
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1.3.6 Definitions of terms
For the purposes of classification, several key terms will be clearly defined here both
conceptually and operationally, including: type 2 diabetes, self-efficacy, self-efficacy
enhancing intervention program (SEEIP), self-care, diabetes self-management,
quality of life, psychosocial well-being and health care utilisation.
Type 2 diabetes
Conceptual definition: type 2 diabetes mellitus (formerly called type II, NIDDM or
adult-onset) is characterised by insulin resistance in peripheral tissue and an insulin
secretory defect of the beta cell (Expert Committee on the Diagnosis and
Classification of Diabetes Mellitus, 1997).
Operational definition: people were eligible for the study if they were diagnosed by a
doctor as having type 2 diabetes according to the clinical criteria.
Self-efficacy
Conceptual definition: self-efficacy is “people’s judgment of their capabilities to
organise and execute the course of action which require designated types of
performances” (Bandura, 1986, p.391).
Operational definition: self-efficacy is the variable “self-efficacy towards
management of type 2 diabetes”, as measured by DMSES (Diabetes Management
Self-Efficacy Scale) and PTES (Perceived Therapeutic Efficacy Scale).
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Self-efficacy enhancing intervention program (SEEIP)
Conceptual definition: the self-efficacy enhancing intervention program (SEEIP) in
this study was different from traditional education programs. The SEEIP emphasised
confidence-enhancing and goal-setting skills with a view to increasing people’s
self-efficacy and changing their behaviours. The intervention of SEEIP was based on
self-efficacy model (Shortridge-Baggett and van der Bijl, 1996).
Operational definition: the SEEIP program designed by the researcher was used to
enhance diabetic people’s self-confidence and ability in caring for themselves. The
SEEIP program provided enhanced sources of development of self-efficacy. It
included: (1) viewing a 10-minute DVD, (2) receiving a “Diabetes Self-Care”
booklet, (3) participating in four efficacy-enhancing counselling intervention sessions
at weekly intervals, and (4) participating in telephone follow-up.
Self-care
Conceptual definition: self-care is defined in terms of “level of diabetes self-care”.
Glasgow, Wilson & McCaul (1985) proposed using the term “levels” of specific
self-care behaviours as they occur in relation to specific regimen areas.
Operational definition: this study used the term “level of diabetes self-care” for the
absolute frequency or consistency of regimen behaviours (e.g. number of days per
week on which subjects engage in physical activity). The Summary of Diabetes
Self-Care Activities (SDSCA) is a self-report measure of the frequency of completing
different regimen activities over the preceding seven days, which was used to measure
self-care of diabetic people in this study. Areas of regimen assessed were glucose
testing, diet, medication taking, exercise, and foot care.
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Diabetes self-management
Conceptual definition: diabetes self-management is relevant because it is assumed
that adoption of a healthy lifestyle will produce better metabolic control of diabetes,
and in turn will aid in the avoidance of subsequent acute and long-term complications
of the disease (Toobert & Glasgow, 1994).
Operational definition: diabetes self-management in this study was defined in its
broadest terms and included all the self-care activities used by patients to maintain
their glycemic levels as close as possible to recommended target levels.
Self-management involves more than just self-care (following daily procedures as part
of a regimen). Effective self-management will produce better health outcomes,
including better self-efficacy, self-care behaviours, health-related quality of life,
psychosocial well-being, and lower utilisation of health services.
Health-related quality of life
Conceptual definition: health-related quality of life in the medical area has been
defined as “a concept encompassing a broad range of physical and psychological
characteristics and limitations, which describe an individual’s ability to function and
to derive satisfaction from doing so” (Walker & Rosser, 1987).
Operational definition: health-related quality of life was a variable for this study (as
measured by Short Form-12).
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Psychosocial well-being
Conceptual definition: psychosocial well-being is defined as “seeking a sense of
control in the face of life-threatening illness characterised by emotional distress,
altered life priorities, and fears of the unknown, as well as positive life changes”
(Ferrell, Grant, Funk, Otis-Green & Garcia, 1998).
Operational definition: in this thesis, the variable of psychosocial well-being included
the factors of social support and depression, as measured by the Medical Outcomes
Study (MOS) Social Support Survey (SSS) tool and the Center for Epidemiology
Studies Short Depression Scale (CES-D).
Health care utilisation
Conceptual definition: health care utilisation includes direct and indirect costs. Direct
costs are the health system costs attributed to program costs for treatment, operational
expenses for fixed overhead costs, and utilisation costs for laboratory and medications.
Indirect costs are patient costs related to lost time from work or leisure (Fanning,
2002).
Operational definition: health care utilisation was an outcome variable for this study
as measured by a tool designed to collect: hospitalisations (yes or no), visit to OPD
(yes or no), and visit to ER (yes or no).
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1.4 Assumptions:
1. Self-efficacy plays a significant part in self-management of diabetic people.
2. Self-care performances will be better among those people with diabetes who have
strong beliefs in self-efficacy (efficacy expectations or just self-efficacy).
3. Strong beliefs in the effectiveness of the regimen (outcome expectations) are likely
to produce better health outcomes.
4. Enhancing self-efficacy (confidence) towards self-management could enable people
with type 2 diabetes to better manage their disease and to produce better health
outcomes.
1.5 Expected outcomes
This study was divided into two research studies and included the following expected
outcomes:
1.5.1 Study I:
Demonstration of the validity and reliability of two diabetes-specific self-efficacy
questionnaires (the DMSES and PTES) in the Taiwanese population in order to enable
other researchers to use these in the future.
1.5.2 Study II:
Provision of a comprehensive diabetes education intervention: the self efficacy
enhancing intervention program and demonstration of the effectiveness of a nursing
intervention (SEEIP) when used in health care service delivery, as follows:
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The nursing intervention (SEEIP) would enhance the ability of people with type 2
diabetes to manage the disease by increasing their efficacy (confidence);
The nursing intervention (SEEIP) would increase the self-efficacy (confidence) and
then improve the level of self-care for people with type 2 diabetes;
The intervention (SEEIP) when incorporated into existing diabetes educational
programs, would improve health-related quality of life and psychosocial well-being
for people with type 2 diabetes;
Reducing health care usage and improving health-related quality of life for people
with type 2 diabetes will indirectly lower health care costs;
Publication of results will provide nurses with knowledge and enable them to
practise safe and competent evidence-based care for people with chronic diseases
such as diabetes;
Publication of results will introduce a comprehensive theory and enrich a growing
body of international knowledge about self-efficacy and self-management of a
chronic disease in Taiwan.
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1.6 Summary
In summary, the motivation for the research was based on the increasing trends of
diabetes prevalence, mortality and healthcare costs in Taiwan, low self-care abilities
and poor control by diabetics in Taiwan, few clear conceptualisations and empirical
studies related to self-efficacy and diabetes and lack of Randomised controlled trial
(RCT) research for diabetes and a great opportunity to link with international research
teams (IPSE). This study proposed that educating people with type 2 diabetes within a
framework that enhances self-efficacy would improve self-management of this
disease, their health-related quality of life, their psychosocial well-being and lower
health care costs.
Chapter 1 has outlined the background and significance of this study, presenting its
aims, objectives, research questions, hypotheses, definitions and outcomes. Chapter 2
will review the literature on the burden of diabetes mellitus and its impact on the
current health care service in Taiwan. Chapter 3 will review the literature on diabetes,
in respect of self-care, self-management, quality of life, and psychosocial issues.
Chapter 4 will describe the framework of the study, Chapter 5 will discuss its
methodology, Chapter 6 will report results, Chapter 7 will present discussions, and
Chapter 8 will present conclusions.
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Chapter 2
Review of the literature on the burden of diabetes
mellitus and on current health care in Taiwan
2.1 Introduction
In order to understand the background to this research study, this chapter provides
an overview of the population profile of Taiwan and of its health characteristics.
Over several decades, with changes in lifestyle and improvements in health care, the
leading causes of death have shifted from acute communicable diseases to chronic
diseases. For example, cerebrovascular diseases, heart diseases, and diabetes
mellitus have been the major causes of death recently. In 1980, diabetes was ranked
as the 13th leading cause of death; in 2002 it was the 4th and is expected to become
the second highest in the future (Taiwan DOH, 2006). Diabetes mellitus has a high
prevalence and mortality rate and is a great cost burden on the Bureau of National
Health Insurance. The rapid growth of health expenditure has presented the
government with greater financial difficulties. Finding solutions to reducing health
expenditure has now become a key issue for the future of Taiwan.
2.2 Population profile of Taiwan including its health characteristics
2.2.1 A profile of Taiwan
Taiwan is an island in East Asia. The total area administered by the Taiwan
government is about 36,188 Km2 (14,000 miles2). The largest city is the capital,
Taipei. In 2003, the population of Taiwan was 23 million. Of this, approximately 4
million live in two cities: 2 million in Taipei and 1.5 million in Kaohsiung. Most
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people in Taiwan are ethnic Han Chinese and were either born on the mainland or
have ancestors from there. They are divided into three groups, based on their native
Chinese dialect: Taiwanese (those who speak Taiwanese, also called Min), Hakka
(those who speak Hakka, also called Kejia), and Mandarin (Government Information
Office, Taiwan, 2004). Because its economy has achieved such rapid growth
recently, Taiwan is known as one of Asia's "Four Tigers," along with Hong Kong,
Singapore, and South Korea. The per capita GNP is US$ 14,216 (Bureau of NHI,
2002). Taiwan thus has one of the highest standards of living in the world.
2.2.2 Health care expenditure
Shifting demographic patterns and recent changes in lifestyle have influenced health
care in Taiwan. The ageing population has brought pension issues to the fore, and
long-term care for the elderly and those with serious chronic disease problems have
triggered government concerns. The total healthcare budget of Taiwan’s Department
of Health in 2002 was US$1.41 billion, and the total expenditure of the Bureau of
National Health Insurance (BNHI) was US$8.5 billion (Bureau of NHI, 2002).
According to a Taiwan government report, 8.43% of the population were aged over
65 in 2002. The health of the general population has greatly improved over recent
decades; for example, life expectancy increased between 1951 and 2001 from 53.38
years to 72.8 years for males, and from 56.33 years to 78.48 years for females,
(Taiwan DOH, 2000). This large population and high percentage of older people
requires a large number of health service institutions to provide basic health services.
The Bureau of National Health Insurance (2002) stated that there were 669 hospitals
and 17,413 clinics in Taiwan. Of the hospitals, 96 (14%) are public and 573 (86%)
private; as for clinics, 483 (2.8%) are public and 16,930 (97.2%) private. These
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facilities provide 127,676 short and long term care beds, averaging nearly 57 beds
per 10,000 people. However, most people use the services nearest to where they are
living, so the majority use private health providers.
2.2.3 National Health Insurance in Taiwan
Health insurance is another important health issue in Taiwan. Prior to March 1995,
only 59% of the population had health insurance. In view of the rapidly growing
medical care costs and the increasing numbers of older people, the government
launched a National Health Insurance (NHI) program on March 1, 1995, to provide
universal medical care (Bureau of NHI, 2002). In 2000, 21,400,826 people were
covered by the NHI program, representing 96.16% of the total 23 million population.
The NHI also signed contracts with 91% of the medical institutions nationwide to
provide medical services to all those insured, a critical point in the history of the
healthcare system in Taiwan. Although there is high public satisfaction with this
program, the rapid growth of health expenditure has placed the government in
greater financial difficulties. In 2001, the third priority of the core health policies in
Taiwan was to promote reform of NHI (Taiwan DOH, 2001). Reducing health
expenditure is the next key issue for the NHI department.
2.2.4 Core health policies in Taiwan
According to the Department of Health in Taiwan, nine core health policies were
proposed in 2001 (including several that are issues in this research study), namely
active promotion of health education to the public; extensive implementation of
community healthcare management programs; establishing a total medical
promotion service system from birth to old age; aiming to diminish medical care and
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long term care; reform of the NHI system; strengthening the national health
information network; training health workers; upgrading standards of health and
medical research; and promoting international exchange in health and medical care
(Taiwan DOH, 2001). Further health policies released in 2003 continue trying to
solve urgent issues, such as strengthening the NHI management system, raising
citizens’ awareness of healthy lifestyles, developing health technology and
participating in international health organisations (Taiwan DOH, 2004).
2.2.5 Chronic diseases in Taiwan
In the last forty years, with changes in lifestyle and improvements in health and
medical care, the ten leading causes of death have shifted from acute communicable
diseases to chronic diseases. As the proportion of elderly people increases, chronic
cardiovascular diseases have replaced infectious diseases as the major causes of
death among adults. In 2004, for example, heart diseases, cerebrovascular diseases,
and diabetes mellitus were the second, third and fourth leading causes of death,
respectively. Hypertensive diseases also overtook bronchitis, emphysema, and
asthma as the tenth leading cause of death (Taiwan DOH, 2006) (see Table 2.1).
Table 2.1 Ten leading causes of death in Taiwan in 2004
Rank Cause of death Deaths per 100,000 population
Percentage of total deaths
1 Malignant tumours 160.54 27.20 2 Heart disease 56.79 9.62 3 Cerebrovascular diseases 54.48 9.23 4 Diabetes mellitus 40.58 6.88 5 Accidents and adverse effects 37.33 6.32 6 Pneumonia 24.44 4.14 7 Chronic liver disease and cirrhosis 23.63 4.00 8 Nephritis, nephritic syndrome, and
nephrosis 20.67 3.50
9 Suicide 15.31 2.59 10 Hypertensive conditions 7.97 1.35
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Adapted from Taiwan Department of Health (2006). The ten leading causes of death in Taiwan.
Retrieved March 10, 2006, from http://www.doh.gov.tw/statistic/english/2/1.xls.htm.
According to the Department of Health (2000), Taiwan in the 21st century will face
the healthcare needs of an ageing population. Threats of cancers and cardiovascular
diseases have not abated; those chronic yet incurable degenerative diseases will
certainly generate a great burden on society and create a great drain on medical
resources. Diabetes mellitus is a chronic disease facing Taiwanese people now, the
fourth leading cause of death in Taiwan. The cerebrovascular diseases, and heart
disease, which were the second, and third leading causes of death in Taiwan, are
also serious complications of diabetes that can cause severe problems for affected
individuals and their families and a heavy burden on health services. Moreover,
diabetes is increasing to the point where health authorities are calling it an
“epidemic” requiring urgent attention (Stevens & Raftery, 1994); this is a problem
worldwide.
2.3 The prevalence, mortality rate and cost burden of diabetes mellitus in Taiwan
Diabetes mellitus in adults is a global health problem. Because it can cause a variety
of severe complications in many major organ systems, diabetes has become one of
the most costly and serious diseases. Although its prevalence varies widely between
different populations, it has generally increased worldwide (Chang et al., 2000). It is
estimated that the global number of diabetes patients will rise significantly from 176
to 370 million between 2000 and 2030 (see Figure 2.1), with more than 80% in
developing countries (Aubert, 1997; King, Aubert & Herman, 1998; WHO, 2003).
This increase has been attributed to longer life expectancy and the excess intake of
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calories and reduced physical activity in modern societies (Zimmet, McCarty &
deCourten, 1997). In 2000, the three countries with the greatest number of diabetic
patients were India, China, and the USA, where the economic burden is enormous
(American Diabetes Association, 1998a; McCarty & Zimmet, 1994) (see Table 2.2).
176,525,312
370,023,002
2000 2030Year
Figure 2.1 Total numbers of people with diabetes in 2000 and 2030
2.3.1 High prevalence rate of diabetes mellitus in Taiwan
In Taiwan, the incidence of diabetes is 0.5-1% overall and 0.9-1.8% for those over
30 years; 96.7% of this is type 2 diabetes (Chou, Li & Tsai, 2001; Tasi, et al, 2002).
A recent study indicated that the overall 5-year incidences were 187.1 for men and
218.4 for women respectively per 100,000 population (Tseng et al., 2006). The
prevalence of diabetes mellitus for the total population in Taiwan is about 4%
(Taiwan Health and Vital Statistics, 2003; Tseng et al., 2006), and for the adult
population 6-12% (Chou, Li & Tsai, 2001). In more recent years, community-based
studies have found that the prevalence of diabetes increased steadily from 5.05% to
7.10% to 8.17% in the years 1970, 1979, and 1986 respectively, for those aged
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above 40; in Taipei city, it was about 8% (Tai et al., 1987). In those aged 30 years or
more, diabetes has recently been recorded at about 12.4% (Tseng, Chong & Heng,
2000) (see Figure 2.2).
In fact, in Taiwan, the population 65 years and older is projected to grow rapidly
from 7.02% in 1993 to 14.72% in 2021 (Government Information Office, Taiwan,
2004); about one in seven Taiwan senior citizens currently suffer from diabetes
(Taiwan DOH, 2004). Taiwan’s rapid socio-economic development during the last
30 years has been accompanied by a substantial increase in the prevalence of
diabetes (Lin & Lee, 1992). It is estimated that in 2002 there were about 540,000
cases of drug-treated diabetes and that diabetes affected around one million people;
half of them being undiagnosed (Tseng, 2003; Taiwan Health and Vital Statistics,
2003; Tseng et al., 2006), out of a total population of 23 million people in Taiwan
(see Table 2.2). Although the number of diabetic patients seems to be small,
compared with other countries, the increasing trend over the past decades cannot be
ignored.
Table 2.2 Total Diabetes Population
Country 2000 2030 Rank World 176,525,312 370,023,002 India 31,705,000 79,441,000 1 China 20,757,000 42,321,000 2 United States of America 17,702,000 30,312,000 3 Indonesia 8,426,000 21,257,000 4 Japan 6,765,000 8,914,000 5 Pakistan 5,217,000 13,853,000 6 Russian Federation 4,576,000 5,320,000 7 Brazil 4,553,000 11,305,000 8 Italy 4,252,000 5,374,000 9 Bangladesh 3,196,000 11,140,000 10 Taiwan 1,000,000 1,800,000
Adapted from World Health Organisation (2004). Diabetes estimates and projections. Retrieved
Aug 25 2004, from http://www.who.int/ncd/dia/databases4.htm
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5.05%7.10%
8.17%
12.40%
0.00%2.00%4.00%6.00%8.00%10.00%12.00%14.00%
1965 1970 1975 1980 1985 1990 1995 2000 2005Years
Figure 2.2 The Prevalence of Diabetes in Taiwan
2.3.2 High mortality rate of diabetes mellitus in Taiwan
Not only have the numbers of people with diabetes increased, mortality from
diabetes is also rising. The rank order of diabetes among the leading causes of death
in Taiwan rose from 13th in 1980, to 7th in 1985 and to 5th since 1987. A recent
statistic from the Department of Health in Taiwan has revealed that diabetes was the
fourth-highest cause of death among Taiwanese in 2002 and is expected to become
the second highest in the future (Taiwan DOH, 2006).
The mortality rate of diabetes has dramatically increased from 7.9 per 100,000
population in 1980 to 16.8 in 1985 and 34.49 in 1998 (Lu et al., 1998; Tseng, Chong
& Heng, 2000) (See Figure 2.3). In 2002, there were 8,818 deaths from diabetes
mellitus, representing 6.95% of total deaths. This contrasts significantly with 198
deaths, or 0.27% in 1960 (Lin & Lee, 1992).
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7.9
16.8
34.49
0510152025303540
1975 1980 1985 1990 1995 2000Years
Figure 2.3 Mortality Rate for Diabetes in Taiwan
2.3.3 The high proportion of health expenditure for the treatment of diabetes mellitus
The number of deaths attributed to diabetes has been increasing over recent decades
and this also impacts on total healthcare expenditure. Diabetes is more prevalent in
older adults (Fitzgerald et al., 2000) and 97% of diabetic cases suffer from type 2
diabetes (Tasi, et al, 2002). Diabetes is associated with long-term complications,
including heart disease, peripheral vascular disease, neuropathy, retinopathy, and
renal disease, and poor health-related quality of life (Guthrie & Guthrie, 2002). In
Taiwan, the complication rates of diabetes are 31.8% for retinopathy, 26.6% for
peripheral vascular disease, 21.2% for neuropathy, and 0.8% for chronic renal
failure (Lin et al., 2001). Diabetic patients also represented 26.6% of those with end
stage renal disease requiring dialysis each year (Tseng, 2002). The level of diabetes-
related complications is impossible to reverse and will be a heavy financial burden
in the future. In a recent retrospective study (Tseng, 2002), the average total cost for
each diabetes patient was estimated to be NT (New Taiwan dollar) $52,532. Of this
cost, 85.5% was direct and 14.5% indirect. The per capita expenditure for diabetic
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patients was 4.3 times higher than for non-diabetic patients (Chen, Yen & Tung,
2001; Lin et al., 2001). The average number per year of out-patient visits and in-
patient admissions were 10.1 and 0.21 respectively for each patient with diabtes.
The average work loss days were 2.7 and 2.1 days, for patients and their family
members, respectively (Chen, Yen & Tung, 2001). Also, Wei, Chuang, Lin, Chao
and Sung (2002) showed that among those with diabetes, 18.6-20.0% of males and
16.5-17.8% of females experienced at least one hospitalisation annually. These
statistics reflect the considerable impact that the disease has on the health care
system.
Diabetes is becoming one of the major public health problems because a large
proportion of the health care expenditure has been spent on its treatment, and
because of its associated morbidity and mortality. Most diabetes expenditure is used
to pay for inpatient services (60-85%); the biggest part of it (70%) because of late
diabetes complications; and diabetes accounts for 3-12% of total health care
expenditure in different countries (Logminene, Norkus & Valius, 2004). According
to Bureau of National Health Insurance data, the health care cost for diabetic
patients amounts to 11.5% of the total health care expenditure in Taiwan (Tseng,
2003) and consumed more than US$320 million in the year 2003 (Taiwan Health
and Vital Statistics, 2003; Tseng, et al, 2006). Of this total, approximately three-
fourths of expenditure has been used in the treatment of diabetes complications
(Tseng, 2003). Diabetes therefore, is not only a serious health problem in Taiwan
but also has a major impact on the National Health Insurance budget.
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2.3.4 Conclusions
The global burden of diabetes is enormous, particularly in developing countries.
Taiwan, too, has increasing trends of diabetes prevalence, mortality and healthcare
costs. It is important to prevent complications and to prolong the life of the patients.
It is easy to become frustrated over these patients; studies have shown that diabetes
can be prevented by regular exercise and dietary control. In other words, preventing
the occurrence of chronic diabetes complications or diabetes itself would seem to be
the most efficient way to reduce the heavy burden of diabetes. Taiwan may need to
introduce different health care services or find a new strategy to address these tough
tasks.
2.4 Current situation for diabetes health care services in Taiwan
2.4.1 Community-based approach
The community-based approach to diabetes treatment and management is confined
to the public health service system. Diabetes is a chronic disease that needs to be
monitored. Health stations, staffed with physicians, pharmacists and nurses, are
community-oriented and form the basis of primary health care in Taiwan; on
average, each health station has one or two doctors. Surveys have shown that 70-
90% of the visits to these centres are for infant and child immunisations. Prior to
1990 the government did not provide any community health care services programs
specifically for diabetes. People who suffer from diabetes only half of them seek
medical treatment (Tseng, 2003) for example, private medical clinic or hospitals.
Between 1990-1999, epidemiological surveys were conducted in communities
across Taiwan, including Taipei, Jilung, Kinmen, Puli, Hualien, and Tainan (Tai et
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al., 1987; Lin, Shieh, Huang & Huang, 1993; Chou, Liao, Kuo, Hsiao & Tsai, 1994;
Chou, Li, Kuo, Hsiao & Tsai, 1997; Chen, Shaw, Tseng, Chen & Lee, 1997; Lu, et
al, 1998); some of these were government funded. These surveys sought to achieve
was a better understanding of the prevalence and mortality rate of diabetes in
Taiwan, and they focused on exploring the morbidity of prediabetes or diabetes,
based on community evidence. Also, during that period, chronic disease control
institutions were asked to provide on-the-spot screening for blood pressure, blood
sugar and cholesterol in areas with poor communications and medical care resources,
in order to detect chronic disease patients early for referral for treatment and follow-
up management. However, no interventions or health programs were conducted in
communities at that time.
During 1999-2000, community diabetes policy gave rise to the shared care network
program conducted in the Ilan and Tao-Yuan areas. Hickman, Drummond &
Crimshaw (1994) defined the project as “the joint participation of hospital
consultants and general practitioners in the planned delivery of care for patients with
a chronic condition, informed by an enhanced information exchange over and above
routine discharge and referral notes”. The purpose was to combine the resources of
public health care systems, acute care systems, and medical professionals to form an
effective and efficient health care service (Chou, Li & Tsai, 2001). This
development is now being evaluated and plans are being made to extend it into
diabetes care in the public health system. At present, however, there is a lack of
concrete community health care programs or interventions related to diabetes.
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2.4.2 Hospital-based approach
It is estimated that in 2002 there were about 540,000 cases of drug-treated diabetes,
and that diabetes mellitus was affecting around 1 million people in Taiwan (Tseng,
2003). That means that half of the people with diabetes were undiagnosed (Tasi et
al., 2002) and that the majority of people use private health services (Bureau of NHI,
2002).
Before the National Health Insurance program was launched in 1995, many people
with diabetes found medical care too expensive and some deliberately ignored their
disease. Hospital resources for diabetes patients were also very limited at that time.
Since 1995, the Bureau of National Health Insurance (BNHI) has improved access
to care for the Taiwanese people and provided them with greater financial risk
protection. This policy benefits most of the population in Taiwan, especially people
who suffer from chronic diseases, such as diabetes or cancer, which impose severe
financial, human and social burdens.
Recently, the rapidly growing costs of medical care and the increasing number of
medical complications from diabetes have attracted the attention of the BNHI. The
existing literature indicates that financial incentives have a significant influence on
provider behaviours (Hanchak, Schlackman & Harmon-Weiss, 1996). So in 2001,
BNHI introduced quality-based payment programs to improve quality of care. Since
October 2001, five major diseases, including cervical cancer, breast cancer, diabetes,
tuberculosis, and asthma were provided for by this program. Extra financial rewards,
in addition to the BNHI fee schedule, were granted to medical providers,
reimbursing them for providing nutrition advice and individual diabetes education. It
is estimated that there are about 139 diabetes educational promotion institutions in
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Taiwan so far, including centres, classes, and outpatient clinics, usually divided into
three levels according to quality of care (Bureau of NHI, 2002). Diabetes quality-
based payment programs are only found in large hospitals, such as medical centres
or area hospitals, who can apply for just part of the extra fee from BNHI (Tasi et al.,
2002). So this program is not easy to extend into general diabetes health care; it
needs to be evaluated and improved continually in the future.
In 2001, another scheme of the Bureau of Health Promotion in the Department of
Health was piloted in many hospitals. A diabetes passport was freely provided for
people when they visited GPs (general practioners) in hospitals; it consisted of
simple medical records and diabetes education information. The government hoped
the passport would prompt people about this disease; however, hospitals or
providers have largely ignored this scheme, as it is not compulsory.
In a survey report (Tasi et al., 2002), conducted by the Taiwanese Association of
Diabetes Educators, data were collected from 53 hospitals that had joined the
quality-based payment programs for diabetes. Extra health services, including
nutritional or medication education, were supposedly provided to 5698 diabetes
patients. A randomised sampling design was used in this study. Results revealed that
96.7% of patients suffered from Type 2 diabetes. Of these, 54.8% were female and
45.2% male; average age was 63.4; average time since diagnosis was 11.8 years. In
terms of complications, 31.8% had retinopathy, 26.6% peripheral vascular disease,
21.2% neuropathy, 0.8% chronic renal failure, 1.5% were blind, and 1.0% had
suffered amputation (see Table 2.3). The results of the survey indicate that diabetes
has been poorly controlled in the medical care system in Taiwan even though an
extra payment program was introduced and applied for their routine care.
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Table 2.3 Results of diabetes care
Categories Diabetes care Number of cases 5055 Female (%) 54.8 Age 63.4±12.4 Length of disease (years) 11.8±7.6 Type 2 (%) 96.7 BMI 25.2±3.5 BMI>25 (%) 47.6 Insulin treatment (%) 22.6 HbA1c (%) 8.9±2.2 Complications: Retinopathy, 31.8% Peripheral vascular disease 26.6% Neuropathy 21.2% Chronic renal failure 0.8% Blind 1.5% Amputation 1.0%
Adapted from Tasi et al. (2002).
A report of diabetes quality care. Annual Report of Taiwanese Association
of Diabetes Educators. Taipei: Taiwanese Association of Diabetes Educator.
2.5 Diabetes in Taiwan: self management issues
About 1 million people in Taiwan suffer from diabetes but only half of them seek
medical treatment (Tseng, 2003). Tseng (2003) stated that 30% of people with
diabetes were found to have an HbA1c level >10% in Taiwan. This means that two-
thirds of diabetic patients do not control their disease appropriately since it is
difficult for them to change their life style and diet habits. The normal range of
HbA1C is below 6%; because an average HbA1C higher than 7% is associated with a
higher risk of complications, the recommended glycemic goal for a diabetic
population is under 7% (ADA, 2002b). A recent study found that still only 9.4 % of
patients < 65 years and 14.0 % > 65 years had HbA1c values within the optimal
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range (HbA1c < 6.5 %) (Tai et al., 2006). This means the disease is being very
poorly controlled.
Many people with diabetes in Taiwan do not visit their doctor regularly until serious
complications have occurred. Moreover, basic clinics and large hospitals do not trust
each other because of keen competition; small private clinics do not transfer patients
to large hospitals until the situation has become critical, resulting in higher medical
costs to treat a worsened situation. According to Tseng (2002), the average annual
number of clinic visits was 35.8 per patient, representing 6.2% of outpatient clinic
use. The average duration of each admission, for diabetic patients was 16.8 days and
for non-diabetic was 7.7 days, representing 22.1% of total admission days.
Admissions of diabetes patients were mostly due to diabetic complications.
People not only fail to change their life style and habits, but also lack information
about and confidence in health care settings. Many people with diabetes prefer to be
managed by their GP (Dunning, 2003), however GPs usually have no systematic
ways of providing education to their patients. For example in Taiwan, patients
expect doctors to offer detailed explanations of test results and self-care information,
but doctors are unlikely to do so because of limited consultation times. Sometimes,
also, people do not ask questions even when doctors are listening to them, because
they are unwilling to challenge doctors. In general, diabetes patient education can be
found in many hospitals and community health services in Taiwan. These traditional
patient educational programs can be conducted through either individual or group
education. Normally nurses or diabetes educators, and only a few nutritionists or
dieticians, will be involved in diabetes patient education programs. Several factors
contribute to the lack of provision of education for diabetic patients, such as pressure
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of time, lack of communication skills, lack of familiarity and confidence with
appropriate education strategies, and lack of counselling skills. These circumstances
often make it more difficult for diabetic patients to cope with their disease. If
outpatient clinics do not provide professional information, people will remain
uninformed about strategies for controlling their illness. Many people with diabetes
in Taiwan do not receive enough medical information and frequently become
frustrated (Chuang et al., 2001).
In addition, while some people have poor control of their disease due to deficits in
self-care knowledge or skills, a large proportion of people with diabetes are not
motivated to make any changes. In Taiwan, two epidemiological surveys showed
that only 30% of people with diabetes have performed self-monitoring of blood
sugar or urine sugar; demonstrating that they either lack skills or have low
participation rates in performing self-care actives (Chuang et al., 2001; Lin et al.,
2001). It is necessary to develop local support groups for diabetes patients and
volunteers where the self-care motivation of patients can be raised with the
professional help of consultants and nutritionists. Only through education and
empowerment can people’s awareness of their self-care abilities be improved,
leading to a better quality of life (Chuang et al., 2001).
2.6 Literature on diabetes care interventions in Taiwan
This study was based on the supposition that educating people with type 2 diabetes
within a self-efficacy framework would enhance their self-management capabilities
for the disease. Early efforts focused on patient education for people with diabetes,
so many diabetes articles have been published in Taiwan, including issues of
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educating patient as individuals and in groups (Chuang et al., 1989). But recently the
importance of psychological and behavioural interventions has been emphasised,
because of the growing recognition that knowledge alone is insufficient to produce
significant changes in behaviour (Peyrot, 1999). Brown (1999) has stated that
interventions combining behavioural techniques with the provision of information
were found to be more effective than those that only provided information.
In Taiwan, there have been 92 studies related to self-efficacy, in areas such as
education, social learning, job satisfaction, information management and exercise
behaviours. Few researchers have engaged in self-efficacy research in health, but
those who did so have shown that self-efficacy is an important predictor of
successful health promotion interventions (Chang, Huang & Lee, 1996; Wang &
Chiou, 1996; Chang & Lin, 1997; Hung & Kao, 1997; Chen, Chang & Lin, 1998;
Wang, Wang & Lin, 1998; Guo, Tsay & Yen, 2002;). Up to now, only three
correlational research studies relating to self-efficacy and diabetes (Chang & Lin,
1997; Chen, Chang & Lin, 1998; Wang, Wang & Lin, 1998), and two intervention
studies relating to empowerment and diabetes have been found (Guo, Tsay & Yen,
2002; Lai & Liu, 2003) (see Table 2.4).
Of these intervention studies, one article describes an empowerment-training
program in a hospital followed by evaluation of HbA1C and depression levels (Guo,
Tsay & Yen, 2002), while another describes a social support and empowerment
education course and evaluates its effect in a community (Lai & Liu, 2003). The
other two intervention studies were not related to self-efficacy theory. One article
evaluated the effects of an aerobic exercise-training program on diabetic patients’
physical parameters and psychosocial aspects (Lin, 2003) and the other study
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evaluated a diabetic patient education program for its effects on weight and blood
glucose control (Chuang et al., 1989). Moreover, few studies used randomised trials,
since they were trying to produce improvements in diabetes knowledge but were less
concerned with measures of self-management or behaviour change. Also, many
studies lacked a comprehensive model and theory. Most current studies did not
include an intervention, and hence there is a lack of diabetes-related studies,
particularly in Taiwan, on changes to self-efficacy based on Bandura’s four sources
of efficacy information. The results of these studies are difficult to apply extensively
in clinical practice.
Glasgow et al. (1989) has highlighted the methodological defects of studies on
diabetes self-care correlates: the lack of clear conceptualisations and the fact that
many empirical studies lacked a comprehensive model and theory. WHO (2003)
pointed out that data from developing countries concerning correlates of adherence
of regimens in patients with diabetes are particularly scarce. Also, the absence of
standard measurement instruments prevents comparisons being made between
studies and real practice. Much work needs to be done to develop standardised,
reliable and valid measurement tools. One of the important epidemiological studies
in Taiwan (Chou, Li & Tsai, 2001) concluded that, once the epidemiological
situation of diabetes is understood, the next step should focus on the self-
management issues regarding diabetes, and that both patient education programs and
training for health professionals will be needed in the future.
Further studies on nursing interventions for diabetes will be particularly crucial in
the future. In addition, it is time to develop and evaluate an intervention that
includes clear conceptualisations and a basis in self-efficacy theory. Testing the
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model in different countries and cultures will also result in important progress in
diabetes services. This could not only increase the self-management ability of
diabetic people to change their health behaviours, but also provide a large body of
knowledge, based on a comprehensive theory, for diabetes professionals in Taiwan.
2.7 International cooperation
According to the Department of Health in Taiwan, in the coming century it is
becoming increasingly important to promote international cooperation, to exchange
information, to share medical care services, and to research and train for the global
promotion of human well-being (Taiwan DOH, 2001). The priorities of core health
policies need to be articulated: to upgrade standards of health and medical research
and to promote international exchange in health and medical care. It can be seen that
international cooperation is an aim of Taiwan’s government at present. This study
provides an excellent opportunity to link with international research teams (the
International Partnership in Self-management and Empowerment; IPSE) and to
develop and test the self-efficacy model in Taiwan. Results of this study may be
compared internationally and will contribute to diabetes services in Taiwan.
2.8 Summary
Key issues facing people with diabetes are discussed below
Government
The National Health Insurance service was launched comparatively recently in
Taiwan, and its financial difficulties are growing, due in part to the high levels of
prevalence and mortality of diabetes mellitus, and the resulting high cost burden. So
far, there are few suitable strategies in place for addressing diabetes, and there are no
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effective program evaluations being conducted. Care providers are not adequately
rewarded by the government.
Healthcare system (communities and hospitals)
The public health system does not manage chronic disease care effectively, even
though it is a priority core health policy. The public health system is not well
coordinated with the acute care system, so that public health and acute care
organisations do not pass on to the government useful suggestions or experiences
obtained from pilot programs. Hospitals are unable to choose appropriate
interventions or apply them effectively to people with diabetes. The quality of
diabetes care in the health care system is not very high, especially for people with
type 2 diabetes, representing 95-97 % of the total diabetes population in Taiwan.
Individual management
There is a gap in expectations, in terms of self-care issues, between health providers
and people with diabetes. People have mistaken ideas about diabetes, such as not
needing to visits their GPs regularly, and do not feel responsible for their own self-
care. They have a lack of knowledge, skills, motivation and willingness to change
lifestyles, and are short of confidence and feelings of empowerment.
There are five summary conclusions for Taiwan’s situation:
1) Epidemiological studies and vital statistics have revealed increasing trends in
prevalence, mortality and healthcare costs for diabetes. Diabetes in Taiwan is
not being effectively controlled, and the direct and indirect expenditures on
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diabetes are very high; its control is vital to avoid complications and prolong
the life of patients.
2) The government and the healthcare systems are struggling with the
difficulties of the diabetes problem. For example, the government is
attempting to build up support networks, and trying to combine professional
resources to improve the accessibility to services for diabetic people in
communities. In addition, the NHI not only provides very high funding for
the healthcare system, but also provides quality-based payment programs to
assure the quality of care in hospitals. These need to be continuously
evaluated and improved.
3) An important key factor is the need to enhance the self-care abilities and
motivation of people with diabetes; otherwise the poor control of diabetes
will remain.
4) There are very few clear conceptualisations and empirical studies related to
self-efficacy in the areas of health and diabetes, and a lack of randomised
trial research for diabetes. Moreover, no researchers are engaged in self-
efficacy studies in relation to diabetes that rely on interventions, particularly
those based on the four sources of information identified by Bandura (1977a)
period, Clearly, much work needs to be done to develop standardised,
reliable and valid measurement tools and to develop a comprehensive self-
efficacy model and theory in Taiwan.
5) Promoting international cooperation is also a major aim of the Taiwan
government.
In summary, improving self-management, enhancing quality of life, and reducing
health service utilisation for persons with type 2 diabetes is an ongoing challenge for
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health-care providers. An important way of addressing these problems is by
reinforcing their self-efficacy (confidence) in self-management.
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Table 2.4 Publications related to self-efficacy or interventions for diabetes care in Taiwan Author Intervention
or correlation studies
Sampling method
/ sample size
Framework Comp-rehensive
theory base?
Result
Chang & Lin (1997)
Correlation A convenience sample/ n=72
Self-efficacy No -There was a strong correlation between the IMDSES scale and the Diabetes Self-Care scale (r=0.94, p<0.01)
Chen, Chang & Lin (1998)
Correlation A convenience sample/ n=66
Self-efficacy No - Subjects had the highest scores in self-efficacy of glucose testing and taking medicine. Also, subjects had the highest scores in self-care behaviours of glucose testing and taking medicine.
-Specific items in self-efficacy were significantly corrected with corresponding items in self-care behaviours (r=0.88, p<0.001).
Wang, Wang & Lin (1998)
Correlation A convenience sample/ n=130
Self-efficacy No -Social support and self-efficacy scores corrected significantly with self-care behaviours.
- Self-efficacy was found to explain 74.0% (a multiple stepwise) variance of self-care behaviours.
Guo, Tsay & Yen (2002)
Intervention (Empower-ment-training program)
A convenience sample/ n=67
Self-efficacy (empowerment)
No -The empowerment had a negative correlation with HbA1c and positive correlation with self-efficacy and self-care scores.
-Patients in the experiment group significantly improved their levels of empowerment, self-efficacy and self-care more than patients in the control group.
-There were no significant in blood sugar control and depressive mood between groups.
Lai & Liu (2003)
Intervention (Social support and empowerment module)
A convenience sample/ n=49
Social cognitive theory, social support, social belief and conception of empowerment
No -The social support and empowerment module (SSEM) education course could significantly increase social support of the experimental group.
-The SSEM education course could significantly increase empowerment of the experimental group and empowering patients with power, self-efficacy and self-care behaviour.
-After intervention, the experimental group was higher than the control group on social support and empowerment.
Chuang et al. (1989)
Intervention (patient education program)
A convenience sample/ n=260
Patient -education
No -The diabetic patient education had a significant influence with the weight control and blood glucose control.
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Author Intervention or correlation
studies
Sampling method
/ sample size
Framework Comp-rehensive
theory base?
Result
Lin (2003) Intervention (an aerobic exercise-training program)
A convenience sample/ n=13
Aerobic exercise-training
No -OGTT glucose level, triglyceride (p<.05) were lower after adjusting possible confounding factors.
-Fasting glucose, HbA1C, body weight, BMI, heart rate, BP were decrease significantly (P<.0001)
-Quality of life (MCS of SF36) were elevated except bodily pain and PCS and more time of exercise training they received, the more their depression improved (p<.05)
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Chapter 3
Review of literature on diabetes, self-care, quality of
life, and psychosocial issues
3.1 Introduction
Diabetes mellitus is the main focus of this research study. The literature review in this
chapter examines the main issues related to diabetes mellitus. The first section
presents general information about diabetes, including its diagnosis and definition,
classification, and complications. The following sections relate to the outcome
variables of this study: self-care of diabetes, such as blood glucose monitoring,
nutrition, exercise, medication and foot care; the quality of life of people with diabetes;
and psychosocial issues.
3.2 Diabetes Mellitus
3.2.1 Diagnosis and Definition
Diabetes mellitus (diabetes) encompasses a heterogeneous group of diseases of
various aetiologies. It is defined as a symptomatic or asymptomatic state of altered
carbohydrate metabolism characterised by two or more fasting plasma glucose levels
of 126 mg/dL (7.0 mmol/L) or greater, or a value of 200 mg/dL (11.1 mmol/L) or
greater at 2 hr, on an oral glucose tolerance test. A diagnosis of diabetes can also be
made with a random blood glucose value of 200 mg/dL (11.1 mmol/L) or greater if it
is associated with symptoms (polydipsia, polyuria, polyphagia, unexplained weight
loss) (Guthrie & Guthrie, 2002; Expert Committee on the Diagnosis and
Classification of Diabetes Mellitus, 1997). However, some people may have even
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been given a warning by a doctor that their “sugar was a bit high”, which they
mistakenly interpreted as a grace period before a diagnosis of diabetes. Impaired
Fasting Glucose (IFG) or Impaired Glucose Tolerance (IGT) are now known as “pre-
diabetes”, where the sugar levels are clearly no longer normal, but not yet at the level
required for the actual diagnosis of diabetes. The diagnosis of impaired fasting
glucose (IFG) as fasting plasma glucose between 110 mg/dL and 126mg/dL (6.1-
7.0mmol/L); and impaired glucose tolerance (IGT) as 2-hr post plasma glucose from
140/dL to <200mg/dL (7.8 to <11.1mmol/L). Both these categories, IFG and IGT, are
risk factors for future diabetes and cardiovascular disease (ADA, 2002b). Table 3.1
shows that diagnostic criteria for diabetes based on the fasting plasma glucose.
Table 3.1 Diagnostic criteria for diabetes based on the fasting plasma glucose (venous)
Stage Fasting plasma glucose (venous)
mmol/L (mg/dL)
Normal < 6.1 (<110)
Impaired Fasting Glycaemia (IFG) ≥ 6.1 and <7.0 (≥ 110 and <126)
Diabetes Mellitus ≥7.0 (≥ 126)
Another definition briefly states that diabetes mellitus is a metabolic disorder in which
the body’s capacity to utilise glucose, fat and protein is disturbed, due to insulin
deficiency or insulin resistance, both of which lead to an elevated blood glucose
concentration and glycosuria (Dunning, 2003). In addition, the American Diabetes
Association and WHO define diabetes as a group of metabolic diseases characterised
by hyperglycaemia resulting from defects in insulin secretion, insulin action, or both.
Common to all types of diabetes mellitus is chronic hyperglycaemia, which is
associated with long-term damage, dysfunction and failure of various organs,
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especially the eyes, kidneys, nerves, heart and vessels (Alberti & Zimmet, 1998).
After defining diabetes, the American Diabetes Association (ADA) announced in
1997 a revised diabetes classification system and diagnostic criteria, described below.
3.2.2 Classifying diabetes
Since 1995, the American Diabetes Association’s expert group has convened to
review the literature and determine what changes to the diabetes classification system
and diagnostic criteria are necessary. New recommendations for the classification and
diagnosis of diabetes mellitus include the preferred use of the terms “type 1” and
“type 2” instead of “IDDM (Insulin Dependent Diabetes Mellitus)” and “NIDDM”
(Non-Insulin Dependent Diabetes Mellitus) to designate the two major types. In June
1997, an international expert committee released a report with new recommendations
for the classification and diagnosis of diabetes mellitus (Expert committee on the
Diagnosis and Classification of Diabetes Mellitus, 1997). These revised data resulted
from a joint activity between the American Diabetes Association (ADA) and the
World Health Organisation (WHO). The new classification system identifies four
types of diabetes mellitus: type 1, type 2, gestational diabetes and other specific types.
Arabic numbers are specifically used in the new system to minimise the occasional
confusion of type “II” as the number “11”. Moreover, the diagnostic criteria do not
require the oral glucose tolerance test (OGTT) (Guthrie & Guthrie, 2002).
Type 1 diabetes mellitus (formerly called type I, IDDM or juvenile diabetes) is
characterised by beta cell destruction caused by an autoimmune process, usually
leading to absolute insulin deficiency (Expert Committee on the Diagnosis and
Classification of Diabetes Mellitus, 1997). Over 95% of persons with type 1 diabetes
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mellitus develop the disease before the age of 25. There are two forms of type 1
diabetes: immune-mediated diabetes mellitus, which results from autoimmune
destruction of the pancreatic beta cell; and idiopathic diabetes mellitus, referring to a
form of the disease that has no known aetiologies (Dunning, 2003).
Type 2 diabetes mellitus (formerly called type II, NIDDM or adult-onset) is
characterised by insulin resistance in peripheral tissue and an insulin-secretory defect
of the beta cell (Expert Committee on the Diagnosis and Classification of Diabetes
Mellitus, 1997). This disease was formerly called adult or maturity-onset diabetes, but
with the increasing prevalence of the disease in children, age related terminology can
no longer be used. The term NIDDM (Non-Insulin Dependent Diabetes Mellitus) was
also changed because many of these individuals require insulin for control. With these
problems in mind, in 1997 the Committee decided to simplify the terminology to type
2 diabetes. This form of disease occurs predominantly in adults (basically persons
older than 30), but may occur at any age (Guthrie & Guthrie, 2002) and is strongly
associated with a family history of diabetes in women, especially women with a
history of gestational diabetes, with old age (especially over 40 years of age), and
with obesity and lack of exercise; however, the prevalence of eating disorders is
similar in type 1 and type 2 diabetes (Herpertz, Albus & Wagener, 1998; Dunning,
2003). Previous research has shown that diabetes is a genetic disease, the gene or
genes being prevalent in all societies, but that the disease becomes manifest primarily
as societies industrialise, and as calorie intake increases and calorie expenditure
decreases (Guthrie & Guthrie, 2002). The majority of people with type 2 diabetes
require multiple therapies to maintain acceptable blood glucose goals, for example 50
to 70% require insulin, often in combination with oral medicine regimes. This means
that diabetes management is more complicated for people with type 2 diabetes, which
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increases their likelihood of non-compliance, and the cost of managing the disease for
both the patient and the health system (Dunning, 2003).
Gestational diabetes mellitus is an operational classification (rather than a
pathophysiologic condition) referring to diabetes mellitus developed by women
during gestation. This definition of gestational diabetes mellitus and its diagnosis was
not altered in the new recommendations (Expert Committee on the Diagnosis and
Classification of Diabetes Mellitus, 1997).
Other specific types of diabetes mellitus include diabetes caused by other identifiable
disease processes: genetic defects of beta cell function such as Maturity Onset
Diabetes in the Young (MODY); genetic defects of insulin action; disease of the
exocrine pancreas, such as cancer and pancreatitis; endocrine diseases such as
Cushing’s disease and acromegaly; and drug or chemically induced diabetes (Expert
Committee on the Diagnosis and Classification of Diabetes Mellitus, 1997).
3.2.3 Complications
Diabetic complications contribute to the overall cost of health care for those with
diabetes and for health care providers; many people are admitted to hospital because
they have active diabetes. Complications can be classified as acute or long term; acute
complications may occur during temporary changes in blood glucose levels, while
long term complications usually accompany long duration of diabetes and persistent
hyperglycaemia (Dunning, 2003). Acute complications include hypoglycaemia;
hyperglycaemia; infection; fat atrophy or hypertrophy; and insulin allergy. In recent
years, vascular disease and neuropathy, long term complications of diabetes, have
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become the leading cause of death among persons with diabetes (Guthrie & Guthrie,
2002).
Long term complications can be divided into macrovascular complications, including
increased atherosclerosis and cardiovascular disease, myocardial infarction and stroke
(Dunning, 2003; Guthrie & Guthrie, 2002) and microvascular complications,
including retinopathy, neuropathy, and nephropathy (Wandell, 1998; Dunning, 2003).
Coronary heart disease, a macrovascular complication of diabetes, is the greatest
cause of death in persons with type 2 diabetes in Caucasian and industrialised
countries. The estimated mortality rates of coronary heart disease range between 50%
and 60% (Panzram, 1987), conferring a 2 to 4 fold increase in mortality risk compared
with the non-diabetic population (Jarret, 1984). Small-vessel disease or
microangiopathy involves the small blood vessels all over the body; its clinical
manifestations occur in only two organs, the kidney and the eye. According to the
American Diabetes Association, diabetic retinopathy is the most frequent cause of
new blindness among adults aged 20 to 74; after 20 years with type 2 diabetes, nearly
60% of patients have some degree of retinopathy (ADA, 1998b).
The relationships between factors and the development of diabetes complications
must be clarified. A number of factors might play a role in the development of
diabetic complications. Studies have showed that the most important factors for
macrovascular complications were the duration of diabetes, age, hypertension,
hyperglycaemia and smoking (Morrish et al, 1991; Wandell, 1998). A study has also
showed that, for microvascular complications, the most important factors were the
duration of diabetes and age (Wandell, 1998). For microvascular complications the
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risk factors include high blood pressure, high serum total and LDL cholesterol, low
serum HDL cholesterol and raised serum triglycerides, poor glucose control and
smoking. In 1998, the United Kingdom Prospective Diabetes Study demonstrated the
importance of controlling blood pressure to reduce the risk of cardiovascular disease
and of lowering blood glucose to reduce the incidence of microvascular complications
(UKPDS, 1998).
In Taiwan, the high complication rate of diabetes places a heavy financial burden on
the government. Recent complication rates for diabetes include: retinopathy (31.8%);
peripheral vascular disease (26.6%); neuropathy (21.2%); and chronic renal failure
(0.8%) (Lin et al., 2001). The prevalence of large vessel disease (LVD) in diabetic
and non-diabetic subjects has been found to be 20.0% and 12.9%, respectively.
Among diabetics, 15.8% have ischemic heart disease (IHD), 1.7% leg vessel disease,
and 2.5% stroke. Diabetics have a significantly higher prevalence of macrovascular
disease than non-diabetic subjects (Chang et al., 2000). Moreover, diabetes mellitus is
one of the chronic diseases facing Taiwanese people today; it is the fourth leading
causes of death in Taiwan, while the cerebrovascular diseases and heart diseases, the
second, and third leading causes of death in Taiwan respectively, are also the
complications of diabetes (see Chapter 2). Its complications can cause severe
problems for affected individuals and their families and are known to impose a heavy
burden on health services. The treatment of diabetes-related complications is a heavy
financial burden and needs to be considered seriously.
Interestingly, reducing the risk of developing most complications is preventable
through appropriate blood glucose control or by lowering factors that cause the
disease to progress. For example, the relationship between microvascular
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complications and the level of metabolic control measured as HbA1C is firmly
established (Dahl-Jorgensen, Brinchmann-Hansen, Bangstad & Hanssen, 1994).
Moreover, the UKPDS has provided strong support for the American Diabetes
Association’s position that vigorous treatment of diabetes can decrease the morbidity
and mortality of the disease by reducing its chronic complications (American Diabetes
Association, 2002a). The chronic complications of diabetes can be avoided by striving
to achieve normal levels of serum glucose, blood pressure and lipids. They can be
effectively treated if they are detected early. Although aggressive therapy can prevent
or improve the progression of diabetic complications and should be started at the time
of diagnosis (Bell & Ala, 2002), establishing self-care responsibilities for people with
diabetes is a base solution for effective management of diabetes. According to
Anderson (1985), people with diabetes indicate that they consider the daily regimen of
self-care activities more difficult than the diagnosis of diabetes itself. The topic of
self-care of diabetes becomes an important role of effective management of diabetes
and will be described in the next section.
3.3 Self-care of diabetes
There is an increasing trend to have patients take an active role in regulating their
treatment and self-care (Downer, 2001). Effective management of diabetes requires a
team care approach that may include the following members: diabetologist; diabetes
nurse specialist or educator; dietician; podiatrist; social worker; psychologist; general
practitioner and the patient (Dunning, 2003); however, the person with diabetes is the
most crucial player in the team. In fact, diabetes is a self-managed disease; over 95%
of diabetes management is done by patients themselves. For diabetes care to succeed,
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patients must be able to make informed decisions about how they will live with their
illness (Funnell & Anderson, 2000).
The aim of diabetes control is to maintain quality of life, to remain free from the
symptoms of diabetes, and to keep blood glucose in an acceptable range. The range is
determined on an individual basis, usually between 4 and 9 mmol/L. Also, people
with diabetes require the adoption and maintenance of multiple self-care behaviours to
achieve and sustain glycaemic control (Drury, 1979) that can include insulin
injections several times daily, oral hypoglycaemics, a strict calorie-controlled diet that
is low in fat and high in fibre, and regular exercise (Wing et al., 1986). Self-care
behaviours play an especially crucial role for the person with diabetes.
Self-care, following daily procedures as part of a regimen, is the minimum level of
competence required for people who have diabetes (Guthrie & Guthrie, 2002).
However, the procedures for self-management involve more than that. In this thesis,
self-care is defined as “level of diabetes self-care”, following Glasgow, Wilson &
McCaul (1985) who proposed using the term “levels” of specific self-care behaviours
as they occur in relation to specific regimen areas. Others have used the term
“diabetes self-management” similarly (Wing et al., 1986; Goodall & Halford, 1991).
According to Toobert and Glasgow (1899), it is difficult to formulate self-care
improvement strategies without a means to determine accurately the frequency or
consistency of a regimen of behaviours. This study uses the term “level of diabetes
self-care” for the absolute frequency or consistency of regimen behaviours (e.g.
number of days per week on which subjects engage in physical activity). The
Summary of Diabetes Self-Care Activities (SDSCA) (Toobert, Hampson & Glasgow,
2000) is a self-report measure of the frequency of completing different regimen
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activities over the preceding seven days that was used to measure self-care of people
with diabetes in this study. Areas of regimen assessed were glucose testing, diet,
medication taking, exercise, and foot care; so the topics of blood glucose monitoring,
nutrition, exercise, medication and foot care therefore, will be described below.
3.3.1. Blood glucose monitoring
The self-monitoring of blood glucose (SMBG) is an important part of diabetes self-
care, as it is a way of evaluating therapy efficiency and adjusting treatment. SMBG
was popularised in 1978 (Walford, Gale, Allison & Tattersall, 1978); patient SMBG
has been available for 20 years since the introduction of blood glucose meters. In
order to maintain tight glycaemic control, blood glucose needs to be frequently
measured; the results of regular systemic testing not only form the basis for adjusting
medication, food intake and activity levels, but also help to prevent serious
complications, for example, the patient may check whether they are hypoglycaemic
during the evening or during intercurrent illness. However, patients must be taught the
correct technique to self-monitor their blood glucose, because studies have revealed
that up to 50% of patient-generated SMBG results are inaccurate (ADA, 2000a).
Maintaining motivation for SMBG is a constant problem in diabetes care, since many
people with diabetes find regular testing difficult to sustain in the long term. SMBG
requires motivation on the part of the patient; it also needs an understanding of the
correct use of the glucose meter. Some recommend a minimum schedule of 1-2 tests
per week pre and post meal (2 hr), or at different times of the day on 2-3 days each
week (Couzos, Metcalf, Murray & O’Rourke, 1998). Harris, Cowie and Howie (1993)
conducted a survey of 2405 patients with type 2 diabetes and found that among
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subjects with type 1 diabetes, 40% monitored their blood glucose at least once per day.
Among subjects with type 2 diabetes treated with insulin, 26% monitored at least once
per day and among type 2 diabetes subjects not treated with insulin, only 5%
monitored blood glucose level. There are some barriers to persuading patients with
diabetes to perform SMBG. A recent study reported that cost was a barrier to self-
monitoring, leading to a low frequency of testing (Heisler, 2004). Zgibor and
Simmons (2002) showed that patient-reported barriers to diabetes care are associated
with blood glucose monitoring, especially in relation to financial (an external physical
barrier), and self-efficacy issues (an internal psychological barrier). Those reporting
personal barrier to diabetes care, especially those relating to finance and access to
community and family support and self-efficacy were less likely to monitor blood
glucose twice weekly.
In Taiwan, two epidemiological surveys have shown that only 30% of people with
diabetes have self-monitored their blood or urine sugar, demonstrating that they either
lack skills or simply have low rates of performing self-care activities (Chuang et al.,
2001; Lin et al., 2001). It is necessary to develop support groups for local diabetes
patients and volunteers to raise self-care motivation of patients with professional help
from consultants and nutritionists. Through education and empowerment, people’s
awareness of their self-care abilities can be improved leading to a better quality of life
(Chuang et al., 2001).
In summary, SMBG allows a profile to be found and treatment appropriately planned.
Accurate testing technique and appropriate maintenance of equipment are needed to
ensure treatment decisions are based on correct data. SMBG is a way to help people
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with diabetes recognise the benefits of self-management of their disease and give
them greater insight into it.
3.3.2. Nutrition
Medical nutrition therapy is integral to diabetes care and management, and can be
achieved by maximizing the involvement of the person with diabetes in their self-
management (ADA, 2001). Diet control is the foundation of all therapy for type 2
diabetics, and is also the most natural and safe control mechanism. Through diet
control alone, one-thirds of patients can control their blood sugar at a satisfactory
level (Funnell, Donnelly, Anderson, Johnson & Oh, 1992). Effective nutrition
intervention in diabetes management results in improved self-monitoring of blood
glucose, blood lipids, glycated haemoglobin level, blood pressure, and weight
management, and can lead to reductions in medication, frequency of hypoglycaemia,
hospitalisation, and cost of overall health care; and most importantly, improved
quality of life for the patient (Downer, 2001). Thus, a nutrition intervention is
worthwhile to pursue for every person with diabetes.
It is currently accepted that the most appropriate diet in the treatment of type 2
diabetes is one that is high in carbohydrates and fibre and low in fat (ADA, 1996a).
Although weight loss is often desirable, the emphasis for dietary advice should be on
glycaemia and lipid control, (Couzos et al., 1998). Hosker et al. (1993) has trialled
food therapy (diets with 50% of the total caloric capacity in carbohydrates, low
saturated fatty acid, and high fibre) on newly diagnosed type 2 diabetics. After a 3-
month trial, they found that blood sugar was under control, and the secretion of
insulin increased. Similarly, Murray (2003) claims that fibre supplement can lower
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blood glucose after a meal by approximately 20% and Chandalia, Gary and Lutjohann
(2000) found that a high-fibre diet improved glycaemia control and plasma lipid
levels. Diabetic diet control issues have recently been summarised by Dunning (2003).
Principles of dietary management for people with diabetes should involve a diet high
in complex carbohydrates (50-60 % of total intake), low in fat (<10 % of total energy
value), especially saturated fat, containing adequate protein (15 % of total intake), low
in simple sugar, less than 25 grams/day, and ensuring that a variety of food is eaten
daily from each of the five food groups and that carbohydrate is consumed at each
meal, especially for patients on insulin or diabetes medication (Dunning, 2003).
One way to encourage responsibility in people with type 2 diabetes and to help them
take an active role in improving their blood glucose is to provide dietary guidelines
(Downer, 2001) that can help people with the self-management of their blood glucose.
For example, weight loss of 10-20 pounds or maintenance of a constant weight; eating
six small meals instead of three large meals is recommended; no large meal late in the
day; spreading meals throughout the day; a light evening snack; and daily self-
monitoring of blood sugar (Downer, 2001). Moreover, according to Savoca and Miller
(2001), providing diet strategies was necessary to help people with type 2 diabetes to
adhere to recommended dietary guidelines. Three types of diet strategies were
suggested in their study. Firstly, food selection and preparation strategies, such as
reducing their dietary fat intake (e.g., grilling, baking, or broiling meat). Secondly,
meal planning strategies, such as preparing a packed lunch, and planning several
meals at one time. Finally, dining out strategies, such as carefully selecting the
restaurant, making sensible food choices, and controlling portions of food. However,
dietary recommendations should be as flexible as possible and individualised, and
education should consist of basic nutrition plus a goal-oriented treatment plan.
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In summary, nutrition therapy should be individualised for people with diabetes,
giving consideration to their usual eating habits and other lifestyle factors. Nutrition
recommendations can then be developed to meet the goals and desired outcomes of
the treatment. Also, how to enhance individual’s level of understanding of the
common aspects of a dietary recommendation and how to encourage individuals to
adhere their dietary recommendations are the most significant issues for people with
diabetes.
3.3.3. Exercise
There are clinical benefits of incorporating a regular exercise program into the
management of diabetes; for type 2 diabetes, the earlier the exercise program is
started, the greater the benefits. Many type 2 diabetics are overweight or have obesity
problems, but they can lose weight by drawing on blood glucose as an energy source
during and after exercising (Fisher et al., 1996). An exercising muscle increases its
glucose uptake and oxygen consumption 20-fold, initiating glycogenolysis and
lipolysis, and stimulating hepatic glucose output (Zinker, Allison & Lacy, 1997). If
diabetics exercise for more than 30 minutes every day, insulin demands can decrease
about 30% to 40%, due to a 7- to 20-fold increase of the usage of glucose by the body
(Wing et al., 1988). Hence people with diabetes who exercise can generally reduce
their plasma glucose levels. Regular exercise will result in improved insulin
sensitivity and glucose usage. Moreover, a leaner body configuration and enhanced
psychological well-being will usually impart a positive effect to any patient (Birrer &
Sedaghat, 2003).
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There are many benefits of exercise for those with diabetes, including increased
insulin sensitivity, improved blood sugars, reduced risk of coronary heart disease, and
decreased blood pressure and lipid levels. Moderate exercise for 30 minutes, five
times a week can result in a 10 to 20% improvement in HbA1C (ADA, 2000b).
Hornsby et al. (1990) conducted a study with type 2 diabetics in which exercise was
undertaken 3 times a week, 30 minutes per session, over a 12-14 week period, which
resulted in the fasting blood sugar and HbA1C readings decreasing significantly.
So regular exercise not only decreases blood sugar and increases insulin sensibility, it
also decreases the potential causes of circulatory problems (Braun, Zimmermann &
Kretchmer, 1995). Wei, Gibbon, Kampert, Nichaman and Blair (2000) conducted an
epidemiological study and found that low cardiorespiratory fitness and physical
inactivity are independent predictors of all-cause mortality in men with type 2
diabetes. The risk of dying from cardiovascular disease is 2-4 times greater among
those who have diabetes than among those who do not (National Center for Health
Statistics, 1993). Studies also show that diabetic patients have lower levels of activity
than those who do not have diabetes (ADA, 2000b). Physical activity is one of the
measures that can reduce the risk of coronary heart disease for people with diabetes
( Foreyt & Poston, 1999).
Even though the benefits of exercise have been documented so well, adherence to
exercise programs has been reported as low, while 50% of participants drop out in the
first 3 to 6 months (Leith, 1992). Also, Searle and Ready (1992) showed that over
50% of Canadians with diabetes fail to exercise more than once per week. Toljamo
and Hentinen (2001) showed that adherence rates of self-care generally vary from 3 to
80%, depending on the intervention and research methods used in the studies.
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According to Glasgow, Hampson, Strycker and Ruggiero (1997) and Ruggiero et al.
(1997), patients with diabetes have more difficulty in adhering to suitable diet and
exercise than to their insulin medication.
The causes of low adherence have been investigated: A study was conducted to
determine whether there are differences in key social-cognitive determinants of
exercise between adults with diabetes and those without. Results showed that the
diabetes group reported significantly lower scores for self-efficacy and perceived
behavioural control. These data suggest that the low levels of self-efficacy and
perceived behavioural control among those with diabetes emphasise the importance of
designing specific strategies to increase their self-confidence in undertaking physical
activity (Plotnikoff, Brez & Brunet, 2003).
In brief, the benefits of exercise are physiological and psychological. Increased
activity and some exercise not only have a therapeutic value, but also increase
optimism and enhance self-confidence. It is time to help people discover and obtain
the feeling that comes with exercising and convert that feeling into internal gain
(Guthrie & Guthrie, 2002).
3.3.4. Medication
Although diet and exercise are important parts of type 2 diabetes self-care, most
patients require medication to maintain adequate glycaemia control. According to
Glasgow et al. (1999), various diabetes self-care behaviours are relatively independent
of one another. Dietary aspects of the regimen are experienced as the most difficult
(Schlundt, Rea, Kline & Pichert, 1994), followed by exercise, while most patients find
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medication taking to be the area in which they have the least difficulty (Glasgow,
1994). This may be because this regimen area is perceived by the public as most
closely associated with “managing an illness” (Glasgow et al. 1997). However, while
most patients may take their medication, they are far less adherent with timing or
adjusting its administration (Ho, 2006). So understanding the regimen of medication
is an important issue in diabetes self-care.
Oral hypoglycaemic agents have added a new dimension to the treatment of diabetes
mellitus since tolbutamide became available in 1956 (Guthrie & Guthrie, 2002); they
are used to stimulate insulin secretion, but are not the same as insulin itself, neither
can they replace it. However, many patients have the misconception of oral agents as
“insulin pills”. In many cases control of blood sugar level cannot simply be achieved
only by diet and exercise and therefore medication is important for the treatment of
diabetes. The ADA (American Diabetes Association) recommends that if a trial diet
for 8 to12 weeks is unsuccessful in controlling blood sugar, oral hypoglycaemic
medication should be introduced (ADA, 1996c). Medication includes oral
hypoglycaemic drugs and insulin injection. Patients should take the exact medicine
and injection prescribed by their doctors. In this way medication can improve the
control of diabetes and decrease the occurrence rate of acute and chronic
complications (Davidson, 1998; LeRoith, Taylor & Olefsky, 2000).
Some new classes of OHA (oral hypoglycaemic agents) have been released in the last
few years. The newer OHAs might extend the life of the beta cells and delay the need
for insulin (Dornhorst, 2001); they do not contain insulin themselves, and should be
used to supplement dietary measures. Excessive dosages are not recommended, nor
are OHAs a substitute for proper dietary compliance. They are not suitable for type 1
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diabetes or during pregnancy (Dunning, 2003). OHAs target the different metabolic
aspects of type 2 diabetes: (1) Biguanides reduce insulin resistance and fasting
glucose; (2) Sulphonylureas and Glitinides are secretagogues, agents that stimulate
insulin production; (3) Thiazolidinediones (TZI) decrease insulin resistance, reduce
daytime preprandial hyperglycaemia and have some effect on the fasting blood
glucose; (4) Alpha-glucosidase inhibitors slow carbohydrate digestion and reduce
postprandial glucose (Phillips, 2000; Braddon, 2001). These drugs can be effective
alone or can be used in combination. Multiple OHAs are often required because type
2 diabetes is a slow progressive multifactorial disease. OHAs can be also combined
with insulin. Adherence to prescriptions and blood glucose monitoring is essential to
assess and tailor the dose in order to maintain the desired level of glycaemia control.
The regularity required in taking medication presents a challenge both to people with
diabetes and to their treating clinicians. Studies have demonstrated that treatments
including multiple medications or frequent dosages have a negative impact on
adherence (Bartels, 2004). Funnell and Meritt (1993) also found that some older
diabetics have other chronic diseases, therefore, they often have to take many
different kinds of medications. Additionally, many older diabetics may have fading
memories, so they may sometimes forget to take the medicines, and there is also the
potential possibility of taking wrong dosages. It is important for people with diabetes
to receive proper education in how to take medication correctly in order to prevent
further progress of the disease and avoid complications.
In conclusion, an understanding of the action of the various oral agents should assist
people with diabetes to cope with their disease. Guidance and education provided by
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health professionals should help individuals to use these medications more carefully
(Cincinnati & Veliko, 2001).
3.3.5. Foot care
Foot problems are the most commonly reported complication of diabetes; they may
result in hospitalisation and sometimes require surgical intervention, which can lead
to a lifetime of disability and low quality of life. Diabetic foot disease is a
heterogeneous disease entity defined as a group of symptoms that leads to tissue
breakdown. Infection, neuropathy and ischaemia are usually present and increase the
risk of infection (Apelqvist & Larsson, 2000). According to a recent report, 40 to 70%
of lower limb amputations occur in people with diabetes, most beginning with an
ulcer (Dunning, 2003); the amputation rate can be reduced by preventative foot care.
Foot disease and its management have an adverse impact on the well-being and
quality of life of people with diabetes (Brod, 1998).
Foot ulcers are common in people with diabetes and are costly in terms of both patient
morbidity and the use of healthcare resources. A study of 1077 people with diabetes
found that 7.4% of patients had past or present foot ulceration (Walters, Gatling,
Mullee & Hill, 1992). The economic burden of foot ulcers has been assessed as
widespread; one study found that patients with diabetes made up 5.5% of admissions,
6.4% of outpatient attendances and 9.4% of bed-days (Currie, Williams & Peters,
1996).
It is important that primary foot care for people with diabetes should incorporate
adequate monitoring and the opportunity to reinforce the message of self-care and
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preventive strategies. Many patients are unable to do self-monitoring due to poor
eyesight, making it difficult for them to inspect their feet (Thomson & Masson, 1992).
Hence it is important for people with diabetes to maintain regular contact with health
professionals. In general, common neurological examinations in hospitals include
tests for vibration sensitivity threshold with a biothesiometer or tuning fork, or for
cutaneous pressure sensitivity with a 10-g monofilament (5.07) (Mason, O’Keeffet,
Mclntosht, Hutchinsont & Young, 1999). These examinations can signal the risk of
diabetes foot problems.
A summary of guideline recommendations for the examination of the foot in those
with diabetes was provided by ADA (1996b), and has been in common use in clinical
practice. The clinical practice guidelines, originally approved in 1990, recommended
basic foot care education for all health professionals regardless of risk category, with
a thorough inspection of the feet at each visit and a comprehensive assessment
annually. Vascular examination involved palpation of pulses and inspection. Tests for
sensorimotor examination are not specified. Range of movement is examined, as is
gait, and inspection for bony abnormality is included in the musculo-skeletal items
listed. The importance of continuing instruction until the patient can verbalise and
demonstrate proper foot care practice is emphasised (ADA, 1996b; Couzos et al.,
1998).
Many people with diabetes may not have sufficient skills or knowledge to properly
manage their condition, including foot care (Mason et al., 1999). Common elements,
such as foot hygiene and awareness of fungal infections, treatment of callous, and
actions required for cutaneous injuries should be included in patient education (Mason
et al., 1999). Epidemiological and clinical risk factors for ulceration also have been
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reported; risk markers include old age, duration of diabetes, peripheral vascular
disease, renal disease, plantar callous, poor vision, poor footwear, cigarette smoking,
social deprivation and social isolation (Walters et al., 1992; Mason et al., 1999). In
addition, Plummer and Albert (1995) conducted research on 136 diabetics to examine
foot self-care behaviour in the high-risk population for amputation. They found that
those in the high-risk group had a high frequency of poor foot self-care behaviours. In
Germany, a 4-year follow-up study on diabetics found that the longer they wore a
protective insole and undertook more frequent foot care, the more significant was the
decrease in recurrence of foot ulcers (Chantelau & Haage, 1994). Consequently,
emphasis on foot care is an important nursing intervention when caring for people
with diabetes.
Education has been recommended as the most important contribution to the
prevention of foot problems in people with type 2 diabetes (ADA, 1996b).
Emphasising the importance of physical activity and of appropriate control of blood
sugar levels are essential components of this. Reiber, Pecoraro and Koepsell (1992)
showed that physical activity, defined as 20 minutes exercise three times per week has
also been found to be protective against amputation (OR 0.6; 95% CI 0.3-0.9). In
another study, fasting plasma glucose levels < 7.8 mmol/L at base line were protective
in a 12-year follow-up study. There were no amputations in this group, irrespective of
the duration of diabetes (Humphrey, Dowse, Thoma & Zimmet, 1996). Nevertheless,
other comprehensive recommendations about foot care should still be included in the
educational content.
Despite the evidence that foot care can prevent amputations, care of feet continues to
be a commonly neglected aspect of management of patients with diabetes. Foot care
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must be organised to provide monitoring, education or intervention and referral in a
manner acceptable to patients (Mason et al., 1999).
In conclusion, successful management of diabetes relies on the individual being able
to perform self-care activities designed to control symptoms and avoid complications.
Many complications arising from diabetes are preventable if rigorous attention is paid
to managing the disease, including following a prescribed medication regimen and
strict calorie-controlled diet, doing regular exercise, undertaking blood glucose checks
and caring for feet (McDowell, Courtney, Edwards & Shortridge-Baggett, 2005).
Addressing the task-related issues of self-management activities required by people
with diabetes is important and an ongoing challenge for health-care providers and the
health care system.
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3.4 Quality of life and diabetes
Quality of life has been recognised as an important health outcome (Snoek, 2000) and
even represented as the ultimate goal of all health interventions (Rubin & Peyrot,
1999). However, there is no universally accepted definition for quality of life, maybe
because the concept is a “vague and ethereal entity, something that many people talk
about, but which nobody very clearly knows what to do about” (Campbell, Converse
& Rodgers, 1976, p.471). In general, the terms “quality of life”, “well-being”, “health
status” and “satisfaction” are often used interchangeably (Snoek, 2000).
Hornquist defines quality of life as a broad spectrum of dimensions of human
experience, ranging from those describing the necessities of life, such as food and
shelter, to those associated with achieving a sense of fulfilment and personal
happiness (Hornquist, 1982). To narrow its extent to those aspects directly related to
disease or medical treatment, the term “health-related quality of life” (HRQOL) was
introduced (Patrick & Erickson, 1988); in the medical area it was defined as “a
concept encompassing a broad range of physical and psychological characteristics and
limitations, which describe an individual’s ability to function and to derive
satisfaction from doing so” (Walker & Rosser, 1987).
Furthermore, Ferrans (1990) defined five domains of the quality of life: normal life,
happiness and satisfaction, achievement of personal goals, social utility, and natural
capacity. Ware (1987) even combined different perspectives and concluded that
quality of life referred to the satisfaction level in an individual’s living environment
toward: physical function; role limitation due to physical problems; role limitation due
to emotional problems; social functions; pain; vitality; mental health and general
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health. Overall, it can be divided into a physical component scale (PCS) and a mental
component scale (MCS) (Ware, 1987; Ware & Kosinski, 2001).
Most people understand what is meant by quality of life but it is a difficult concept to
measure. A number of instruments have been developed that measure the general
aspects of quality of life, and diabetes-specific quality of life tools are also available
(Dunning, 2003). According to Rubin and Peyrot (1999), two broad approaches to
health-related quality of life measurement have emerged: generic and disease-specific.
The generic approach involves the use of measures applicable across all health and
illness groups. The generic measure of quality of life most widely used in studies of
people with diabetes is the Medical Outcomes Study (MOS) Short-Form General
Health Survey, including several forms: SF-36; SF-20; and SF-12 (Stewart et al.,
1989). The MOS instrument includes physical, social and role functioning scales to
capture behavioural dysfunction caused by health problems. Measures of mental
health, perceptions of overall health, and pain intensity reflect more subjective
components of health and general well-being (Rubin & Peyrot, 1999). The MOS tool
comprises 8 subscales: physical function (PF); role-physical (RP); role-emotional
(RE); social function (SF); bodily pain (BP); vitality (VT); mental health (MH); and
general health (GH); and physical and mental component summary scores (PCS and
MCS scores) (Ware, Losinski & Keller, 1994). These instruments have been
translated into many languages and used in studies, including those on people with
diabetes (Ware & Sherbourne, 1992; Ware, Losinski & Keller, 1994).
In general, most studies report that quality of life among people with diabetes is worse
than that in the general population (Rubin & Peyrot, 1999). Several studies have
measured quality of life using the SF-36 and SF-20 versions. Ware and colleagues
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published data based on responses to the 1990 National Health Survey of Functional
Status, finding that those with diabetes reported lower quality of life than the general
population on scales assessing physical functioning, role functioning and general
health; however differences were not significant on scales assessing social functioning
and mental health (Ware & Sherbourne, 1992; Stewart, Hays & Ware, 1988).
Similarly, a study that included patients with both types of diabetes but did not
distinguish subjects by complication status, found that those with type 2 diabetes
scored lower than controls on all quality of life scales (Aalto, Uutela & Kangas, 1996).
However, a recent study has found that for people with type 2 diabetes prior to
diagnosis, physical and mental functioning measured by SF-12 was already lower for
subjects who met the new criteria than for those in the comparison group, perhaps
because of obesity or other aspects of the insulin resistance syndrome (Nichols &
Brown, 2004).
Some demographic variables or psychosocial factors are related to quality of life
(Rubin, 2000a) and influence it for people with diabetes. In general, men report better
quality of life than women; younger people report better quality of life than older
people; those with more education or income generally report better quality of life
than those with less of either (Glasgow, Dryfoo & Ruggiero et al., 1997; Quittan et al.,
1999; Rubin & Peyrot, 1999; Rubin, 2000a; Dunning, 2003). Psychosocial factors,
including health-related beliefs, social support, coping style, and personality type
might have potent effects on quality of life (Rubin, 2000a). Other factors, such as
medication and physical exercise are all important indications (Glasgow, Dryfoo &
Ruggiero et al., 1997; Quittan et al., 1999). Having better glycaemic control is
associated with better quality of life; and complications of diabetes are the most
important disease-specific determinant of quality of life (Rubin & Peyrot, 1999;
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Guttwann-Bauman, Flaherty, Strugger & McEevoy, 1998). However, many studies
have found that patients’ quality of life is not related to whether their diabetes is type
1 or type 2, rather, the most important factor is complications of diabetes (Ahroni,
Davignon, Boyko & Pecoraro, 1994; Franch, 1999; Edlman, Olsen, Dudley, Harris &
Oddone, 2002).
In conclusion, many studies have shown that people with diabetes have experienced a
lower quality of life compared with population norms, in aspects either of mental or
physical health. For example, Wexler et al. (2006) found that people with type 2
diabetes have a substantially decreased health-related quality of life in association
with symptomatic complications. Therefore, it is very important to know how to
improve the quality of life for people with diabetes. Rubin (2000a) recommended that
certain interventions, including the introduction of blood glucose-lowering
medications and educational and counselling interventions designed to facilitate the
development of diabetes-specific coping skills, can improve both glycaemic control
and quality of life in people with diabetes. Special education interventions initiatives
should be established to help people with diabetes to improve the health outcome of
health-related quality of life.
3.5 Psychosocial issues and diabetes
It is inevitable that nurses or other professionals will take on an increased clinical role
for diabetes care. Not only do they focus on the medical aspect of diabetes, but also
recognise its psychosocial impact for people with diabetes. Several studies have
shown that psychosocial factors play an integral role in diabetes management; the
impact of psychosocial factors is a stronger predictor of mortality in diabetic patients
than many physiological variables (Delamater et al., 2001). Psychosocial factors
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include cognitive functioning, depression, stress, social support, and self-efficacy
(Seeman & Chen, 2002) and they help predict differences in Activities of Daily
Living (ADLs) (Martin, Grunendahl & Martin, 2001). Psychosocial well-being is
defined as “seeking a sense of control in the face of life-threatening illness
characterised by emotional distress, altered life priorities, and fears of the unknown,
as well as positive life changes” (Ferrell et al., 1998). In this thesis, the variable of
psychosocial well-being includes the factors of social support and depression which
will be discussed in the following sections.
3.5.1 Diabetes and social support
People with diabetes are encouraged to care for themselves in managing their illness.
Diabetes creates a need for increased support, as the demands of the regimen are
extensive (Guthrie & Guthrie, 2002). Social support has been found to be significantly
correlated with higher functional status (Shih & Shih, 1999) or diabetes health status
(Wierenga, 1994) and enhanced self-care (Dimkovic & Oreopoulos, 2000). Williams
and Bond (2002) conducted a survey and found that social support was associated
with the exercise of self-care, and the relationship between the two variables was
mediated by self-efficacy. Belgrave and Lewis (1994) examined the role of social
support in compliance and other health behaviours and found that social support was
significantly associated with the positive health behaviours of appointment keeping
and adherence to health activities. Of all the health activities chosen by the authors,
which included diet, exercise, having regular blood pressure tests, taking medication
as prescribed, and foot care, social support was found to have the greatest impact on
diet and foot care. However, a cross-sectional study was conducted with 95 insulin-
requiring Hispanic adults to explore social support and diabetes self-management. The
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results showed that participants were least satisfied with the help they received for
diabetes-related self-care, personal care, and financial assistance and that social
support was not strongly related to diabetes self-management (Gleeson-Kreig, Bernal
& Wooley, 2002).
Social support has a positive influence on the overall psychosocial well-being of an
individual. Due to the growing recognition of this, health care interventions have
increasingly incorporated social support. As White, Richter and Fry (1992) have
shown, the greater the perceived social support, the better the psychosocial adjustment
to illness. The enhancing component bolsters the social support of chronically ill
patients (Hebert, Robichaud, Roy, Bravo & Voyer, 2001). In a randomised clinical
trial conducted by Maxwell, Hunt and Bush (1992), 204 patients with diabetes were
studied, randomly divided into two groups. The control group received the training
program only, whereas the experimental group was offered that program in addition to
eight support group meetings, at which they had the opportunity to receive
informational and emotional support. After 7 months of follow-up, patients in both
groups showed improved metabolic control (HBAIC), diabetes knowledge, frequency
of practising recommended diabetes management behaviours, and emotional
adjustment; however, no additional improvement was seen in the people in the
experimental group. Nevertheless, the authors suggested that a better understanding of
the possible contribution of support groups to health is necessary before such groups
are routinely recommended to patients with diabetes.
There has been some attention in the research literature on the role personal
characteristics play in the social support that is received by people with diabetes. Men
with diabetes have reported more support from family members, whereas women
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received more from friends (Kvam & Lyons, 1991). Murphy, Williamson and Nease
(1994) conducted a cross-sectional research design using a telephone survey to
examine the role of social support among adult patients with type 2 diabetes, and
found that 51% of the men in the study identified their wives as the family health
monitor, but only 8% of the women identified their husbands as the family health
monitor. Moreover, people with a higher educational level were also found to have
greater feelings of support from family and friends (Kvam & Lyons, 1991). However,
Ford, Tilley and McDonald (1998) summarised a literature review for the African-
American population and concluded that socio-economic status was not emphasised
in the studies reviewed, although it might be expected that education and income
would positively influence health incomes and glycaemia control. So the relationship
between personal characteristics and social support needs to be explored in further
studies.
In conclusion, the rising incidence and prevalence of diabetes continues to be a major
health concern. Social support has been found to be a relevant factor in diabetes self-
management. The problem is further magnified among ethnic groups, including the
Taiwanese population. Further research should continue to examine the interaction of
social support and diabetes self-management in different populations.
3.5.2 Diabetes and depression
A number of studies have shown the association between diabetes and depression
(Gavard, Lustman & Clouse, 1993; Anderson, Freedland, Clouse & Lustman, 2001;
Lustman et al., 2000). This is an important public health issue because depressive
disorders generally have been associated with the outcomes of chronic disease such as
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diabetes (Finkelstein et al., 2003). Causes underlying the association between diabetes
and depression are poorly understood (Jack Jr. et al., 2004), however, diabetes
increases the risk of depression, with prevalence rates from 15 to 40 % (Harris, 2003).
Depression can contribute to decreased physical and mental functioning that causes
individuals to be less likely to follow daily diabetes self-care routines, thus exposing
them to poor glycaemic control and increasing their risk for complications (Lustman
et al., 2000). Ciechanowski, Katon and Russo (2000) have stated that people who are
depressed are more likely to have inadequate self-care and to require specialist
intervention. The relationship of depression and self-care is interwoven (Talbot &
Nouwen, 2000); depressed people with diabetes may present with the typical
symptoms of low energy, worthlessness, hopelessness, and helplessness that manifests
in a ‘why bother’ attitude and poor follow-through. People with diabetes may get
labelled as noncompliant with the diabetes self-care regimen (Guthrie & Guthrie,
2002), while the underlying problem of depression may go undiagnosed. An effective
screening instrument needs to be used to detect the symptoms of depression earlier.
Depression remains unrecognised and untreated in a majority of cases, despite its
specific relevance to diabetes (Lustman et al, 1997). Most estimates suggest that only
about one-third of people with diabetes and major depression are recognised and
treated (Lustman & Harper, 1987). Many generic measures of emotional status have
been employed in studies that include people with diabetes. Psychometric instruments
include the Well-being Questionnaire; the Profile of Mood States, the Symptom
Checklist (SCL-90R); the Kellner Symptom Questionnaire and the Affect Balance
Scale. Depression in people with diabetes has been studied using the following scales:
the Beck Depression Inventory, the Zung Self-Rating Depression Scale and the Center
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for Epidemiological Studies Depression Scale (CES-D) (Rubin & Peyrot, 1999). They
are also effective tools for detecting depression in people with diabetes.
The number of research articles that include information about depression in diabetes
has increased. In 1997, Lustman et al. adopted the Beck Depression Inventory in
surveying people with diabetes, and found that about 70% of 172 people with diabetes
had a depression problem, 3 to 4 times higher than in healthy individuals (Lustman et
al, 1997). Hanninen, Takala and Keinanen-Kiukaanniemi (1999) conducted a study on
people with type 2 diabetes and found that 28.8% of the subjects had a tendency to
depression. Also, studies have found that people with diabetes have higher levels of
depression than the norms derived from the general population (Gavard, Lustman &
Clouse, 1993; Bourdel-Marchasson et al., 1997; Lustman, Griffin, Gavard & Clouse,
1992; Rubin & Peyrot, 1999). For example, Peyrot and Rubin (1997) found that rates
of disturbance for depression (41%) and anxiety (49%) were higher than those typical
in the general population (< 10%). Egede, Zheng and Simpson (2002) found that the
average rate of people with diabetes with depression was twice higher than for healthy
individuals and for diabetes with depression disorder, the average medical expense
each year was 4.5 times higher than diabetes without depression disorder.
Depression is associated with the outcomes of diabetes and contributes to the high
economic burden of health care costs; deGoot, Anderson, Freedland, Clouse and
Lustman (2001) found that depressive symptoms were associated with an increase in
the severity or number of diabetes complications in 89% of 27 studies and there was a
significant relationship between depression and retinopathy, neuropathy, nephropathy
and sexual dysfunction. As for health care costs, DeRekeneier, Resnick and Schwartz
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(2003) showed that depression was associated with an approximately five-fold
increase in health expenditure for diabetes.
In addition, psychological disturbance may be associated with the number of diabetes-
related complications and with certain demographic variables. Anderson et al.(2001)
and Fisher, Chesla, Mullan, Skaff and Kanter (2001) all indicated that depression
disorder in people with diabetes was significantly related to gender, education level,
marital status, blood sugar control, and multiple complications. There were higher
rates of depression in women, those who were unmarried, and those with lower levels
of education (Peyrot & Rubin, 1997; Rubin & Peyrot, 2001). Acute or chronic
complications caused by unstable blood sugar control are important factors of
depression (Hanninen et al., 1999; Fisher et al., 2001). Peyrot and Rubin (1997) found
a higher rate of depression in those with three or more diabetes related complications.
Additionally, glycaemic control was significantly worse in patients with depression
compared to those who were not depressed (DeGroot, Jacobson, Samson & Welch,
1999). Researchers also have indicated that appropriate blood sugar control can
improve the problem of depression in people with diabetes (Talbot & Nouwen, 2000;
Anderson et al., 2001). However, there is no significant association with diabetes
types (type 1 or type 2) or duration of disease (Peterson, Lee, Young, Newton &
Dornan, 1998; Rubin & Peyrot, 1999; Talbot & Nouwen, 2000).
From the above literature, it can be concluded that people with diabetes do have a
tendency for depression problems. Moreover, depression problems are also influenced
by many basic attributes, such as gender, age, education, marital status, physical
activity, complication, family diabetics history, and blood sugar. This issue has
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engaged the attention of many researchers, and finding ways to improve the
depression problems in people with diabetes is obviously a critical factor.
3.6 Summary
The literature review on diabetes provides the main key points of this study. Five
issues related to diabetes mellitus have been explored, including: diagnosis and
definition, classification, and complications of diabetes. Diabetes is a chronic disease
that requires daily regimentation of all activities including:
(1) blood glucose monitoring;
(2) adhering to dietary restrictions;
(3) maintaining or increasing levels of physical activity;
(4) managing and administering medications; and
(5) active participation in self-care routines, such as foot care.
Although the Taiwanese health care system has persistently emphasised the
importance of patient health education (see Chapter 2.4.2), improvement in self-care
activities and control of diabetes has been limited. Two Taiwanese surveys showed
only 30% of people with diabetes had performed self-monitoring of blood sugar or
urine sugar demonstrating people with diabetes lack skills or have low participation
rates in performing self-care activities (Chuang et al., 2001; Lin et al., 2001).
Alarmingly, only 14.0% of patients > 65 years have HbA1c values within the optimal
range of < 6.5% (Tai et al. 2006). For diabetes care to succeed, patients must be able
to make informed decisions about how they will live with their illness (Funnell &
Anderson, 2000). Thus, improving self-management and prevention of diabetic
complications for people with diabetes is an ongoing challenge for health-care
providers and the government.
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Quality of life and psychosocial well-being are other very common and crucial
outcome variables for chronic diseases. Also, the variable of psychosocial well-being
including the factors of social support and depression is very important for people
with diabetes. The relationships between diabetes and quality of life and psychosocial
well-being have also been described above and most studies report that quality of life
and psychosocial well-being among people with diabetes are worse than those in the
general population (Rubin & Peyrot, 1999). However, in general, cross-sectional
designs are limited, in that causality cannot be established between the phenomena
being studied, for example, the effects of social support or depression on diabetes
control over time cannot be assessed in cross-sectional studies (Ford, Tilley &
McDonald, 1998). In terms of previous research studies, very few studies have been
conducted by way of well-designed randomised controlled trials. Clearly, more
research, particularly randomised trials, is needed regarding self-management, and
self-efficacy on quality of life and psychosocial well-being.
There is a doubt about how effective it is in achieving the desired effect of
improvement in the prevalence, mortality rate and health care costs of diabetes in
Taiwan. A gap between knowledge and behaviour change is evident in diabetic
studies that demonstrate patients with diabetes do not perform self-care although they
received diabetic patient education (Glasgow & Osteeen, 1992). Self-efficacy offers a
basis for improving the effectiveness of diabetes education because it focuses on the
capacity for behavioural change (van der Bijl & Shortridge-Baggett, 2001). The self-
efficacy approach to diabetes education seeks to enhance the self-care knowledge,
skills, self-awareness, and sense of personal autonomy of patients to encourage them
to take charge of their own diabetes care. Educating people with type 2 diabetes
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within a framework that enhances self-efficacy may improve self-management of this
disease, health-related quality of life, psychosocial well-being and may lower health
care costs. Thus the issue of self-efficacy and relevant outcome variables will be
discussed in the following chapter, Chapter 4.
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Chapter 4
Framework
4.1 Introduction
A model of self-efficacy adapted from Shortridge-Baggett and van der Bijl (1996) is
used as a framework for this study. The basic premise underlying self-efficacy theory,
according to Bandura (1977a; 1986), is that individuals’ expectations of self-efficacy
(efficacy expectations) and success (outcome expectations) determine whether they
will engage in a specific behaviour. There are two main parts of this chapter, an
overview of self-efficacy theory and a description of the intervention (SEEIP) used in
the study.
The self-efficacy model is discussed first, including its two main cognitive
components (self-efficacy and outcome expectations), information sources
(performance accomplishments, vicarious experience, verbal persuasion, and
self-evaluation) and behaviours, and then the issues of self-efficacy in diabetes
self-management are explored. Self-efficacy and outcome variables, such as quality of
life and psychosocial well-being issues, will be dealt with at the end of that section.
The second part of this chapter includes the rationale for the promotion of
self-efficacy, and a plan of SEEIP, the self-efficacy enhancing intervention program.
4.2 Self-efficacy model
Over the last decade and a half, Bandura’s social cognitive theory has been
increasingly applied, both as a model of health behaviour and as a framework for
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developing effective health interventions (Bandura, 1977b; 1986). Self-efficacy is one
important part of social cognitive theory (SCT) (Bandura, 1977b), formerly known as
social learning theory. According to Bandura, self-efficacy was originally defined as
“a specific type of expectancy concerned with one’s beliefs in one’s ability to perform
a specific behaviour or set of behaviours required producing an outcome” (Bandura,
1977a). However, this definition has been expanded to refer to “people’s judgment of
their capabilities to organise and execute the course of action which require
designated types of performances” (Bandura, 1986, p.391). Thus, one’s self-efficacy
judgments are concerned, not with skills, but with one’s perceived competency in
using whatever skills one has (Bandura, 1986).
Self-efficacy theory is one theory of the behaviour of a person, her or his
characteristics, and the environment in which the behaviour occurs. The model of
self-efficacy used in this study is adapted from Shortridge-Baggett and van der Bijl
(1996) (see Figure 4.1). In this model, the main concepts include the characteristics of
a person, his or her behaviour and the outcomes of that behaviour. The basic premise
underlying self-efficacy theory, according to Bandura (1977a, 1986), is that
expectations of personal mastery (self-efficacy or efficacy expectations) and success
(outcome expectations) determine whether an individual will engage in a specific
behaviour (van der Bijl & Shortridge-Baggett, 2001).
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Environment
Figure 4.1 Self-efficacy Model adapted from Shortridge-Baggett and van der Bijl (1996)
Self-efficacy theory has two cognitive components, the first being perceived efficacy
belief (efficacy expectations, or just self-efficacy). The second cognitive component
of self-efficacy is outcome expectation (Bandura, 1977a; 1982). Although
self-efficacy and outcome expectation are viewed as different mechanisms, their
influence on behaviour change is synergistic. Both self-efficacy (confidence in ability)
and outcome expectation (belief that the behaviour will have the desired effect) are
required for any given outcome. Both efficacy expectation and outcome expectation
Person -Characteristics -Perception -Self-referent
Behaviour -Initiation -Effort -Persistence
Outcome
Efficacy-Expectations -Magnitude -Strength -Generality
Outcome-expectations
Information sources -Performance accomplishment -Vicarious experience -Verbal persuasion -Self appraisal
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are important determinants of behaviour and their differential influence is explained
in the following sections.
4.2.1. Self-efficacy (efficacy expectations)
The definition of self-efficacy is “people’s judgment of their capabilities to organise
and execute the course of action which require designated types of performances”
(Bandura, 1986, p.391). This description shows that people’s self-efficacy is not of a
general nature, but is related to specific situations. Individuals can judge themselves
to be very competent in a specific field and less competent in another field. For
example, a person can be convinced that she or he can walk 10 km in a flat area, but
be quite certain that he or she cannot do it in the mountains (van der Bijl, van
Poelgeest-Eeltink & Shortridge-Baggett, 1999). This concept emphasises not people’s
skills, but their judgments of what they can do (Bandura, 1986). So self-efficacy is not
a personality trait, but is related to specific situations (van der Bijl &
Shortridge-Baggett, 2001).
Because self-efficacy is strictly situational and task-related (van der Bijl, van
Poelgeest-Eeltink & Shortridge-Baggett, 1999), an expression of personal efficacy is
an assertion of confidence in one’s capability to overcome the difficulties inherent in
achieving a specified level of behavioural attainment (Maibach & Murphy, 1995).
Judgment about the specific task is built on past experiences and will vary according
to three factors that constantly interact: level (or magnitude), strength, and generality
of the efficacy belief (Bandura, 1977a; Bandura, 1986); magnitude considers the
difficulty of the task; strength looks at the conviction a person holds that the task can
be done; and generality considers how experiences of self-efficacy can either be
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specific to one task in one situation or generalised to new or challenging situations
(Shortridge-Baggett & van der Bijl, 1996). Consequently, behavioural, cognitive and
social skills must be integrated if a person is to undertake a specific task.
Bandura (1986) claimed that self-efficacy is the most effective predictor of change in
behaviour. In other words self-efficacy influences how people think, feel, motivate
themselves and perform (van der Bijl & Shortridge-Baggett, 2001). People who have
a high level of self-efficacy are more persistent in the face of difficulties than those
with a lower level (Bandura & Cervone, 1983; Bandura, 1997). Motivation and
perseverance in performing behaviours depend on the individual’s evaluation of his or
her self-efficacy. If individuals do not believe they can perform a behaviour, their
performance in it will decline (Bandura, 1997); in contrast, people who believe in
their efficacy create benign environments in which they exercise some control; the
effects on their life choices are profound (Bandura, 1997). Self-efficacy is a crucial
determinant of performance that operates, in part, independently of underlying skills
(Bandura, 1986); for example, in patients recovering from a heart attack it has been
found that their perceived self-efficacy regarding physical capability is a better
predictor of resumption of an active life than their cardiovascular capacity (Ewart,
Taylor, Reese & Debusk, 1983; Bandura, 1986). In particular, lifestyle behavioural
changes are likely to be reliant on self-efficacy (efficacy belief) to overcome
perceived barriers to adopting the new behaviour (Schultz & Shultz, 1998).
Self-efficacy regulates human behaviour through cognitive, motivational, affective,
and selection processes (Bandura, 1997). These processes usually work together in
regulating actions. The first process is that efficacy beliefs affect thought patterns in
terms of promoting or destroying performance; for example, people with high
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self-efficacy are more likely to have high aspirations, and firmly believe in
themselves in meeting these challenges. The second process is motivational, by which
people motivate themselves by forming beliefs about what they can do, expecting
likely outcomes, and setting goals. The third process is affective, in that self-efficacy
regulates emotional states by supporting effective courses of action to transform the
environment in ways that alter its emotive potential (Bandura, 1997); this means that
the degree of stress or depression people experience in threatening or difficult
situations depends on how well they think they can deal with them; low self-efficacy
can lead to depression and reduce social support (Bandura, 1997). The final process is
selective, in that people with high self-efficacy prefer normatively difficult activities
and display high staying power in these pursuits. According to Bandura (1986), the
stronger their perceived efficacy beliefs, the more vigorous the efforts and the longer
the persistence.
The expectation that a certain behaviour will have a desired outcome serves as a
motivation to continue the behaviour (Bandura, 1995), so belief in one’s ability to
perform a task that will lead to the desired outcome is a strong predictor of one’s
performance of the task. Consequently, self-efficacy has been suggested to be one of
the most influential agents in human behaviour. It has been found that a strong sense
of personal efficacy is related to better health, higher achievement and better social
integration (Conner & Sparks, 1995).
However, having high self-efficacy does not imply that the behaviour can be
conducted without any anxiety (Feist, 1994). Bandura (1991) stated that self-efficacy
is able to mediate the relationship between stress or anxiety and a sense of the
controllability of an adverse situation; to resist threats, an optimistic sense of personal
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efficacy is required (Bandura, 1986). Individuals with a stronger efficacy belief may
feel anxious, but will have fewer self-doubts and will recover quickly (Bandura, 1997).
As to health, people with a higher self-efficacy were less likely to be depressed than
those with a low self-efficacy (Gecas, 1989; Bandura, 1997).
In conclusion, an efficacy expectation is about the confidence in one’s capability to
produce the behaviour. People are motivated to perform tasks they believe will
produce desired outcomes. Outcome expectations are highly dependent on efficacy
expectations. Therefore, efficacy expectations predict performance much better than
outcome expectations (Bandura, 1986). According to Shortridge-Baggett (2001), it is
hypothesised that self-efficacy plays an important role in predicting behaviour and its
outcomes (Bandura, 1986).
4.2.2 Outcome expectations
Perceived self-efficacy is a judgment of one’s ability to organise and execute given
types of performances, whereas an outcome expectation is a judgment of the likely
consequence such performances will produce (Bandura, 1997, p.21). Performance is
causally prior to outcomes. According to Bandura (1997), how one behaves largely
determines the outcomes that one experiences. Similarly, the outcomes people expect
depend largely on their judgments of how well they will be able to perform in given
situations. Outcomes, therefore, arise from actions.
Outcome expectation is a judgment about the result of enacting the behaviour in
question; it is about whether the recommended behaviour will have the desired effect
(Bandura, 1989). Bandura differentiates between efficacy expectation and outcome
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expectations, by the questions “Can you perform this task?” (efficacy expectations);
and “If you managed to perform this task, what would the outcome be?” (outcome
expectations). He also stated that individuals can believe that a particular course of
action will produce certain outcomes, but they may not act on that outcome belief if
they are doubtful that they can actually execute the necessary activities (Bandura,
1986).
An outcome expectation has been defined as a positive or negative expectation of a
physical, social or self-evaluative nature (Bandura, 1997). Positive forms of physical
expectations include pleasant sensory experiences and physical pleasures, and
negative ones include pain and physical discomfort. Positive forms of social effect
include social reactions of others as expressions of interest, approval, and social
recognition, while negative forms include disinterest, disapproval, and social rejection.
The third major class of outcomes includes positive and negative self-evaluative
reactions to one’s own behaviour. For example, an athlete’s anticipation of social
recognition, applause, monetary prizes, and self-satisfaction resulting from a
high-jump of two metres represent positive self-evaluative reactions, and a superior
feeling of attainment; whereas if the athlete anticipates social disappointment, loss of
rewards, and self-criticism, this represents a negative self-evaluation, and a deficient
level of attainment (Bandura, 1989; 1997).
Although Bandura (1986) and Shortridge-Baggett (2001) hypothesised that
self-efficacy plays an important role in predicting behaviour and its outcomes,
outcome expectations have nor been measured in many studies, and mixed results
were found (Shannon, Bagby, Wang & Trenker, 1990). Outcome expectations and
self-efficacy were found to be good predictors of intention to undertake breast
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self-examination. Conversely, outcome expectations were not predictive of intention
to lose weight (Shannon et al., 1990). Evidence of an association between
self-efficacy and self-care has recently appeared in diabetes literature (Kingery &
Glasgow, 1989; Hurley & Shea, 1992); a study conducted by Kingery and Glasgow
(1989), was part of a larger investigation of the behavioural aspects of type 2 diabetes
and one of its purposes was to determine whether outcome expectations alone, or the
interaction between self-efficacy and outcome expectations, added to the utility of
self-efficacy in predicting levels of self-care. The results of the study showed that
self-efficacy and outcome expectations were weakly intercorrelated (r = .21 and .19
for diet and .04 and .27 for glucose, at time one and time two respectively). The
addition of outcome expectations to self-efficacy and the other variables did explain
an additional two to four percent of the variance on exercise self-care, however,
despite low correlations (r = .42 at both assessments) between the two measures. Also,
Williams and Bond’s (2002) study showed that outcome expectations accounted for
an average 10% of the variance in self-care. Because the previous mixed results were
found, some researchers have argued that the variables are indeed redundant (Kirsch
& Wickless, 1983).
Bandura (1982) proposed that behaviour is best predicted by considering both
self-efficacy and outcome expectations; this is especially relevant when the
performance of an activity does not ensure positive outcomes (Bandura, 1977a) as in
the case of diabetes self-care, in which metabolic control is also influenced by
physiological and emotional factors. As a result, the inclusion of outcome expectancy
measures in diabetes research may improve the understanding of adherence. Few
studies have included both of these components, although Skelly, Marshall, Haughey,
Davis & Dunford (1995) presented a model including both self-efficacy and outcome
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expectancies that accounted for 22%, 24% and 56% of the variance in blood glucose
testing, diet and exercise adherence, respectively. As an independent predictor,
however, outcome expectancy reached significance only for blood glucose testing.
Therefore, the value of including outcome expectancy measures in studies of diabetes
self-care practice requires further investigation (Williams & Bond, 2002).
To sum up, when predictions are to be made of an individual’s likelihood of success
in a program, self-efficacy expectations and outcome expectations should both be
considered. Greater attention should be directed to examining the relationship
between self-efficacy and outcome expectations and the variables in future
interventions (Kingery & Glasgow, 1989; Johnson, 1996; Williams & Bond, 2002).
4.2.3 Information sources
The development of self-efficacy for a particular task requires four main sources of
information, from direct and indirect experiences; these are performance
accomplishments, vicarious experience, verbal persuasion, and self-evaluation
(Bandura, 1977a; van der Bijl & Shortridge-Baggett, 2001). These four sources of
information influence with a person’s self-efficacy in novel situations, and they affect
expectations about the magnitude and strength of one’s self-efficacy
(Shortridge-Baggett & van der Bijl, 1996). These four information resources are
described in the following sections.
4.2.3.1 Performance accomplishments
Performance accomplishments (practising and earlier experience) are the most
effective in developing one’s perception of self-efficacy (Shortridge-Baggett & van
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der Bijl, 1996). Performance accomplishments involve practising and experiencing
success in achieving goals; and this performance mastery experience is a composite of
prior experiences in carrying out the behaviour (McAuley, Lox & Duncan, 1993).
Successful achievements will strengthen self-efficacy (efficacy expectations) about
ability to perform specific tasks and generalise to similar tasks, while they will also
increase the individual’s ability to resist failure.
Experiences of success enhance self-efficacy, while frequent failure decreases it,
especially when the failure takes place early in the learning process. If a person has
developed a strong self-efficacy, a single failure does not have much influence
(Shortridge-Baggett, 2001); once a person has high self-efficacy, she or he tends to
generalise from one experience to another. Thus, the greater the perceived difficulty
of the task, the greater its contribution to self-efficacy when success in the behaviour
is achieved.
Successful direct performance of a behaviour results in higher, stronger self-efficacy
belief than vicarious experience or other behavioural feedback sources (Bandura,
1982). Therefore, accomplishing the behaviour has consistently explained a greater
percentage of self-efficacy belief than other sources (Bandura, 1986, Gecas, 1989).
4.2.3.2 Vicarious experience
Vicarious experience (observing others perform tasks successfully), obtained by
watching the desired behaviour, is another but less effective method to increase
self-efficacy (Shortridge-Baggett & van der Bijl, 1996). Vicarious experience enables
judgments based on the observation of another’s performance. Others can serve as
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examples and role models and provide information about the degree of difficulty of a
specific kind of behaviour (Shortridge-Baggett, 2001). The greater the perceived
similarity to oneself, the greater is the impact of the modelled success or failure
(Bandura, 1997).
The people serving as role models should be similar to the observer in those
characteristics that are relevant to the issue. The model in vicarious learning should be
able to convince the observer that the challenge can be met; a clear outcome is also
important, so that people can persuade themselves that, if others can do it, they can
too (Liebert & Spiegler, 1994). According to Schunk and Carbonari (1984), a
vicarious learning model, for young people with type 1 diabetes who are learning how
to control their blood glucose level, could illustrate the competing commitments of
the relevant age groups. This is an example of vicarious experience.
Although vicarious experience is the second most important source of enacting
behaviour, it cannot be relied upon as the sole source of efficacy information.
Furthermore, its effect can be negated by perceived personal failure (Bandura, 1997).
4.2.3.3 Verbal persuasion
Verbal persuasion can increase both self-efficacy and outcome expectation, leading to
change in behaviour intention (Maddux, Sherer & Rogers, 1982). Although verbal
persuasion is the most often used information source for self-efficacy, it is weaker
than the previous two sources as it is not related to one’s own experience or other
examples. Verbal persuasion (receiving positive verbal reinforcement from others),
the “you can do it” phenomenon, is limited, because it does not provide experimental
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knowledge of self-efficacy. This technique is useful when people have slipped into old
behaviours after accomplishing new ones (Shortridge-Baggett & van der Bijl, 1996).
Because verbal persuasion is easy to provide and readily available, it is also easily
countered by a subsequent less than ideal performance, and then may even discredit
the persuader. Thus, verbal persuasion is a weaker source of mastery expectation than
performance accomplishments and vicarious experience. However, Bandura (1977a)
has stated that, used in conjunction with other resources, rather than having just a sole
role, advice and suggestions by credible others can be effective.
4.2.3.4 Self-appraisal
Physiological information (self-evaluation of the physical and emotional effects of
sources, particularly if this occurs during the early learning phase) provides feedback
to the person of how well the task is being performed (Shortridge-Baggett & van der
Bijl, 1996). Information from the human body can affect someone’s judgment of their
capability to show a specific behaviour. In judging their own capacities, people use
information on their physiological and emotional situations (Shortridge-Baggett,
2001). Emotional arousal, expressed in physiological cues such as heartbeat and
breathing pattern, is used by individuals to judge their degree of anxiety and readiness
to act. Excessive levels of anxiety act as negative feedback that can decrease
self-confidence and performance, particularly for complex tasks (Bandura, 1986).
People experience stress, anxiety and depression as signs of personal deficiency. In
activities that need strength and perseverance, they may interpret fatigue, pain,
symptoms of hypoglycaemia as indicators of low physical efficacy. Persons expect to
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be more successful when they are not stressed than when they are (Shortridge-Baggett,
2001). In summary, the more positive the feedback, the greater is the enhancement of
self-efficacy (Bandura, 1997).
4.2.4 Behaviour
According to Bandura (1997), the behaviour adopted depends on three perspectives of
people’s understanding: their perceptions of the degree of risk, followed by an
expectation that the behaviour will reduce that risk, and their expectation that they are
able to make the behaviour change. The three perceptions together affect behaviour
intention; in general, they influence behaviour adoption from initiation through to
long-term maintenance (Bandura, 1986).
Many of the different models of behaviour change are overlapping and in conflict
with one another in their effects on confidence, which helps to explain a person’s
degree of motivation or readiness to change. However, Rollnick, Mason and Butler
(2003, p.18) conclude: “if a change feels important to you, and you have the
confidence to achieve it, you will feel more ready to have a go, and more likely to
succeed”. Self-efficacy concerns the confidence in one’s capability to produce the
behaviour; people are motivated to perform tasks they believe will produce desired
outcomes. Outcome expectations are highly dependent on efficacy expectations, so
efficacy expectations predict performance much better than expected outcomes
(Bandura, 1986).
Moreover, behaviour is as important in the aetiology of many chronic conditions as it
is to the self-care regimen (Gecas, 1989). Diabetes is a chronic illness that requires
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long-term self-management. Low levels of psychosocial support and self-efficacy
factors can be considered as barriers because a high level of self-efficacy is generally
facilitative of self-management (Glasgow, Toobert & Gillette, 2001). Diabetes
management is a specific behaviour domain; thus the issue of self-efficacy regarding
one specific behavioural domain, diabetes self-management, will be discussed in the
next section
4.3 Self-efficacy and diabetes self-management
Diabetes self-management is a concern because it is assumed that adopting a healthy
lifestyle will produce better metabolic control of diabetes, which in turn will help to
avoid subsequent acute and long-term complications of the disease (Toobert &
Glasgow, 1994). Self-management approaches depend on drawing on patient
judgments and values within the context of daily living to inform how a
comprehensive treatment plan can best be agreed and implemented (Goldstein, 2002).
The procedures for self-management involve more than self-care that merely follows
through on daily procedures as part of a regimen. Self-management requires
participation, teamwork and frequent glucose monitoring, especially for intensive
diabetes management (Garg, Campbell, Delahanty & Halvorson, 2000).
Self-management in this study therefore, is defined in its broadest terms and includes
all efforts by patients to maintain levels of glycaemia as close as possible to the
recommended targets. Better self-efficacy will produce effective self-management,
better health outcomes, including, self-care behaviours, health-related quality of life,
psychosocial well being, and lower utilisation of health services.
There has been a trend for the responsibility for day-to day disease management to
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shift gradually from health care professionals to the individual; a recent review of the
self-management literature pertaining to chronic disease found that a large proportion
of these studies was published in the 1990s (Barlow, Wright, Sheassby, Turner &
Hainsworth, 2002). Persons with diabetes are responsible for decisions regarding food
intake, foot care, exercise, eye care, and adherence to a diabetes regimen to prevent
medical complications (Wang, Abbott, Goodbody, Hui & Rausch, 1999). According to
Fitzgerald et al. (2000), diabetes is a self-managed disease; treatment and prevention
of complications are largely a function of the patients’ willingness to care for
themselves on a daily basis. Because patients deliver most of their own diabetes care,
understanding the factors that affect self-management behaviour is important.
However, lowering blood sugar levels requires changing lifelong behaviours of diet
and physical activity and this is a very difficult and complex process (Prochaska &
DiClemente, 1983).
A patient’s self-management depends on patient education, empowerment, and their
self-monitoring of the results of self-care (Pasavic, 1980). Clement (1995) has stated
that more than 50% of patients with diabetes receive limited diabetes
self-management education or none. So, assisting people with diabetes to change their
behaviour is significant in effecting self-management and in reaching the highest
possible level of health (Shortridge-Baggett, 2001). Moreover, Lorig (1995) has
suggested that most effective self-management interventions use cognitive and
behavioural modification, in addition to providing information.
Low levels of psychosocial support and self-efficacy factors can be considered as
barriers to diabetes management, because a high level of self-efficacy is generally
facilitative of self-management (Glasgow, Toobert & Gillette, 2001). Johnson (1996)
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suggested that developing an educational program based on self-efficacy theory for
the self-management of diabetes is important; it can improve upon the traditional
diabetes education that focuses only on the transformation of information or skills
(van de Laa & van der Bijl, 2001; Moens et al., 2001). Several studies of individuals’
perceptions of their ability to perform self-care behaviour have shown self-efficacy to
be an important variable in the self-management of diabetes (McCaul, Glasgow &
Schafer, 1987; Glasgow & Osteen, 1992; Hurley & Shea, 1992).
The early focus of diabetes research studies was on educational interventions to
improve diabetic knowledge, self-care behaviours and improvement in metabolic
control (Brown, 1990; Welch, Dunn & Beeney, 1994; Fain, Nettles, Funnel & Charron,
1999). However, over the last two decades the focus of diabetes research studies has
moved and expanded to recognise the importance of psychosocial factors (Dunn, 1986;
Hunt, Arar & Larme, 1998), and cognitive factors such as self-efficacy theory
(Glasgow et al., 1992; Anderson et al., 1995; Johnson, 1996; Bandura, 1997).
Physician-directed, compliance-oriented care is not an effective solution, since
patients in this context are more like passive recipients of medical knowledge. Brown
(1990) stated that patient education has a moderate to significant effect on improving
patient knowledge but is less effective in improving glucose control over time.
However, Bodenheimer, Lorig, Holman and Grumbach (2002) used a central concept
in self-management education, self-efficacy. Patients’ self-efficacy is enhanced when
they succeed in solving problems that they have identified themselves. This approach
to self-management education teaches problem-solving skills, allows patients to
identify their problems, offers techniques to help them make decisions, take
appropriate actions, and change their behaviours in their lives, whereas traditional
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patient education merely provides information and technical skills. Self-management
education, therefore, complements traditional patient education in supporting patients
to live the best possible quality of life along with their chronic condition.
Diabetes-related self-efficacy research has focused on predicting self-care ability. In
the United States of America (USA), self-efficacy was found to be a significant
predictor of adherence to self-care activity. Those in the low adherence group, as well
as those with longer duration of diabetes, had significantly lower self-efficacy and
higher illness demand than those in the high adherence group (Poradzisz, 2001). In
Japan, Nakahara et al. (2006) examined the causal relationship between psychosocial
factors and glyceamic control using structural-equation modelling and found that
self-efficacy directly reinforced self-care adherence. In the Netherlands, diabetic
patients with high self-efficacy show more compliance with self-care in their lives
than patients with low self-efficacy (van de Laar & van der Bijl, 2001). Efficacy
belief scores related to regimen-specific behaviours were found to predict self-care
behaviours such as blood glucose management, diet, exercise, and insulin use
(Kingery & Glasgow, 1989; Hurley & Shea, 1992). Also, systematic reviews
examining self-efficacy in patients with diabetes show that self-efficacy positively
influences the health behaviours of patients with diabetes (Norris, Engelgau &
Narayan, 2001; Krichbaum, et al., 2003).
In addition, diabetes-related self-efficacy research has focussed on predicting various
health status outcomes. The strengthening of diabetes-specific self-efficacy has been
associated with a reduction in glycated haemoglobin (Anderson et al., 1995) or in
weight (Glasgow et al., 1992). In those studies in which glycated haemoglobin has
been measured, blood glucose self-management (BGSM) behaviours were more often
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found to be independent (Padgett, 1991; Glasgow et al., 1992). A large body of
behavioural science research in diabetes, reviewed by Glasgow and colleagues (1999),
demonstrated a strong relationship between patient participation in diabetes
self-management and several psychological constructs including self-efficacy,
empowerment, behavioural intentions and problem solving or coping skills.
In the USA, a 10-session, self-management training program was designed for people
over 60 years of age with type 2 diabetes (Glasgow et al., 1992). It targeted
problem-solving skills and self-efficacy; 102 adults were randomly assigned to
immediate or delayed intervention conditions. At post-test, subjects in the immediate
group showed significantly greater reductions in calorie intake (29% versus 10%, p
< .05) and percent of calories from fat (45% versus 29%, p< .05) than control subjects.
Correlations between changes on behavioural measures and change in physiological
measures were modest. The intervention group produced greater weight reductions
(r = .33, p< .01) and increased the frequency of glucose testing (r =- .21, p< .05)
compared to the control group. In contrast the improvement in exercise self-care
showed no significant changes from pre-test to post-test.
Anderson et al. (1995) conducted a randomised controlled evaluation of their
empowerment program in the USA, focusing on self-efficacy and its component skills.
These included the ability to identify satisfaction and dissatisfaction related to living
with diabetes and to achieve personal goals, to use problem-solving to eliminate the
barriers to goals, to manage stress, to obtain appropriate social support, to strengthen
motivation to perform and to make cost-benefit decisions about planned behaviours.
Forty-six volunteers, mainly overweight, well educated women, were randomly
assigned to immediate program attendance, or waiting list control, after a full
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induction into the study design and intervention approach. Participants were asked to
complete experiential worksheets, attend six sessions and participate in group
discussions. At 12 weeks from baseline, the intervention group demonstrated a
significantly greater improvement in glycosylated haemoglobin than the control group.
Self-efficacy was significantly increased among the intervention group in terms of
setting goals, managing stress, obtaining social support and making self-care
treatment decisions.
In Shanghai, mainland China, Fu et al. (2003) conducted a study to evaluate the
effectiveness of a chronic disease self-management program (CDSMP). A randomised
controlled trial was undertaken with six-month follow-up, comparing patients who
received treatment with those who did not. Participants in the treatment group
received education from a lay-led CDSMP leader and one copy of a help book. In
total, 954 volunteer patients with a medical record noting a confirmed diagnosis of
hypertension, heart disease, chronic lung disease, or diabetes, who were assigned
randomly to treatment (n=430) and control (n=349) groups. The results showed that
patients who received treatment had significant increases in the time of their weekly
periods of aerobic exercise (> 25 minutes, p= .01), and scores in their practice of
cognitive symptom management by .37 (p= .005), both measures of self-efficacy:
increase of .69 and .63 in self-efficacy to manage symptoms and in self-efficacy to
manage disease in general (both p= .001). Also, patients in the treatment group had
significant improvements in eight measures of health status (p < .05) and .12 fewer
hospitalisations than the control group (p= .04).
A recent systematic review and meta-analysis conducted by Ismail, Winkley and
Rabe-Hesketh (2004) analysed the randomised controlled trials of psychological
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interventions (supportive or counselling therapy; cognitive behaviour therapy,
psychodynamic psychotherapy and interpersonal psychotherapy) to improve
glycaemic control in patients with type 2 diabetes. Eight studies in the review had
outcome data on blood glucose. There was no evidence that psychological therapies
improved current blood glucose concentrations between patients assigned to a
psychological therapy and those in the control group; 25 trials were eligible for the
review and in 12 trials, the mean percentage of glycated haemoglobin was lower in
people assigned a psychological intervention than in the control group; the people
mean difference was -.32 (95% CI -.57 to -.07) equivalent to an absolute difference of
-.76%. However, the author made the criticism that most of the studies were of
moderate to poor quality in the reporting of potential biases, and had small sizes.
There is also inconsistent data in the literature between self-efficacy and
self-management for people with diabetes. Padgett (1991) found that glycaemic
control was not significantly correlated with either self-care ratings or with
self-efficacy for a type diabetic group. Rapley (1991) tested the association between
self-efficacy and glycaemic control, a type 1 diabetes group was found to have a
significant negative correlation (r= - .31) with glycosylated haemoglobin while no
association was found for the type 2 group.
Although most studies have shown that self-efficacy is a useful predictor for diabetic
self-management (Glasgow et al., 1992; Anderson et al., 1995; Glasgow et al., 1999;
Fu et al., 2003; Ismail, Winkley & Rabe-Hesketh, 2004), there has been limited and
inconsistent research in the literature into self-efficacy and self-management for
people with diabetes (Padgett, 1991; Rapley, 1991). The role of self-efficacy in
improving self-care behaviours and health outcomes, such as health-related quality of
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life, psychosocial well being is limited in Taiwanese research studies and health
service utilisation needs to be explored further in later studies.
4.4 Self-efficacy and health outcome variables
4.4.1 Self-efficacy and quality of life
Since implementing diabetes management lies largely with the patient’s daily effort,
patient education programs have placed increased emphasis on the patient’s role and
responsibility (Glasgow et al., 1999). Some patient activation interventions
(Greenfield et al., 1988; Grey, Boland, Davidson & Tamborlane, 2000) have reported
strong effects including promoting in self-efficacy, improvements in self-management,
and quality of life. Also, studies have investigated empowerment or self-efficacy
education as a conceptual framework for teaching diabetes self-management
(Caravalho & Saylor, 2000). Quality of life was recognised as a central outcome
measure of diabetes management in the landmark DCCT (The Diabetes Control and
Complications Trial) (Ingersoll & Marrero, 1991; Ambler, Fairchild, Craig &
Cameron, 2006).
Grey et al. (2000) conducted research to determine whether initial effects on
metabolic control and quality of life associated with a behavioural intervention
combined with intensive diabetes management (IDM) could be sustained over 1 year
in youth. Seventy-seven participants electing to initiate IDM were randomly assigned
to one of two groups: with or without coping skills training (CST), which consists of
6 small group sessions and monthly follow-up to help youth cope with their lives;
skills included social problem solving, cognitive behaviour modification, and conflict
resolution. The results showed that CST subject had lower glycosylated haemoglobin
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(p= .001) and better diabetes (p= .002) and medical (p= .04) self-efficacy, and less
impact of diabetes on their quality of life (p= .005) than youth receiving IDM alone
after 1 year.
Poradzisz (2001) stated that self-efficacy was found to be a significant predictor of
both adherence of self-care activities (R2= .35, p< .001) and QOL (R2= .40, p< .001).
Illness demand and family support contributed to QOL, but did not significantly
influence adherence for this sample. A moderate correlation (r= .50, p< .001) was
found between adherence and QOL. The results suggest that diabetes educators
should focus on efforts to improve self-efficacy, the individual’s perception of QOL
and adherence to diabetes regimen.
Bodenheimer, Lorig, Holman & Grumbach (2002) used a central concept in
self-management, which is self-efficacy. Confidence enables people to carry out a
behaviour necessary to reach a desired goal. Self-efficacy is enhanced when patients
succeed in solving patient identified problems. Self-management education
complements traditional patient education in supporting patients to live the best
possible quality of life with their chronic condition.
Fu, et al. (2003) conducted a chronic disease self-management program (CDSMP)
and found that after six months follow-up patients who received treatment (n=430)
had significant improvements in HRQOL (eight measures of health status) (p< .05),
and .12 fewer hospitalisations than the control group (p= .04).
Maddigan et al. (2004) argued that interventions aimed at improving the management
of diabetes have been somewhat successful in changing the processes for delivering
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care and have improved intermediate or surrogate outcomes, such as glycaemic
control and patient-reported outcomes, however, they have often been overlooked in
the evaluation of such interventions (Renders et al., 2001; Gaede et al., 2003). In a
review of 41 studies of community-based controlled interventions to improve
processes of care or outcomes in patients with diabetes (Renders et al., 2001), only
four studies evaluated patient-reported outcomes in a manner that would be
considered scientifically valid.
According to a literature review study (Hornquist, Wikby, Stenstrom, Andersson &
Akerlind, 1995), an attempt was made to describe how type 2 diabetes affects the life
of the ill person. A substantial proportion of patients are primarily affected with
fatigue, anxiety and depression. Some negative social circumstances have also been
noted. Social support appears to be helpful, although self-efficacy and health practices
seem to be as important. The author suggested that there was a great need for more
research on type 2 diabetes; broad prospective longitudinal follow-up studies
monitoring natural disease progression, as well as examining the predictive
significance of quality of life, would be welcome.
Fostering self-efficacy by helping the patient reach attainable goals and providing for
opportunities to develop self-management skills will bring the patient closer the
concept of patient empowerment (Via & Salyer, 1999). Rose, Fliege, Hildebrandt,
Schirop and Klapp (2002) using the structural equation model to derive a
mathematical model and confirm that if a patient reports strong beliefs in self-efficacy,
he/she is more likely to report a higher quality of life. HRQOL is important to
consider in further studies because the burden associated with diabetes may extend
beyond what is captured by clinical measures (Maddigan et al., 2004). Although
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several authors (Greenfield et al., 1988; Grey et al., 2000) have theorised that patient
activation or self-management interventions have shown significant effects of quality
of life. The effect of a self-efficacy enhancing intervention on quality of life was
studies in a few studies which designed with randomised controlled trial. Patient
reported outcome, measures such as health-related quality of life of patients with type
2 diabetes need to be involved in further experimental studies.
4.4.2 Self-efficacy and psychosocial well-being
Self-efficacy was found to provide a linking mechanism between psychosocial factors
and health outcomes. Psychosocial factors combined with cognitive functioning,
depression, stress, social support, and self-efficacy (Seeman & Chen, 2002) and they
help predict differences in Activities of Daily Living (ADLs) (Martin, Grunendahl &
Martin, 2001). In this thesis, the variable of psychosocial well being includes the
factors of social support and depression. It assumes that a self-efficacy enhancing
intervention program can improve psychosocial well being for people with diabetes in
this study. Both factors of social support and depression therefore are discussed as
follows.
4.4.2.1 Self-efficacy and social support
Diabetes is a largely self-managed disease with a major psychosocial impact on the
lives of patients and their family (Snoek, 2002). To understand patients’ self-care
behaviour, we need to take into account various psychological and social factors.
According to Snoek (2002), negative attitudes and low self-efficacy expectations are
common among people with diabetes. Cumulative negative experiences can result in a
state of “learned helplessness” or “diabetes burnout”. In diabetes care, a
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bio-psychosocial approach to the patient and his or her coping problems is warranted.
Social support has been reported to influence metabolic control through positive
effects on adherence (Glasgow & Toobert, 1988). Bandura (1977a) suggested that the
effects of social support are mediated by self-efficacy, while others may act as a
source of efficacy information relevant to the task at hand. A lack of social support
may lead to lower self-efficacy, which will in turn reduce the likelihood of a given
behaviour (Williams & Bond, 2002). Williams and Bond (2002) found that social
support was associated with exercise self-care and the relationship between the two
variables was mediated by self-efficacy. Moreover, Gallent (2003) and Nakahara et al.
(2006) stated there might be an indirect influence of social support on diabetes
self-management through self-efficacy.
Maxwell, Hunt, & Bush (1992) studied 204 patients with diabetes who were randomly
divided into two groups. The control group received only a normal diabetes training
program, whereas the experimental group was offered the same program in addition
to eight support group meetings, during which they had the opportunity to receive
informational and emotional support. After 7 months of follow-up, patients in both
groups showed improved metabolic control (HbA1C), diabetes knowledge, frequency
of practicing recommended diabetes management behaviours, and emotional
adjustment. However, no additional improvement was seen in those people in the
experimental group. The authors suggest that it is possible that sufficient social
support developed among the participants in the training group settings in which
individual self-disclosure, mutual comparison and support, interpersonal feedback,
and other elements that are thought to enhance in support groups may have been
facilitated.
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Aalto and Uutela (1997) tested a model of the Health Belief Model (HBM),
supplemented by other factors (locus of control, self-efficacy, health value, and social
support) and found that in multiple regression analyses both DA (diet adherence) (p<.
01) and SMBG (self-monitoring of blood glucose) were related to HbA1C.
Theoretically derived path models for the HBM (estimated using the LISREL
statistical model) required modifications. DA showed strong associations with
diabetes related social support (p< .001) and net benefits of DA (p< .001). SMBG
showed strong associations with self-efficacy in SMBG and net benefits of SMBG
(p< .001).
Seeman and Chen (2002) used data from the MacArthur Study of Successful Aging to
examine the impact of socio-demographics, health status, health behaviours, and
social and physical factors on patterns of change in physical functioning. The results
found that levels of functioning were not solely determined by clinical disease/health
status, but rather modifiable factors that respond best to environmental interventions,
such as increased levels of physical activity, access to a social support network, and
self-efficacy, to effectively overcome possible constraints.
Lai and Liu (2003) undertook a social support and empowerment education module
(SSEM) and evaluated the effect of social support for people with type 2 diabetes in a
community in Taiwan (n=49). The experimental group took part in a series of SSEM
courses, which was based on social cognitive theory, during a 4-week period. The
SSEM course significantly increased social support and empowerment of the
experimental group and gave patients support with power, self-efficacy and self-care
behaviour.
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All the previously mentioned studies have been applied with social support as a
mediator or outcome variable in diabetes care; however, studies which introduce a
self-efficacy enhancing intervention program and then examine the effect of social
support status are rare. Williams and Bond (2002) also suggested that programs
designed to increase confidence in self-care abilities are likely to be effective. As an
integrated model for self-efficacy is used that is supplemented with social
psychological factors, such as self-efficacy, health-related quality of life, social
support and depression, the test of the effectiveness will be explored in this thesis.
4.4.2.2 Self-efficacy and depression
People are interested in more immediate impacts of diabetes on their daily lives;
patient-centred outcomes increasingly are incorporated into the development of care
plans and the evaluation of treatment success (Laine & Davidoff, 1996; Piette,
Weinberger & McPhee, 2000). These outcomes include symptoms of depression and
anxiety, common in patients with diabetes, that can lead to poor glycaemic control
and may be at least as important in determining their health-related quality of life
(HRQOL) and service use (Piette, Weinberger & McPhee, 2000).
Piette, Weinberger and McPhee (2000) evaluated the impact of automated telephone
disease management calls, with nurse telephone follow-up, as a strategy for
improving outcomes such as mental health, self-efficacy, satisfaction with care, and
HRQOL among low-income patients with diabetes. A randomised controlled trial
involved 248 primarily English- and Spanish-speaking adults with diabetes in the U.S.
and patient-centred outcomes were measured at 12 months via telephone interview.
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The results showed that, compared with patients receiving the usual care, intervention
patients at follow-up reported fewer symptoms of depression (p= .023), greater
self-efficacy to conduct self-care activities (p= .006) and fewer days in bed because of
illness (p= .026). Intervention and control patients had roughly equivalent scores for
established measures of anxiety, diabetes-specific HRQOL, and general HRQOL.
A randomised controlled trial of self-management training for people with chronic
disease, including endometriosis, diabetes, osteoporosis and myalgic
encephalomyelitis, was conducted by Wright, Barlow, Turner and Bancroft (2003).
They determined the effectiveness of a community-based chronic disease
self-management course (CDC) for UK participants (n=232) with a range of chronic
diseases. The CDC comprised six weekly sessions (each of 2 hours) and aimed to
enhance self-efficacy through weekly action planning sessions that involved problem
solving, decision-making, role modelling, and persuasion. The result showed that no
significant changes were found at four-month follow-up for male participants (Ps=
.180) in depressive and anxious mood (Ps= .118), respectively; however, significant
reductions were found in these for female participants.
The latest meta-analysis conducted by Ismail, Winkley and Rabe-Hesketh (2004)
systematically reviewed and analysed the randomised controlled trials of
psychological interventions to improve specific psychological problems such as
depression in patients with type 2 diabetes. Five studies showed that psychological
distress was significantly lower in the intervention groups.
There are inconsistent data in the literature between self-efficacy and depression for
people with diabetes. Ikeda, Aoki, Saito, Muramatsu & Suzuki (2003) investigated the
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possible relations of HbA1c with scores on anxiety, depression, and self-efficacy for
113 outpatients with type 2 diabetes. The relation between the HbA1C level and the
self-efficacy scores as well as with ratings of anxiety and depression was evaluated. A
significant relationship was found for the HbA1C level with anxiety, depression, and
self-efficacy scores; however, self-efficacy and anxiety and depression showed no
association. These results suggest that HbA1C can be maintained at better levels by
increasing the self-efficacy of diabetic patients.
In conclusion, several studies have shown that psychosocial factors play an integral
role in diabetes management. Their impact is a stronger predictor of mortality in
diabetes patients than many physiological variables (Delamater et al., 2001).
Depression and diabetes self-efficacy have been found to be negatively correlated; the
higher the level of depression, the lower the self-efficacy (McClendon, 1996). Using a
psychological intervention may help people with diabetes to improve the depressive
mood. However, more studies related to self-efficacy and depression requires to be
explored in the future.
4.4.3 Self-efficacy and health care expenditure
Studies show that diabetes self-care education, especially interventions that use
counselling strategies to change behaviour, can lead to significant improvements in
glycaemic control as well as reductions in diabetes-related hospitalisations and health
care costs (Glasgow et al., 1992; Jack, Jr. et al., 2004). Health care utilisation includes
direct and indirect costs. Direct costs are the health system costs attributed to program
costs for treatment, operational expenses for fixed overhead costs, and utilisation
costs for laboratory and medications. Indirect costs are patient costs related to lost
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time from work or leisure (Fanning, 2002). Little is known about the impact of
disease management programs on medical costs for patients with diabetes (Fanning,
2002). Moreover, there are no prospective randomised trials measuring the impact of
diabetes self-management education on hospitalisation rates (Clement, 1995).
A study of an educational intervention was retrieved, involving 203 diabetic patients
with either uninfected ulcers or previous amputation (Malone et al., 1989). In addition
to usual care, the intervention group received a single 1-hour education session on
foot care that included a slide show of infected feet and amputated limbs and a patient
instruction checklist. The study showed a reduction in the combined endpoint of limbs
free of infection, ulcer or amputation, favouring education (education 90 %, control
72 %). Although there were no significant differences in infection or mortality during
follow-up, there was an excess of ulceration (education 5 %, control 15 %) and
amputation (education 4 %, control 12 %) in the control group.
Piette, Weinberger and McPhee (2000) evaluated the impact of automated telephone
disease management (ATDM) calls with telephone nurse follow-up as a strategy for
improving outcomes. The results showed that compared with patients receiving usual
care, intervention patients at follow-up reported fewer days in bed because of illness
(p= .026).
Fanning (2002) estimated the cost-effectiveness of HbA1C final endpoints of
treatment by a nurse case manager following a treatment algorithm for
hyperglycaemia management of patients with type 2 diabetes, compared to costs of
conventional diabetes care by a primary care physician in USA. The results showed
that the average total cost per patient for the community clinic site (CC-TA) in this
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12-month analysis was 26 % lower, although this reduction was not significantly
different from the conventional care site (PCP) ($997 ± 90 vs $1,344 ± 209, p= .08).
The CC-TA health system cost was significantly less expensive ($865 ± 84 vs $1,249
± 192, p= .05), but the patient cost was not significantly different (($112 ± 6 vs $95 ±
18, p= .3).
Fu, et al. (2003) conducted a study of the chronic disease self-management program
(CDSMP) in mainland China to evaluate the effectiveness of the Shanghai CDSMP.
Patients in the treatment group had significant improvements in eight measures of
health status (p< .05) and .12 fewer hospitalisations than the control group (p= .04).
Many costing studies have documented the total burden of diabetes to the health
system and society, with varying focus on the impact of diabetes-related
complications (Pagano, Brunette, Tediosi & Garattini, 1999). According to Clarke,
Gray, Legood, Briggs & Holman (2003), using a model for estimating the immediate
and long-term health care costs associated with seven diabetes-related complications
in patients with type 2 diabetes participating in the UK Prospective Diabetes Study
(UKPDS), results showed that the cost of first complications were as follows:
amputation ₤8459 (95 % confidence interval ₤5295, ₤13200); non-fatal myocardial
infraction₤4070 (₤3580, ₤4722); fatal myocardial infarction ₤1152 (₤941, ₤1396);
fatal stroke ₤3383 (₤1935, ₤5431); non-fatal stroke ₤2367 (₤1599, ₤3274); ischaemic
heart disease ₤1959 (₤1467, ₤2541); heart failure ₤2221 (₤1690, ₤2896); cataract
extraction ₤1553 (₤1320, ₤1855); and blindness in one eye ₤872 (₤526, ₤1299). Thus,
preventing complications related to type 2 diabetes is an important way to reduce
health care expenditure.
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Although people with type 2 diabetes have frequent contact with health care providers,
their health outcomes are often poor. Varroud-Vial et al. (2004) suggested that to
achieve the goals of reduction in complications and health care costs, it is probably
necessary to combine several strategies into an intervention, including educating the
providers and the patients. Therefore, this thesis will examine over a 6 month-SEEIP
intervention whether a theory-based nursing intervention program can improve
diabetic self-management and reduce health care utilisation in a primary care setting.
4.5 An intervention program based on self-efficacy theory
Studies into self-efficacy theory have demonstrated that it has the potential to
facilitate behaviour change and improve health outcomes in diabetes. Facilitating
personal self-efficacy in the person’s ability to manage therapeutic self-care is the
main idea of the self-efficacy model. In this section, the rationale for developing an
intervention program based on self-efficacy theory (Self-Efficacy Enhancing
Intervention Program: SEEIP) is described first. After justifying the choice of the
SEEIP program, the development of self-efficacy for people with diabetes and a plan
of the SEEIP are then described.
4.5.1 The rationale for developing SEEIP
The first reason is that, for this study, a comprehensive intervention program to
improve health related outcomes needs to be established and then tested to evaluate its
effectiveness. The second reason is that diabetes management requires a new
conceptual framework to inform the behavioural, educational and clinical treatment
approaches. The third reason is that traditional patient educational programs in
Taiwan are insufficient for people’s diabetic control; a new diabetes service program
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needs to be introduced into the Taiwanese health care system. Self-efficacy is the
main concept in the empowerment approach and it plays an important role in
successful behavioural change, consequently, the self-efficacy model of
Shortridge-Baggett and van der Bijl (1996) (see Figure 4.1), which was discussed in
Section 4.2, will be used as the basis for the intervention. These three reasons for
developing the SEEIP are explained further in the following sections.
4.5.1.1 To test the self-efficacy model requires establishing a comprehensive intervention program
Bolstering patients’ confidence about their ability to successfully implement care is a
critical step in promoting active self-management (Fu et al., 2003; Ismail, Winkley &
Rabe-Hesketh, 2004). Research affirms that people with higher diabetes self-efficacy
follow better care practices (Glasgow et al., 1989; Kingery & Glasgow, 1989). There
are many studies investigating self-efficacy in patients with diabetes, and these have
shown that self-efficacy positively influences their health behaviours and outcomes
(McCaul et al., 1987; Rapley, 1990; Padgett, 1991; Hurley & Shea, 1992; Glasgow &
Osteen, 1992; Johnson, 1996). The literature offers various examples of programs that
increase perceptions of personal control by enhancing self-efficacy (Bodenheimer et
al., 2002; Dongbo et al., 2003). As can be understood, enhancing patients’
self-efficacy programs in self-care can facilitate the improvement of patients’ health
outcomes (Corbett, 1999; Taal, Rasker, Seydel & Weigman, 1993).
The testing of self-efficacy theory’s role in behaviour change and health outcomes
relevant to chronic illness management has also been discussed (See Sections 4.3 and
4.4), however, most of the studies cited did not incorporate an intervention and hence,
lack results on behaviour changes relying upon Bandura’s four sources of efficacy
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information. In Taiwan particularly, no researchers are engaged in self-efficacy
research with interventions in relation to diabetes. In contrast, in this study, the four
sources of information adopted from Bandura (1977a) are applied in the intervention.
Bandura (1977a) recommended that strategies to build up self-efficacy belief not only
operate differently for each of the sources, but also that they have the potential to
increase the person’s sense of confidence in ability. The self-efficacy model and the
intervention of SEEIP (based on information resources, see Figure 4.2) is an
important part in this framework. Testing this model requires establishing a
comprehensive intervention program and then evaluating its effectiveness.
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Intervention (SEEIP) - Views a DVD - Receives the
“Self-Care behaviours” booklet
- Four efficacy-enhancing intervention sessions
- Telephone follow up
Person
-Demographic
variables: age, gender,
education, married
status, etc.
-illness history
Behaviour
-Self management
behaviour (SDSCA)
Outcome -Self-efficacy towards management of type 2 diabetes -Health-related quality of life (SF12) -Psychosocial well-being (MOS-SSS; CES-D) -Health care utilisation
Efficacy-Expectations
-DMSES scale Outcome-expectation
-PTES scale
Environment
Figure 4.2 Modified self-efficacy model for evaluation of the self-efficacy enhancing intervention program (SEEIP) for persons with type 2 diabetes
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4.5.1.2 A new conceptual framework: the empowerment approach (increased self-efficacy is an integral part of an empowerment education program)
In recent years, patient empowerment has become an alternative to the
compliance-oriented approach to diabetes management. Empowerment incorporates
components of knowledge, behavioural skills and self-care responsibility (Anderson,
Funnel, Barr, Dedrick & Davis, 1991). The primary purpose of empowerment for
people with diabetes is to prepare them to make informed decisions about their
self-care, as a supplement to basic diabetes education.
In 1991 the education team at the University of Michigan Diabetes Research and
Training Centre (MDRTC) realised that diabetes self-management was radically
different from the treatment of acute illness and required a new conceptual framework
to inform the behavioural, educational and clinical approaches to be used. Called
‘patient empowerment’ this paradigm was contrasted with the more traditional
medical model approach to care and education (Anderson et al., 1991).
The team of MDRTC realised that patients with diabetes were fully responsible for
the self-management of their illness; this immutable responsibility rests on three
characteristics of the disease. Firstly, the most important choices affecting the health
and well being of a person with diabetes are made by the person, not by diabetes
educators or health professionals. Secondly, people with diabetes are in control of
their diabetes self-management. Finally, the consequences of the choices people make
every day about their diabetes care accrue, first and foremost, to the people
themselves (Anderson et al., 2000). Because the patient empowerment approach to
diabetes patient education seeks to maximise the self-management knowledge, skills,
self-awareness and sense of personal autonomy of patients to enable them to take
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charge of their own diabetes care, enhancing people’s responsibilities for their
self-management is crucial for people with diabetes. Moreover, the evaluation of the
patient empowerment approach should focus on patient achievement of self-selected
diabetes care goals, improved psychosocial adaptation and enhanced self-efficacy
(Anderson et al., 2000). As a result, self-efficacy is a main concept in the
empowerment approach and it plays an important role in successful behaviour change.
Increased self-efficacy is an integral part of an empowerment education program.
According to Anderson et al. (1995), increases in self-efficacy are linked to
empowerment and improved outcomes. Clement (1995) has claimed that diabetes
self-management education is effective only when behaviour change strategies are
extensively used. Also, Caravalho and Saylor (2000) state that whether a patient is
motivated to perform positive health behaviours may be decided by the patient’s
belief in his or her ability to succeed in a skill or to achieve self-selected goals. This
belief is known as self-efficacy. Also, they revealed that self-efficacy plays a central
role in behavioural interventions, because efficacy beliefs are dynamic and subject to
influence; they are ongoing cognitive, behavioural and communication processes.
Personal self-efficacy is changeable by different modes of influence. Enhancement of
efficacy beliefs increases motivation and success with behavioural efforts (Maibach &
Murphy, 1995). In brief, more studies are needed to focus on how to enhance
self-efficacy, especially for chronic illness, such as diabetes.
4.5.1.3 Traditional patient educational programs in Taiwan are insufficient for
people’s diabetic control
The traditional model of diabetes education has been ineffective in bringing about
desired outcomes (Funnell et al., 1991). Glasgow and Osteen (1992) have stated that
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changes in knowledge and attitude through information transfer and instruction are
not sufficient to realise the desired self-care behaviour; they also recommend that
diabetes education should include a patient perspective, such as the patient’s
self-efficacy. Self-efficacy, therefore, is an important component of diabetes
management and can be used for prediction of adherence to self-care behaviours
(Johnson, 1996).
Self-management approaches imply the involvement of patient judgments and values
within the context of daily living to inform how a comprehensive treatment plan can
be best agreed and implemented (Goldstein, 2002). Consistent with this
self-management perspective, the American and British Diabetes Association
(Diabetes UK) now refers to diabetes education as diabetes self-management
education (Goldstein, 2002). However, more than 50% of patients with diabetes
receive limited diabetes self-management education, or none (Clement, 1995; Johnson,
1996). Taal et al. (1993) claimed that to improve the self-management of disability
and adherence to health recommendations, patient education should be aimed at
strengthening self-efficacy expectations. Self-efficacy is one important part of social
cognitive theory, and offers a basis for improving the effectiveness of diabetes
education, because it focuses on behavioural change (van der Bijl &
Shortridge-Baggett, 2001). This can improve traditional diabetes education that relies
on just the transfer of information or skills (Brown, 1990; van de Laa & van der Bijl,
2001; Moens et al., 2001).
In general, diabetes patient education can be found in some hospitals and community
health services in Taiwan. These traditional patient educational programs can be
conducted as either individual or group education. Normally nurses or diabetes
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educators will be involved in patient education programs, and a few nutritionists or
dieticians may also be involved. In 2001, Bureau of National Health Insurance (BNHI)
commenced a few quality-based payment programs to improve quality of care, thus
diabetes was involved in a financial program. This allows extra payment for medical
care providers if they provide nutrition consulting and individual diabetic education. It
is estimated that there are about 139 diabetes educational promotion institutions in
Taiwan so far (see Section 2.4.2). Even though patient education has been widely
promoted, there remains a lingering doubt about how effective it can be in achieving
the desired effect of improve diabetic care. Unfortunately, previous literature has
shown most diabetic patients do not control their disease appropriately in Taiwan,
even though patient education has been provided (see Section 3.6). Moreover, no
researchers are engaged in self-efficacy research with interventions based on the four
sources of information adopted from Bandura (1977a) being applied in relation to
diabetes. A new diabetes service program needs to be introduced into the Taiwanese
health care system in order to improve the poor situation of diabetes care.
In Taiwan, individual or group diabetic education and nutrition consulting are offered
in many hospitals, especially in academic medical centres or local community
teaching hospitals. Traditional education in Taiwan usually gives out an educational
sheet and then explains the content of the sheet; normally, about 10-20 minutes is
spent on each session. Because of the importance that perceived self-efficacy can have
on performance of behaviours, this concept was selected for the present study. A
self-efficacy enhancing intervention program (SEEIP) is different from a traditional
education program. Traditional patient education emphasises disease-specific
information and technical skills, and health care professionals decide what
information and skills to teach (Bodenheimer et al., 2002) whereas the SEEIP teaches
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self-efficacy enhancing and goal-setting skills in order to enhance people’s confidence
and change people’s behaviours. While traditional patient education defines the
problems, the SEEIP guides people to identify their own problems and provides
techniques to help them make decisions, and take proper actions as they encounter
changes in circumstances or disease. The comparison of traditional patient education
and the SEEIP in this research study is demonstrated in the next chapter (pilot study)
(Table 5.2).
4.5.2 Development of self-efficacy for people with diabetes
Fostering self-efficacy by helping the patient reach attainable goals and providing for
opportunities for them to develop self-management skills will bring the concept of
patient empowerment closer (Via & Salyer, 1999). The follow-up literature of
counselling skills and self-efficacy enhancing strategies are guides to structure the
development of self-efficacy for people with diabetes. It requires application in other
diabetes-related interventions.
4.5.2.1 Counselling skills to develop self-efficacy
For practitioners, five practical principles of enhancing self-efficacy can be derived
from the work of Bandura and others (Egan, 1994). Firstly, self-efficacy is not an
all-or-none quality. One can provide encouragement for those situations where it is
high, and help the person look at different approaches for improving self-efficacy in
situations where he or she feels less confident. Secondly, doing is the best way to
enhance self-efficacy. Thirdly, people need to have skills to succeed but sometimes
these lie dormant; they need to be built up. Fourthly, feedback should be provided
about deficiencies in performance, not deficiencies in the person. Finally, people learn
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by modelling themselves on others, hence there is value in talking about friends and
patients who have succeeded, attending self-efficacy enhancing groups, and so on
(Rollnick, Mason & Butler, 2003).
According to Rubin (2000b), health care providers’ facilitation of the development of
diabetes-related coping skills in people with diabetes involves a number of specific
techniques. These techniques help patients to identify their problematic
diabetes-related issues, identify attitudes and beliefs underlying the problems and
establish self-care goals, and develop a plan for achieving these goals. These coping
skills training techniques include: ask questions; start with the patient’s agenda and
individualise the treatment plan for each patient; be as specific as possible in defining
the problem; take a step-by-step approach; and maintain contact with patients between
visits. Moreover, some strategies, based on Bandura’s social learning theory, includes:
do little more; scaling questions; brainstorm solutions; past efforts of successes and
failures; and reassessing confidence, dealing with specific changes in self-efficacy
about behaviour change (Rollnick, Mason & Butler, 2003). These are very important
points of information for enhancing self-efficacy in this study.
The skills and strategies to develop self-efficacy described below are derived from
Rubin (2000b) and Rollnick, Mason and Butler (2003) in order to provide an evidence
base to be used for the SEEIP in this study, especially for the self-efficacy counselling
intervention sessions of the SEEIP.
1. Ask questions
Asking questions like “what’s the hardest thing for you right now about dealing with
your diabetes?” “How often are you testing your blood sugar these days?” can
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actually save valuable time for the health care provider and the patient. Participants
begin the process by identifying their own regimen barriers or “sticking points”. The
more specifically the problem is defined, the easier it is to solve (Rubin, 2000b).
2. Start with the patient’s agenda and scaling questions
Starting with the patient’s agenda actually increases the likelihood that the health care
provider will accomplish his or her goals for the patient, because when patients see
that their needs are the provider’s primary concern, openness to the provider’s
suggestions will be likely to grow (Rubin, 2000b). Scaling questions are linked to the
numerical assessment of confidence. For example, “If you decided right now to
change (your diet) how confident do you feel about succeeding with this? If 0 was
‘not confident’ and 10 was ‘very confident’, what number would you give yourself?”
(Rollnick, Mason & Butler, 2003, p.64). The participant will do most of the thinking
and talking, while your role is to ask questions and help with clarifying the stumbling
blocks to change.
Having gained a numerical judgment from the participant about confidence to change,
try some simple advice, like: “So you gave yourself a score of 3/10 for confidence to
actually change your diet. What about cutting out those snacks between meals from
now on?” (Rollnick, Mason & Butler, 2003, p.96).
Having conducted an assessment of how confident the person feels to make a
particular change, providers have been told a rating, out of 10. Ask either or both of
the following questions and then follow them on with other open questions or
reflective listening statements. Ask why the participant scored a given number and not
a lower one: “You said that you were fairly confident about your ability to change.
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Why have you scored 4 and not 1?”. For example, “I am at 4 and not 1 because I
know that if the situation is right, if I can keep away from friends who push me in the
wrong direction, I can succeed.” This will allow providers to respond in ways such as,
“So you have got the confidence to succeed if only you could organise your social life
differently.” Providers can either pursue this in more detail, or keep the focus broad to
begin with, by asking a question like “What other reasons do you have for giving
yourself a score of 4 not 1?” (Rollnick, Mason & Butler, 2003, p.97)
However, there are other different questions, for example “You gave yourself a score
of 4. So you do have some confidence that you could succeed. How could you
become more confident, so that your score goes up to 5 or 6?” or “What would help
you to become more confident?” or “What stops you moving up from 4 or 5?”. These
questions need to be practised skilfully by providers and will be more effective for
participants.
3. Brainstorm solutions (decision making)
In most behaviour change consultations patients probably prefer greater autonomy in
decision-making. If clinical judgment tells you that a participant really wants you to
tell him or her what to do, then you should respond accordingly. However, most
patients, the authors believe, will react against simple advice-giving (Rollnick, Mason
& Butler, 2003). If a participant said “I don’t know what to do about…”, the providers
could answer “Have you thought about before….?” This simple strategy is usually
called brainstorming. There are some examples that can be practised: “There is
usually not one but many possible courses of action”; “You will be the best judge of
what works for you”; “Let’s go through some of the options together”. Try to avoid
spending too much time evaluating the options. If the participant says: “Yes! But, that
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won’t work because….”, say something like: “That’s fine, let’s not get too stuck on
one idea, let’s move on….what else could you do?”. However, let the participant
select the most suitable option, with questions like “Which one suits you the most?”
or “What makes the most sense to you?”. The provider’s task is to elicit and to
understand how the participant really feels about what to do (Rollnick, Mason &
Butler, 2003).
4. Set goals (take a step-by-step approach)
Caravalho and Saylor (2000) have stated that whether a patient is motivated to
perform positive health behaviours may be decided by the patient’s belief in his or her
ability to succeed in a skill or to achieve self-selected goals. No one can solve
problems all at once; many people can solve them one-step-at-a-time. Most
diabetes-related problems are daunting. Health care providers can help their patients
cut a problem down to size by taking a step-by-step approach (Rubin, 2000b). The
goals of a problem for people with diabetes also need to be taken by a step-by-step
approach. The strategy of selecting a goal needs to move from the general to the
specific, such as from a goal, through strategies, to targets. Help the participant set
small, achievable targets, if at all possible. Using weight loss as the example, getting
more exercise might be a goal for one person but it needs more detail about the
strategies and targets (see Table 4.1) (Rollnick, Mason & Butler, 2003). According to
Bodenheimer et al. (2002), an important concept in self-management education is
self-efficacy. An action plan usually a shorter duration, such as 1 or 2 weeks for
example, “This week I will walk around the block before lunch on Monday, Tuesday,
and Thursday”. The action plan should be realistic, proposing behaviour that patients
are confident they can accomplish. Confidence can be measured by asking, “On a
scale of 0 to10, how sure are you that you can walk around the block before lunch on
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Monday, Tuesday, and Thursday?” Experience shows that if the answer is 7 or higher,
the action plan is likely to be accomplished.
Table 4.1 Goals, strategies and targets: from the general to the specific
Goal→ Strategy→ Target
Lose weight 1. Eat less fatty food 1. Cut out fried potatoes 2. No red meat during the week 3. No full-fat milk
2. Start eating new food 1. Fruit once a day 3. Replace certain foods 1. Baked potatoes or rice instead of
chips 2. Fish instead of meat at weekends 3. Fruit instead of pudding 3/7 days 4. Poached egg or beans on toast instead
of bacon for breakfast 4. Get more exercise 1. Walk to work whenever possible 2.Arrange sport or dancing once a week 3. Use the stairs instead of the lift Adapted from Rollnick, S., Mason, P., & Butler, C. (2003). Health behaviour change: A guide for
practitioners. New York: Churchill Livingstone. P.94
Moreover, establishing a realistic timescale is also important. Changing habits takes
time and is a gradual process. A good timescale is one that is slow enough to be
manageable but fast enough to show some results so as to keep up the participant’s
motivation. A useful question like “one of the things you said you liked about
drinking was the socializing- would there be any advantage in waiting until after
Christmas before beginning to cut down?” (Rollnick, Mason & Butler, 2003, p.99).
5. Consider past efforts - successes and failures
According to Bandura (1977a), performance accomplishments (practising and earlier
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experience) are the most effective in developing one’s perception of self-efficacy in
the four information sources. Performance accomplishments mean practising and
experiencing success in achieving goals and this performance mastery experience is a
composite of prior experiences related to carrying out the behaviour. Successful
achievements will strengthen self-efficacy (efficacy expectations) about ability to
perform specific tasks and generalise to similar tasks (McAuley, Lox & Duncan,
1993).
From past experience, we can learn what we are good at and what we find most
difficult by looking back at previous attempts to change. This can be a good way of
learning. Helping someone to see the past as a valuable piece of information, to help
plan a more successful future is a skill. Use words like failure and frame the question
in terms of what the participant did wrong rather than in terms of a faulty plan or
adverse circumstances which could be altered if another attempt was made. For
example, “You have not been very successful in the past, have you? Perhaps we better
take a long, hard look at what you did wrong last time and see if you can make a
better go at it this time” (Rollnick, Mason & Butler, 2003, p.101).
Ask about the person’s most successful attempt to date. What made it different from
any other attempts? Are any of these differences things that could be built into a new
plan? Solutions-focused therapists emphasise the value of encouraging people to talk
about their strengths rather than their difficulties and to guide conversations towards
“solution talk” (Iveson & Ratner, 1990). If a participant acknowledges that he or she
did change, briefly, but discounts this, saying “Yes but it was dreadful, it nearly killed
me!”, he or she may be helped to reframe and the provider can say “Looking back on
it now you must be really impressed with yourself for coping with such a difficult
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situation!” Keep the discussion of past experience as a way of building confidence.
6. Reassess confidence
Levels of self-efficacy will vary across the specific strategies and targets for
confidence building them. For example, someone wishing to change his or her diet
might be more confident about eating more fruit. To return to an assessment of levels
of confidence can be very useful. That can be done formally, in numerical form, as
described on the previous strategy of scaling questions.
7. Maintain contact with patients between visits
According to Rubin (2000b), effective approaches to maintaining contact include:
phone calls, postcards, e-mail messages and office-based support groups. This
strategy can be difficult for many health care providers, but research and clinical
experience show that even brief, occasional contact with a health care provider can
powerfully affect people struggling with a chronic disease.
In conclusion, the strategies need to structure a conversation in a useful way that
encourages the participant to take the lead as much as possible. The above strategies
require application in other diabetes-related interventions. The following literature has
used self-efficacy enhancing strategies according to Bandura’s information sources;
these methods could apply in the intervention of SEEIP.
4.5.2.2 Self-efficacy enhancing strategies according to Bandura’s information sources
To develop self-efficacy beliefs (level/magnitude, strength, and generality of the
belief) for a specific task there are four information sources. A certain hierarchy exists
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in the four information sources of self-efficacy: performance accomplishment,
vicarious experience, verbal persuasion, and self-evaluation (Bandura, 1977a; van der
Bijl & Shortridge-Baggett, 2001).
1. Performance accomplishment
Performance accomplishment, the repeated execution of the task, is the most powerful
source, as it is based on direct information; people immediately experience success or
failure (van der Bijl & Shortridge-Baggett, 2001). When starting a task, people need
experience of success to improve their self-efficacy (Gonzalez, Goeppinger & Lorig,
1990). Rapid successes are beneficial to self-efficacy, while failure at an early stage is
disadvantageous. Repeating a single task until the patient has mastered it eventually
leads to success. Johnson (1996) has stated that persons with diabetes should be
allowed time and opportunity to try out a blood-glucose monitoring device until they
are successful. Furthermore, they should practice first in simple situations, and later in
more complex ones (Bandura, 1986).
Sometimes people interpret their successes negatively; they do not recognise them, or
underestimate their importance. In these cases, it is important to establish goal setting
in order to enhance self-efficacy (van der Laar & van der Bijl, 2001). Goals influence
achievement because they motivate people to exert themselves again and thus they
persevere longer in their task; goals, however, have to be realistic and achievable.
Short-term goals are more motivating than long-term ones (Locke, Saari, Shaw &
Latham, 1981). After each education session, the contract should be discussed and
new goals set by the client (Gonzalez, Goeppinger & Lorig, 1990).
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The combination of setting goals in a contract and giving feedback is important.
Before every education session, feedback should be given on the goals of the
preceding period, and clients should report their achievements (van der Laar & van
der Bijl, 2001). At least 30% of each education session should be used for discussing
contracts and feedback, and regular contact by phone to ask about the client’s
achievements can also be effective (Gonzalez, Goeppinger & Lorig, 1990). In
addition, a diabetes diary is another good source of feedback for persons with diabetes.
For example, blood glucose values, self-care actions and the prevailing circumstances
can be noted in the diary, and the client can thus gain insight into self-regulation (van
der Laar & van der Bijl, 2001).
When clients know what is expected of them, are conscious of what will happen to
them, and are able to choose behaviour strategies, their self-efficacy is enhanced (van
der Laar & van der Bijl, 2001).
2. Vicarious experience
Vicarious experience (modelling), by seeing other people demonstrate the desired
behaviour, can offer very important self-efficacy information, but it is not based on
one’s own experiences (van der Bijl & Shortridge-Baggett, 2001). Comparability of
models is based on two criteria: shared experiences and similar personal
characteristics. People with a comparable lifestyle, like friends or colleagues, can
serve as models, and models can demonstrate skills for the intended behaviour (van
der Laar & van der Bijl, 2001). In group education, one possibility is to choose a
person with the same health problems, such as diabetes. For each problem the group
leader can ask the group members for solutions or ideas and thus group members can
be encouraged to help each other in solving their problems. They may offer
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innovative solutions that have not been thought of by professionals (Gonzalez,
Goeppinger & Lorig, 1990).
Moreover, modelling can also be used with other educational media like television,
videos, movie, brochures and textbooks. Some investigations have looked at movies
or videos as a strategy for vicarious learning because the desired behaviour can be
demonstrated using comparable models whenever possible. Results found an increase
in self-efficacy (Gross, Fogg & Tucker, 1995; Johnson, 1996). According to Johnson
(1996), the medium of video can show all aspects of diabetes care and specific role
models can be used for demographic groups, such as children, teenagers and older
persons with diabetes.
Another form of learning by observation is demonstration of specific skills or
behaviour. Nurses, educators or course leaders can demonstrate specific actions. For
example, skills of injecting insulin and measuring blood glucose can be demonstrated
by professionals (Johnson, 1996; Oetker-Black, Teeter, Cukr & Rininger, 1997).
3. Verbal Persuasion
Verbal persuasion is an easily used, but weak source, and is usually used to support
the other sources (van der Bijl & Shortridge-Baggett, 2001). Verbal persuasion may
stimulate persons to set higher goals than they would have done by themselves.
Positive feedback is another important reward to induce people to show a specific
behaviour and keep it up (van der Laar & van der Bijl, 2001). The more reliable the
person who is communicating the message, the greater is the success in changing
attitudes or learning a new behaviour.
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Bandura (1997) has emphasised the importance of the credibility and expertise of the
educator. Confidence can also arise from observed equality with the educator,
whereas patients can also stimulate each other. Patients who are experiencing
difficulties in a specific area can often be influenced by a group (Gross, Fogg &
Tucker, 1995; Johnson, 1996). For people with diabetes, verbal persuasion primarily
consists in the transfer of knowledge. Once patients have insight into the reasons why
they have to change their behaviour, they need to be stimulated to start making those
changes, such as changes in diet and physical exercise. Instructions can be given on
blood glucose monitoring and on the use of the blood-glucose monitoring device;
explanations can then be given on the recommended frequency of monitoring.
Patients, therefore, have to be observed and encouraged in their behaviour (Johnson,
1996).
In conclusion, positive feedback on the actions they have taken and a positive
interpretation of possible faults can enhance self-efficacy (van der Laar & van der
Bijl, 2001).
4. Self-evaluation
Self-evaluation is the least concrete source of information for self-efficacy. People
rely on their physical and emotional states to judge their capabilities (Bandura, 1997;
van der Bijl & Shortridge-Baggett, 2001). Self-efficacy can be increased by
improving the patient’s physical situation, reducing stress, and decreasing negative
emotions, as well as by correcting false interpretations of the patient’s physical
situation. Maddux and colleagues (1995) claim that persons have more confidence in
their own abilities when they feel relaxed. Strategies that reduce and control
emotional tension can thus enhance self-efficacy, particularly when learning new
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behaviour.
Physical symptoms can be seen as indicators of personal ineffectiveness, and
changing these interpretations is important. Health care professionals need to
determine what people believe and why they believe it, and if possible, help people
change their beliefs (van der Laar & van der Bijl, 2001). Stress can influence diabetes
regulation and lead to metabolic disorders; physiological stressors like pain and
trauma produce heightened insulin intolerance, and so do psychological stressors like
undesired life events and daily worries. Suffering with diabetes inevitably leads to
some level of stress.
Johnson (1996) claimed that having patients feel relaxed is crucial. Education,
therefore, should be given in a relaxed and stress-free environment, because fear and
distress have a negative effect on self-efficacy. Clearly, physiological indicators of
self-efficacy play a large part in healthy functioning. However, this source of
self-efficacy should be seen in the context of the other three sources, which are more
concrete and can be better measured (Bandura, 1977a; van der Laar & van der Bijl,
2001).
5. Combination of sources
Combining different sources of self-efficacy is best for enhancement of self-efficacy,
and combining all four sources is the most effective (Maddux & Lewis, 1995;
Bandura, 1997). However, the influence of the different sources can differ in each
situation and for each person, and few investigations have looked at multidimensional
efficacy information (Bandura, 1997). The following studies have demonstrated
evidence and effects for self-efficacy enhancing interventions.
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Wing, Epstein, Nowalk, Koeske and Hagg (1985) examined the effects of a
behavioural program on weight loss for patients with type 2 diabetes, using elements
of the first three sources of self-efficacy information. The patients received
information on nutrition and physical exercise and learned a number of strategies for
enhancing their behaviour. Participants had to set their goals and keep a diary;
meetings were used to practice and discuss progress; also role-play allowed
observation of others. The result was a significant loss of body weight during the first
four months; however, this was poorly sustained. After 16 months the effects of the
program had disappeared.
Padgett (1991) examined factors related to self-efficacy and found that persons with
higher self-efficacy shared a number of characteristics. Younger persons, males, and
higher educated persons usually have higher self-efficacy than older persons, women
and persons with less education. Persons with higher depression tend to have lower
self-efficacy. Thus, identifying individual risk factors can increase the effectiveness of
interventions to enhance self-efficacy.
According to Johnson (1996), self-efficacy could be used as a framework to enhance
the effectiveness of community pharmacy-based diabetes education programs. All
four information sources of self-efficacy can be used with different learning methods.
For example, when people are learning to measure and interpret blood glucose, the
educator first has to explain the advantages and supply the necessary knowledge. The
equipment and procedure then can be demonstrated, after which the persons with
diabetes have an opportunity to practice at home. This author recommended that a
videotape of patients with diabetes successfully performing specific self-care
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behaviours and incorporating such behaviours into their daily routine could be
provided for patients to view at their convenience. This medium would provide
additional vicarious experience in a low-stress environment; fear can have a negative
effect on self-efficacy. Practitioners should routinely monitor self-efficacy for
adherence and self-care behaviours among patients with diabetes (Kavanagh, Gooley
& Wilson, 1993); one questionnaire of SDSCA is recommended for use (Johnson,
1996). However, to conquer the weakness of this scale, converging measures of
self-management should be collected when possible. For example, patients may be
encouraged to maintain diaries of self-care behaviours (e.g. food records or a
blood-glucose monitoring dairy).
Grey et al. (1998) found that training in coping skills had a positive effect on
self-efficacy among teenagers with diabetes. The training was aimed at avoiding
inappropriate coping and establishing more positive coping and behaviours.
Participants were trained based on the elements of modelling, verbal persuasion and
practicing skills. When people change behaviour, maintenance of the desired
behaviour is critical. Absence of a coping response will lead to lower self-efficacy and
relapse. Correct use of a coping response will lead to success, which enhances
self-efficacy (Marlatt & Gorden, 1985).
According to Rubin (2000b), psycho-education incorporating a coping skills training
component could have contributed to several outcomes in different ways. Diabetes
self-efficacy could have been affected directly, and other outcomes such as
self-esteem, depression, anxiety, self-care behaviour and glycaemia control could
have been affected indirectly (Rapley, 1991;Ismail, Winkley and Rabe-Hesketh,2004).
The addition of coping skills training seems financially feasible for most diabetes
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education programs. Costs for adding this component are relatively low (US $35 per
patient for the Hopkin program), and the additional patient time required is relatively
small (2.5 hours). However, the most difficult obstacle for establishing any coping
skills training program may be identifying a professional who is sufficiently
experienced in diabetes-specific coping skills training. It may be possible to identify a
mental health professional who is interested in developing expertise in working with
people with diabetes. Alternatively, diabetes health care providers who are not mental
health specialists may be interested in developing expertise in coping skills training.
This approach is teachable and professionals have successfully been trained to
implement the intervention. Rubin (2000b) has suggested further studies in which the
control group receives traditional diabetes education and the intervention group
receives traditional education supplemented by coping skills training.
A study was conducted on counselling women with breast cancer using principles
developed by Bandura’s theory (Lev & Owen, 2000). Eighteen women with breast
cancer were randomly assigned to efficacy-enhancing experimental (n=10) and
usual-care control (n=8) groups. The experimental group received five interventions
delivered monthly. The counselling technique given to women in this study included:
receiving a booklet describing self-care behaviours and receiving five counselling
interventions at monthly intervals and receiving a videotape. A trained
nurse-counsellor had contact with the women in the study. The results showed that
interventions to promote self-efficacy increase quality of life and decrease distress for
women diagnosed with breast cancer.
Barrera, Jr. Glasgow, McKay, Boles and Feil (2002) conducted a randomised trial of
160 adult type 2 diabetes patients and provided computers and internet access to
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novice internet users assigned to 1 of 4 conditions: diabetes information only; a
self-management coach; a social support intervention; or a self-management coach
and the social support intervention. After three months, participants in the two support
interventions showed significant increase in the support outcome and participants’ age
was found to be significantly related to change in social support. The social support
intervention provided activities on the internet that offered opportunities to exchange
diabetes-related information, coping strategies, and emotional support, for example,
through a peer-directed (but still professionally monitored) forum for participants to
interact with one another in a safe, supportive setting where they were encouraged to
express their concerns, successes, and frustrations. As can be seen, this support
strategy is effective for people with type 2 diabetes.
A randomised controlled trial was conducted by Howells et al. (2002), which aimed to
evaluate changes in self-efficacy for self-management in young people with type 1
diabetes participating in a “Negotiated Telephone Support” (NTS) intervention
developed using the principles of problem solving and social learning theory. The
result has shown that participants in group 2 (continued routine management with
NTS, n=25) and group 3 (annual clinic with NTS, n=26) received an average of 16
telephone calls per year (5-19), median duration 9 minutes (2-30), with a median
interval of 3 weeks (1-24) between calls. Significant correlations were found between
age and average length of calls (r = .44, P < .01) and frequency of contact (r = .36,
P<0.05). After one year, while the participants in the two intervention groups showed
significant improvements in self-efficacy (p = .035), there was no difference in
glycaemia control in the three groups. This study has shown that telephone support is
an effective medium to deliver a simple theory-based psychological intervention to
enhance self-efficacy for diabetes self-management.
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In summary, to develop self-efficacy beliefs for a specific task it is necessary to use
the four information sources of Bandura’s self-efficacy theory. The counselling skills
and self-efficacy enhancing strategies are guides to structuring the development of
self-efficacy. However, this requires application in a diabetes-related intervention.
4.6 Summary
There are some studies that showed that there are significant relationships between
self-efficacy theory and diabetes care (Rapley, 1990; Padgett, 1991; Hurley & Shea,
1992; Glasgow & Osteen, 1992; Johnson, 1996). Research conducted thus far has
shown that diabetic self-care behaviours can be improved by interventions based on
social learning theory (with the four information sources). However, most published
research on diabetes self-efficacy thus far has been conducted in the US or western
countries; it showed that self-efficacy is a predictor of self-care behaviour, and it
would seem useful to assess self-efficacy among other countries or linguistic groups,
such as Taiwan.
This chapter provides the overview of the self-efficacy model and the framework for
the study. A literature review of self-efficacy and outcome variables, such as
health-related quality of life, psychosocial well being and health care expenditure has
been explored. Moreover, three reasons for developing the intervention program
(SEEIP) and self-efficacy enhancing strategies have been described in this chapter, as
a guide to structuring the development of the SEEIP.
Glasgow and Osteen (1992) conclude that the past decade has seen a dramatic shift
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from knowledge-attitude-belief models of diabetes education to a focus on
patient-centred perspectives, self-efficacy, self-management, and empowerment issues.
To address this change, we need to modify our assessment approaches to the
measurement of outcomes such as program reach and appeal to different patient
populations, health-related quality of life and cost effectiveness.
This study is therefore designed to assess the effectiveness of self-management for
persons with type 2 diabetes, following the implementation of a self-efficacy
enhancing intervention program (SEEIP). The SEEIP designed by the researcher was
used to enhance diabetic people’s self-confidence and ability in self-care for
themselves. This program uses interventions that add to the sources of development of
self-efficacy including: (1) viewing a 10-minute DVD (2) receiving the “Diabetes
Self-Care” booklet (3) participating in four efficacy- enhancing counselling
intervention sessions at weekly intervals (4) participating in telephone follow-up. It is
anticipated that the SEEIP component will affect diabetes self-efficacy directly, and
other outcomes such as self-care behaviours, glycaemic control, depression and social
support could be affected indirectly also. This program and the research methods will
be introduced in the next chapter.
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Chapter 5
Methods
5.1 Introduction
The study was divided into two research studies. Study I (Phase 1) translated two
diabetes-specific self-efficacy instruments (DMSES & PTES: the Diabetes
Management Self-Efficacy Scale and the Perceived Therapeutic Efficacy Scale) into
Chinese for use in a Taiwanese population, and tested their reliability and validity.
Study II covered two phases: Phase 2 consisted of development of an intervention
based on self-efficacy theory, and then Phase 3 was a randomised controlled trial to
evaluate the efficacy of the intervention in a Taiwanese population (see Figure 5.1).
This chapter outlines the research design, population and sample (including sample
size calculation), setting and procedure, instruments/measurement strategies, data
analysis, and ethical considerations in each phase of the study.
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Figure 5.1 Two studies (or three phases) of the research
5.2 Study I: Translation, testing of validity and reliability of two
diabetes-specific self-efficacy instruments in a Taiwanese population
In Study I, two diabetes-specific self-efficacy instruments (DMSES and PTES) were
translated and tested for reliability and validity in a Taiwanese population.
5.2.1 Research design
A two-stage study design was used in order to test the validity and reliability of two
diabetes-specific self-efficacy instruments in a Taiwanese population. This study
was undertaken over two stages. Stage one involved forward translation, consensus
Study I Translation, testing of
validity and reliability of two
diabetes-specific self-efficacy
instruments in a Taiwanese
population
Translation
Content validity (CVI: a
panel of content experts,
n=8)
Criterion validity (n=230)
Convergent validity (n=230)
Construct validation: factor
analysis (n=230)
Internal consistency:
Cronbach’s alpha (n=230)
Stability: test-retest (after
2-4 weeks, n=30): ICC; a
Bland-Altman plot
Study II (Pilot study)
Development of an
intervention based on
self-efficacy theory &
Piloting of the intervention
Developing a suitable
intervention in Taiwanese:
included DVD, “Diabetes
Self-Care” booklet,
efficacy- enhancing
counselling intervention
sessions and telephone
follow-up
•Validation of the
intervention: provider
experts (n=4) and patients
(n=6)
•Pilot the intervention
Study II (Main study)
Randomised controlled trial
to evaluate the efficacy of
the intervention
Pre-test / post-test/
experimental study
(n=145)
Baseline- 3months- 6 months
Outcome measures:
C-DMSES
C-PTES
SDSCA
SF-12
MOS-SSS
CES-D
Health Service utilisation
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meetings, focus groups, and backward translation of the instruments and examined
the content validity (CVI). Stage Two established the psychometric properties of the
Chinese version of the DMSES and PTES by examining the criterion, convergent
and construct validity, internal consistency and stability test (test-retest).
5.2.1.1 Stage one: translation and instruments development
The first stage involved the translation of the DMSES and PTES and examination of
the newly developed Chinese version of the DMSES and PTES for cultural
equivalency. Chinese versions of the DMSES and PTES were developed according
to the steps described in Brislin’s (1986) and Jones, Lee, Phillips, Zhang & Jaceldo
(2001) model of translation in order to assure equivalence. Several forward and
backward translations were undertaken by both monolingual and bilingual
personnel. The processes of Stage One (see Figure 5.2) involved:
(1) Forward translation
Two bilingual translators independently translated the DMSES and PTES scales
from English into Chinese.
(2) A consensus meeting
In a consensus meeting, a researcher, two translators, and a diabetes educator,
checked and agreed on a version of the DMSES and PTES that best reflected the
linguistic and conceptual matter of the original English DMSES and PTES scales.
(3) Focus group
A researcher, two diabetes educators, and three patients with diabetes were invited as
experts to give their opinions on the cultural equivalency of the DMSES and PTES
and the appropriateness of the language used in the items.
(4) Backward translation
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Two translators who had not seen the questionnaire in its original language
translated the new translation back into the original language. Ideally the
back-translators should be native speakers of the language in which the original
questionnaire is designed and fluent in the language of the translation (Bradley,
1994). In this study, two native English speaking translators with experience in
biomedical sciences and nursing but unaware of the original English DMSES &
PTES performed a back-translation of the Chinese DMSES and PTES formats into
the English language.
(5) A consensus meeting
The back-translations were then compared with the original to identify any linguistic
inaccuracies. Any poorly translated items identified were then translated and
subsequently back-translated by a back-translator (Bradley, 1994). In this study, a
team consensus meeting (two native English speaker researchers, and a bilingual
researcher) compared the back-translations with the English DMSES and PTES to
check for conceptual discrepancies. The team members of the consensus meeting
reviewed the English DMSES and PTES for conceptual equivalence with the
original source form. These discussions helped to streamline the translations
cross-culturally and contribute to the standarisation of the DMSES and PTES.
(6) Content validity (A panel of content experts)
The content validity of the instruments was examined using a method described by
Lynn (1986). The CVI (Content Validity Index) was the proportion of experts that
judged an item as content valid (a score of 3 or 4). The starting point was that a CVI
score of at least a score of 3 or higher should be maintained. The instrument was
sent to eight experts (two diabetologists, one teacher of nursing, two diabetes nurses
with expertise in patient education, two experts in self-efficacy theory and one
consultant) who judged the content validity of the Chinese version of the DMSES
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and PTES. Content validity was assessed by asking the panel members to rate each
item as a valid measure of the construct using a five-point Likert scale (1 = ‘strongly
disagree’, 5 = ‘strongly agree’) based on two criteria: the applicability of content and
clarity of phrasing, which were described as follows:
(1) Applicability of content: this referred to the applicable level of expression and
content with local culture and research objective.
(2) Clarity of phrasing: this referred to the applicability of meaning in expression
and sentences to interviewees; description, clarity, understandability, and
comprehension.
A content validity index was calculated for each item as well as an overall score for
the Chinese version of the DMSES and PTES. An acceptable CVI score should be >
.78 (Grant & Davis, 1997). Thereafter, the panel was asked to make comments on
individual items in relation to the accuracy, clarity, style, and cultural relevance of
the translation. A panel-modified version was subsequently developed in this stage.
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Figure 5.2.Stage one of the development processes of the C-DMSES & C-PTES
Translation 2
Chinese DMSES & PTES (First version)
English DMSES &
PTES
Translation 1 (A bilingual translator )
Translation 2 (A bilingual translator )
Consensus Meeting (A researcher, two
translators, and a diabetes
educator)
Translation 1
Chinese DMSES & PTES (First version)
Focus group (A researcher, two diabetes
educators, and three patients with diabetes)
Back-translation 1 (An native English speaker translator with
experience in biomedical sciences but
unaware of the original English DMSES &
PTES)
Back-translation 2 (An native English speaker translator
with experience in nursing but unaware
of the original English DMSES &
PTES)
Consensus Meeting (Two native English speaker researchers, and a bilingual
researcher)
Chinese DMSES & PTES
(Second version)
Chinese DMSES & PTES
Content validity (CVI, n=8)
(Third version)
Items not O.K.
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5.2.1.2 Stage two: validation and reliability of instruments
Following the translation and development stage, the second research stage tested
the validity and reliability of the Chinese version of the DMSES and PTES
(C-DMSES and C-PTES). The validity of questionnaires in the field has most often
been evaluated by criterion, convergent and construct validity. In addition,
estimation of scale scores, reliability used internal consistency and test-retest
methods.
(1) A pilot test of instruments
Before Stage Two (validation and reliability of instruments) was undertaken, the
panel-modified versions of the DMSES and PTES, together with an additional
section on demographic and clinical data, were pilot tested with ten type 2 diabetes
patients. We pilot tested these Chinese versions with ten diabetes patients to identify
difficulties in understanding. This was also done to check the data collection
procedures, completed time and the administration of the scale for clarity and
patients' willingness to complete it.
(2) Criterion validity
One of the assumptions underlying this study was that “self-efficacy is a useful
predictor for diabetic self-care behaviour and that self-care performances will be
improved among people with diabetes who have strong beliefs in self-efficacy”
(Williams and Bond, 2002). In this study, it was expected that the C-DMSES/
C-PTES would be a predictor for the Summary of Diabetes Self-Care Activities
(SDSCA) scale (Toobert, Hampson & Glasgow, 2000).
(3) Convergent validity
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According to Bandura (1986), self-efficacy was the most important predictor of
change in behaviour. Self-efficacy was categorised into three different dimensions
according to its generality: task specific self-efficacy (TSSE), generalized
self-efficacy (GSE), and middle ranged self-efficacy. GSE was good for predicting
outcomes of new and ambiguous situations. It also could be gained from a specific
mastery experience of one situation that may be generalized to other similar
situations (Bandura, 1986). The General Self-Efficacy Scale (GSE) (Schwarzer,
1992) appeared to be the most consistent for measuring the generalized self-efficacy
concept. In order to examine whether the C-DMSES/C-PTES was valid in the
self-efficacy domain, the Chinese version of the GSE (Chueng & Sun, 1999) and
C-DMSES/C-PTES were selected to provide convergent validity of this study.
(4) Construct validity (Factor analysis)
Factor analysis (exploratory factor analysis) could be undertaken to examine
construct validity of instruments. Items that were closely related were clustered into
a factor. The analysis might indicate the presence of several factors, which might
indicate that the instrument reflected several constructs rather than a single construct
(Burns & Grove, 1993). In this study, factor analysis was examined for construct
validity by undertaking Principal-Component Factor Analysis with a Varimax
rotation.
(5) Internal consistency
A Cronbach’s alpha-coefficient was calculated for each subscale and the overall
C-DMSES/C-PTES score to determine internal consistency.
(6) Stability test (test-retest)
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Two to four weeks after the initial survey, a random sample of 30 participants, using
a random number table, was asked to fill in the same questionnaire when they
visited a doctor again in the same outpatient setting. The respondents were used to
test the temporal stability of the instruments. The process of the validation and
reliability of instruments of the C-DMSES & C-PTES is illustrated in Figure 5.3.
Figure 5.3 Stage two of the validation and reliability of instruments of the
C-DMSES & C-PTES
A pilot test
(Pilot test with patients with
type 2 diabetes, n=10)
Criterion validity (Regression analysis, n=230)
Convergent validity (Pearson correlation, n=230)
Construct validity (Factor analysis, n=230)
Internal consistency
(A Cronbach’s alpha-coefficient, n=230)
Test-retest
(Pearson correlation coefficient and Bland-Altman plots
with 95% limits of agreement (LOA), n=30)
Chinese DMSES & PTES
(Third version)
A random sampling (2-4 weeks after
the initial survey)
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5.2.2 Population and sample
A convenience sample for stage II of 230 people with type 2 diabetes from a diabetic
outpatient clinic in a medical center in Taipei, Taiwan, formed the sample of the
study. The sample size was determined by the number of participants required to
conduct a factor analysis using Tanaka (1987) recommended ratio of at least five
participants for each item. As the questionnaire was composed of two main scales:
20 items for C-DMSES and 10 items for C-PTES, at least 200 people with type 2
diabetes would be required as a minimum sample size.
Inclusion Criteria:
People were eligible for the study if they:
1) were aged 30 years or more;
2) satisfied clinical criteria for type 2 diabetes;
3) had an oral medication regime of diabetes;
4) spoke and understood Chinese or Taiwanese;
5) had a telephone in their residence and were able to use it effectively.
5.2.3 Setting and procedure
1) This study was conducted in an outpatient clinic in Tri-Service General Hospital
in Taipei, Taiwan.
2) Advertisements for the project were distributed in an outpatient clinic and
participants were invited to participate. Potential participants were contacted by the
project co-ordinator in the outpatient clinic or by telephone in response to an
advertisement. At that time each respondent was screened by the researcher to
determine whether the inclusion criteria were met. If so, once approval had been
received from QUT UHREC (University Human Research Ethics Committee),
potential participants were invited to join the study.
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3) Each participant was given a questionnaire by a data collector and asked to
independently complete the questionnaire and provide feedback on the questions.
4) If participants were unable to complete the questionnaire alone, for example due
to vision impairment, they were provided assistance from the data collector. If
participants became weary, the interview was ceased and resumed at a later time.
5) The questionnaire was composed of two main scales: 20 items for C-DMSES, 10
items for C-PTES, 10 items for GSE, 12 items for SDSCA and demographic data.
6) Two to four weeks after the initial survey, a random sample of 30 participants
from this study were asked to fill in the same questionnaire when they visited a
doctor again in the same outpatient setting. The respondents were used to test the
temporal stability of the instruments.
5.2.4 Research Concept and Instruments/Measurement Strategies
In order to examine the criterion, convergent and construct validity, internal
consistency and stability are considered. The following instruments and
measurement strategies are summarised in Table 5.1. Moreover, the details of these
instruments used to examine validity and reliability are shown at the end of the
section.
Table 5.1 Instrument/ measurement strategies (Study I)
Used to examine Domains Instrument/ Measurement Strategies
Criterion, convergent,
construct validity, internal
consistency, and stability test
Self-efficacy towards
management of type 2
diabetes:
(Efficacy expectations)
The Diabetes Management Self-Efficacy
Scale (DMSES)
Criterion, convergent,
construct validity, internal
consistency, and stability test
Self-efficacy towards
management of type 2
diabetes:
The Perceived Therapeutic Efficacy Scale
(PTES)
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(Outcome expectations)
The criterion-related validity Self-care activities The Summary of Diabetes Self-Care
Activities (SDSCA)
The convergent validity General Self-Efficacy The General Self-Efficacy Scale (GSE)
Characteristics
of population
Demographics, and illness
history
A self-report questionnaire was designed to
collect: age; gender; education; marital
status; employment status; diagnosis
duration (years); diabetic complications; and
history of other diseases
-Instruments:
The Diabetes Management Self-Efficacy Scale
The Diabetes Management Self-Efficacy Scale (DMSES) (McDowell et al., 2005)
was a self-administered scale containing 20 items. It assessed the extent to which
respondents were confident they could manage their blood sugar, diet, and level of
exercise. Responses were rated on an 11 point scale ranging from “can’t do at all”
(0) to “certain can do” (10). Possible total scores ranged from 0 to 200 points.
DMSES was primarily directed on the strength dimension of self-efficacy (van der
Bijl, van Poelgeest-Eeltink & Shortridge-Baggett, 1999). Self-care tasks of type 2
diabetes were grouped under three main categories: 1) performing activities (use of
medication, such as insulin or tablets; keeping to a diet; and physical exercise); 2)
self-observation (reporting on glucose in urine and blood; body weight; skin
condition of the feet); 3) self-regulation activities: correct of hypo- and
hyperglycemia; preparation for a vacation; variation in nutrition (Pennings-van der
Eerden, 1992). As the DMSES tool has demonstrated acceptable reliability (alpha
.81-.91; test-retest .76- .79) and validity previously (McDowell et al., 2005; van der
Bijl, van Poelgeest-Eeltink & Shortridge-Baggett, 1999) it was chosen as the target
scale for validation in this study.
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The Perceived Therapeutic Efficacy Scale
People with diabetes perform self management activities which lead to the desired
outcome (outcome expectations). The PTES measured participants’ confidence
(outcome expectations) (Dunbar-Jacob, 2000). It focused on activities of people with
type 2 diabetes who were taking prescribed medication. This activity has been
incorporated into the PTES. The tool consisted of 10 items. Responses were rated on
an 11 point scale from “no confidence” (0) to “highest confidence” (10). The
responses were summed to become a total score for “confidence”. Possible scores
range from 0 to 100 points with higher scores indicating greater confidence. The tool
has had acceptable reliability and validity in the USA and UK. Internal consistency
was high (alpha .94-.96). Test-retest reliability was also high (.64-.80)
(Dunbar-Jacob, 2000; Shortridge-Baggett, 2001; Sturt & Hearnshaw, 2002). This
scale was chosen as the target scale for validation in this study.
The Summary of Diabetes Self-Care Activities (SDSCA) scale
The Summary of Diabetes Self-Care Activities (SDSCA) scale (Toobert, Hampson
& Glasgow, 2000) assessed the history of self-care activities of people with diabetes.
The relationship between SDSCA and C-DMSES/C-PTES was explored in this
study. The SDSCA questionnaire used the term “level of diabetes self-care” for the
absolute frequency or consistency of regimen behaviours. The Chinese version of
the SDSCA was a self-reporting measure of the frequency of performing diabetes
self-care tasks and consisted of 12 items that asked how often several activities such
as diet (items 1, 2, and 3), exercise (items 4 and 5), medication taking (item 6),
blood sugar testing (items 7 and 8), and foot care (items 9, 10, 11 and 12) were
carried out over a 7-day period. The possible total scores ranged from 0 to 84 points
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with higher scores indicating a higher frequency of performing diabetes self-care
activities (Chiou, 2002). As the Chinese version of the SDSCA (Chiou, 2002) has
demonstrated acceptable reliability and validity, it was chosen for testing criterion
validity. It was expected that the C-DMSES/ C-PTES would be a predictor for (or
would positively associate with) the Summary of Diabetes Self-Care Activities
(SDSCA) scale. The instrument has demonstrated internal consistency exceeding .50
and test-retest reliability ranged from .55 to .64 and validity reports were also high
(Glasgow et al., 1989; Glasgow et al., 1998; Toobert, Hampson & Glasgow, 2000).
The Cronbach alpha coefficient of the Chinese version of the SDSCA in this study
was .70.
The General Self-Efficacy Scale
The Chinese version of the General Self-Efficacy (GSE) Scale (Zhang & Schwarzer,
1995) was a 10-item scale that was designed to assess optimistic self-beliefs to cope
with a variety of difficult demands in life and measured the strength dimension of
self-efficacy. Bandura (1977b) stated that the concept of self-efficacy had three
dimensions, including magnitude, strength and generality. Also, Bandura (1997)
claimed that self-efficacy predicted behaviour-specific beliefs that would not
increase if the behaviour did not persist. The strength dimension of
behaviour-specific efficacy was of importance as a diagnostic strategy for diabetes
self-management aimed at the improvement of health outcomes (Maibach & Murphy,
1995).
Jerusalem and Schwarzer originally developed the GSE scale in 1981. It has been
used in many studies and it is now available in 29 languages (Schwarzer, 1992). The
Chinese version adapted from the English version was developed and tested among
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a Chinese population. High internal consistency was noted (alpha= .91-.92) (Zhang
& Schwarzer, 1995; Chueng & Sun, 1999). There was a 4 point Likert scale
response format for each item with 0 = ‘not at all true’; 1 = ‘hardly true’; 2 =
‘moderately true’; and 3 = ‘exactly true’. Scores were added to give a total ranging
from 0 to 30; higher scores represented more self-efficacy. The Cronbach alpha
coefficient of the Chinese version of the GSE in this study was .93. It was expected
that participants who reported better C-DMSES/C-PTES scores would also report
having better GSE scores. Therefore, this tool was used to test for convergent
validity.
5.2.5 Data Analysis
(1) Descriptive statistics were used to establish the frequency, range, mean, and SD
of demographics and clinical characteristics of the sample.
(2) A regression analysis or Pearson correlation were performed to examine the
relationships between the C-DMSES /C-PTES, and SDSCA for criterion
validity.
(3) Pearson’s correlation coefficients between the C-DMSES/C-PTES, and GSE
were selected as a convergent validity of the scales.
(4) A Cronbach’s alpha-coefficient was calculated for each subscale and the overall
C-DMSES/ C-PTES score to determine internal consistency.
(5) Factor analysis was used to determine the construct validity of the scales.
(6) Pearson’s correlation coefficients and Bland-Altman plots (Bland & Altman,
1986) with 95% limits of agreement (LOA) were performed to evaluate stability
through a test-retest of the tool at a 2-4 weeks interval.
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5.2.6 Ethical considerations
1) All participation in this study was voluntary.
2) All participants were provided with information both verbally and via an
information sheet, and asked to sign a consent form.
3) Personal information was keyed into a secure, computerised database, maintained
by the research team.
4) Potential participants were allowed to withdraw from the project during the
period of study without penalty to their further care.
5) Telephone numbers of the chief investigator and QUT Research Ethics
Committee were available to the participants if they required further information
about the project.
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5.3 Study II (Pilot Study): Development of an intervention based on self-efficacy theory and piloting of the intervention
It is important to develop educational programs based on self-efficacy theory for the
self-management of diabetes (Johnson, 1996). The rationale for developing an
intervention program based on self-efficacy theory and development of self-efficacy
for people with diabetes was described in the previous chapter (see Section 4.5), for
example, the traditional model of diabetes education has been ineffective in bringing
about desired outcomes in Taiwan (see Section 2.5 and 4.5.1.3). We chose multiple
information resources and elements in the self-efficacy enhancing intervention
program (SEEIP) because combining different sources of self-efficacy is best for
enhancement of self-efficacy, and combining all four sources is most effective
(Maddux & Lewis, 1995; Bandura, 1997). The strengths of using the multiple
elements have been discussed in Section 4.5.2.2 also. Traditional patient education
emphasises disease-specific information and technical skills whereas the SEEIP
teaches self-efficacy enhancing skills in order to enhance people’s confidence and
change people’s behaviours. The comparison of traditional patient education and the
SEEIP in this research study is demonstrated in Table 5.2 below.
Table 5.2 Comparison of traditional patient education in Taiwan and the SEEIP
Topics Traditional education in Taiwan SEEIP
What is
taught?
Information and technical skills
about the disease
Information and technical skills about the
disease; skills on how to understand and act on
problems; skills of enhancing self-efficacy
What is the
goal?
Compliance with the behaviour
changes taught to the patient to
improve clinical outcomes
Increased self-efficacy to improve self-care
ability and clinical outcomes
How is
behaviour
changed?
External motivation Internal motivation. Patients gain understanding
and confidence to accomplish new behaviours
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Topics Traditional education in Taiwan SEEIP
Who is the
educator
(team
members)?
A health professional (may
include: doctor, nurse, or dietician)
A health professional (doctor, nurse, diabetes
educator, dietician, consultant, and podiatrist),
peer leader or other patients, often in group
settings
Materials? One page patient educational sheet Multiple information resources, such as:
videotape or DVD, “Diabetes Self-Care”
booklet, counselling sessions (group support),
telephone follow-up
Procedures? Depend on health providers, in
general the procedures is: (1) give
an educational sheet (2)
explanation the content of the
educational sheet
(1) View a 10-minute videotape
(2) Receive the “Diabetes Self-Care” booklet
(used in four efficacy - enhancing
counselling intervention sessions and give
them an explanation)
(3) Participate in four efficacy - enhancing
counselling intervention sessions
(40mins/session: a facilitator discusses with
particiapnts)
(4) Participate in telephone follow-up (2-3 times
during 6 months, 10-20 minutes per time)
Time? 10-20 minutes/ session 20-40 minutes per session (sequence of sessions)
What is the
theory
underling the
intervention?
Disease-specific knowledge creates
behaviour change, which in turn
produces better clinical outcomes
Related to a clear conceptualisations and
self-efficacy theory base (Shortridge-Baggett &
van der Bijl, 1996)
Greater patient confidence in his/her capacity to
make life-improving changes yields better
clinical outcomes
Theory based Information and technical skills
about the disease
. Information resources: -Performance accomplishments
-Vicarious Experience
-Verbal Persuasion
-Self appraisal (Bandura, 1977a)
Outcome
evaluation
Information and technical skills Self-efficacy in managing type 2 diabetes; self
management behaviour (such as, diabetes
self-care activities; health-related quality of life;
psychosocial well-being and health care
utilisation)
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The phase of Study II (Pilot Study) developed and pilot-tested a suitable intervention
(SEEIP) for Taiwanese people with diabetes. The intervention was perceived as a
supplement to a standard educational program that was provided by a researcher to a
group of people with type 2 diabetes. The SEEIP included viewing a DVD,
“Diabetes Self-Care” booklets, four weekly efficacy-enhancing counselling
intervention sessions, and follow -up telephone calls. It aimed to assist people to
maintain a healthy lifestyle, seek support, solve problems and make an action plan.
The methods and results of the pilot study of the intervention are provided in this
section.
5.3.1 Research design
A pilot test was used in order to test the validation of a self-efficacy enhancing intervention program (SEEIP).
5.3.2 Population and sample
A convenience sample of four people who were provider experts and six people with
type 2 diabetes from a diabetes outpatient setting formed the sample of the study.
Inclusion criteria
Provider experts:
People were eligible for the study if they were one of the following:
1) Nurse;
2) Doctor;
3) Nutritionist;
4) Clinical diabetes educator.
Patients:
People were eligible for the study if they:
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1) were aged 30 years or more;
2) satisfied clinical criteria for type 2 diabetes;
3) had an oral medication regime of diabetes;
4) spoke and understood Chinese or Taiwanese;
5) had a telephone in their residence and were able to use it effectively.
5.3.3 Setting and procedure
1. Permission has been sought and granted by the authors to translate and modify
each of the booklets into Chinese.
2. Four people (a nurse; a doctor; a nutritionist; and a clinical diabetes educator)
who were provider experts were contacted by telephone and invited to participate
in the study. Their roles involved expert input to assist with the development and
validation of the intervention of SEEIP.
3. Six potential participants were contacted by the project co-ordinator in the
outpatient clinic and asked if they would like to participate in the pilot study. They
were provided with information both verbally and via an information sheet, and
asked to sign a consent form.
4. Based on the comments from the sample of 10 people, the intervention of SEEIP
was modified and validated.
5.3.4 Ethical considerations
1) All participation in this study was voluntary.
2) All participants were provided with information both verbally and via an
information sheet, and asked to sign a consent form.
3) All participants were informed that they were free to withdraw from this study at
any time without comment or penalty.
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4) Personal information was keyed into a secure, computerised database maintained
by the research team.
5) Full confidentiality was maintained.
5.3.5 Results: Study II (Pilot Study)
The intervention of SEEIP focused on five issues: diet control, physical activity,
blood glucose testing, adherence to medication regime, and foot care. This helped
people with type 2 diabetes to successfully manage their disease by providing four
ways to improve self-efficacy. Four information sources in the self-efficacy theory
are applied in the SEEIP intervention. Different interventions use different
information sources.
Four people (a nurse; a doctor; a nutritionist; and a clinical diabetes educator)
contributed expert suggestions for the intervention of SEEIP. For example, the panel
members were asked to make comments on four sessions of the “Diabetes Self-Care
booklet” in relation to the accuracy, clarity, and cultural relevance of the translation.
Experts added context and changed wording to make the booklet easier for people
with diabetes to understand the meanings of the contents. Also, the experts agreed to
show real stories of people with type 2 diabetes in the DVD and recommended the
material source of the 10 minute-story of Uncle Asparagus.
The panel-modified interventions of the SEEIP were pilot-tested with 6 patients
from a diabetes outpatient clinic in a medical center. All participants attended four
efficacy-enhancing counselling intervention sessions at weekly intervals
(participants had to participate in at least three of the four sessions). They stated they
had no difficulties in understanding the contents of a DVD, “Diabetes Self-Care”
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booklet, and four weekly efficacy-enhancing counselling intervention sessions and
they all expressed willingness to receive follow -up telephone calls. The final
intervention suit of the SEEIP was summarised in Table 5.3.
Table 5.3 Intervention suite of the SEEIP
Timing Intervention Self-efficacy
theory
applications
Main content
Week 1 10 minute a
DVD
viewing
Information
source:
-Vicarious
experience
- The DVD showed people with type 2 diabetes who successfully
used self-care activities to prevent the occurrence rate of acute
and chronic complications.
- We discussed and cooperated with the Chung-Hua Christian
hospital in Taiwan to use the DVD materials of patient education
for diabetes. This DVD was released by the Bureau of Health
Promotion (see Appendix 20, p. A100).
- Real stories were provided in the DVD. One of diabetic patients
as a role model. That is Uncle Asparagus. 10 mins was shown
about one day in the daily life for Uncle asparagus. He could do
all the jobs of planting asparagus and do all his own self-care
activities, including checking blood sugar, taking medicine and
checking his feet when he finished his work.
Week 1 Receives the
“Diabetes
Self-Care”
booklet
Information
source:
-Vicarious
experience
-Performance
accomplishments
- The booklet includes author’s notes (coping with diabetes), unit
one, unit two, unit three, and unit four (see Appendix 20,
p.A68-99).
- The booklet presented stories of how Mei-mei, Wan-tsai, and
Ai-Jiau who have experienced their difficulties and met different
problems.
- The booklet showed real stories from people with type 2 diabetes
about how to perform their daily self-care activities, including
diet control, physical activity, blood glucose testing, adherence to
medication regime, and foot care.
- Questions in the booklet promote discussions.
- Goal-setting sheets for diabetes self-care were provided in the
booklet to encourage people to keep a record of their own
diabetic control.
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Week
1- 4
Four
efficacy-
enhancing
counselling
intervention
sessions
undertaken
Information
source:
-Performance
accomplishment
-Vicarious
experience
-Verbal
persuasion
- Self-evaluation
-Four efficacy-enhancing counselling intervention sessions at
weekly intervals were undertaken. Participants had to participate
in at least three of the four sessions.
- Each group was limited to between 15-20 participants according
to participants’ preferences.
-Each practice session lasted 40 minutes and contained
self-efficacy enhancing skills fostering, self-goal setting sharing
and peer support for diabetics, which were facilitated by the
researcher.
-A registered nurse and nurse educator, who was trained in
counselling techniques in Australia and Taiwan (see Appendix 18
& 19, p.A66-67).
-A booklet was used in the four sessions as well.
Week 8
and 16
after the
commenc
ement of
SEEIP
Telephone
follow-up
Information
source:
-Performance
accomplishment
-Verbal
persuasion
-The facilitator contacted participants by telephone 8 and 16
weeks after the commencement of the intervention.
-Telephone follow-up provided continuous self-efficacy enhancing
skills fostering, goal-setting sharing and mental support for
diabetics.
-The purpose of calling was to foster continued performance
accomplishment via verbal persuasion.
5.3.5.1 Viewing a 10-minute DVD
People’s beliefs that they can motivate themselves and regulate their own behaviour
play an important role whether they are even considering changing harmful health
habits or pursuing rehabilitative activities (Bandura, 1997). The media, particularly
television, plays a major role in informing the public about health risks. Efforts to
get people to adopt health practices that prevent disease, therefore, rely heavily on
persuasive communications in health education campaigns (McGuire, 1984). In
group education, group members can be encouraged to help each other in solving
their problems. They may offer innovative solutions that have not been thought of
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by professionals (Gonzalez, Goeppinger & Lorig, 1990). Also, modelling can also
be used with other educational media like television, videos, movie, brochures and
textbooks. Some investigations have looked at movies or videos as a strategy for
various learning approaches because the desired behaviour was demonstrated using
comparable models whenever possible. Results found an increase in self-efficacy
(Gross, Fogg & Tucker, 1995; Johnson, 1996).
In this study, the DVD was designed to provide participants with vicarious
experience by showing people with type 2 diabetes (Uncle Asparagus) successfully
using self-care activities to prevent the occurrence rate of acute and chronic
complications. Uncle asparagus shared and described his number of years since the
initial diabetes diagnosis, what he did to help himself, the worst part of the
experience and how he dealt with his worst times, the best part of the experience and
what he would like to tell others going through treatment for illness and how the
experience of diabetes influenced his family or life. This intervention method,
utilizing the information resource of self-efficacy, is vicarious experience and verbal
persuasion.
5.3.5.2 Receiving the “Diabetes Self-Care” booklet
“Diabetes Self-Care” booklet was developed by the Australia IPSE team (“Get to
know your blood glucose level workbook”) (Courtney et al., 2006) and involved diet
control, physical activity, blood glucose testing, adherence to medication regime,
and foot care. These were translated, culturally adapted and modified to the
Taiwanese setting. The booklet was to give participants information through
vicarious experience and performance accomplishments by showing real stories
from people with type 2 diabetes about how they performed their daily self-care
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activities. Observing how others deal with similar situations (vicarious experience)
was an effective method by which people would learn.
The content of the booklet involved author’s notes (coping with diabetes), unit one,
unit two, unit three, and unit four. The booklet showed stories of Mei-mei, Wan-tsai,
and Ai-Jiau. These real stories were provided by these patients from the Tri-Service
General Hospital in Taipei. Stories described that those patients have experienced
their difficulties and met different problems and these situations are presented with
questions in the booklet to provide discussions. Moreover, the goal-setting sheets of
diabetes self-care were also provided in the booklet to encourage people to keep a
record of their own diabetes control. The content was easy to read and understand
with illustrations and photographs related to self-management of diabetes. The
booklet was given out at the first efficacy- enhancing counselling intervention
session for discussion.
5.3.5.3 Participating in four efficacy- enhancing counselling intervention
sessions
Efficacy-enhancing counselling intervention sessions were made up of 4 (weekly)
sessions focused on increasing performance accomplishment, sharing experience
(vicarious experience), using verbal persuasion, and self-evaluation. Each practice
session lasted 40 minutes and contained fostering self-efficacy enhancing skills,
self-goal setting sharing and peer support for diabetics, and was facilitated by the
researcher, a registered nurse and a nurse educator, who was trained in counselling
techniques (a 10-week self-efficacy enhancing program which was conducted in
Australia and a 24-hour chronic diseases counselling skills program which was
conducted in Taiwan).
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A major concept in the sessions was self-efficacy: the confidence that people could
carry out behaviour necessary to reach a desired goal. A facilitator applied
self-efficacy counselling skills for participants, including asking questions; focusing
on patient’s agenda; planning personal treatment schedules; defining problems;
setting goals (taking a step-by-step approach); regular follow-up and contact with
patients; scaling questions; brainstorming solutions; considering past
efforts-successes and failures; reassessing confidence; and finally checking
behaviour changes. For example, people were asked to assess their confidence on
the 0-10 scale that they could achieve their plan. Higher patient confidences in their
own capacity to make life-improving changes (self-efficacy) then yielded better
clinical outcomes.
The material in the “Diabetes Self-Care” booklets which included a number of
worksheets as mentioned previously was used in each session. Each session had the
same structure: participants worked with the facilitator, supported by the worksheet.
A final discussion which focused on self-efficacy fostering, self-goal setting sharing
and peer support for diabetics was conducted. Moreover, in the final session, group
participants were provided with a list of members’ phone numbers and encouraged
to call when in need of support.
5.3.5.4 Participating in telephone follow-up
The facilitator contacted the participants by telephone 8 and 16 weeks after the
commencement of the interventional program. The purpose of calling was to foster
continued performance accomplishment via verbal persuasion. Moreover,
maintaining contact not only helped patients feel cared for, which enhanced
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motivation, it also provided the health care provider with an invaluable
early-warning system for problems that might get much worse before the patient
calls about them.
In summary, the self-efficacy enhancing intervention program (SEEIP) in this study
was different from the traditional education program in Taiwan. The SEEIP
emphasised confidence enhancing and goal-setting skills in order to increase
self-efficacy and change people’s behaviours. The SEEIP guided people to identify
their problems and provided techniques to help people make decisions, and take
proper actions as they encounter changes in circumstances or disease. The aim was
to improve their health outcomes. In this pilot study, based on the comments from
the sample of 10 people, the intervention of SEEIP was modified and validated. The
SEEIP was then used in the main study.
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5.4 Study II (Main Study): Randomised controlled trial to evaluate
the efficacy of an intervention
The main study was a randomised controlled trial to evaluate the efficacy of the
intervention of SEEIP in a Taiwanese population.
5.4.1 Research design
A 2 × 3 randomised controlled trial (RCT) design was conducted in Study II (Main
Study) with pre (baseline) and post-testing (undertaken at 3 months and 6 months
following baseline collection).
5.4.2 Population and sample
A multistage sampling method was chosen in order to select at least 140 participants
(70 participants per group). Initially, potential participants in a diabetes outpatient
clinic were invited to participate through advertisements about the research, which
were posted on a bulletin board in a clinical setting. A sample of eligible people was
recruited and randomised to become the intervention group and the control group
using a random number table. It was expected there would be less than 30% dropout
rate and 5% potential attrition (see Figure 5.4).
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Figure 5.4 Sampling strategy and procedures to collect the study sample in
Study II (Main Study)
5.4.3 Sample size
Statistical power analysis was used to calculate the required sample size. One of the
Population in diabetes
outpatient clinic
Ineligible or refuse
(Participants were invited to
contact the researcher by tel.
or at the outpatient clinic)
Advertisements on an
outpatient bulletin board in
clinic setting
Recruit sample
(An information sheet and consent form were
given and signed; and participants completed
a baseline questionnaire)
Randomly selected
Intervention group Control group
A dropout rate
and potential
attrition
A dropout rate
and potential
attrition
Final study sample Final study sample
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major outcome variables in this project was health-related quality of life (as
measured by SF-12). The main hypothesis was that the mean quality of life scores of
diabetic subjects in the intervention group would be higher than those of control
group. We thereby measured the effect size (ES) of how “wrong” the null hypothesis
was, based on Cohen’s (1977) provided rule. A medium effect size should be
substantial, so it could be detected by the naked eye. Figure 5.5 displayed the results
of repeated measures ANOVA power analysis. A repeated measures design had two
groups of 69 subjects each for a total of 138 subjects. Each subject was measured
three times. The between-subject standard deviation was 18.78 (effect size= .27) and
the within-subject standard deviation was 16.26 (effect size= .15). This design
achieved 87% power when an F-test was used to test the group factor at a 5%
significance level.
Power vs n by Terms
0
0.2
0.4
0.6
0.8
1
0 20 40 60 80n
Powe
r GroupsTimesGxT
Term
s
Figure 5.5 The result of repeated measures ANOVA power analysis
In other words, sample size calculations were based on a significance level of p= .05
(two tailed) and power of 80%, z-alpha (v=1.96) and z-beta (u=.84). The sample size
was n=70 per group. However, a total of 110 were considered adequate to recruit for
a dropout rate (30%) and potential attrition (5%). Thus, 220 eligible people needed
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to be approached in order to retain 140 participants (70 participants per group) at the
end of the study.
Inclusion Criteria:
People were eligible for the study if they:
1) were aged 30 years or more;
2) satisfied clinical criteria for type 2 diabetes;
3) had an oral medication regime of diabetes;
4) spoke and understood Chinese or Taiwanese;
5) had a telephone in their residence and were able to use it effectively.
Exclusion Criteria:
People were excluded from the study if they:
1) had major complications which would interfere with self-care (e.g. legally blind,
severe stroke, or undertaking kidney dialysis);
2) were cognitively impaired
5.4.4 Setting and procedure
1) This study was conducted in an outpatient clinic in a municipal hospital in Taipei.
2) A heterogeneous group of outpatients who were 30 or more years of age and had
type 2 diabetes were recruited. An advertisement was placed on the noticeboard
of the diabetes outpatient clinic and participants were invited to contact the
researcher by telephone or contact the researcher at the outpatient clinic.
3) An information sheet and consent form were given and signed. Participants were
advised that they would be given the opportunity to ask questions regarding this
study.
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4) Participants completed a baseline assessment questionnaire and then were
randomly assigned to either the control group or intervention group by using a
random number table.
5) Both the control group and intervention group received a standard diabetic
educational program in the outpatient clinic. The standard diabetes educational
program, which was undertaken in Taiwan in 2001, consisted of a 15-20 minute
nutrition consultation with a nutritionist and an individual diabetic education
consultation with a diabetic nurse educator. The Bureau of National Health
Insurance (BNHI) reimbursed medical care providers if they provided nutrition
consulting and individual diabetic education. Therefore, this standard diabetes
educational program was provided for people with diabetes in the hospital where
this study was undertaken.
Control group participants received only the standard diabetes educational
program provided by nurse educators and nutritionists in the outpatient clinic as
outlined previously.
Intervention group participants received the standard diabetes educational
program provided by nurse educators and nutritionists as well as the following
additional interventions provided by the researcher: 1) viewed a 10 minute DVD;
2) received a “Diabetes Self-Care” booklet; 3) attended four, weekly focused
practice sessions (participants had to participate in at least three of the four
sessions); and 4) participated in a follow-up survey by telephone (see Figure
5.6).
6) Both groups underwent the same three measurements:
M1 (Measurement 1): baseline; prior to the intervention);
M2 (Measurement 2): 3 months from commencement of the intervention); and
M3 (Measurement 3): 6 months from commencement of the intervention).
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Week1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Baseline Experimental Group Control Group Figure 5.6 Research design- experimental study
Measure 1 Demographics
C-DMSES,
C-PTES,
SDSCA, SF-12,
SSS, CES-D
Health Service
utilisation
The standard
diabetes
educational
program and
SEEIP
The standard diabetes
educational program
Measure 2 Demographics
C-DMSES,
C-PTES,
SDSCA, SF-12,
SSS, CES-D
Health Service
utilisation
Measure 2 Demographics
C-DMSES,
C-PTES,
SDSCA, SF-12,
SSS, CES-D
Health Service
utilisation
The
standard
diabetes
educational
program and
Tel F/U
Measure 3 Demographics
C-DMSES,
C-PTES,
SDSCA, SF-12,
SSS, CES-D
Health Service
utilisation
Measure 3 Demographics
C-DMSES,
C-PTES,
SDSCA, SF-12,
SSS, CES-D
Health Service
utilisation
Measure 1 Demographics
C-DMSES,
C-PTES,
SDSCA, SF-12,
SSS, CES-D
Health Service
utilisation
The standard diabetes
educational program
Tel
F/U
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5.4.5 Research concept and instruments/measurement strategies
In this study, the dependent variables (self-efficacy in managing type 2 diabetes, self
management behaviour, health-related quality of life, psychosocial well-being and
health care utilisation) were measured at three points in time: M1 (baseline: prior to
the intervention), M2 (3 months from commencement of the intervention) and M3 (6
months from commencement of the intervention).
Instruments used in data collection included:
1) Self-efficacy towards management of type 2 diabetes (as measured by C-DMSES
and C-PTES);
2) Self management behaviour (as measured by the SDSCA);
3) Health-related quality of life (as measured by Short Form-12);
4) Psychosocial well-being (as measured by the Medical Outcomes Study (MOS)
Social Support Survey tool and the Center for Epidemiology Studies Short
Depression Scale (CES-D)); and
5) Health care utilisation (as measured by health care utilisation self reporting
instrument). Measurement strategies of the study were summarised in Table 5.4.
Table 5.4 Instrument/ measurement strategies (Study II: Main Study)
Domains
Instrument/ Measurement Strategies
Self-efficacy towards
management of type 2
diabetes
The Chinese version of the Diabetes Management Self-Efficacy
Scale (C-DMSES)
The Chinese version of the Perceived Therapeutic Efficacy Scale
(C-PTES)
Self-management behaviours The Summary of Diabetes Self-Care Activities (SDSCA) was
designed to collect the diabetes self-care activities:
Adherence to medication regime;
Adherence to food regime;
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Adherence to exercise regime;
Adherence to blood glucose testing;
Adherence to feet check
Health-Related Quality of life Short Form- 12 (SF-12)
Psychosocial well-being The Medical Outcomes Study (MOS) Social Support Survey
(SSS) tool
The Center for Epidemiology Studies Short Depression Scale
(CES-D)
Health care utilisation
A tool was designed to collect:
Hospitalisations (yes or no)
Visit to OPD (yes or no)
Visit to ER (yes or no)
Demographics
Illness history
A self-report questionnaire was designed to collect:
Age; gender; ethnic status; religion; education; marital status;
employment; living arrangement
The length of time since diagnosed with diabetes; other chronic
conditions; diabetic complications; treatment regimen; patient
education
The Chinese version of the Diabetes Management Self-Efficacy Scale (C-DMSES)
The C-DMSES was developed and tested reliability and validity in Study I. This was
a self-administered scale containing 20 items. It assessed the extent to which
respondents were confident that they could manage their blood sugar, diet, and level
of exercise. The responses were summed to become a total score for “self-efficacy”.
Possible scores ranged from 0 to 200 points. The tool had acceptable reliability and
validity in a Taiwanese population. The analysis of the Cronbach’s alpha for
C-DMSES was .93 in Study I. According to the factor analysis results of Study I, four
subscales have been identified. The Cronbach’s alpha was .93 for nutrition (Items 4, 5,
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9,10, 13, 14, 15, 16, 17), .81 for physical exercise and weight (Items 6, 8, 11, 12), .79
for medical treatment (Items 18, 19, 20) and .77 for blood sugar and feet check (Items
1, 2, 3, 7). Test-retest reliability was also high (.86). The internal consistency (alpha)
of C-DMSES in this main study was .95.
The Chinese version of the Perceived Therapeutic Efficacy Scale (C-PTES)
The C-PTES measured participants’ confidence (outcome expectations)
(Dunbar-Jacob, 2000). It focused on activities of people with type 2 diabetes who
were taking prescribed medication. The C-PTES was developed and tested for
reliability and validity in Study I. The tool consisted of 10 items. Responses were
rated on an 11-point scale from “no confidence” (0 points) to “highest confidence”
(10 points). The responses were summed to become a total score for “confidence”.
Possible scores ranged from 0 to 100 points, with higher scores indicating greater
confidence. The tool had acceptable reliability and validity in Study I (alpha .95).
Test-retest reliability was also high (.79). The Cronbach alpha coefficient of the
C-PTES in this main study was .96.
The Summary of Diabetes Self-Care Activities (SDSCA) scale
The SDSCA scale (Toobert, Hampson & Glasgow, 2000) was the same as in Study I
(see Section 5.2.4). The internal consistency (alpha) of Chinese version of the SDSCA
in this main study was .74.
Health-Related Quality of Life (Short Form-12) scale
Health-related quality of life of people with diabetes was measured using the
well-known and well-validated Short Form-12 (SF-12v2). The SF-12 (Ware, Kosinski
& Keller, 1996) contained at least one item from each of the eight scales composing
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the SF-36 (physical function (PF)(items 2a and 2b); role-physical (RP)(items 3a and
3b); role-emotional (RE)(4a and 4b); social function (SF)(item 7); bodily pain
(BP)(item 5); vitality (VT)(item 6b); mental health (MH)(items 6a and 6c); and
general health (GH)(item 1). Item responses were weighted and combined to produce
a Physical Health Component Summary (PCS-12) and a Mental Health Component
Summary (MCS-12) score. The PCS-12 and MCS-12 referred to physical well-being
and emotional well-being, respectively. High scores for all dimensions reflected better
health-related quality of life. Possible total scores for PCS-12 and MCS-12 ranged
from 0 to 100 points.
Two-week test-retest reliabilities in a general United States population were .89
(n=232) and .86 from the United Kingdom population (n=187) for the PCS-12.
Coefficients of .76 and .77 were observed for the MCS-12. Moreover, PCS and MCS
scores for the general United States population, and in patients with different diseases,
congestive heart failure (CHF) and diabetes mellitus (DM), were available (Ware,
Kosinski & Keller, 1996; Ware, Kosinski & Keller, 1998; Nichols & Brown, 2004).
Higher scores indicated better health-related quality of life. The internal consistency
(alpha) of Chinese version of the SF-12 in this main study was .92.
The Medical Outcomes Study (MOS) Social Support Survey (SSS) scale
The MOS Social Support Survey tool (Sherbourne & Stewart, 1991) is a
self-administered tool containing 19 items, measuring a multidimensional of the
functional aspects of perceived social support developed for use with chronically-ill
patients. The tool consisted of 19 items and covered five dimensions: tangible support
(items 1, 4, 11, and 14), affection (items 5, 9, and 19), positive social interaction
(items 6, 10, and 17), emotional and information support (items 2, 3, 7, 8, 12, 15, 16,
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and 18) and additional item (item 13). Each item was responded by a 5-point
Liker-type scale to indicate how often the respondent received the support, with 0
representing “none of the time” and 5 representing “all of the time”.
The total range of raw data was from 1 to 95. However, these scores were rescaled to
a 0-100 range for each subscale by using the following algorithm: 100× (observed
score- minimum possible score)/ (maximum possible score- minimum possible score).
The index of social support or global social support was calculated from the mean of
the subscale scores and the structure support scores (RAND Health, 2006). The
higher scores indicated more support. Internal consistency of this scale was high
(alpha .97). Test-retest reliability was also high (.78) and item-scale corrections all
exceed .72. Correlations between the four subscales were .69-.82 (Sherbourne &
Stewart, 1991). Moreover, Yu, Lee and Woo (2004) showed that internal consistency
is .93-96 (alpha) and test-retest reliability was .84 in a Chinese version of the SSS.
The internal consistency (alpha) was .92 in a Chinese version of the SSS in this main
study.
The Center for Epidemiology Studies Short Depression Scale (CES-D)
The depression level of people with diabetes was measured using the CES-D scale
(Anderson, Carter, Malmgren & Patrick, 1994). The CES-D was a self-administered
tool which was a 10-item measure of depression. The CES-D 10-item survey was
used rather than a more comprehensive instrument such as the CES-D 20-item survey
in order to minimize respondent burden (Kibourne et al., 2002). Patients screened
positive for significant depressive symptoms if they obtained a standard cut point of
10 or more out of a possible 30 points. The cut point in the 10-item CES-D had a
sensitivity of 96% and specificity of 100% when compared to the CES-D 20-item
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survey in a sample of adults in primary care (Anderson et al., 1994; Kibourne et al.,
2002).
Responses to this tool were rated on a 4-point scale from “rarely or none of the time”
(0 points) to “all the time” (3 points). Scores were added to give a total ranging from 0
to 30; higher scores represented more severe depression. However, items five and
eight were reversed, so response of 3 were change to 0, 2 to 1, 1 to 2, and 0 to 3.
Kibourne et al. (2002) classified scores 0 to 9 as indicating a mild level of depression
symptoms, 10 to 14 as moderate depressive symptoms, and >15 representing severe
depressive symptoms. This scale’s internal consistency was alpha.84 (tested on 605
subjects with chronic disease). The internal consistency (alpha) of the Chinese version
of the CES-D in this main study was .68.
Health care utilisation self report scale
A tool was designed to collect data on hospitalisations, visit to OPD, and visit to ER.
Demographic and illness history data self-report questionnaire
A self-reporting questionnaire was designed to collect demographic data and illness
history, including: age, gender, marital status, ethnic status, education, employment,
living arrangements, the length of time since being diagnosed with diabetes and other
chronic conditions.
5.4.6 Data management and analysis
After the collection of data, all data or records of this study were stored in computer
files, protected by password and also coded to protect anonymity. In the study, data
management including the analytical plan, data coding, entry, and checking were
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carried out using a personal computer. After data management, data analysis was
performed using the SPSS for Windows statistical packages (SPSS Version 14). Data
management and analysis were discussed as follows.
5.4.6.1 Data management
1. The analytical plan
An analytical plan including table shells for analysis was developed before entering
the data in order to minimize potential data entry error.
2. Data coding and entry
A numerical coding scheme was implemented to transfer the information from the
questionnaires to the coding sheet. The same person entered the data. The coded data
were then entered into a computer data file using a database management package.
3. Data checking
Range and consistency checks were performed to find erroneous or inconsistent
values, which were then corrected according to the original questionnaire. The first
step was to examine the distribution of each of the variables to check for possible
errors. The next step was to conduct consistency checks, to search for cases where
two or more variables were inconsistent. Possible errors were checked against the
original questionnaire. In some cases, it was possible to correct the data. In other cases,
it was necessary to insert a “missing value” code if it was clear that the data were in
error.
4. Storing of Confidential Information
All confidential records of this study were kept in a locked cabinet for five years and
were only accessed by the researcher. Any information stored in the computer files
was protected by password and code to protect anonymity.
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5.4.6.2 Data analysis
Computer analysis of frequencies of each value of every variable was performed as a
check of the accuracy of the data entry. Demographic and baseline variables for both
the control and intervention groups were analysed to ensure comparability of the
groups. Differences detected were controlled for during the subsequent analysis.
Based on the design and the purpose of the study, the following analysis was
performed. Statistical significance was reported at the conventional p-value of less
than .05 level (two-tailed).
1. Descriptive analysis
Descriptive analysis was used to examine demographic variables, health care
utilisation, self-efficacy towards management of type 2 diabetes, self-management
behaviour, health-related quality of life and psychosocial well-being. The mean and
standard deviation for continuous variables and the count and percentages for the
dichotomous or nominal data (categorical data) were calculated.
2. Inference analysis
Before evaluating the effects of the SEEIP, differences between the groups on a range
of variables were examined. T-tests were used to analyse differences on continuous
data between mean scores for the intervention and control groups. Categorical data
were analysed using Chi-square statistics to test the significance of different
proportions. The progressions of study variables between the two groups were
described separately for pre- and post-periods respectively. To assess the group
differences of dependent variable changes, we used repeated ANOVA/ ANCOVA, for
repeated measures.
3. Hypotheses testing
For each continuous outcome variable, a relevant scale score was developed.
Assuming that the outcome variables were normally distributed, Student’s t-tests were
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used to analyse differences between mean scores for the intervention and control
groups at the different time points for these variables. Where outcome variables were
not normally distributed, a non-parametric equivalent test was used. Therefore, the
following hypotheses were tested:
- People who received the intervention will have greater self-efficacy towards
managing their type 2 diabetes, undertake diabetes self-care activities more frequently,
have better HRQOL, have better social support and lower depression than people who
do not receive the intervention.
The self-efficacy towards management of type 2 diabetes, self-care activities,
HRQOL, social support and depression over the three time points and across the
groups (control and intervention) were tested by two-way repeated measures ANOVA.
Possible influences of the independent variables were controlled in this analysis. Thus,
two-way repeated measures ANCOVA might also be used. The changes between
Time1 and Time 2; Time 2 and Time 3; and Time 1 and Time 3 were examined.
- People who received the intervention will have a lower usage of health services
than people who do not receive the intervention.
Health care utilisation (as measured by self-reported questionnaires) measurement
items consisted of the dichotomous data (yes or no) related to hospitalisation, visit to
ER, and visit to the out-patient department (OPD). To compare the health care
utilisation of people with type 2 diabetes at Time 1, Time 2, and Time 3 between the
groups (control and intervention), data were analysed using the chi square statistic to
test the significance of different proportions.
5.4.7 Ethical Considerations
1) Participation in this study was voluntary.
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2) Potential participants were identified in conjunction with investigators and invited
to join the study.
3) Potential participants were not disadvantaged if they chose not to participate or
withdrew from the project during the period of study.
4) An information sheet and consent form was given and signed. The procedures
involved in this study were explained to participants and they were given the
opportunity to ask questions regarding this study.
5) If participants wished, they completed the questionnaire with the assistance of the
data collector through an interview. If they felt tired, the interview was ceased and
resumed at a later time.
6) All control group participants were provided with the opportunity to view the DVD
and were given the set of booklets at the end of the study.
7) Data collection tools did not included participant names. A separate database of
participant names and contact details were kept. Each participant was assigned a
number, and this number was used throughout the study.
8) Personal information of potential participants was keyed into a secure database,
maintained by the research team.
9) Telephone numbers of the chief investigator and QUT Research Ethics Committee
were available to the participants if they required further information about the
project.
5.5 Summary
The thesis has been divided into two studies (or three phases). Study I translated and
tested the reliability and validity of two diabetes-specific self-efficacy instruments.
Study II consisted of development of an intervention based on self-efficacy theory
(Pilot study) and was a randomised controlled trial to evaluate the efficacy of the
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intervention in a Taiwanese population (Main study). This chapter has discussed
methodology in each phase of the research study. The research design, population and
sample (including sample size calculation), setting and procedure,
instruments/measurement strategies, data analysis, ethics consideration were
described in each phase of the study.
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Chapter 6
Results
6.1 Introduction
This chapter firstly presents the results of Study I: the translation and development of
two instruments (the Diabetes Management Self-Efficacy Scale; DMSES (McDowell
et al., 2005) and the Perceived Therapeutic Efficacy Scale; PTES (Sturt & Hearnshaw,
2003) in a Taiwanese population. Secondly, results of Study II: ‘Provision of a
comprehensive diabetes education intervention: SEEIP (the self efficacy enhancing
intervention program) and demonstration of the effectiveness of a nursing intervention
will be presented.
Result of Study I
Research question 1: Are the two diabetes-specific self-efficacy instruments - the
DMSES and PTES - valid and reliable in a Taiwanese
population?
6.2 Description of sample Two hundred and forty-five patients with type 2 diabetes were asked to participate in
the study. Of these 245 patients, 15 did not complete the study for the following
reasons. Seven withdrew for non-specified reasons, three patients did not meet the
inclusion criteria (such as must be taking oral diabetic medications; aged above 30)
and five did not complete the questionnaire. Therefore, two hundred and thirty
respondents’ data was analysed. The mean age was 63.3 (SD=12.5) years with a
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diagnosis of diabetes on average for 8.6 (SD=8.2) years. The youngest respondent
was 30, the oldest was 90. The average number of years they had suffered from
diabetes was 8.6 (SD=8.2) years. The respondents consisted of 55% females.
Thirty-one per cent had primary school education only, 54% were unemployed or
retired. When they visited their doctor for diabetes, either AC (before meals) or PC
(after meals) blood sugar examination was tested for each person. The average AC
sugar was 157mg% and PC sugar was 188mg%. The characteristics of participants are
presented in Table 6.1.
Table 6.1 Characteristics of participants (Study I) (n=230)
Characteristics Number % Mini-
mum
Maxi-
mum
Mean ( SD)
Age 230 100 30 90 63.3 (12.5)
Diagnosis duration (years) 230 100 .1 40 8.6 ( 8.2)
Blood sugar AC (mg %) 117 50.8 60 400 157.1 (50.6)
Blood sugar PC (mg %)
(Either AC or PC sugar examination for each
person when they visit the doctor)
113 49.1 64 499 188.3 (78.5)
Gender: Male
Female
103
127
44.8
55.2
Education: No education
Primary school
Junior high school
Senior high school
College or university
41
71
30
43
45
17.8
30.9
13.0
18.7
19.6
Marital status: Single
Married
Divorced/ Widowed
11
206
13
4.8
89.6
5.6
Employment status: None or retired
Presently employed
Home makers
124
45
61
53.9
19.6
26.5
Diabetic complications: No
Yes
97
133
42.2
57.3
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History of other diseases: No
Yes
101
129
43.9
56.1
Management of diabetes:
Insulin injection: No
Yes
193
37
83.9
16.1
Diet control: No
Yes
71
159
30.9
69.1
Exercise control: No
Yes
102
127
44.3
55.2
Thirty people with type 2 diabetes were randomly selected (by using a random
number table) from the total sample of participants and were asked to complete the
C-DMSES and C-PTES scales for the second time after two to four weeks. Data for
the 30 subjects who completed questionnaires twice were used for examining
test-retest reliability. The mean age was 61.3 (SD=12.4) years and 50% of the
participants were men. The characteristics of the retest sample were similar to those of
the total sample (see Table 6.2).
Table 6.2 Characteristics of participants of the total and retest sample (Study I) (n=30)
Characteristics Total sample (n=230) Retest sample(n=30)
Number (%) Mean ( SD) Number (%) Mean ( SD)
Age 230 (100) 63.3 (12.5) 30(100) 61.3(12.4)
Diagnosis duration (years) 230(100) 8.6(8.2) 30(100) 6.7(8.5)
Blood sugar PC (mg %) 113(49.1) 188.3(78.5) 30(100) 155.93(74.4)
Gender: Male
Female
103(44.8)
127(55.2)
15(50)
15(50)
Education: No education
Primary school
Junior high school
Senior high school
College or university
41(17.8)
71(30.9)
30(13.0)
43(18.7)
45(19.6)
4(13.3)
6(20)
3(10)
9(30)
8(26.7)
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Marital status: Single
Married
Divorced/widowed
11(4.8)
206(89.6)
13(5.6)
2(6.7)
28(93.3)
0(0)
Employment status:
None or retired
Presently employed
Home makers
124(53.9)
45(19.6)
61(26.5)
19(63.3)
6(20)
5(16.7)
Diabetic complications: No
yes
97(42.2)
133(57.3)
12(40)
18(60)
History of other diseases: No
Yes
101(43.9)
129(56.1)
13(43.3)
17(56.7)
Management of diabetes
Insulin injection: No
Yes
193(83.9)
37(16.1)
20(66.7)
10(33.3)
Diet control: No
Yes
71(30.9)
159(69.1)
10(33.3)
20(66.7)
Exercise control: No
Yes
102(44.3)
127(55.2)
15(50)
15(50)
6.3 Result of the Chinese version of the DMSES (C-DMSES) 6.3.1 Result of Stage one: translation and development of the C-DMSES
Based on the method and principles of translation proposed (see Chapter 5.2.1.1), the
translators were advised to maintain semantic equivalence and clarity, readability and
recognisability of the Chinese translation. Due to inherent differences in the linguistic
structure of English and Chinese, minor adaptations were made to the wording of
three items in the DMSES during the translation process. The translated Chinese
version of DMSES was finalized after four revisions during the process of forward
translation and backward translation. The modifications identified by group
discussion on the back-translation refer to the C-DMSES. To summarize the main
points of the translation and back-translation, challenges to be considered were found
concerning the semantic and content equivalence. Results of the modification of the
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C-DMSES included: Item No. 6, “I am able to keep my weight under control” was
modified to “I am able to control my body weight and maintain it within the ideal
weight range”; Item No. 7, “ I am able to examine my feet (e.g. for cuts or blisters)”
was modified to “I am able to examine both of my feet (e.g. for cuts or blisters)”; and
Item No. 15, “I am able to follow a healthy eating plan when I am on holiday” was
modified to “I am able to follow a healthy eating plan during festive periods”.
Although three items were modified, no items were removed. Table 6.3 shows a few
items for which the back-translations were notably discrepant from the meaning of the
original wording in the process.
Table 6.3 Results of the translation and the back-translation of the C-DMSES
Original Items Back-Translation
Items
Comments of Experts and Patients Revised Items
6. I am able to
keep my weight
under control.
I am able to control
my body weight and
maintain it within the
ideal weight range.
Most patients don’t understand what “under
control” means, it would be more concrete
and easier for people to understand by
saying, “maintain the weight within the
ideal weight range”.
I am able to
control my body
weight and
maintain it within
the ideal weight
range.
7. I am able to
examine my feet
(e.g. for cuts or
blisters).
I can check my foot
by myself (such as
cuts or blisters).
The reason that ‘foot’ appears in single
form, instead of plural form, in the
back-translation is that the Chinese
language makes no difference between the
singular and plural forms of a noun.
I am able to
examine both of
my feet (e.g. for
cuts or blisters).
15. I am able to
follow a healthy
eating plan when
I am on holiday.
When I am in
festivities, I still can
follow my eating
plan.
Eating habits don’t change much on
weekends and holidays, but are influenced
by special festivities, for example, Chinese
New Year, the Dragon Boat festival and
Mid-Autumn Festival.
I am able to
follow a healthy
eating plan during
festive periods.
6.3.2 Result of Stage two: validation and reliability of the C-DMSES
Following the translation stage, the second research stage tested the validation and
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reliability of the C-DMSES. The validity of questionnaires in the field has most often
been evaluated by examining content, criterion, convergent and construct validity. In
addition to these methods, the estimation of the reliability scale scores used in this
research will apply internal consistency and test-retest methods.
6.3.2.1 The content validity of the C-DMSES
A panel of content experts judged the content validity of the diabetes specific
instruments (see Table 6.4). Content validity was assessed by asking the panel
members to rate each item as a valid measure of the construction using a five-point
Likert scale (1 = ‘strongly disagree’, 5 = ‘strongly agree’) based on two criteria: the
applicability of content and clarity of phrasing. Moreover, the panel was asked to
make comments on individual items in relation to the accuracy, clarity, style, and
cultural relevance of the translated items.
Table 6.4 Expert panel for content validity
Experts Positions
Yu-Chan Lee Consultant
Su-Lan Lin Diabetes nurse with expertise in patient education
Jian-De Hong Diabetologist
Yung-Yi Chen Diabetes nurse with expertise in patient education
Liang-Gung Chen Diabetologist
Lian-Hua Hung Teacher of nursing
Shiou-Luan Cai Expert in self-efficacy theory
Li-Chi Jiang Expert in self-efficacy theory
The C-DMSES obtained an average score of .86 for CVI. Item No. 6, obtained a score
of .83, Item No. 15 obtained a score of .89, and it was agreed by the experts to change
the wording during the translation stages. Item No. 13 and Item No. 14 obtained a
score of.89 and .84. Two scholars thought that Items No. 13 and No. 14 were too
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similar but were provisionally accepted. Finally, according to the regulations for the
Bureau of National Health Insurance, the clinicians suggested that Item No. 18, “I am
able to visit my doctor once a year to monitor my diabetes” which obtained a score
of .86 was changed to “I am able to visit my doctor four times a year to monitor my
diabetes”. Considering the cultural differences, the experts accepted the changes of
the above items. Table 6.5 shows the content validity score of each item for the
C-DMSES.
Table 6.5 Content validity score of C-DMSES
Items
Applicab
ility of
content
Clarity
of
phrasing
Average
scores of
CVI
1. I am able to check my blood sugar if necessary
當有需要時,我有能力自行檢測血糖
.83 .83 .83
2. I am able to correct my blood sugar when the sugar level is too high (e.g. eat
different foods)
當我的血糖太高時,我有能力調整我的血糖值(例如:食用不同種類的食
物)
.75 .80 .78
3. I am able to correct my blood sugar when the sugar level is too low (e.g. eat
different foods)
當我的血糖太低時,我有能力調整我的血糖(例如:食用不同種類的食物)
.75 .80 .78
4. I am able to choose the foods that are best for my health
我有能力選擇最有利於我健康的食物
.90 .90 .90
5. I am able to choose different foods and maintain a healthy eating plan
我有能力選擇不同種類的食物來維持健康的飲食計畫
.80 .80 .80
6. I am able to control my body weight and maintain it within the ideal weight
range
我有能力將我的體重控制在理想範圍內
.85 .80 .83
7. I am able to examine both of my feet (e.g. for cuts or blisters)
我有能力自行檢查我的雙腳(例如:傷口或起水泡)
.93 .90 .92
8. I am able to do enough physical activity (e.g. walking the dog, yoga, gardening,
stretching exercises)
我有能力做足夠的身體活動 (例如:溜狗、瑜珈、園藝、或伸展運動等)
.83 .88 .86
9. I am able to maintain my eating plan when I am ill
當我生病時,我仍然能維持我的飲食計畫
.88 .83 .86
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10. I am able to follow a healthy eating plan most of the time
大部份的時間內,我都能確實遵守我的健康飲食計畫
.88 .88 .88
11. I am able to do more physical activity if the doctor advises me to do
當醫師建議我多做一些身體活動,我有能力確實做到
.88 .75 .82
12. When doing more physical activity, I am able to adjust my eating plan
當我身體活動量增加時,我有能力自行調整我的飲食計畫
.95 .90 .93
13. I am able to follow a healthy eating plan when I am away from home
當我外出時,我仍然能遵行健康的飲食計畫
.90 .88 .89
14. I am able to choose different foods and maintain my eating plan when I am
away from home
當我外出時,我有能力選擇不同的食物種類,來維持我的飲食計畫
.85 .83 .84
15. I am able to follow a healthy eating plan during festive periods
在特殊節日時,我仍然能遵守健康飲食計畫
.90 .88 .89
16. I am able to choose different foods and maintain a healthy eating plan
when I am eating out or at a party 當我在外用餐或參加聚會時,我有能力選
擇不同種類的食物來維持我的健康飲食計畫
.88 .88 .88
17. I am able to maintain my eating plan when I am feeling stressed or anxious
當我面對壓力或焦慮時,我仍然能維持我的飲食計畫
.93 .88 .91
18. I am able to visit my doctor four times a year to monitor my diabetes
我能每年至少去看醫生四次,以監測我的糖尿病狀況
.93 .78 .86
19. I am able to take my medication as prescribed
我能夠依醫師處方按時服藥
.93 .93 .93
20. I am able to maintain my medication when I am ill
當我生病時,我仍然能維持我的糖尿病藥物治療
.93 .90 .92
Total scores 17.48 17.03 17.31
Average scores .87 .85 .86
The panel-modified version of the C-DMSES was pilot tested with ten patients from a
diabetes outpatient clinic in a medical center. All participants stated they had no
difficulties in understanding the items and expressed willingness to complete all items,
taking about 15 to 20 minutes for completion.
6.3.2.2 The criterion validity of the C-DMSES
According to Bandura (1986), self-efficacy is the most important predictor of change
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in behaviour. The assumption of this study was that self-efficacy is a useful predictor
for diabetic self-care behaviour. Therefore, the C-DMSES and the Summary of
Diabetes Self-Care Activities (SDSCA) were used to test the relationship at this stage.
A regression analysis was performed to explore how well the C-DMSES could
explain the SDSCA. Results indicated that the C-DMSES was significantly associated
with the SDSCA scores (see Figure 6.1). The C-DMSES was a significant predictor of
diabetes self-care activities using a regression analysis (R=.58; t=10.75, p<.01), and
accounted for 33.6% of the variance in the total SDSCA scores. Significant
statistically linear correlations were found between C-DMSES and SDSCA at each
subscale of self-care activities (from stronger to weaker): foot care (R=.45, p<.01);
diet (R=.39, p<.01); exercise (R=.33, p<.01); and blood sugar testing (R=.23, p<.01)
(see Table 6.6). This result suggests that the C-DMSES does measure self-efficacy
towards undertaking diabetes self-care activities.
0.00 50.00 100.00 150.00 200.00
todmses
0.00
20.00
40.00
60.00
80.00
100.00
tosd
sca
R Sq Linear = 0.336
Figure 6.1 Scatter plot between the Summary of Diabetes Self-Care Activities (SDSCA) scale
and the Chinese version of the Diabetes Management Self-Efficacy Scale (C-DMSES)
for individual observations
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Table 6.6 A regression analysis summary for the C-DMSES predicting the SDSCA (n=230)
Variables R R square t Sig
Total score of SDSCA .58 .34 10.75 .00**
Foot care .45 .25 8.70 .00**
Diet .39 .15 6.40 .00**
Exercise .33 .11 5.29 .00**
Blood sugar testing .23 .05 3.55 .00**
Medication taking .07 .00 .99 .33
**p< .01
6.3.2.3 The convergent validity of the C-DMSES
The General Self-Efficacy Scale (GSE) (Schwarzer, 1992) appears to be the most
consistent for measuring the generalized self-efficacy concept. In order to examine
whether the C-DMSES is valid in the self-efficacy domain, the Chinese version of the
GSE and C-DMSES were selected to provide convergent validity of this study. A
Pearson’s correlation coefficient between scores on the C-DMSES and the Chinese
version of the GSE revealed a moderate association (r= .55; p< .01) which provides
evidence that the C-DMSES does measure self-efficacy.
6.3.2.4 The construct validity of the C-DMSES
Data were examined for construct validity by undertaking principal-component factor
analysis with a varimax rotation. The following criteria were used in order to obtain
the best fitting structure and the correct number of factors: (1) Eigenvalues greater
than 1.0, (2) Cattell’s scree test, (3) the percentage of total variance explained by each
factor, and (4) factor loading cutoff of .4.
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Firstly, Bartlett’s chi-square test of sphericity was used to determine if the sample size
was appropriate for a factor analysis and to determine if the data came from a sample
of the population with a normal distribution. This test was significant (χ2=3261.22,
p<.00). In addition to Bartlett’s test, the Kaiser-Meyer-Olkin (KMO) measure of
sampling adequacy was examined and found to be acceptable at .90. Based on the
results of these two tests, it was determined that a factor analysis could be computed
on this dataset.
The principal-component factor analysis for C-DMSES revealed four factors with an
Eigenvalue > 1, explaining 68.32% of the total sample variance. All included
variables loaded highly on these factors (see Table 6.7). After inspecting the scree plot
(Figure 6.2), a four factor solution (Eigenvalue value: 9.33, 1.77, 1.49, and 1.08) was
considered. These four factors accounted for 46.65, 8.84, 7.43 and 5.40% of variance,
respectively.
Table 6.7 The result of the principal-component factor analysis for C-DMSES (n=230)
Factor number Eigenvaluea Percentiles of varianceb Cumulative percentilesb
1 9.33 46.65 46.65
2 1.77 8.84 55.49
3 1.49 7.43 62.92
4 1.08 5.40 68.32 a The latent dimension is usually taken to be equal to the number of Eigenvalues that are > 1.0 b Explained variation given inclusion of this factor.
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Scree Plot
Component Number
2019
1817
1615
1413
1211
109
87
65
43
21
Eige
nval
ue10
8
6
4
2
0
Figure 6.2 Scree plot of the C-DMSES
Table 6.8 shows the results of the component factor analysis using Varimax rotation.
Factor one contained 9 items, factor two contained 4 items, factor three contained 4
items, and factor four contained 3 items that all loaded above .40. Four factors (four
subscales) specifically related to nutrition (Items 16, 14, 13, 15, 17, 10, 5, 4, 9), blood
sugar and feet check, (Items 3, 2, 1, 7), physical exercise and weight (Items 11, 8, 12,
6) and medical treatment (Items 19, 20, 18). Although the items of the subscales are
different from the Dutch version DMSES scale, overall, the factorial structure was
fairly consistent and the results reflect the four factors.
Table 6.8 Rotated factor matrix of the C- DMSES. Principal-component method with Varimax
rotation (n=230)
Items Factor 1 Factor 2 Factor 3 Factor 4
Factor 1 :
16. I am able to choose different foods and maintain a healthy eating plan when I am
eating out or at a party
.87
14. I am able to choose different foods and maintain my eating plan when I am away .86
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from home
13. I am able to follow a healthy eating plan when I am away from home .81
15 I am able to follow a healthy eating plan during festive periods .77
17. I am able to maintain my eating plan when I am feeling stressed or anxious .68
10. I am able to follow a healthy eating plan most of the time .53
5. I am able to choose different foods and maintain a healthy eating plan .53
4. I am able to choose the foods that are best for my health .47
9. I am able to maintain my eating plan when I am ill .42
Factor 2 :
3. I am able to correct my blood sugar when the sugar level is too low (e.g. eat
different foods)
.85
2. I am able to correct my blood sugar when the sugar level is too high (e.g. eat
different foods)
.81
1. I am able to check my blood sugar if necessary .52
7. I am able to examine both of my feet (e.g. for cuts or blisters) .48
Factor 3 :
11. I am able to do more physical activity if the doctor advises me to do .78
8. I am able to do enough physical activity (e.g. walking the dog, yoga, gardening,
stretching exercises)
.37 .75
12. When doing more physical activity, I am able to adjust my eating plan .66
6. I am able to control my body weight and maintain it within the ideal weight range .46 .48
Factor 4 :
19. I am able to take my medication as prescribed .87
20. I am able to maintain my medication when I am ill .85
18. I am able to visit my doctor four times a year to monitor my diabetes .74
Variance explained (%) 68.32
6.3.2.5 Internal consistency of the C-DMSES
A Cronbach’s alpha coefficient was calculated by means of the reliability option. The
analysis of the Cronbach’s alpha for C-DMSES was .93. According to the results of
factor analysis, four subscales were formed. The Cronbach’s alpha was .93 for
nutrition (Items 4, 5, 9,10, 13, 14, 15, 16, 17), .81 for physical exercise and weight
(Items 6, 8, 11, 12), .79 for medical treatment (Items 18, 19, 20) and .77 for blood
sugar and feet check (Items 1, 2, 3, 7) (see Table 6.9).
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Table 6.9 Cronbach’s α value of C-DMSES
Instruments (n=230)
Number of items Cronbach’s α
C-DMSES 20 .93
Nutrition (items 4, 5, 9,10, 13, 14, 15, 16, 17) 9 .93
Physical exercise and weight (items 6, 8, 11, 12) 4 .81
Medical treatment (items 18, 19, 20) 3 .79
Blood sugar and feet check, (items 1, 2, 3, 7) 4 .77
Analysis of the item level according to the “alpha if item deleted” procedure showed
that removal of one or more weakly correlated items would not have much
consequence for the height of the alpha value. The mean-item correlation was .42
(min. = .09, max= .86) for C-DMSES. This analysis indicated a non-unidimensional
scale. Furthermore, item-to-total correlations ranged from .37. to .76 for the
C-DMSES.
6.3.2.6 Stability of the C-DMSES
The test-retest was calculated using a Pearson’s correlation to determine the strength
of relationship between responses (n=30) to the C-DMSES over time, with three
weeks between administration. Pearson’s correlation coefficient of .86 for the total
scores indicated the instrument is stable over time. Similarly, coefficients for the
subscales (nutrition = .79; physical exercise and weight = .91; medical treatment = .69;
and blood sugar and feet check = .83) indicated they are reliable over time.
Calculation of intra-class correlations (ICC) using a 2-way random variable absolute
agreement approach resulted an average ICC of .82. Furthermore, in order to offer
information regarding agreement and detect systematic bias in response from one time
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to another, test-retest reliability for the C-DMSES was determined by means of a
Bland-Altman plot (Bland & Altman, 1986) with 95% limits of agreement (LOA). In
the plot, the differences (d) between the two measurements were plotted against the
mean values of both measurements. Ninety-five per cent of those differences may be
expected to fall within ± 2 SDs of the mean difference between the test-retest scores.
The Bland-Altman plot illustrating the test-retest agreement is shown in Figure 6.3.
The mean difference of the total C-DMSES score was 10.13 and the 95% confidence
interval for the mean difference ranged from -24.09 to +44.35 (possible 0-200). Only
one subject was outside the limits of agreement and 97% (29/30) of the subjects were
within 2 standard deviations of the mean. The results showed a strong level of
agreement between individuals over time.
180.00150.00120.0090.0060.00
75.00
50.00
25.00
0.00
-25.00
-50.00
Diff
eren
ce in
DM
SES
scor
e
Bland-Altman plot for reproducibility
of DMSES
Average of two measurements
M=10.13; SD=17.46
Figure 6.3 Bland-Altman plot for reproducibility of C-DMSES scores
Mean+1.96SD= 44.35
Mean-1.96SD= -24.09
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6.4 Result of the Chinese version of the PTES (C-PTES) 6.4.1 Result of stage one: translation and development of the C-PTES
The translated Chinese version of PTES was finalized after four revisions during the
process of forward translation and backward translation. There was little debate about
the Chinese version of PTES. The resulting overall high agreement of response
between the two versions and the feedback from the clinical experts suggested the
translated C-PTES has semantic equivalence with the source version.
6.4.2 Result of stage two: validation and reliability of the C-PTES
6.4.2.1 The content validity of the C-PTES
A panel of eight experts judged the content validity of the diabetes specific
instruments. Content validity was assessed based on two criteria: the applicability of
content and clarity of phrasing. Moreover, the panel was asked to make comments on
individual items in relation to the accuracy, clarity, style, and cultural relevance of the
translated items. The average CVI score obtained by C-PTES was .83. Based on the
expert panel’s comments, the wording of only four items were modified. These
included: Item No. 2, (CVI= .82); Item No. 5 (CVI= .84); Item No. 9 (CVI= .78) and
Item No. 10 (CVI= .78) (see Table 6.10). The expert panel believed the modifications
of the content and wording were necessary to ensure the wording reflected Taiwanese
culture, and that the wording would be easier for patients to understand. Table 6.11
shows the content validity score of each item for the C-PTES.
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Table 6.10 The C-PTES after modification based on the experts’ comments
Expressions used in the
original Scale
Score Experts and patients’
opinions
Expressions adopted for the final
version
2.My level of confidence in
the ability of my diabetes
medication to prevent
episodes of high blood sugar
is:
.82 After revision, the meaning
was more complete and
easier for people, especially
the elderly, to understand.
My level of confidence in the
ability that my diabetes medication
can keep my blood sugar at a
stable level and prevent it from
becoming elevated is:
5.My level of confidence in
the ability to control my
diabetes by maintaining my
medication dose is:
.84 After revision, the meaning
was more complete and
easier for people, especially
the elderly, to understand.
My level of confidence in the
ability that the maintenance of the
dose of my medication can control
my diabetes effectively is:
9. My level of confidence in
my health professionals’
advice about my diabetes
treatment is:
.78 Giving some examples
could help patients to
answer the question.
My level of confidence in my
health professionals’ advice that
experts such as doctors or
nutritionists give me in my
diabetes treatment is:
10. My overall level of
confidence in my ability to
manage my diabetes is:
.78 After revision, the meaning
was more completed, and
easier for people, especially
the elderly, to understand.
My overall level of confidence in
my ability to cope with my
diabetes is:
Table 6.11 Content validity score for C-PTES
Items Applicab
ility of
content
Clarity
of
phrasing
Average
scores of
CVI
1.My level of confidence in the ability of my diabetes medication to control
my blood sugar is:
我的糖尿病藥物能夠控制我的血糖值,我對這件事的信心程度是:
.85 .83 .84
2.My level of confidence in the ability that my diabetes medication can keep
my blood sugar at a stable level and prevent it from becoming elevated is:
我的糖尿病藥物能夠穩定血糖,減少高血糖發作,我對這件事的信心
程度是:
.88 .75 .82
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3.My level of confidence in the ability of my diabetes medication to limit the
severity of complications (e.g. eye or foot problems) is:
我的糖尿病藥物能夠減少併發症的嚴重程度(例如:眼睛或腳的併發症) ,
我對這件事的信心程度是:
.88 .83 .86
4.My level of confidence in the ability of my diabetes medication to prevent
me getting (more) complications is: 我的糖尿病藥物能夠預防我得到
(更多)併發症,我對這件事的信心程度是:
.88 .80 .84
5.My level of confidence in the ability that the maintenance of the dose of my
medication can control my diabetes effectively is: 維持我的藥物劑量可
以有效控制我的糖尿病,我對這件事的信心程度是:
.88 .80 .84
6.My level of confidence in the need to take my medication each day exactly
as prescribed to control my diabetes is: 每天需要依照處方正確服藥可
以控制我的糖尿病,我對這件事的信心程度是:
.90 .83 .87
7.My overall level of confidence in the value of the diabetes medication that I
am prescribed is: 醫師處方開給我的糖尿病藥物是有療效, 對於這件
事我的整體信心程度是:
.83 .77 .80
8.My level of confidence in the ability of medication in general to control my
diabetes is: 一般來講,藥物治療能夠有效控制我的糖尿病:
.83 .83 .83
9.My level of confidence in my health professionals’ advice that experts such
as doctors or nutritionists give me in my diabetes treatment is:
在我的糖尿病治療中,專家如醫師或營養師所給的專業建議,我對這件
事的信心程度是:
.80 .75 .78
10. My overall level of confidence in my ability to cope with my diabetes is:
我能應付自己的糖尿病,對於這件事我的整體信心程度是﹕
.80 .75 .78
Total scores 8.53 7.94 8.26
Average scores .85 .79 .83
The panel-modified version of the C-PTES was pilot tested with ten type 2 diabetes
patients to identify the linguistic and cultural equivalence. All of the participants also
stated that they had no difficulties in understanding items and expressed willingness
to complete all items and it takes about 10-12 minutes for completion.
6.4.2.2 The criterion validity of the C-PTES
The C-PTES (measuring outcome-expectations) was correlated as predicted with the
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theoretically linked psychological variables of self-care behaviours and health
outcomes (Bandura, 1986; Kingery & Glasgow, 1989). The PTES measures
participants’ confidence (outcome expectations) and the extent to which the individual
believes their treatment will lead to personally desirable outcomes (Dunbar-Jacob,
2000; Sturt & Hearnshaw, 2003). The assumption of this study was that self-care
performance and blood sugar control will be better among people with diabetes who
hold strong beliefs in outcome-expectation. Therefore, the Summary of Diabetes
Self-Care Activities (SDSCA) and the C-PTES were used to test the relationship at
this stage.
Result revealed that the Pearson’s correlation coefficient between C-PTES and
SDSCA was r= .32; p< .01 demonstrating outcome expectations is moderately
correlated with self-care performances. Moreover, a regression analysis was
performed to explore how well the C-PTES could explain the SDSCA scores. Results
indicated that the C-PTES was significantly associated with the SDSCA scores (see
Figure 6.4 and a significant predictor of the SDSCA (Beta= .32; t= 5.14, p<. 00),
accounting for 10.4% of the variance. The results showed that the C-PTES total score
was a predictor of the diabetes self-care activities.
0.00 20.00 40.00 60.00 80.00 100.00
toptes
0.00
20.00
40.00
60.00
80.00
100.00
tosd
sca
R Sq Linear = 0.104
Figure 6.4 Scatter plot between the Summary of Diabetes Self-Care Activities (SDSCA) scale
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and the Chinese version of the Perceived Therapeutic Efficacy Scale (C-PTES) for
individual observations
6.4.2.3 The convergent validity of the C-PTES
The C-PTES is a measure of efficacy expectation. In order to examine whether the
C-PTES is valid in the self-efficacy domain, the Chinese version of the GSE and the
C-PTES were selected to provide convergent validity of this study. Responses to the
C-PTES and the Chinese version of the GSE scale were correlated to assess the
strength of relationship. Pearson’s correlation coefficient between the C-PTES and the
Chinese version of the GSE total score revealed a moderately positive association
(r= .42; p< .01). The results provided evidence that the C-PTES does measure the
self-efficacy concept as well.
6.4.2.4 The construct validity of the C-PTES
Data were analysed by means of principal-component factor analysis and varimax
rotation. The following criteria were used in order to obtain the best fitting structure
and the correct number of factors: (1) Eigenvalues greater than 1.0, (2) Cattell’s scree
test, (3) the percentage of total variance explained by each factor, and (4) factor
loadings cut-off of .4.
Bartlett’s test of the C-PTES was significant ( χ 2=2183.13, p<.01) and the
Kaiser-Meyer-Olkin measure of sampling adequacy was found to be acceptable at .93.
The principal-component factor analysis for the C-PTES revealed only one factor
with an Eigenvalue > 1, explaining 71% of the total sample variance. All included
variables loaded highly on this factor. An examination of the scree plot (see Figure 6.5)
and the Eigenvalue suggested a one-factor solution accounting for 70.80% of the
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variance was acceptable.
Scree Plot
Component Number
10987654321
Eige
nval
ue
8
6
4
2
0
Figure 6.5 Scree plot of the C-PTES
Table 6.12 shows the results of the component factor analysis using Varimax rotation.
Only one factor has been found and includes 10 items.
Table 6.12. Rotated factor matrix of the C-PTES. Principal-component method with Varimax
rotation (n=230)
Items Factor 1
8. My level of confidence in the ability of medication in general to control my diabetes is: .90
7.My overall level of confidence in the value of the diabetes medication that I am prescribed is: .89
2.My level of confidence in the ability that my diabetes medication can keep my blood sugar at a stable
level and prevent it from becoming elevated is:
.86
6.My level of confidence in the need to take my medication each day exactly as prescribed to control
my diabetes is
.85
5.My level of confidence in the ability that the maintenance of the dose of my medication can control
my diabetes effectively is:
.85
4.My level of confidence in the ability of my diabetes medication to prevent me getting (more)
complications is:
.83
1.My level of confidence in the ability of my diabetes medication to control my blood sugar is: .81
9.My level of confidence in my health professionals’ advice that experts such as doctors or nutritionists
give me in my diabetes treatment is:
.81
3.My level of confidence in the ability of my diabetes medication to limit the severity of complications .80
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(e.g. eye or foot problems) is:
10. My overall level of confidence in my ability to cope with my diabetes is: .80
6.4.2.5 Internal consistency of the C-PTES
The C-PTES showed high internal consistency in this study (Chronbach's alpha .95).
The mean-item correlation was .67 (min.=.56, max=.88) and item-to-total correlations
ranged from .75 to .86. All of the 10 items had high item-total correlation values.
Table 6.13 shows under 'alpha if item deleted' that removal of these items only
reduced the over alpha by .001 to .005. Therefore, all 10 items were retained.
Table 6.13 Pearson item-total coefficient of correlation of the C-PTES (n= 230)
Alpha if item Deleted Correct Item- total Correlation
Item1 .949 .768
Item2 .946 .830
Item3 .949 .763
Item4 .948 .797
Item5 .947 .806
Item6 .947 .807
Item7 .946 .854
Item8 .945 .863
Item9 .949 .756
Item10 .950 .752
6.4.2.6 Stability of the C-PTES
The test-retest was calculated using a Pearson product moment correlation to
determine the strength of relationship between responses (n=30) to the C-PTES over
time, with three weeks between administrations. The test-retest reliability resulted in a
coefficient of .79 (p< .01) for the C-PTES. Furthermore, calculation of intra-class
correlations (ICC) using a 2-way random variable absolute agreement approach
resulted in an average ICC of .77.
Test-retest reliability for the C-PTES was also examined by means of a Bland-Altman
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plot (Bland & Altman, 1986) with 95% limits of agreement (LOA) to offer
information regarding agreement and detection of systematic bias in response from
one time to another. In the plot, the differences (d) between the two measurements
were plotted against the mean values of both measurements. The Bland-Altman plot
illustrating the test-retest agreement is shown in Figure 6.6. The mean difference of
the total C-PTES score was 3.90 and the 95% confidence interval for the mean
difference ranged from -14.37 to +22.17 (possible 0-100). Only one subject was
outside the limits of agreement and 97% (29/30) of the subjects were within 2
standard deviations of the mean. Ninety-five per cent of those differences, as expected,
fall within ± 2 SDs of the mean difference between the test-retest scores. The
C-PTES was deemed to be a stable over the 2-week testing period.
100.0080.0060.00
40.00
20.00
0.00
-20.00Diffe
renc
e in
PTE
S sc
ore
Bland-Altman plot for reproducibility
of PTES
Average of two measurements
M=3.90;SD=9.31
Figure 6.6 Bland-Altman plot for reproducibility of C-PTES scores
Mean+1.96SD= 22.17
Mean-1.96SD= -14.37
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6.5 Summary result of Study I A two-stage study design was used in order to test the validity and reliability of Study
I. During the translation process, three items were modified for the C-DMSES,
however, there was little debate about the C-PTES. Validity issues are at the heart of
findings in cross-cultural research (Jones & Kay, 1992). The content validity results of
this study showed that the C-DMSES and C-PTES were clear and understandable in
their Chinese versions after some items have been modified. There were adequate
results of criterion, convergent and construct validity of these two instruments. The
reliability of instruments was also examined and the results of the Cronbach’s alpha
showed that the C-DMSES and C-PTES were internally consistent. Finally, a Pearson
correlation-coefficient was calculated to determine the strength of relationship
between responses to the C-PTES and C-DMSES over time (within two to four weeks)
and the level of agreements between individual responses over time were strong. Thus,
one can conclude that the C-DMSES and C-PTES are reliable and stable instruments.
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Result of Study II (Main Study)
6.6 Introduction
This chapter presents the results of Study II (the main study): Utilizing a randomised
controlled trial to evaluate the self-efficacy enhancing intervention program (SEEIP)
in a Taiwanese population. This chapter begins with a description of the sample,
examining differences between groups and key variables, and answers the following
research questions:
Research Question 2: Can an intervention (SEEIP) based on self-efficacy theory
improve self-management in people with type 2 diabetes in
Taiwan?
Within research question 2, the following research questions and hypotheses were
examined:
Question 2.1: Is there a difference in the self-efficacy of people with type 2 diabetes
following implementation of the SEEIP? (Hypothsis 1: People who
receive the intervention will have greater self-efficacy towards
managing their type 2 diabetes than people who do not receive the
intervention.)
Question 2.2: Is there a difference in the self-care activities of people with type 2
diabetes following implementation of the SEEIP? (Hypothsis 2: People
who receive the intervention will undertake diabetes self-care activities
more frequently than people who do not receive the intervention.)
Question 2.3: Is there a difference in health related quality of life of people with type
2 diabetes following implementation of the SEEIP? (Hypothsis 3:
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People who receive the intervention will have better HRQOL than
people who do not receive the intervention.)
Question 2.4: Is there a difference in the psychosocial well-being of people with type
2 diabetes following implementation of the SEEIP? (Hypothsis 4:
People who receive the intervention will have better psychosocial
well-being than people who do not receive the intervention.)
Question 2.5: Is there a difference in health care utilisation of people with type 2
diabetes following implementation of the SEEIP? (Hypothsis 5: People
who receive the intervention will have a lower usage of health services
than people who do not receive the intervention.)
6.7 Description of Sample
One hundred and seventy-three people met study criteria. One hundred and fifty-eight
people agreed and signed the consent form and were randomly assigned to either the
control group or intervention group using a random number table (81 participants in
the intervention group and 77 participants in the control group).
Of these 81 participants in the intervention group, nine did not complete the study for
the following reasons: four did not complete the questionnaires and two withdrew for
non-specified reasons. After the intervention was undertaken, three only attended the
first session of efficacy-enhancing intervention sessions. They did not satisfy the
inclusion criteria of this study (at least three of the four efficacy-enhancing
intervention sessions). We excluded these participants in this study. Therefore, the
final sample of the intervention group at Time 1 , time 2 , and Time 3 was consisted of
72.
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In the intervention group, all participants completed the questionnaires and
participated in the following activities: (1) viewing a 10-minute DVD; (2) receiving
the “Diabetes Self-Care” booklet; (3) participating in at least three of the four
efficacy-enhancing counselling intervention sessions at weekly intervals (There were
four groups of efficacy-enhancing counselling intervention sessions which were
conducted at different times and in different settings. Each group was limited to
between 15-20 participants according to participants’ preferences); and (4)
participating in telephone follow-up. This high retention rate of the intervention group
was attributed to the implementation of a retention strategy which allowed
participants to make up a missed lesson at an alternate time and setting and being able
to easily contact the researcher.
On the other hand, of these 77 participants in the control group, four did not complete
the study for the following reasons: three refused to participate as they were not
allocated to a group they preferred, and one did not complete the questionnaires.
These participants were excluded in this study. Therefore, the final sample of the
control group was consisted of 73. In the control group, participants were asked to
complete questionnaires at Time 1, Time 2, and Time 3 and received the routine care
in the outpatient clinic. The high retention rate of control group was attributed to
patients being required to routinely return to the outpatient clinic every two or four
weeks to obtain oral medication. (see Figure 6.7 sample of the main study).
The characteristics of participants who dropped out were similar to those who stayed
in the study.
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Figure 6.7 Sample of the main study
The baseline data (Time 1) of 145 respondents from the total sample were analysed in
this section. Age ranged from 30-81 years, with a mean of 64.4(SD=9.9) years. The
average number of years they had suffered from diabetes was 5.8 (SD =6.7) years.
The respondents consisted of 64.1% females. Most participants were married (83.4%),
Agreed and participated in the study (n=158)
Intervention group (n=81) Control group (n=77)
Time 1 (n=72)
Time 2 (n=72)
Three months following baseline collection
Randomly assigned
Time 2 (n=73)
Three months following baseline collection
Time 3 (n=72)
Six months following baseline collection
Time 1 (n=73)
Met study criteria (n=173)
Time 3 (n=73)
Six months following baseline collection
-Not complete
questionnaires (n=4)
-Withdrew
non-specified reasons
(n=2)
-Did not complete the
intervention (n=3)
-Refused as not preferred group (n=3) -Did not complete the questionnaires (n=1)
Refuse to participate (n=15)
Allocation
Follow-Up
Analysis
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Buddhist (48.3%) and came from the southern part of Fukien Province (78.6%). The
majority of participants had below primary schooling (59.3%), were living with
family (91.7%) and 84.1% had never been employed. Half of the participants (51.0%)
had a chronic disease other than diabetes. Sixty per cent of participants did not
experience complications related to diabetes and 66.2% experienced monotherapy.
Nearly half of the participants had been receiving diabetes patient education (49.7 %).
6.8 Checking differences between groups
6.8.1 Sociodemographics and illness history
Before evaluating the effects of the SEEIP, differences between the groups on a range
of variables were examined.
No significant differences were found between the intervention and the control groups
on sociodemographics, and illness history. (see Table 6.14). This means that both
groups had similarities in relation to the characteristics of participants.
Table 6.14 Comparisons of sociodemographics and illness history between intervention and
control groups (n=145)
Variables Intervention (n=72) Control (n=73) Significance
Sociodemographics: Mean SD Mean SD
Age 64.83 9.77 64.05 10.07 t=.47; p=.64
Duration of disease (years) 6.05 6.91 5.59 6.49 t=.41; p=.68
Gender Count % Count %
Male 25 34.7 27 37.0 χ2=.08;
Female 47 65.3 46 63.0 p= .86
Ethnic status
Fukien province 56 77.8 58 79.5 χ2=.09;
Mainland 9 12.5 8 11.0 p= .99
Hakka 5 6.9 5 6.8
Others 2 2.8 2 2.7
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Religion
Buddhist 36 50.0 34 46.6 χ2=1.21;
Taoist 27 37.5 26 35.6 p= .88
Christian 5 6.9 9 12.3
Catholicism 3 4.2 3 4.1
Others 1 1.4 1 1.4
Education
Illiteracy 22 30.6 27 37.0 χ2= .92;
Primary school 20 27.8 17 23.3 p= .92
Junior high school 16 22.2 14 19.2
Senior high school 13 18.1 14 19.2
college 1 1.4 1 1.4
Marital status
Unmarried 1 1.4 1 1.4 χ2= .32;
Married 59 81.9 62 84.9 p= .96
Divorced 3 4.2 3 4.1
Widower/Widow 9 12.5 7 9.6
Employment
None 60 83.3 62 84.9 χ2= .07;
Yes 12 16.7 11 15.1 p= .82
Living arrangement
Living alone 5 6.9 4 5.5 χ2= .45;
Living with family 66 91.7 67 91.8 p= .80
Others 1 1.4 2 2.7
Illness history
Other chronic conditions
None 36 50.0 38 52.1 χ2= .06;
Yes 36 50.0 35 47.9 p= .81
Complications
None 44 61.1 43 58.9 χ2= .07;
Yes 28 38.9 30 41.1 p= .87
Treatment regimen
Monotherapy (oral
medication)
49 68.1 47 64.4 χ2= .22;
Complexity (combine others) 23 31.9 26 35.6 p= .73
Patient education
None 36 50.0 37 50.7 χ2= .01;
Yes 36 50.0 36 49.3 p= 1.00
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6.8.2 Key variables of participants
The instruments used for the collection of data on key variables included:
self-efficacy towards management of type 2 diabetes (as measured by the Chinese
version of the Diabetes Management Self-Efficacy Scale (C-DMSES) and the Chinese
version of the Perceived Therapeutic Efficacy Scale (C-PTES)); self management
behaviour (as measured by the Summary of Diabetes Self-Care Activities (SDSCA));
health-related quality of life (as measured by Short Form-12 (SF-12)); and
psychosocial well-being (as measured by the Medical Outcomes Study (MOS) Social
Support Survey tool and the Centre for Epidemiology Studies Short Depression Scale
(CES-D).
The mean score of the C-DMSES was 131.80 (SD= 44.52) for the intervention group;
and 129.61 (SD= 42.10) for the control group. The mean score of the C-PTES was
M= 70.64 (SD=23.47) for the intervention group; and 68.95 (SD=23.21) for the
control group. The mean score of the SDSCA was 46.15 (SD= 15.24) for the
intervention group; and 46.99 (SD= 14.46) for the control group. The SF-12 outcomes
used for analysis in this study were physical and mental component summary scores
(PCS-12 and MCS-12). The PCS-12 and MCS-12 refer to physical well-being and
emotional well-being, respectively. High scores for all dimensions reflect better
health-related quality of life (HRQOL). The mean score of the PCS-12 was 43.26
(SD=10.20) for the intervention group; and 43.13 (SD=9.20) for the control group.
The mean score of the MCS-12 was 45.99 (SD=11.32) for the intervention group; and
44.56 (SD=11.19) for the control group.
The mean score of the MOS-SSS was 63.43 (SD= 17.53) for the intervention group;
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and 65.68 (SD= 17.01) for the control group. Finally, the mean score of the CES-D
was 9.64 (SD= 4.75) for intervention group; and 9.29 (SD=3.88) for control group.
Kibourne et al. (2002) classified scores 0 to 9 as indicating a mild level of depression
symptoms, 10 to 14 as representing moderate depressive symptoms, and >15
representing severe depressive symptoms. The mean score (9.29-9.64) showed that
the participants in the intervention and control group indicated a mild level of
depression symptoms at baseline.
No significant differences were found between the intervention and the control groups
for the key outcome variables. This means that there were similar mean scores of key
variables for the intervention and control groups at the baseline data (see Table 6.15).
Table 6.15 Differences between groups on the key variables of baseline (n=145)
Variables
Intervention group
(n=72)
Control group
(n=73)
M SD M SD t p
Self-efficacy towards management of
type 2 diabetes:
Efficacy expectation (C-DMSES) 131.80 44.52 129.61 42.10 .30 .76
Outcome expectation (C-PTES) 70.64 23.47 68.95 23.21 .44 .66
Self-management behaviours :
(SDSCA)
46.15
15.24
46.99
14.46
-.34
.74
Health-Related Quality of life :
(SF-12)
Physical health 43.26 10.20 43.13 9.20 .08 .94
Mental health 45.99 11.32 44.56 11.19 .77 .44
Psychosocial well-being:
The Medical Outcomes Study (SSS) 63.43 17.53 65.68 17.01 -.78 .43
Depression Scale (CES-D) 9.64 4.75 9.29 3.88 .49 .63
The key variable of health care utilisation (as measured by self-reported
questionnaires) measurement consisted of hospitalisation, visit to ER, and visit to the
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out-patient department (OPD). Most participants reported that they had not been
hospitalised and had not received emergency treatment in the last three months.
However, they did regularly visit the outpatient clinic in the last three months. No
significant differences were found between the intervention and the control groups for
the variables of health care utilisation (see Table 6.16).
Table 6.16 Differences between groups on health care utilisation of baseline (n=145)
Variables Intervention (n=72) Control (n=73) Significance
Hospitalisations
None 66 91.7 67 91.8 χ2= .00;
Yes 6 8.3 6 8.2 P= 1.00
Visit to ER
None 65 90.3 67 91.8 χ2= .10;
Yes 7 9.7 6 8.2 P= .78
Visit to OPD
None 17 23.6 22 30.1 χ2= .79;
Yes 55 76.4 51 69.9 P= .46
6.9 Question 2: Can an intervention (SEEIP) based on self-efficacy
theory improve self-management in people with type 2 diabetes
in Taiwan?
Participants for both groups were similar in relation to their sociodemographics,
illness history, the key variables, and health care utilisation. Thus, Question 2 of the
main study “Can an intervention (SEEIP) based on self-efficacy theory improve
self-management in people with type 2 diabetes in Taiwan?” is explored in this
section. Within Question 2, five research hypotheses were examined.
Two-way repeated measures ANOVA was conducted with 2×3 design (group× time).
The between-subjects factor was the intervention and control group. Repeated
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measures included time with three levels (Time 1, Time 2, and Time 3). Two-way
repeated measures ANOVA was used to examine the differences in each variable
between groups and across three time points. The assumptions for the ANOVA were
examined as follows: the dependent variables were continuous; the data were
approximately normally distributed; and the variances were equal (by Mauchly’s
Sphericity Test, p> .05). If Mauchly’s Sphericity Test, p> .05 (the variances were
equal), it could report the standard univariate F results. If Mauchly’s test < .05, it
could either report the multivariate results (Wilks’ Lambda) for the time factor and for
the interaction between group and time, or it could report the univariate results with
an epsilon correction (eg.Greenhouse-Geisser, Huynh-Feldt) (Munro, 2000).
However, Green and Salkind (2005) recommended Wilks’ Lambda (it appears
frequently in the social science literature).
If the interaction is significant, it would normally be necessary to conduct follow-up
simple main effect tests, and interaction comparisons (independent t test at Time 1,
Time 2 and Time 3). Moreover, as the time main effect was significant, it would be
necessary to conduct follow-up tests (paired t test, Time 1-2, Time 1-3, and Time 2-3)
to this main effect. Familywise error rate across these tests was controlled by using
Holm’s sequential Bonferroni approach (Bonferroni correction involved revising the
significance level such that the desired alpha is divided by the number of pairs being
compared) (Polit, 1996).
6.9.1 Question 2.1: Is there a difference in the self-efficacy in people with
type 2 diabetes following implementation of the SEEIP?
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The means and standard deviations for the efficacy expectations and outcome
expectations scores for the three time points and two groups are presented in Table
6.17.
Table 6.17 The mean (SD) for the efficacy-expectation and outcome-expectation scores
Variables Intervention group
M(SD)
Control group
M(SD)
Time 1 Time2 Time3 Time 1 Time2 Time3
Efficacy-expectations
(C-DMSES)
131.79
(44.52)
146.64
(37.01)
157.89
(34.68)
129.62
(42.10)
130.45
(42.31)
130.32
(41.95)
Outcome-expectations
(C-PTES)
70.64
(23.47)
83.04
(15.30)
83.64
(15.44)
68.95
(23.21)
68.26
(22.86)
68.57
(23.01)
Efficacy expectations
A two-way repeated measures ANOVA was conducted to test the effects of efficacy
expectations of the SEEIP. Main and group× time interaction effects were tested using
the multivariate criterion of Wilks’ Lambda (Λ).
The main effect of time of measurement of efficacy expectations was significant
(Wilks’ Λ=.81, F (2,141) = 16.58, p =.00). The group main effect was also significant
between groups, F (1,142) =5.44, p =.02. The interaction effect of group by time was
also significant, Wilks’ Λ=.80, F (2,141) =17.42, p =.00. The associated Partial Eta
square was .20, indicating a moderate effect size (see Table 6.21).
To interpret the significant main effect of time, planned post-hoc comparisons using
paired t-test were conducted with Bonferroni’s adjustment, where the p level was set
at .017 (to test for differences between the three pairs at the .05 significance level,
the alpha would be .05/ 3, or .017) (Polit, 1996). The follow-up paired t-test
comparisons showed Time 1-2 (t= - 3.63, p= .00), Time 1-3 (t= - 5.18, p= .00), and
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Time 2-3 (t= - 3.09, p= .00) (see Table 6.22). The mean score of efficacy expectations
was statistically different at Time 1-2, Time 1-3, and Time 2-3.
To interpret the significant interaction of group by time (see Figure 6.8), independent
pairwise comparisons were conducted. These tests showed that the intervention group
had significantly better efficacy-expectations than the control group at Time 2 (t=2.45,
p= .02), and Time 3 (t=4.3, p= .00) but not at Time 1 baseline data (t=.30, p=.76 (see
Table 6.23). These results supported Hypothesis 1 that people who receive the
intervention will have greater self-efficacy (efficacy expectations) towards managing
their type 2 diabetes than people who do not receive the intervention.
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Time
Figure 6.8 Graph of the interaction between time and group for the efficacy expectations
Outcome expectations
The main effect of time of measurement of outcome expectations of diabetes was
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significant (Wilks’ Λ=.89, F (2,141) = 8.36, p =.00). The group main effect was also
significant between groups, F (1,142) =11.11, p =.00. The interaction effect of group
by time was significant, Wilks’ Λ=.87, F (2,141) =10.27, p =.00. The associated
Partial Eta square was .127, indicating a small to moderate effect size.
To interpret the significance of main effect over time, planned post-hoc comparisons
using paired t-test were conducted, with Bonferroni’s adjustment, where the p level
was set at .017. The follow-up paired t-test comparisons showed the significance at
Time 1-2 (t= -3.75, p= .00), Time 1-3 (t= -3.67, p= .00), and Time2-3 (t= - .42, p= .68)
(see Table 6.22). The mean score of outcome expectations was statistically different at
Time 1-2, and Time 1-3. However, there was no significant difference at Time 2-3.
To interpret the significant interaction of group by time (see Figure 6.9), independent
pairwise comparisons were conducted, with Bonferroni’s adjustment, where the p
level was set at .017. These tests showed that the intervention group had significantly
better outcome expectations than the control group at Time 2 (t=4.58, p= .00), and
Time 3 (t=4.62, p= .00) but not at Time 1 baseline data (t=.44, p=.66) (see Table 6.23).
These results supported the Hypothesis 1 that people who receive the intervention will
have greater self-efficacy towards (outcome expectations) managing their type 2
diabetes than people who do not receive the intervention.
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Time
Figure 6.9 Graph of the interaction between time and group for the outcome expectations
6.9.2 Question 2.2: Is there a difference in the self-care activities of
people with type 2 diabetes following implementation of the
SEEIP?
Two-way repeated measures ANOVA was used to examine the differences in the
self-care activities (as measured by the SDSCA) between groups and three time points.
The means and standard deviations for the self-care activities scores for the three time
points and two groups are presented in Table 6.18.
Table 6.18 The mean (SD) for the self-care activities scores
Variables Intervention group
M(SD)
Control group
M(SD)
Time 1 Time2 Time3 Time 1 Time2 Time3
Self-care activities
( SDSCA)
46.15
(15.24)
52.86
(14.10)
55.06
(16.01)
46.99
(14.46)
46.78
(14.14)
46.71
(14.28)
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The main effect of time of measurement of the self-care activities for diabetes patients
was significant (Wilks’ Λ=.89, F (2,141) = 9.05, p =.00). The group main effect was
also significant between groups, F (1,142) =4.16, p =.04. The interaction effect of
group by time was significant, Wilks’ Λ=.87, F (2,141) =10.32, p =.00. The associated
Partial Eta square was .13, indicating a moderate effect size.
To interpret the significant of main effect of time, planned post-hoc comparisons
using paired t-test were conducted, with Bonferroni’s adjustment, where the p level
was set at .017. The follow-up paired t-test comparisons showed the significance at
Time 1-2 (t= -3.13, p= .00), Time 1-3 (t= -4.00, p= .00), and Time 2-3 (t= - 1.44,
p= .15) (see Table 6.22). The mean score of the self-care activities was statistically
different at Time 1-2, and Time 1-3. However, there was no significant difference at
Time 2-3.
To interpret the significant interaction of group by time (see Figure 6.10), independent
pairwise comparisons were conducted, with Bonferroni’s adjustment, where the p
level was set at .017. These tests showed that the intervention group had significantly
better self-care activities than the control group at Time 2 (t= 2.59, p= .01), and Time
3 (t=3.30, p= .00) but not at Time 1 baseline data (t= .34, p=.74) (see Table 6.23).
These results supported the Hypothesis 2 that people who receive the intervention will
undertake diabetes self-care activities more frequently than people who do not receive
the intervention.
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intervention or control
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Time
Figure 6.10 Graph of the interaction between time and group for the self-care activities
6.9.3 Question 2.3: Is there a difference in health-related quality of life of
people with type 2 diabetes following implementation of the
SEEIP?
Two-way repeated measures ANOVA was used to examine the differences in
health-related quality of life of people with type 2 diabetes. The SF-12 outcomes
used for analysis of health related quality of life in this study were physical and
mental component summary scores (PCS-12 and MCS-12). The PCS-12 and MCS-12
refer to physical well-being and emotional well-being, respectively. The means and
standard deviations for the PCS and MCS scores for the three time points and two
groups are presented in Table 6.19.
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Table 6.19 The mean (SD) for the physical health and mental health scores
Variables Intervention group
M(SD)
Control group
M(SD)
Time 1 Time2 Time3 Time 1 Time2 Time3
Physical health
(PCS)
43.26
(10.20)
46.28
(8.01)
46.24
(8.89)
43.13
(9.20)
43.18
(8.97)
43.17
(9.19)
Mental health
(MCS)
46.00
(11.32)
48.18
(9.19)
47.16
(9.12)
44.56
(11.19)
44.72
(11.20)
44.76
(11.11)
Physical health related quality of life
The main effect of time of the physical health-related quality of life was not
significant (Wilks’ Λ=.96, F (2,141) = 2.70, p =.07). The group main effect was also
not significant between groups, F (1,142) =2.08, p =.15. The interaction effect of
group by time was not significant (Wilks’ Λ=.96, F (2,141) = 3.04, p =.05) (see Figure
6.11).
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Time
Figure 6.11 Graph of the interaction between time and group for the physical health-related
quality of life
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Mental health related quality of life
The main effect of time of the mental health-related quality of life was not significant
(Wilks’ Λ=.99, F (2,141) = 1.08, p =.34). The group main effect was also not
significant between groups (F (1,142) =2.45, p =.12). The interaction effect of group
by time was not significant (Wilks’ Λ= .99, F (2,141) = .89, p = .41) (see Figure 6.12).
These results can not support the Hypothesis 3 that people who receive the
intervention will have better HRQOL (mental health) than people who do not receive
the intervention.
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Time
Figure 6.12 Graph of the interaction between time and group for the mental health-related
quality of life
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6.9.4 Question 2.4: Is there a difference in the psychosocial well-being of
people with type 2 diabetes following implementation of the
SEEIP?
Two-way repeated measures ANOVA was used to examine the differences in the
social support (as measured by the MOS-SSS), and depression (as measured by
CES-D) between groups and three time points. The means and standard deviations for
the MOS-SSS and CES-D scores for the three time points and two groups are
presented in Table 6.20.
Table 6.20 The mean (SD) for the social support and depression scores
Variables Intervention group
M(SD)
Control group
M(SD)
Time 1 Time2 Time3 Time 1 Time2 Time3
Social support
(MOS-SSS)
63.43
(17.53)
68.29
(18.60)
70.43
(16.64)
65.68
(17.01)
65.66
(17.01)
64.77
(16.75)
Depression
(CES-D)
9.64
(4.75)
9.33
(4.97)
9.34
(4.65)
9.29
(3.88)
9.45
(3.95)
9.50
(3.88)
Social support
The main effect of time of the social support for type 2 diabetes was significant
(Wilks’ Λ=.94, F (2,141) = 4.74, p = .01). The group main effect was not significant
between groups, F (1,142) =.62, p = .43. The interaction effect of group by time for
the social support was significant (Wilks’ Λ= .90, F (2,141) =8.01, p =.00). The
associated Partial Eta square was .10, indicating a small to moderate effect size.
To interpret the significance of main effect of time, planned post-hoc comparisons
using paired t-tests were conducted, with Bonferroni’s adjustment, where the p level
was set at .017. The follow-up paired t-test comparisons showed the significance at
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Time 1-2 (t= -2.08, p= .04), Time 1-3 (t= -2.94, p= .00), and Time 2-3 (t= - .80, p= .43)
(see Table 6.22). The mean score of the social support was statistically different at
Time 1-3. However, there was no significant difference at Time 1-2 and Time 2-3
after they were examined by Bonferroni’s correction, where the p level was set
at .017.
To interpret the significant interaction of group by time (see Figure 6.13), independent
pairwise comparisons were conducted, with Bonferroni’s adjustment, where the p
level was set at .017. These tests showed that the intervention group did not have
significantly better social support than the control group at Time 1 (t=-.78, p= .43),
Time 2 (t= .89, p= .38), and Time 3 (t=2.04, p= .04) (see Table 6.23). Even though the
group main effect was not significant between groups, the main effect of time and the
interaction effect of group by time for the social support were significant. These
results supported the Hypothesis 4 that people who receive the intervention will have
better psychosocial well-being (social support) than people who do not receive the
intervention.
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Estimated Marginal Means of social support
Time
Figure 6.13 Graph of the interaction between time and group for the social support
Depression
The main effect of time of the depression was not significant (Wilks’ Λ= .1.00, F
(2,141) = .04, p =.97). The group main effect was also not significant between groups
(F (1,142) = .00, p =1.00). The interaction effect of group by time was not significant
(Wilks’ Λ= .99, F (2,141) = .44, p = .64) (Figure 6.14). These results can not support
the Hypothesis 4 that people who receive the intervention will have better
psychosocial well-being (less depression) than people who do not receive the
intervention.
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Time
Figure 6.14 Graph of the interaction between time and group for the depression
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Table 6.21 Repeated measure analysis of variance for the outcome variables (n=145)
Effect df Wilks’ Λ Effect sizes
(Eta square)
F p
Efficacy expectations
Group 1,142 .04 5.44 .02*
Time 2,141 .81 .19 16.58a .00**
Group× Time 2,141 .80 .20 17.42a .00**
Outcome expectations
Group 1,142 .07 11.11 .00**
Time 2,141 .89 .11 8.36 a .00**
Group× Time 2,141 .87 .13 10.27a .00**
Self-care activities
Group 1,142 .03 4.16 .04*
Time 2,141 .89 .11 9.05 a .00**
Group× Time 2,141 .87 .13 10.32 a .00**
Physical health-related QOL
Group 1,142 .01 2.08 .15
Time 2,141 .96 .04 2.70 a .07
Group× Time 2,141 .96 .04 3.04 a .05
Mental health-related QOL
Group 1,142 .02 2.45 .12
Time 2,141 .99 .02 1.08a .34
Group× Time 2,141 .99 .01 .89 a .41
Social support
Group 1,142 .00 .619 .43
Time 2,141 .94 .06 4.74 a .01**
Group× Time 2,141 .90 .10 8.01 a .00**
Depression
Group 1,142 .00 .00 1.00
Time 2,141 1.0 .00 .04 a .97
Group× Time 2,141 .99 .01 .44 a .64 *p< .05, **p< .01 a Exact statistic
Note: To interpret effect sizes: .02= small magnitude, .15= medium magnitude, .35= large magnitude
(Cohen, 1988: 477-478)
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Table 6.22 Comparisons of outcome variables by time of groups (Paired-t Test) (n=145)
Variables Mean
difference
SD t pa
Efficacy expectations
Pair T1- T2 -7.79 25.85 -3.63 < .017 *
Pair T1- T3 -13.01 30.12 -5.18 < .017 *
Pair T2- T3 -5.16 20.01 -3.09 < .017 *
Outcome expectations
Pair T1- T2 -5.81 18.68 -3.75 < .017 *
Pair T1- T3 -6.22 20.32 -3.67 < .017 *
Pair T2- T3 -.36 10.36 -.42 ns
Self-care activities
Pair T1- T2 -3.23 12.40 -3.13 < .017 *
Pair T1- T3 -4.31 12.92 -4.00 < .017 *
Pair T2- T3 -1.06 8.80 -1.44 ns
Physical health-related QOL
Pair T1- T2 -1.52 8.07 -2.27 ns
Pair T1- T3 -1.39 8.06 -2.07 ns
Pair T2- T3 .14 4.99 .33 ns
Mental health-related QOL
Pair T1- T2 -1.17 9.60 -1.46 ns
Pair T1- T3 - .72 8.25 -1.04 ns
Pair T2- T3 .46 6.33 .88 ns
Social support
Pair T1- T2 -2.41 13.94 -2.08 ns
Pair T1- T3 -3.09 12.59 -2.94 < .017 *
Pair T2- T3 -.67 10.07 -.80 ns
Depression
Pair T1- T2 .07 3.21 .26 ns
Pair T1- T3 .06 3.63 .21 ns
Pair T2- T3 -.01 3.04 -.03 ns
a Bonferroni correction applied *p< .017
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Table 6.23 Comparisons of outcome variables by time of groups (Independent-t Test) (n=145)
Variables t pa
Efficacy expectations
Time 1 .30 ns
Time 2 2.45 < .017 *
Time 3 4.30 < .017 *
Outcome expectations
Time 1 .44 ns
Time 2 4.58 < .017 *
Time 3 4.62 < .017 *
Self-care activities
Time 1 -.34 ns
Time 2 2.59 < .017 *
Time 3 3.30 < .017 *
Physical health-related quality of life
Time 1 .08 ns
Time 2 2.19 ns
Time 3 2.04 ns
Mental health-related quality of life
Time 1 .77 ns
Time 2 2.03 ns
Time 3 1.41 ns
Social Support
Time 1 -.78 ns
Time 2 .89 ns
Time 3 2.04 ns
Depression
Time 1 .49 ns
Time 2 -.16 ns
Time 3 -.23 ns
a Bonferroni correction applied *p< .017
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6.9.5 Question 2.5: Is there a difference in health care utilisation of
people with type 2 diabetes following implementation of the
SEEIP?
Health care utilisation (as measured by self-reported questionnaires) measurement
items consisted of the dichotomous data (yes or no) related to hospitalisation, visit to
ER, and visit to the out-patient department (OPD). To compare the health care
utilisation of people with type 2 diabetes at Time 1, Time 2, and Time 3 between the
groups (control and intervention), data were analysed using the chi square statistic to
test the significance of different proportions.
Hospitalisation
Table 6.24 showed that no significant differences were found after comparison of the
proportion of the hospitalisation between the intervention and the control groups at
Time 1 and Time 2. However, there was a significant difference at Time 3 (χ2= 9.10,
P= .00). The results showed that a greater proportion of the participants in the control
group had been hospitalised (15.1%) than the participants who were in the
intervention group (1.4 %) at the point of Time 3 (see Figure 6.15).
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0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
Time 1 Time 2 Time 3
Intervention
Control
Figure 6.15 The percentage of the hospitalisation between the intervention and
control groups at Time 1, Time 2 and Time 3
Visit to emergency room
No significant differences were found after comparison of the proportion of visits to
the emergency room between the intervention and the control groups at Time 1 and
Time 2. However, there was a significant difference at Time 3 (χ2= 4.10, P= .04) (see
Table 6.24). The results showed that a greater proportion of the participants in the
control group had visited the emergency room (17.8%) than the participants who were
in the intervention group (6.9%) at the point of Time 3 (see Figure 6.16).
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0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
18.00%
20.00%
Time 1 Time 2 Time 3
InterventionControl
Figure 6.16 The percentage of visits to emergency room between the intervention and control
groups at Time 1, Time 2 and Time 3
Visit to OPD
No significant differences were found after comparison of the proportion of visits to
the OPD between the intervention and the control groups at Time 1, Time 2, and Time
3 (see Table 6.24). Therefore, there was no significant change in the proportion of
visits to OPD between groups at any points of time (see Figure 6.17).
56.00%
58.00%
60.00%
62.00%
64.00%
66.00%
68.00%
70.00%
72.00%
74.00%
76.00%
78.00%
Time 1 Time 2 Time 3
Intervention
Control
Figure 6.17 The percentage of visits to OPD between the intervention and control groups
at Time 1, Time 2 and Time 3
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These results supported Hypothesis 5 that people who receive the intervention will
have a lower usage of health services (hospitalisation and visit to emergency room)
than people who do not receive the intervention. However, the lower usages of
hospitalisation and visit to emergency room were not found until Time 3 (six months
following baseline collection).
Table 6.24 Comparison of visits to emergency room between intervention and control groups
(n=145)
Intervention
(n=72)
Control
(n=73)
Significance Variables
Count % Count %
Hospitalisation
Time 1 Yes 6 8.3 6 8.2 χ2= .00;
No 66 91.7 67 91.8 p=1.00
Time 2 Yes 7 9.7 6 8.2 χ2= .10;
No 65 90.3 67 91.8 P= .78
Time 3 Yes 1 1.4 11 15.1 χ2= 9.10;
No 71 98.6 61 83.6 p= .00**
Visit to emergency room
Time 1 Yes 7 9.7 6 8.2 χ2= .10 ;
No 65 90.3 67 91.8 p= .78
Time 2 Yes 9 12.5 8 11.0 χ2= .08 ;
No 63 87.5 65 89.0 p= .80
Time 3 Yes 5 6.9 13 17.8 χ2= 4.10 ;
No 67 93.1 59 80.8 p= .04*
Visit to OPD
Time 1 Yes 55 76.4 51 69.9 χ2= .79 ;
No 17 23.6 22 30.1 p= .46
Time 2 Yes 53 73.6 47 64.4 χ2= 1.44 ;
No 19 26.4 26 35.6 p= .28
Time 3 Yes 46 63.9 50 68.5 χ2= .50;
No 26 36.1 22 30.1 p=.60
*p< .05, **p< .01
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6.10 Summary result of Study II
The participants for both groups were similar in relation to the sociodemographics,
illness history, the key variables and health care utilisation. Five hypotheses were
examined and answered:
1). People who receive the intervention will have greater self-efficacy towards
managing their type 2 diabetes than people who do not receive the intervention.
The finding showed that the scores of efficacy expectation and outcome
expectation were significantly increased in the intervention group at Time 2 and
Time 3 compared to the control groups (p<.01). Efficacy expectations and
outcome expectations were increased between Time 1 and Time 2 and Time 2 and
Time 3.
2). People who receive the intervention will undertake diabetes self-care activities
more frequently than people who do not receive the intervention.
The score of self-care activities was significantly increased in the intervention
group at Time 2 to and Time 3 compared to the control groups (p<.01). Self-care
activities increased between Time 1 and Time 2 and Time 1 and Time 3.
3). People who receive the intervention will have better HRQOL than people who do
not receive the intervention.
The scores of the health (physically and mentally) related quality of life were not
significantly increased in the intervention group at Time 2 or Time 3 compared to
the control groups. The results indicated that the change over time was not
different in the two groups.
4). People who receive the intervention will have better psychosocial well-being than
people who do not receive the intervention.
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The interaction effect of group by time for the social support was significant and
the score of social support was increased between Time 1 and Time 3 (p<.01).
However, the results of the depression scores indicated that the change over time
was not different in the two groups.
5). People who receive the intervention will have a lower usage of health services
than people who do not receive the intervention.
A smaller proportion of the participants significantly in the intervention group,
have been hospitalised (p<.01) and visited the emergency room (p<.05) than the
participants who were in the control group at Time 3.
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Chapter 7
Discussion
7.1 Introduction
This chapter will discuss the evidence found in this study in response to the research
questions and hypotheses. Firstly, Study I : ‘Demonstration of the validity and
reliability of two diabetes-specific self-efficacy questionnaires in the Taiwanese
population’ will be discussed. The original version of the Diabetes Management
Self-Efficacy Scale (DMSES) and the Perceived Therapeutic Efficacy Scale (PTES)
were translated and psychometrically tested as instruments in the diabetes population
in Taiwan. Although the scales have been tested before (McDowell et al., 2005; van
der Bijl, van Poelgeest-Eeltink & Shortridge-Baggett, 1999; Sturt & Hearnshaw,
2003), it is of great importance to continue to test them in different countries with
different languages. Very few self-efficacy towards management of diabetes studies
and instrument development have been found in Taiwan. In this research, the DMSES
and PTES are used for the first time in the Chinese population. To test a self-efficacy
and diabetes specific instrument in Taiwan is a new challenge and a significant issue.
Secondly, Study II: ‘Provision of a comprehensive diabetes education intervention:
SEEIP (the self efficacy enhancing intervention program) and demonstration of the
effectiveness of a nursing intervention will be discussed. Diabetes is a prevalent,
costly condition associated with substantial morbidity and mortality in Taiwan. Even
though the health care system has persistently emphasised patients’ health education,
the increased knowledge of individual cases may not represent the well-controlled
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levels of blood glucose. Taiwan also has increasing trends of diabetes mortality and
healthcare cost. It is important to prevent the complications and to prolong the life of
the patients. The concept of self-efficacy provides a scientific evidence base for health
promotion strategies (Bandura, 1986; Poradzisz, 2001). Thus, developing and
evaluating the self-efficacy enhancing intervention program (SEEIP) for diabetes
mellitus based on the self-efficacy theory is the next topic which will be discussed.
Discussion of Study I
Research question 1: Are the two diabetes-specific self-efficacy instruments, the
DMSES and PTES valid and reliable in a Taiwanese
population?
7.2 Discussion of the Chinese version of the DMSES (C-DMSES) 7.2.1 Discussion of Stage one: translation and development of the
C-DMSES
The use of Western instruments translated from English into other languages has been
a frequent feature and trend around the world. Language is one of the most obvious
barriers to assessment; simple, direct translation of standardised or new instruments
will not solve this problem (Brislin, 1986; Marin & vanOss, 1991). In translating an
instrument for cross-cultural use, it is significant that the meaning of test items be
approximately the same across the different language versions. However, measures of
health related concepts must be sensitive to these subtle language differences, as well
as to cultural differences that influence understanding of the constructs (Varricchio,
2004). The recommended procedure for translating research instruments is known as a
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back-translation (Brislin, 1986). Jones et al. (2001) claimed an adaptation and
extension of the Brislin’s model which includes simultaneous translations and
back-translations followed by group consultation by the bilingual experts is
recommended. We applied a revised approach to increase efficiency, strengthen the
integrity of the translation process, and to achieve the goals of cultural and functional
equivalence. In this present study, a rigorous multi-stepped translation and
back-translation process was undertaken in developing the C-DMSES. These
processes aim to ensure the equivalent meaning of items in both languages.
The translator attended to inherent differences in the overall linguistic structure of
English and Chinese that may require item modification beyond literal translation.
Three modifications identified by group discussion on the back-translation refer to the
C-DMSES. To summarize the main points of the translation and back-translation,
challenges for consideration were found concerning the semantic and content
equivalence. After discussions between the researchers and the translators it was
found that the questionable concepts were actually identical in meaning. For example,
‘my feet’ was translated into ‘my foot’. When the difference was slight, but the
meaning was considered the same, changes were not made in the translation. In two
cases, wording of items was modified through adding context or using synonyms
when literal translations seemed unclear or awkward. For example, the item “I am
able to keep my weight under control” was modified to “I am able to control my body
weight and maintain it within the ideal weight range”. Moreover, one term in the item
was changed due to the culture differences. Generally speaking, eating habits do not
change much on weekends and holidays, but are influenced by special festivals, for
example, people eat rice cakes (niangao) at Chinese New Year, glutinous rice
dumplings (zongzi) during the Dragon Boat festival and moon cakes at Mid-Autumn
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Festival. Diet control is the basis of the whole therapy for diabetics and through diet
control a satisfactory level of the blood sugar can be maintained for one-third of
diabetic patients (Funnell et al., 1992). The eating habits and other lifestyle factors
influence diabetes control effectively. Thus, we replace ‘holiday’ with ‘festivals’.
Although Brislin (1986) stated that adding context can narrow the possibilities of
meanings and make the test item more specific, the C-DMSES is specifically a
self-efficacy and diabetes instrument, so adding context or wording was considered a
solution to address the difficulty in translating English words. These changes would
be more concrete and make it easier for people to understand the meanings of the
items.
7.2.2 Discussion of Stage two: validation and reliability of the C-DMSES
7.2.2.1 The content validity of the C-DMSES
Content validity is established by using a team of experts who agree that the items on
the instrument provide adequate coverage of the concepts (Kim & Han, 2004) and this
is essential for all instruments and should not be seen as less important than other
forms of validity evidence (Berk, 1990). The suggested number of experts is five to
ten experts who meet detailed criteria for expertise in order to respond to specific
questions about the content relevance of each item and the total scale, suggest
revisions, and identify omissions (Grant & Davis, 1997). In this study, a panel of eight
experts judged the content validity of the Chinese version DMSES and content
relevance was determined as based on two criteria: including the applicability of
content and clarity of phrasing. The C-DMSES obtained a score of the applicability of
content .87 and the clarity of phrasing .85. Thus, the C-DMSES obtained a total
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average score of .86 for CVI. Grant and Davis (1997) proposed that the minimum
acceptable agreement score should range from .7 to .8. An acceptable CVI was greater
than .85 for this instrument. That means that there was at least 85% agreement among
eight experts that each one of the items fitted its own concept clearly. The results of
the content validity indicate that the C-DMSES was content valid.
The experts’ comments
In addition to their quantitative ranking of the items, the experts identified several
specific concerns with item content. In the C-DMSES, two of the eight experts
thought that Item No. 13, “I am able to follow a healthy eating plan when I am away
from home” (CVI= .89), and Item No. 14 “I am able to choose different foods and
maintain my eating plan when I am away from home” (CVI= .84) were too similar.
However, the average total score of CVI still remains high and greater than .80. Thus,
both two items were provisionally accepted. A number of items were culturally or
contextually irrelevant to Taiwanese society, for example, Item No. 15, “I am able to
follow a healthy eating plan during festive periods” (CVI= .89), People generally
over-eat or have a different eating habit during special festivities. Considering the
cultural differences, experts accepted that the term “holiday” has been replaced with
“festival” during the translation process. The other example is that Item No. 18, “I am
able to visit my doctor four times a year to monitor my diabetes” (CVI= .86), because
according to the regulations of the Bureau of National Health Insurance, prescriptions
for patients with chronic diseases are only valid for three months, therefore, doctors
and experts suggested that patients should visit their doctor at least four times a year.
Although some items were modified, no items were removed and be further tested
their psychometric.
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7.2.2.2 The criterion validity of the C-DMSES
Establishing criterion-related validity involves determining the relationship between
an instrument and an external criterion. The instrument is said to be valid if its score
correlates highly with the score on the criterion (Polit & Beck, 2004). Studies
demonstrate that self-efficacy is a useful predictor for diabetic self-care behaviour and
self-care performance will be improved in people with diabetes who have strong
beliefs in self-efficacy. (Williams & Bond, 2002; Sigurardóttir & Árún, 2005).
Therefore, the Summary of Diabetes Self-Care Activities (SDSCA) and the
C-DMSES were used to test the relationship using regression analysis for the
criterion-related validity. Regression analysis is to use to make predictions about
phenomena (Green & Salkind, 2005). In bivaricate regression, one predictor
(C-DMSES) is used to predict a dependent variable (SDSCA).
Results (R=.58; R2= .34, t=10.75, p=.00) show the C-DMSES is a significant
predictor of diabetes self-care activities. This means that higher self-efficacy has a
correlation with self-care performances. These findings were similar to Hurley and
Shea’s study (1992), which showed self-efficacy accounted for an average 33.0 % of
the variance in self-care and Williams and Bond’s study (2002), which demonstrated
self-efficacy was a significant predictor of self-care activities, contributing between
14% and 35 % (average 24%) of the variance of self-care activities. Therefore, the
C-DMSES instrument performed as predicted for criterion validity testing.
7.2.2.3 The convergent validity of the C-DMSES
Convergent validity refers to substantial correlations between an instrument and other
measures to which it should theoretically relate (Kim & Han, 2004). Convergent
validity is generated from the correlations between two different methods measuring
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the same trait (Polit & Beck, 2004). In the General Self-Efficacy Scale (GSE) higher
scores equate with higher personal expectations of ability to initiate and persist with a
task and reflect the strength of self-efficacy as a willingness to perform and persist
with behaviour in difficult situations (Schwarzer, 1992). The General Self-Efficacy
Scale (GSE) (Schwarzer, 1992) appears to be the most consistent for measuring the
self-efficacy concept and this scale been used to test whether the C-DMSES is valid in
this trait. The results showed that C-DMSES and GSE score had moderate
associations (r= .55; p< .01). This result confirms the convergent validity, which the
DMSES was tested in an Australia population (r= .52; p< .00) (McDowell et al.,
2005). The Chinese version DMSES is a domain-specific measure of efficacy
expectations (or self-efficacy) in a diabetic population. This result indicated that
C-DMSES has the ability to measure underlying the strength dimension of
self-efficacy.
7.2.2.4 The construct validity of the C-DMSES
The evidence of construct validity would further support the clinical meaningfulness
of an instrument (Nunnally & Bernstein, 1994). Construct validity of the C-DMSES
was assessed through factor analysis. According to Green and Salkind (2005) the
criteria of eigenvalues higher than 1.0 and factor loadings higher than .4 could attain
the best fitting structure and the correct number of factors. The results of C-DMSES
gave four factors, rotated in the initial solution which had eigenvalues >1.0; consistent
with the previous analysis with the Dutch DMSES (van der Bijl, van
Poelgeest-Eeltink & Shortridge-Baggett, 1999) a four-factor solution was generated.
These four factors explained 68.32% of the total sample variance and the loading
factor of each item greater than .4. Factor one accounts for the largest percentage of
variance (46.65%) and is a comprehensive factor with high internal consistency.
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Because the Australian/English version of the DMSES has not tested the construct
validity (factor analysis), the results of factor analysis thus compared with the Dutch
version DMSES.
Although the scale can be classified into four functional factors, the four clusters of
diabetes self-care activities of C-DMSES, namely nutrition, blood sugar and feet
check, physical exercise and weight, and medical treatment, are different from the
Dutch version instrument outlined by van der Bijl, van Poelgeest-Eeltink and
Shortridge (1999). In fact, in the development of the Dutch version DMSES, the
authors stated it is tricky to conclude the four factors represent four subscales: (a)
nutrition specific and weight; (b) nutrition general and medical treatment; (c) physical
exercise; and (d) blood sugar (van der Bijl, van Poelgeest-Eeltink &
Shortridge-Baggett, 1999). They hope more research with this scale would confirm or
modify their findings. Interestingly, this present study revealed better and more
suitable four categories: (a) nutrition (Items 4, 5, 9, 10, 13, 14, 15, 16, 17); (b) blood
sugar and feet check (Items 1, 2, 3, 7); (c) physical exercise and weight (Items 6, 8, 11,
12); and (d) medical treatment (Items 18, 19, 20).
Differences in the subscales found between the Chinese and Dutch versions may be
attributed to the changes to wording and cultural difference which were better
reflection of the Taiwanese environment and society as mentioned previously. In the
C-DMSES, the first factor all related to food or nutrition (Items 16, 14, 13, 15, 17, 10,
5, 4, and 9). Factor two is related to the checking issue (Items 3, 2, 1, 7). Generally
speaking, blood sugar and feet checking takes time and equipment, such as a blood
sugar testing machine or mirrors so that the two issues cluster in the same factor.
Factor three (Items 11, 8, 12, and 6) related to physical exercise and weight. This is
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different from the Dutch version DMSES where nutrition and weight were
categorized in the same factor. This may be due to local perception in Taiwan where
controlling body weight is more likely to be associated with exercise rather than
nutrition. Factor four (Items 18, 19, and 20) related to medical treatment. In Taiwan
people believe accessing health providers and taking medication is sufficient
treatment to control their diabetes. Table 7.1 shows the differences between the Dutch
version DMSES and the Chinese version DMSES.
Table 7.1 Comparison of subscales in the Dutch and Chinese versions of DMSES
The Dutch version DMSES Chinese version DMSES
Nutrition specific and weight (5 items) Nutrition (9 items)
6. I think I’m able to keep my weight under
control
4. I am able to choose the foods that are best for
my health
13. I think I’m able to follow a healthy eating plan
when I am away
5. I am able to choose different foods and
maintain a healthy eating plan
14. I think I’m able to adjust my diet when I am
away from home from home
9. I am able to maintain my eating plan when I am
ill
15. I think I’m able to follow my diet when I am
on vacation
10. I am able to follow a healthy eating plan most
of the time
16. I think I’m able to follow my diet when I am
at a reception/party
13 I am able to follow a healthy eating plan when
I am away from home
Nutrition general and medical treatment (9
items)
14. I am able to choose different foods and
maintain my eating plan when I am away from
home
4. I think I’m able to select the right foods 15 I am able to follow a healthy eating plan
during festive periods
5. I think I’m able to select different foods but
stay within my diabetic diet
16. I am able to choose different foods and
maintain a healthy eating plan when I am
eating out or at a party
7. I think I’m able to examine my feet for skin
problems
17 I am able to maintain my eating plan when I
am feeling stressed or anxious
9. I think I’m able to adjust my diet when I am ill Medical treatment (3 items)
10. I think I’m able to follow my diet most of the
time
18 I am able to visit my doctor four times a year
to monitor my diabetes
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17. I think I’m able to adjust my diet when I am
under stress or tension
19 I am able to take my medication as prescribed
18. I think I’m able to visit the doctor once a year
to monitor my diabetes
20. I am able to maintain my medication when I
am ill
19. I think I’m able to take my medication as
prescribed
Physical exercise and weight (4 items)
20. I think I’m able to adjust my medication when
I am ill
6 I am able to control my body weight and
maintain it within the idea weight range
Physical exercise (3 items)
8 I am able to do enough physical activity (e.g.
walking the dog; yoga; gardening; stretching
exercises)
8. I think I’m able to get sufficient physical
activities, for example, talking a walk or biking
11 I am able to do more physical activity if the
doctor advises me to do
11. I think I’m able to take extra physical
activities, when the doctor advises me to do so
12 When doing more physical activity I am able
to adjust my eating plan
12.When taking extra physical activities, I think
I’m able to adjust my diet
Blood sugar and feet check (4 items)
Blood sugar (3 items) 1 I am able to check my blood sugar if necessary
1. I think I’m able to check my blood sugar if
necessary
2 I am able to correct my blood sugar when the
sugar level is too high (e.g. eat different foods)
2. I think I’m able to correct my blood sugar when
the sugar value is too high
3 I am able to correct my blood sugar when the
sugar level is too low (e.g. eat different foods)
3. I think I’m able to correct my blood sugar when
the sugar value is too low
7. I am able to examine both of my feet (e.g. for
cuts or blisters)
7.2.2.5 Internal consistency of the C-DMSES
Internal consistency reliability evaluates the degree to which items designed to
measure the same content domain are inter-correlated (Polit & Beck, 2004).
Cronbach’s alpha for the total scale of a new instrument was expected to be greater
than .7 (Nunnally & Bernstein, 1994; Jacobson, 2004). The target language version is
treated as a new instrument, with an alpha of .70 (Nunnally & Bernstein, 1994).
Reliability of C-DMSES was high with a value of .93 for the total scale and ranged
from .77 to .93 for the subscales for C-DMSES, which is sufficient for assessment at
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an individual level (Jacobson, 2004). It is a little higher than that found for the Dutch
version (Cronbach’s alpha .81) of the DMSES (van der Bijl, van Poelgeest-Eeltink &
Shortridge-Baggett, 1999) but similar to results reported for the Australia/ English
version (Cronbach’s alpha .91) (McDowell et al., 2005).
Item analysis is an additional means of finding weaknesses in the measure and
assessing how well each item contributes to the overall measure (Kim & Han, 2004).
The items were homogenous to the scale, as there was no significant increase in the
Cronbach’s alpha when any item was left out. The correlated item-to–total
correlations ranged from .37 to .76. The recommend Pearson correlation coefficient
item-total correlation coefficients should be greater than .3 and inter-item correlations
should be less than .7 to indicate a lack of multicollinearity (Nunnally & Bernstein,
1994). The mean-item correlation= .42 (min. = .09, max= .86) for the C-DMSES in
this study. This analysis indicated a non-unidimensional scale for the C-DMSES.
7.2.2.6 Stability of the C-DMSES
The stability of an instrument is the extent to which similar findings are gained on two
separate administrations (Polit & Beck, 2004). The test-retest reliability of the
C-DMSES was tested with a sample of 30 participants assessed twice over an interval
of three weeks. The results of the Pearson r were high with a value of .86 for the total
scale and ranged from .77 to .93 for the subscales for C-DMSES, indicating good
consistency of the test results over time. The results were a little higher than that
found for the Australia / English version DMSES (r= .76, p< .00) (McDowell et al.,
2005) and the Dutch version DMSES (r= .79, p< .00) (van der Bijl, van
Poelgeest-Eeltink & Shortridge-Baggett, 1999). These outcomes confirm previously
undertaken analysis of temporal stability in other versions of the instrument.
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Traditionally, within the nursing literature the test-retest reliability or stability of
psychometric questionnaires was examined by the Pearson correlation (Polit &
Hungler, 1999). Bland and Altman (1986) argued that correlations are an indication of
relationship and do not offer information regarding agreement, so are unable to detect
systematic bias in response from one time to another. Therefore, a Bland-Altman plot
was used to graphically display the variability involved in this study as well. The
result of the mean difference was greater than zero indicated that there may be bias in
the data. It is a similar result that found for an Australian population (M= 4.13,
SD=15.5) (McDowell, Courtney & Edwards, 2005). This may be attributed to
participant’s previous knowledge of the C-DMSES scale. The level of agreement (2
SD of the difference between the test-retest measurements) between individual
responses over time is strong. Thus, one can conclude that the C-DMSES is a reliable
and stable instrument. A limitation to the proportion of agreement approach
(Bland-Altman plot) employed in other studies of testing reliability for DMSES
instrument are still absent, it would seem that there is a need for future research to
extend this method to their studies.
7.3 Discussion of the Chinese version of the PTES (C-PTES) 7.3.1 Discussion of stage one: translation and development of the
C-PTES
There is little debate regarding the translation of the C-PTES. The items may not have
a translation problem because, based on translation theory, the accurate and
appropriate processes of translation and back-translation had been undertaken for the
study (see Chapter 5.2.1.1).
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7.3.2 Discussion of stage two: validation and reliability of the C-PTES
7.3.2.1 The content validity of the C-PTES
The score for the applicability of content was .85 and the clarity of phrasing was .79
for the C-PTES. The total average score was .83 of CVI for the C-PTES. An
acceptable CVI for this instrument is greater than .79, which was in the acceptable
range from .7 to .8 suggested by Grant and Davis (1997). However, some items have
been changed due to selections of culturally appropriate wording. The results of the
content validity indicate the C-PTES was content valid.
The experts’ comments
Regardless of the different grammatical forms or languages, three items of the
C-PTES have been changed. Item No. 2, “My level of confidence in the ability of my
diabetes medication to prevent episodes of high blood sugar is” (CVI=.81) was
changed to “My diabetes medication can keep my blood sugar at a stable level and
prevent it from becoming elevated”; Item No. 5, “My level of confidence in the ability
to control my diabetes by my maintaining my medication dose is” (CVI=.84) was
changed to “The maintenance of the dose of my medication can control my diabetes
effectively”; and No. 10 “My overall level of confidence in the ability to manage my
diabetes is” (CVI=.78) was changed to “My overall level of confidence in my ability
to cope with my diabetes is”. Moreover, the experts suggested adding specific
examples to the item No. 9 to further explain the intended meaning. Item No. 9 “My
level of confidence in my health professionals’ advice about my diabetes treatment is”
(CVI=.78) was changed to “The professional advice that experts such as doctors or
nutritionists give me in my diabetes treatment”. Experts thought that the modifications
of the above content and wordings would fit better with Taiwanese culture, and were
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easier for patients to understand.
According to Bijnen, van der Net and Poortinga (1986), each item must be considered
as a separate measurement and be checked for adequacy of translation, systemic item
response bias, and fairness within each cultural group. The experts’ comments and the
positive results from the CVI enhanced the usefulness and practicability of the
instruments and may serve as an indicator of the efficacy of that cross-cultural
translation. The measures are ready to be evaluated for their psychometric properties
when the research team is satisfied that the language versions are conceptually and
linguistically equivalent (Kim & Han, 2004). Testing psychometric properties will
thus be discussed next regarding the process in cross-cultural instrumentation.
7.3.2.2 The criterion validity of the C-PTES
People with diabetes perform self management activities which lead to the desired
outcome (outcome expectations). The PTES measures participants’ confidence
(outcome expectations) and the extent to which the individual believes their treatment
will lead to personally desirable outcomes (Dunbar-Jacob, 2000; Sturt & Hearnshaw,
2003). It focuses on activities of people with type 2 diabetes who are taking
prescribed medication. We chose the Summary of Diabetes Self-Care Activities
(SDSCA) to examine the criterion validity, because the C-PTES (measuring outcome-
expectation) was correlated as predicted with the theoretically linked psychological
variables of self-care behaviours and health outcomes (Bandura, 1986; Kingery &
Glasgow, 1989). The assumption of this study was that self-care performance will be
better among people with diabetes with strong beliefs in outcome expectations.
Therefore, the SDSCA and C-PTES were used to test the relationship for the
criterion-related validity.
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The result of Pearson’s correlation coefficients (r= .32; p< .01) showed the C-PTES
correlated with self-care activities. Moreover, the C-PTES was a significant predictor
of the Summary of Diabetes Self-Care Activities (SDSCA) (Beta= .32; t= 5.14, p<.
01), accounting for 10.4 % of the variance. This means that higher
outcome-expectation has a correlation with self-care performances. These results were
similar to Williams and Bond’s study (Williams & Bond, 2002) which showed that
outcome expectancies accounted for an average 10% of the variance in self-care. The
average variance in self-care accounted for by outcome expectancies was about 10%,
considerably less than that found in Skelly et al. (1995). However, results of the
criterion validity indicate that the C-PTES was valid.
7.3.2.3 The convergent validity of the C-PTES
Efficacy expectations and outcome expectations combine to determine an individual’s
self-efficacy perceptions, which itself is an important determinant of empowerment
(Sturt & Hearnshaw, 2003). Convergent validity is the most direct evidence, which
comes from the correlations between two different methods measuring the same trait
(Polit & Beck, 2004). The PTES measures participants’ confidence which the
individual believes their medication will lead to personally desirable outcomes
(Dunbar-Jacob, 2000; Sturt & Hearnshaw, 2003). Responses to the C-PTES and the
Chinese version of the GSE scale were correlated to assess the strength of relationship
between both instruments. The C-PTES and the Chinese version of the GSE total
score revealed positive associations (r= .42; p< .01). The C-PTES is a measure of
outcome expectations; we tested the relationship between the C-PTES and the
Chinese version of the GSE to provide evidence of the instrument’s ability to measure
underlying self-efficacy. This is the first time to test the convergent validity of the
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C-PTES and the results expertly provided evidence that the C-PTES does measure the
self-efficacy concept as well. However, continuing research with this scale will have
to confirm these findings.
7.3.2.4 The construct validity of the C-PTES
According to Green and Salkind (1995) the criteria of eigenvalues higher than 1.0 and
factor loadings higher than .4 could attain the best fitting structure and the correct
number of factors. The results of C-PTES revealed one factor, rotated in the initial
solution which had an eigenvalue >1.0; this result was consistent with previous
analysis of the English version of the PTES in UK which also generated only one
single factor related to medication (Sturt & Hearnshaw, 2003).
7.3.2.5 Internal consistency of the C-PTES
The internal consistency of the analysis resulted in an alpha of .95 for the C-PTES. A
similar result was found in a study in a UK population where the Cronbach’s alpha for
the English version of the PTES was reported as .94 (n=121) (Sturt & Hearnshaw,
2003). Although the alpha is high and could suggest items overlap, we believe that in
some situations, a higher coefficient may be required as the higher the coefficient, the
more stable the measure (Polit & Beck, 2004). The item-to-total correlations ranged
from .75 to .86 and were assessed to contribute to the internal consistency. Nunnally
and Bernstein (1994) noted that items with high item-total correlation values have
more variance and add more to the reliability of a test than items with low correlation
values. Therefore, items with low item-total correlation should be considered for
deletion from the scale. In order to reach the desired reliability, items were deleted
one-at-a-time from the C-PTES. However, item deletion did not effectively change
the reliability of the C-PTES (only reduced the over alpha by .001 to .005). Moreover,
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the content validity for the overall CVI was appropriate. Thus, in the end no items
were deleted in terms of item analysis. However, as this is a newly developed
instrument, the C-PTES needs further replication studies that will contribute to
evidence of its reliability and validity.
7.3.2.6 Stability of the C-PTES
A Pearson correlation-coefficient (r= .79, p< .01) was found to determine the strength
of relationship between responses (n=30) to the C-PTES over time, with two to four
weeks between administrations. These results indicated good consistency of the test
results over time. It is a similar result that found for a UK population (Spearman’s
p= .64 to .80, p< .00) (Sturt & Hearnshaw, 2003) and this result was a little higher
than that found for the Australia / English version PTES (r= .68, p< .00) (McDowell,
Courtney & Edwards, 2005). These outcomes confirm previously undertaken analysis
of temporal stability in other versions of the instrument.
Moreover, in order to offer information regarding agreement and detection of
systematic bias in response from one time to another, a Bland-Altman plot (1986) was
used to graphically display the variability involved in this study. The result of the
mean difference was greater than zero indicated that there may be bias in the data. It is
a similar result that found for an Australian population (M=.54, SD=12.05)
(McDowell, Courtney & Edwards, 2005). This may be attributed to participant’s
previous knowledge of the C-PTES scale. The level of agreement (2 SD of the
difference between the test-retest measurements) between individual responses over
time, however, is strong. Thus, one can conclude that the C-PTES is a stable
instrument.
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7.4 Summary discussion of Study I
Results of this study support both the validity and reliability of the C-DMSES and
C-PTES in providing a measure for self-efficacy specific to persons with diabetes
type 2. Adapting an existing instrument for cross-cultural use not only requires
language translation; cultural and environmental characteristics need to be taken into
account also. Kim and Han (2004) suggest a number of essential steps in developing
instruments for cross-cultural research, including building a bicultural research team,
identifying the research goal translation method, testing psychometric properties and
revaluation. They believe that validity and reliability can be greatly enhanced by the
well designed process in cross-cultural instrumentation. As discussed previously a
strong bicultural research team and a two-stage design was used for this study.
Therefore, we can answer in regard to the research question of study 1 that both the
C-DMSES and C-PTES are valid and reliable in a Taiwanese population due to the
following conclusions: the convergent validity of the C-DMSES and C-PTES were
supported, as they correlated well with the validated measure of the Chinese version
GSE in measuring the same domain of self-efficacy; the significant correlation
between the C-DMSES and C-PTES and SDSCA scores also demonstrated modest
evidence for criterion-related validity. Further, factor analysis supported the
C-DMSES being composed of four subscales equivalent to the Dutch version DMSES
although it clustered different items in the four subscales. However, the C-PTES
demonstrate consistency in just one factor with the original version PTES. According
to the criteria set for reliability testing, the internal consistency and the stability of the
C-DMSES and C-PTES were acceptable. Item analysis showed the homogeneity of
the items in measuring the construct. In addition, the 20-item C-DMSES and 10-item
C-PTES is relatively short and is easy to administer to Taiwanese persons with
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diabetes. It generally requires only 15-20 minutes for completion of the C-DMSES
and 10-12 minutes for completion of the C-PTES. In conclusion, together with the
good psychometric properties of the C-DMSES and C-PTES, their value for use in
persons with diabetes in Taiwan is heightened.
For developing professional knowledge in self-efficacy in diabetes care in Taiwan, the
establishment of psychometrically sound assessment tools for clinical use is very
important. The above evidence of reliability and validity strengthens confidence in
using the C-DMSES and C-PTES. Validation and reliability of a measurement tool is
an ongoing process. Both of the C-DMSES and C-PTES thus need future studies to
strengthen psychometrically property.
The next section will discuss the evidence of this present study related to the
self-efficacy enhancing intervention program and the stated hypotheses.
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Discussion of Study II (Main Study)
7.5 Description of sample, sociodemographics, and illness history of
participants
The mean age of the total sample was 64.44 years and the average number of years
for which they had suffered from diabetes was 5.82 years. The respondents consisted
of 64.10% females. Most participants were married (83.40%). The majority of
participants had below primary schooling (59.30%), were living with family (91.75%)
and 84.10% had never been employed. The demographic characteristics of
participants were similar to those of a large Taiwanese survey report of diabetes (n=
5698) which was conducted by Tasi et al. (2002).
Half of the participants (51%) had been suffering chronic diseases other than diabetes.
This figure was similar to the finding of Chen, Chang and Lin (1998) that 68.20% of
diabetic patients had been suffering chronic diseases and the percentage of suffering
from chronic disease was higher than the general elderly population in Taiwan. Sixty
per cent of participants did not experience complications related to diabetes and
66.20% experienced monotherapy (oral hypoglycemics). These figures were similar
to the finding of Via and Salyer (1999) that the medication regimen for the majority of
the participants (65%) was oral hypoglycemics and 30% required insulin therapy.
Generally speaking, Taiwanese diabetic patients regard oral hypoglycemics as the first
choice for their disease treatment. Participants must visit the outpatient clinic
regularly to obtain their diabetic oral medicines.
Moreover, since 2001, the Bureau of National Health Insurance commenced a
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quality-based payment program for improving diabetes care (Bureau of NHI, 2002).
This extra payment reimburses medical care providers if they provide nutrition
consulting and individual diabetic education. That is why nearly half of the
participants (49.70%) of this study readily accessed the patient education from
hospitals when they visited the OPD (73.10% of participants at baseline did regularly
visit the OPD).
Most of the limitations (attrition, experimenter’s expectations) were minimised
through a range of retention strategies employed in this study, such as, allowing
participants to make up a missed lesson at an alternate time/ setting and the researcher
being easily contactable. Thus, the retention rate was high in the intervention group.
Also, the high retention rate of control group participants was due to the requirement
for patients to routinely return to the outpatient clinic every two or four weeks for oral
medication. In addition, participants received a certificate of participation which
helped to maintain interest in the study and minimize attrition. Moreover, the role of
research assistants in recruiting participants and collecting data could minimize the
impact of the experimenter’s expectations regarding the results.
7.6 Research Question 2: Can an intervention (SEEIP) based on
self-efficacy theory improve self-management in people with type
2 diabetes in Taiwan?
7.6.1 Hypothesis 1: People who receive the intervention will have greater
self-efficacy towards managing their type 2 diabetes than people
who do not receive the intervention
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Changes in self-efficacy over time
The present findings indicated that the self-efficacy (efficacy-expectations) could be
enhanced through the self-efficacy enhancing intervention program (SEEIP) at
three-month and six-month follow-up. These results support those of researchers who
have examined the effect of diabetes education programs on self-efficacy (Rubin,
Peyrot & Saudek, 1993; Anderson et al., 1995; Corbett, 1999; Guo, Tsay & Yen,
2002).
Rubin, Peyrot and Saudek (1993) found an improvement in self-efficacy scores at 6
and 12 months following their diabetes education program which focused on coping
skills training on emotional well-being and diabetic self-efficacy. The results of their
study reported that this program increased self-efficacy and decreased anxiety and
these effects remained 12 months after the program finished. Anderson et al. (1995)
observed gains in self-efficacy in their patient empowerment diabetes education
program for their intervention group, and overall sustained improvements in all
self-efficacy areas at the 12-week follow-up. Corbett et al. (1999), who based her
study on Bandura’s four sources of self-efficacy, measured self-efficacy before and
after a home visit by a nurse. Interventions were teaching and other
efficacy-enhancing activities. Diabetes-related self-efficacy improved significantly
after home care. People with lower self-efficacy received more general interventions
from the home care nurses but people with high self-efficacy received two advanced
self-care activities, prevention of hypo and hyperglycaemias and adjustment of insulin.
In Taiwan, Guo, Tsay and Yen (2002) conducted an empowerment-training program
for persons with diabetes in hospitals and then evaluated improvements in HbA1c,
self-efficacy and depression levels. Patients in the experiment group showed more
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significant improvement in the levels of empowerment, self-efficacy and self-care
than the patients in the control group. The finding of this present study met the
hypotheses and was consistent with the modified self-efficacy model for evaluation of
the SEEIP for people with type 2 diabetes
Changes in outcome expectations over time
The present findings indicated that outcome expectations also could be enhanced
through the self-efficacy enhancing intervention program (SEEIP) at three-month and
six-month follow-up. Very few studies have examined outcome expectations (as the
dependent variable) following the implementation of a diabetic intervention related to
self-efficacy theory. The present results support those of Miller, Edwards, Kissling &
Sanville (2002). Their intervention study evaluated a social cognitive-based nutrition
intervention and examined outcome expectations (Miller et al., 2002). Older adults
with diabetes were involved in the study with 48 in the experimental and 50 in the
control group. Participants in the experimental group attended a 10 weekly nutrition
intervention. Study findings found the experimental group had significant
improvement in outcome expectations compared to the control group.
Although the result of the present study was consistent with Miller’s study, there were
differences in the sample and the design of diabetic intervention between these two
studies. No previous studies could be found to compare the effects of outcome
expectations following the delivery of a diabetic intervention related to self-efficacy
theory. Some studies, however, have shown a relationship between outcome
expectations and self-efficacy or self-care behaviour. For example, Kingery and
Glasgow (1989) found self-efficacy and outcome expectations were moderately
strongly associated with self-care behaviour (dietary and glucose testing) and the
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authors argued greater attention should be directed toward examination of the
outcome-variable in future diabetic interventions.
Self-efficacy offers a basis for improving the effectiveness of diabetes education
because it focuses on behavioural change (van der Bijl & Shortridge-Baggett 2001).
There are two cognitive components in the theory, efficacy expectations and outcome
expectations (Bandura 1977a) and Bandura (1982) proposed that behaviour is best
predicted by considering both self-efficacy and outcome expectations. Self-efficacy
provides the confidence to overcome barriers to undertake a certain behaviour
whereas outcome expectations provide the motivation for the behviour (Bandura,
1995). In hypothesis 1 of the present study, self-efficacy towards managing type 2
diabetes (including both self-efficacy and outcome expectations scores) can be
increased with a moderate effect size (.13 to .20). This approach contributes to the
strategies and instruction of the SEEIP. A major concept in the efficacy- enhancing
counselling intervention sessions of the SEEIP was self-efficacy (confidence)
whereby people were encouraged to believe they could carry out behaviour necessary
to reach a desired goal. During the intervention, participants were asked to assess their
confidence to achieve their plans on a 0-10 scale where ‘0’ refers to ‘no confidence at
all’ and ‘10’ refers to ‘very confident’. For example, the facilitator asked participants
“If you decide to change the regularly of your blood sugar level check, how confident
are you that it will work?”. Participants were asked to choose a number and said “why
do you give yourself this score instead of a higher score?” Facilitator would proceed
with the following question: “you gave yourself a score of 4”. How do you think you
could increase your confidence to pursue a higher score? How could you make
yourself more confident? ” The practice sessions were designed to foster self-efficacy
enhancing skills and focused on increasing performance accomplishment, sharing
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experience (vicarious experience), using verbal persuasion, and self-evaluation in
order to assist participants in managing their diabetes.
In addition, in this present study, examination of the reliability and validity of the
C-DMSES (used to measure self-efficacy) and C-PTES (used to measure outcome
expectations), adds to current tools available to evaluate diabetes-related self-efficacy
in self-management of diabetes. The findings support the importance of incorporating
self-efficacy and four information sources into the diabetes education interventions.
Van de Laar and Van der Bijl (2001) reported that helping people set achievable goals
and focusing on the success of attaining the goals enhances self-efficacy. Bandura
(1977b) remarked that efficacy expectations (confidence in ability) and outcome
expectations (belief that the behaviour will have the desired effect), and their
influence on behaviour change is synergistic. The findings of the present study
demonstrated enhanced levels of self-efficacy and outcome expectations and
confirmed the effects on diabetic patients as those who received the SEEIP had
greater self-efficacy towards management of their type 2 diabetes.
7.6.2 Hypothesis 2: People who receive the intervention will undertake
diabetes self-care activities more frequently than people who do
not receive the intervention
This study evaluated an intervention based on self-efficacy theory to improve diabetes
self-care for people with type 2 diabetes. Results showed that people who received the
intervention undertook diabetes self-care activities more frequently than people who
did not receive the intervention at both three-month and six-month follow-up. This
finding was consistent with findings reported by Glasgow et al. (1992), Anderson et al.
(1995) and Fu et al. (2003).
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In the USA, Glasgow et al. (1992) conducted a 10-session self-management training
program designed for people over 60 years of age with type 2 diabetes which targeted
problem-solving skills and self-efficacy. 102 adults were randomized to immediate or
delayed intervention conditions. At post-test, subjects in the immediate group showed
significantly greater reductions in calorie intake (29% versus 10%, p< .05) and
percent of calories from fat (45% versus 29%, p< .05) than control subjects.
Additionally, the intervention group increased the frequency of glucose testing
(r=- .21, p< .05) compared to the control group.
Anderson et al. (1995) conducted a randomized controlled evaluation of their
empowerment program, focusing on self-efficacy and its component skills in the US.
Participants (n=86) were asked to complete experiential worksheets, attend six
sessions and participate in group discussions. At 12 weeks from baseline, the
intervention group demonstrated a significantly greater improvement in glycosylated
haemoglobin than the control group (intervention 11.75 ± 3.01% to 11.02 ± 2.89 %;
control 10.82 ± 2.94 % to 10.87 ± 2.59 %, p=.05). Self-efficacy was significantly
increased among the intervention group in terms of setting goals, managing stress,
obtaining social support and making self-care treatment decisions.
In Shanghai, mainland China, Fu et al. (2003) conducted a study to evaluate the
effectiveness of a chronic disease self-management program (CDSMP). A randomised
controlled trial was undertaken with six month follow-up comparing patients who
received treatment with those who did not receive treatment. Participants in the
treatment group received education from a lay-led CDSMP leader and one copy of a
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help book. Results showed that patients who received treatment (n=526) had
significant improvements in their weekly minutes of aerobic exercise (> 25 minutes,
p= .01), and scores in their practice of cognitive symptom management increased
by .37 (p= .01).
Findings presented by participants of the present study demonstrated it was also
participants (especially older people) need to repeat a single task until they have
mastered it and this eventually leads to success. Performance accomplishment, the
repeated execution of the task, is the most powerful source of improving self-efficacy
as it is based on direct information. Sometimes people interpret their successes
negatively. They do not see their successes or they underestimate their importance. In
these cases, it is important to establish goal setting in order to enhance self-efficacy
(van der Laar & van der Bijl, 2001). The combination of setting goals in a contract
and giving feedback is important in the present study. Before every education session,
feedback should be given on the goals of the preceding period, and clients should
report their achievements (van der Laar & van der Bijl, 2001). Moreover, a diabetes
diary is another good source of feedback for persons with diabetes. For example,
blood glucose values, the self-care actions and the surrounding circumstances can be
noted in the diary, and therefore the client can gain insight into self-regulation (van
der Laar & van der Bijl, 2001).
The contents and strategies built into the design of the intervention improve self-care
behaviour. Hurley and Shea (1992) claimed diabetes education can be focused on
promoting independence and confidence, therefore, patients will carry out their
self-care activities. When patients believe they can perform self-care activities (with
higher self-efficacy), they make the most of their skills and easily succeed.
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7.6.3 Hypothesis 3: People who receive the intervention will have better
HRQOL than people who do not receive the intervention
In the present study, health-related quality of life (HRQOL) was not significantly
increased in the intervention group at either the three-month or six-month follow-up
compared to the control group. Results indicate change over time was not different in
the two groups. However, several researchers have found significant improvement in
quality of life in previous studies (Grey et al., 2000; Rose et al., 2002; Fu, et al.,
2003).
Grey et al. (2000) conducted a behavioural intervention combined with intensive
diabetes management (IDM) sustained over 1 year in a youthful population.
Participants (n=77) electing to initiate IDM were randomly assigned to one of two
groups: with or without coping skills training (CST), which consisted of 6 small
group sessions and monthly follow-up to help the youth cope with their lives; skills
included social problem solving, cognitive behaviour modification, and conflict
resolution. The results showed the CST subjects had lower HbA1C (p= .00) and better
diabetes (p= .00) and medical (p= .04) self-efficacy, and less impact from diabetes on
their quality of life (p= .01) than youth receiving IDM alone after 1 year.
Rose et al. (2002) used structural equation modelling and confirmed when a patient
reports strong beliefs in self-efficacy, he or she is more likely to report a higher
quality of life. Furthermore, Fu, et al. (2003) conducted a chronic disease
self-management program (CDSMP) and found that, after six months follow-up,
patients who received treatment (n=430) had significant improvements in HRQOL
(eight measures of health status) (p< .05).
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Even though some previous studies have shown self-efficacy could enhance HRQOL,
Maddigan et al. (2004) argued few patient-reported outcomes such as HRQOL were
captured and it was important for its effect to be examined in further diabetic
intervention studies. The finding of this present study failed to find congruence
between the significant effects of the self-efficacy enhancing intervention program
and HRQOL. This may well be explained by the fact that participants in the present
study had quite high HRQOL scores at baseline. For example, in this present study,
the mean score of PCS for the intervention at baseline (43.26) was higher than those
of the diabetic study (39.50 for the intervention) which was reported by Nichols and
Brown (2004). These higher mean scores may have precluded the ability to detect
further significant increases in the present study.
The other explanation for these findings may be may be that other factors influenced
the concept of quality of life. The lack of detecting other concepts which affect
HRQOL may potentially influence the results of the SEEIP. Wexler et al. (2006)
examined the relationship of clinical variables to HRQOL in primary care patients
with type 2 diabetes and found depression is a well-recognised determinant of quality
of life in diabetes and people with type 2 diabetes have a substantially decreased
quality of life in association with symptomatic complications. Authors suggested that
treatment of depression and prevention of complications have the greatest potential to
improve HRQOL in type 2 diabetes. The other example is that coping with a chronic
disease and improving quality of life requires substantial effort and a great capacity to
adjust to new and changing situations on the part of the ill person (Kuijer & deRidder,
2003). Several tasks, such as maintaining an emotional balance, maintaining
self-esteem and attaining personal goals are common to a chronic disease and may be
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difficult to meet for some patients. Kuijer and deRidder (2003) found greater
discrepancy in goal attainability was generally associated with lower levels of quality
of life. In this present study, the lack of detecting other concepts that affect HRQOL
may influence the effects of the SEEIP.
Moreover, to improve HRQOL for people with diabetes requires time to adjust to
circumstances and to refine goals. The result of this present study may be a reflection
of the follow-up intervention. The outcome measure of HRQOL may have been
different if the intervention could have been extended over a longer period of time. As
a further limitation, the 6-month follow-up period for evaluating changes in
humanistic outcomes, particularly HRQOL, was relatively short. Evaluation over a
longer period of time for this study needs to be considered.
7.6.4 Hypothesis 4: People who receive the intervention will have better
psychosocial well-being than people who do not receive the
intervention
Changes in social support over time
Diabetes creates a need for increased support, as the demands of the regimen are
extensive (Guthrie & Guthrie, 2002). White, Richter and Fry (1992) stated the greater
the perceived social support, the better the psychosocial adjustment to illness.
Williams and Bond (2002) found that social support was associated with exercise
self-care and the relationship between the two variables was mediated by self-efficacy.
Moreover, Gallant (2003) stated there might be an indirect influence of social support
on diabetes self-management through self-efficacy. In this present study, people who
received the SEEIP had better social support than people who did not receive the
intervention, and social support for the intervention group was increased between
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Time 1 and Time 3. These results were consistent with those of researchers who have
examined the effect of diabetes education programs previously (Maxwell, Hunt &
Bush, 1992; Lai & Liu, 2003).
In a randomised clinical trial conducted by Maxwell, Hunt and Bush (1992), 204
patients with diabetes were randomly divided into two groups. The control group
received a training program only, whereas the experimental group was offered the
same program in addition to eight support group meetings, where they had the
opportunity to receive informational and emotional support. After 7 months of
follow-up, patients in both groups showed improved metabolic control (HbA1C),
diabetes knowledge, frequency of practicing recommended diabetes management
behaviours, and emotional adjustment. No further improvement was seen in those
people in the experimental group. However, more than 80% of the participants in the
experimental group reported that members of the group supported each other and
helped them to cope with problems related to diabetes more easily.
Lai and Liu (2003) undertook a social support and empowerment education module
(SSEM) and evaluated the effect of social support on people with type 2 diabetes in a
community in Taiwan (n=49). The experimental group took part in a series of SSEM
courses based on social cognitive theory during a 4-week period of time. The SSEM
course significantly increased social support and empowerment in the experimental
group and empowered patients with self-efficacy and self-care behaviour.
The efficacy-enhancing counselling intervention sessions involving small group
practice sessions for fostering self-efficacy enhancing skills, self goal-setting, sharing
and peer support, aimed at changing norms in the intervention group and were
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particularly effective for the variable of social support. For example, viewing a
10-minute DVD provided participants with a vicarious experience opportunity,
showing a person with type 2 diabetes who successfully used self-care activities to
control the occurrence rate of acute and chronic complications.
Also, a booklet presented four stories of how Mei-mei, Wan-tsai, and Ai-Jiau
experienced difficulties and encountered different problems. Questions in the booklet
promoted discussions. Participants in the intervention group realised they were not the
only person who had difficulty in controlling their disease. Comparison of their own
situation with others in a small group setting promoted medical referral, increased
confidence, and encouraged goal setting. Increasing confidence and goal setting were
important in maintaining self-management activities (Barlow, Wright, Turner &
Bancroft, 2005). In this study, social support from peer members was one resource for
building diabetes self-efficacy. The social environment in which individuals operate
might facilitate people’s self-efficacy.
Changes in depression over time
Depression is a major outcome experienced by people with diabetes and contributes to
high economic burden and health care costs (deGoot et al., 2001). Therefore, it is
necessary to explore the impact of depression on people with diabetes. In the results
of the present study, depression scores did not change over time in the two groups.
However, Rubin, Peyrot and Saudek (1993) and Wright and colleagues (Wright et al.,
2003; Barlow et al., 2005) found significant improvement in depression when
undertaking their study.
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Rubin, Peyrot and Saudek (1993) reported an improvement in self-efficacy scores at 6
and 12 months following their diabetes education program which focused on coping
skills training related to emotional well-being and diabetic self-efficacy. They
reported increased self-efficacy and decreased anxiety. The research thus
recommended the incorporation of diabetes self-efficacy and behavioural efforts into
diabetes education designed to improve emotional status.
An RCT study of self-management training for people with chronic disease was
conducted by Wright et al. (2003). They determined the effectiveness of a
community-based chronic disease self-management course (CDC) for UK participants
(n=232) with a range of chronic diseases. The CDC comprised six weekly sessions
and aimed to enhance self-efficacy through weekly action planning sessions which
involved problem solving, decision-making, role modelling, and persuasion. In the
results, significant reductions were found for female participants in respect of
depressive and anxious moods. Also, the research team undertook a 12-month
follow-up study of self-management training for people with a chronic disease, and no
significant changes between 4 and 12 month assessments were found in any study
variable (Barlow et al., 2005). They concluded attendance at the self-management
training program may lead to longer-term changes in self-efficacy, self-management
behaviours and depressed mood.
On the other hand, results of the present study were consistent with a previous study
reported in Taiwan. Guo, Tsay and Yen (2002) undertook an empowerment-training
program for people with diabetes in hospitals and then evaluated improvements in
HbA1C, and depression levels. There were no significant findings in blood sugar
control and depressive mood between groups.
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In this present study, failure to find change in relation to depression may be attributed
to the type of questionnaire, the length of this study and nature of the chronic disease
in the sample. The CES-D (Center for Epidemiology Studies Short Depression) Scale
is a self-administered tool which is a 10-item measure of depression. Even though
Kibourne et al. (2002) explain that the CES-D 10-item survey is used instead of a
more comprehensive instrument such as the CES-D 20-item survey, in order to
minimise respondent burden, it seems difficult to collect enough participant data
regarding depression through the 10-item tool. Moreover, the length of the study was
not sufficient to examine the effects of depression. The findings of this study reflected
the outcome only during a short period of time (6 months). Longer (1-2 years)
follow-up studies are needed to determine whether benefits are found over the
life-course of the disease.
Kibourne et al. (2002) classified CES-D scores 0 to 9 as indicating a mild level of
depression symptoms, 10 to 14 as moderate depressive symptoms, and >15
representing severe depressive symptoms. In this present study, the mean score of
depression at the baseline for the intervention (9.64) and control group (9.29)
indicated a mild level of depression symptoms. Comparing with the score of CES-D
scale in those of study of van der Ven et al. (2005), the proportion of diabetic patients
who were likely to be clinically depressed (CES-D > 16) accounts for 44% of the
intervention group at the baseline. The high baseline score of this present study may
preclude the ability to detect further significant decreases. Moreover, Grigg,
Thommasen, Tildesley and Michalos (2006) undertook an investigation for people
with type 2 diabetes and found patients with diabetes understand they have poorer
health than others, but no more likely to be unhappy or dissatisfied with their lives.
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The authors claimed even though a person may recognize that his or her current health
is not well, he or she may not feel motivated to maintain or improve it if they are
already satisfied with it. This also may explain why failure to find change in relation
to depression over time in the two groups in the present study.
The impact of psychosocial factors is a stronger predictor of mortality in diabetic
patients than many other physiological variables (Delamater et al., 2001). In this
present study, the variable of psychosocial well-being includes the factors of social
support and depression; however, only social support was significantly improved in
this study.
7.6.5 Hypothesis 5: People who receive the intervention will have a lower
usage of health services than people who do not receive the
intervention
According to 2003 Taiwanese Bureau of National Health Insurance data, healthcare
cost for diabetic patients amounts to 11.50% of the total healthcare expenditure in
Taiwan (Tseng, 2003) and consumes more than 320 million US dollars (Taiwan
Health and Vital Statistics, 2003; Tseng et al., 2006). The costs of diabetic patients
have increased rapidly under the Taiwanese National Health Insurance (NHI)
program. How to improve the quality of diabetes care cost-effectively is an urgent
issue (Tseng et al., 2006).
In this present study, 8.30-9.70% of participants in the intervention group and
8.20-15.10% of participants in the control group had been admitted to hospital
previously. Furthermore, 6.90-12.50% of participants in the intervention group and
8.20-17.80% of participants in the control group had visited an emergency room.
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Tseng (2003) reported the rate of previous admission to hospital in 2001 was 19.90%,
and visits to an emergency service, 20.80%. The admission to hospitals and visits to
emergency room rates of our study were found to be less than figures identified in
Tseng et al.’s work.
The results of health service usage in this study showed a greater proportion of
participants in the control group have been hospitalised and have visited an
emergency room than for the participants who were in the intervention group at Time
3 (six-month follow-up). These results support those of previous researchers who
examined the effect of a chronic disease self-management program (CDSMP) in
Shanghai (Fu et al., 2003). Their study results showed patients who received
treatment (n=430) had significant improvements and fewer hospitalisations (p= .00)
compared with those in the control group.
The health service usage of participants in this present study did not change during the
first three months (Time 2), but decreased at sixth months (Time 3). This gradual
improvement in hospitalisations and emergency room visits in the intervention group
may be attributed to the longer term effect of behaviour change. According to
Bandura (1986), self-efficacy plays an important role in predicting behaviour and its
outcomes. Obviously, participants’ self-efficacy towards self-management increased
following the implementation of the SEEIP, which in turn increased respondents’
sense of confidence in attending to their self-care activities. Prochaska and
DiClemente (1983) stated maintaining long-term motivation and cooperation are the
main problems for patients with diabetes; it requires the changing of lifelong
behaviours of diet and physical activities, and this is a very difficult and complex
process. It is clear that behaviour change needs time to take effect as demonstrated in
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the reduction in hospitalisations and emergency visits after 6 months rather than 3
months.
Interestingly, there was no significant change (reduction) in the rate of OPD visits
between the intervention group compared to the control group at all three points of
time. In Taiwan, people with diabetes believe regular OPD visits are a superior and
effective way to control diabetes. In this present study, there were no significant
differences between intervention and control group participants who visited the OPD
regularly. According to Tseng et al. (2006), who conducted a large diabetic
investigation in Taiwan (n=2259), the observations of multiple care unit visits (mean
21.70± 18.10) of diabetic patients revealed the convenience of seeking medical care in
Taiwan. Due to the lack of an orthodox system of family physicians in Taiwan,
patients can visit a hospital directly without referral from general practitioners. People
have free access to medical care as the NHI provides convenient transportation and
applies no strict regulation in the referral process (Tai et al., 2006). Although visiting
the OPD is an effective solution for participants in Taiwan, there was no significant
change in the proportion of OPD visits in the intervention or the control groups at any
points of time.
7.7 Summary discussion of Study II (Main Study) The participants for both groups were similar in relation to socio-demographics,
illness history, and health care utilisation. Overall, the findings were consistent with
the modified self-efficacy model for people with type 2 diabetes (Section 4.5.1.1),
except for the variables of HRQOL and depression. Failure to find change in
depression may be attributed to the high scores at baseline, the nature of the chronic
disease in our sample and the length of this study.
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Findings of the present study indicate the SEEIP can advance both levels of
self-efficacy and outcome expectations, self-care activities, and social support with a
small or moderate effect size (Eta equare ranged from .10 to .20). These findings may
contribute to developing the content and design of SEEIP, for example, the booklet
and the efficacy-enhancing counselling intervention sessions for fostering
self-efficacy enhancing skills, self-goal setting, sharing and peer support for diabetics
which aimed at changing norms in the intervention group were particularly effective.
Moreover, the SEEIP reduced health care utilisation in Taiwan. This gradual
improvement (decreasing at the sixth month) in hospitalisations and emergency room
visits in the intervention group was attributed to the behaviour change. In conclusion,
SEEIP focused on promoting independence and confidence in patients to carry out
their self-care activities and produce better health outcomes. The information about
the SEEIP effects of self-management for people with type 2 diabetes can be useful in
Taiwan.
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Chapter 8
Conclusions and Recommendations
8.1 Introduction
Diabetes mellitus is a prevalent, costly condition associated with substantial morbidity
and mortality in Taiwan. Taiwanese health care system has persistently emphasised
patients’ health education, however, there remains a lingering doubt about how
effective it is in achieving the desired effect of improvement in self-care of people
with diabetes. It is important to prevent diabetic complications through patients’
self-management and to prolong the lives of the patients. The self-efficacy model
provides a useful framework and scientific evidence base for diabetes interventions. A
pilot study of the main study revealed that the effectiveness of the SEEIP for type 2
diabetes based on the self-efficacy theory was culturally acceptable to Taiwanese
people with diabetes and the main study showed that the SEEIP is effective in the
self-management for people with type 2 diabetes.
The purpose of this study was to develop, trial and evaluate a theory-based nursing
intervention program suitable for people with type 2 diabetes in Taiwan. The
evaluation focussed on the effects of enhancing self-management, health-related
quality of life, and psychosocial well-being for people, to determine if there was any
reduction in health service usage. To achieve the purposes, several objectives and
questions were developed.
Objectives:
• Translate and test the validity and reliability of two diabetes-specific
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self-efficacy instruments (DMSES scale & PTES scale) in a Taiwanese
population.
• Develop an intervention based on self-efficacy theory that is appropriate for
the Taiwanese population; and
• Use a randomised controlled trial to evaluate the efficacy of the intervention in
a Taiwanese population in improving:
1. Self-efficacy towards management of type 2 diabetes;
2. Diabetes self-care activities, i.e., adherence to medication regime;
blood glucose testing; foot care;
3. HRQOL (health-related quality of life);
4. Psychosocial well-being; and
5. Health service utilisation.
Research Questions:
Study I
Research Question 1: Are the two diabetes-specific self-efficacy instruments, the
DMSES and PTES, valid and reliable for a Taiwanese population?
Study II
Research Question 2: Can an intervention based on self-efficacy theory improve
self-management in people with type 2 diabetes in Taiwan?
Within Research Question 2, the following further questions were examined.
For people with type 2 diabetes, following implementation of the SEEIP, is there a
difference in their: self-efficacy, self-care activities, health-related quality of life,
psychosocial well-being and health care utilisation?
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This chapter will provide an overview of the key findings of the study and present
recommendations for clinical practice, nursing education and research in the future.
8.2 Conclusion and significance of Study I
Results of this study supported the validity and reliability of the Chinese version of
the DMSES (C-DMSES) in providing a measure for self-efficacy specific to people
with type 2 diabetes. Three items were modified to better reflect Chinese practice
during the translation process. The C-DMSES obtained a total average CVI score
of .86. The convergent validity of the C-DMSES correlated well with the validated
measure of the General Self-Efficacy Scale in measuring self-efficacy (r=.55; p<.01).
Criterion-related validity showed the C-DMSES was a significant predictor of the
Summary of Diabetes Self-Care Activities scores (Beta= .58; t=10.75, p< .01). Factor
analysis supported the C-DMSES being composed of four subscales. Good internal
consistency (Cronbach’s alpha= .93) and test-retest reliability (Pearson’s correlation
coefficient r= .86, p< .01 and a Bland-Altman plot showed that 97% of the subjects
were within 2 standard deviations of the mean) were found.
Similarly, results of this study supported the validity and reliability of the Chinese
version of the PTES (C-PTES) in providing a measure for self-efficacy specific to
persons with type 2 diabetes. Four items on the C-PTES scale were changed during
the development process. Significant criterion-related validity was demonstrated
between the C-PTES and the Summary of Diabetes Self-Care Activities scores
(Beta= .32; t= 5.14, p<. 00). Convergent validity was confirmed as the C-PTES
converged well with the General Self-Efficacy Scale in measuring self-efficacy
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(r= .42; p< .01); Construct validity using factor analysis composed of single subscale.
Internal consistency showed Cronbach’s alpha was .95 and the test-retest reliability
resulted in a coefficient of .79 (p< .01) and a Bland-Altman plot showed that 97% of
the subjects were within 2 standard deviations of the mean.
The 20-item C-DMSES and 10-item C-PTES were relatively short and were easy to
administer to Taiwanese persons with diabetes. It generally required only 15-20
minutes for completion of the C-DMSES and 10-12 minutes for completion of the
C-PTES. Together with the good psychometric properties of the C-DMSES and
C-PTES, their value for use in people with type 2 diabetes in Taiwan was heightened.
The findings provide nurses and other health providers or researchers using the
instruments to examine the development of interventions for diabetes.
8.3 Conclusion and significance of Study II
Pilot study
A self-efficacy enhancing intervention program (SEEIP) emphasised confidence
enhancing and goal-setting skills in order to increase self-efficacy and change
people’s behaviours. Four sources of information adopted from Shortridge-Baggett
and van der Bijl (1996) and Bandura (1977a) are applied in the intervention of the
SEEIP. The SEEIP guided people to identify their problems and provides techniques
to help people make decisions, and take proper actions as they encounter changes in
circumstances and improve their health outcomes.
Four provider experts (a nurse; a doctor; a nutritionist; and a clinical diabetes educator)
contributed expert input to assist with the development and validation of this
intervention. The panel-modified version of the SEEIP was pilot tested with 6 patients
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from a diabetes outpatient clinic in a medical center. All participants stated they had
no difficulties in understanding the contents of a DVD, “Diabetes Self-Care” booklet,
and four weekly efficacy-enhancing counselling intervention sessions, and they all
expressed willingness to receive follow -up telephone calls. In this pilot study, based
on the comments from the sample of 10 people, the intervention of SEEIP was shown
valid and was then used in the main study. The intervention suite of the SEEIP is
summarised in Chapter 5, Table 5.3.
Main study
The participants for both groups were similar in relation to the sociodemographics,
illness history, the key variables and health care utilisation. Five hypotheses were
examined and answered:
Hypothesis 1: People who receive the intervention will have greater
self-efficacy towards managing their type 2 diabetes than people who do not
receive the intervention.
The scores of the efficacy expectations and outcome expectations were significantly
increased in the intervention group at Time 2 and Time 3 compared to those of the
control groups (p<.01). Efficacy expectations and outcome expectations were
increased between Time 1 and Time 2 and Time 2 and Time 3.
Hypothesis 2: People who receive the intervention will undertake diabetes
self-care activities more frequently than people who do not receive the
intervention.
The score of self-care activities was significantly increased in the intervention group
at Time 2 to and Time 3 compared to those of the control groups (p<.01). Self-care
activities increased between Time 1 and Time 2 and Time 1 and Time 3.
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Hypothesis 3: People who receive the intervention will have better HRQOL
than people who do not receive the intervention.
The results of this study could not support the Hypothesis 3 as the scores of the health
(physically and mentally) related quality of life were not significantly increased in the
intervention group at Time 2 or Time 3 compared to those of the control groups. The
results indicated that the change over time was not different in the two groups.
Hypothesis 4: People who receive the intervention will have better
psychosocial well-being than people who do not receive the intervention.
The interaction effect of group by time for the social support was significant and the
score of social support was increased between Time 1 and Time 3 (p<.01). However,
the results of the depression scores indicated that the change over time was not
different in the two groups.
Hypothesis 5: People who receive the intervention will have a lower usage of
health services than people who do not receive the intervention.
A smaller proportion of the participants in the intervention group, have been
hospitalized (p<.01) and visited the emergency room (p<.05) than the participants
who were in the control group at Time 3.
Overall, the findings met the hypotheses and were consistent with the modified
self-efficacy model for evaluation of the SEEIP for people with type 2 diabetes
(Section 4.5.1.1), except for the variables of HRQOL and depression. Failure to find a
change on depression may be attributed to the high scores at baseline, nature of the
chronic disease in our sample and the length of this study. The information about the
SEEIP effects of self-management for people with type 2 diabetes can be helpful in
Taiwan.
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8.4 Implications
The study has implications for various areas, including further clinical practice,
nursing education and nursing research.
1. Both the C-DMSES and C-PTES are relatively short and easily administered and
provide a measure of self-efficacy and outcome expectations in people with type 2
diabetes in a Taiwanese population. Facilitating personal self-efficacy of an
individuals’ ability to manage self-care regimens, is viewed as an effective solution
for diabetes management in Taiwan. However, there are few instruments measuring
self-efficacy towards management of diabetes, in particular, focusing on measuring
outcome expectations, which have been found useful to measure the effectiveness of
self-management. For developing professional knowledge, in self-efficacy in diabetes
care in Taiwan, the establishment of psychometrically sound assessment tools for
clinical use is very important. The above evidence of reliability and validity
strengthens confidence in using the C-DMSES and C-PTES in further diabetic
research undertaken in Taiwan.
2. It is important that interventions for Taiwanese patients with type 2 diabetes
incorporate the concept of self-efficacy in their design and implementation. Four
information sources of the self-efficacy model applied into the strategies of the
intervention were found to be effective. The SEEIP is based on self-efficacy theory,
which effectively assists people with diabetes to self-manage their disease, for
example, the SEEIP can advance both levels of self-efficacy and outcome
expectations, self-care activities, and social support with a small or moderate effect
size (Eta equare ranged from .10 to .20). The SEEIP aims to assist people to maintain
a healthy lifestyle, seek support, solve problems and make an action plan and may be
an improvement on the traditional health education of diabetes.
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This study, through transforming the theory into actual clinical health plans,
demonstrates how it is possible to carry out and apply the self-efficacy-enhancing
training program in individual cases with diabetes, and to strengthen confidence of
self-care ability and change health behaviours. Diabetes educators and researchers
could understand these factors related to self-efficacy and self-care behaviour applied
in diabetic patients and their use in diabetes education or interventions. We suggested
that the SEEIP program should be included in the clinical care for people with type 2
diabetes.
3. This study was conducted in a medical center in Taipei. In general, the SEEIP has
had great effects on the self-management in people with type 2 diabetes. Replication
of this study in various setting (such as regional hospitals or communities) or other
population (such as type 1 diabetes) would also be beneficial. Moreover, the
applicability of the intervention program design may be modified and extended to
other chronic diseases, for example, hypertension or heart diseases.
4. This study provides evidence and increases nursing staff’s confidence to apply the
SEEIP in practice because nursing staff can be trained to effectively implement the
SEEIP. Patient education faces the challenge of generating new and innovative ideas
for practice. Peyrot et al. (2005) mentioned that to improve psychosocial health
outcomes of diabetic patients, it also requires increased training for providers to
enhance their confidence and skills in managing patients’ problems. Health providers
can introduce self-efficacy enhancing strategies into their nursing interventions and
can be trained to provide relevant diabetic interventions based on self-efficacy theory.
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5. It is important to provide care for patients both physically and mentally. Thus this
study has taken a cross-discipline approach across the fields of nursing care and
counselling. In this study, four efficacy-enhancing counselling intervention sessions
were undertaken. Subjects participated in small counselling group which contained
self-efficacy enhancing skills fostering self-goal setting, sharing and peer support for
diabetes. There were numerous opportunities for patients to share with and learn from
others who experienced the same problems as themselves. Also, nurses or other health
providers involved played a vital role in affecting changes in self-care for diabetes
management. We suggest providing support-based interventions to groups rather than
individuals. It is worth promoting this kind of application for diabetes patients and
encouraging related research to integrate physical and mental health care for chronic
patients which will lead to greater self-efficacy and peer support.
6. The knowledge obtained from this study enhance future nursing education.
Publication of the present research study (see List of Publications, p. iv) introduce a
comprehensive theory and a rich growing body of international knowledge about
self-efficacy and self-management of a chronic disease in Taiwan and provide nurses
with knowledge and enable them to practise safe and competent evidence-based care
for people with chronic diseases such as diabetes. Results apply to chronic diseases
where patients are required to make changes to their self-management practices.
Teaching the relevance of the concept of self-efficacy to nurses can lead to
improvement in patient education and subsequently improvement in self-management
and patients’ health outcomes. Education for practising nurses could include seminars
or training course on the usefulness of self-efficacy in patient education.
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8.5 Limitations
Research limitations were primarily related to the research design. Although most of
the limitations were minimised through strategies incorporated as part of the research
process (for example, the randomised controlled trail is considered to be the strongest
design when testing hypotheses), the non- double blind design may appear to be
biased in that participants may exaggerate the data they provide. Moreover, the
potential for response bias may be attributed to the self-reporting nature of the data.
It has not been possible with this study design to completely exclude the possibility of
a Hawthorn effect. The effects of the SEEIP of this present study may be influenced
by a Hawthorn effect due to the increase of the researcher’s attention on participants
in the intervention group. We provided a standard research procedure to undertaken
the intervention of SEEIP in order to minimise the limitation.
The findings of this study reflected the outcomes only during a short period of time (6
months). The length of the study was not sufficient to examine the effects of the
SEEIP; for example, the change of health-related quality of life and depression over
time had no significant differences in the intervention and control group. Longer
follow-up studies are needed to determine whether benefits are found over the
life-course of disease. A 1-2 year follow-up study is required to be undertaken in the
future.
A tool designed to collect the health care utilisation at the beginning of this study
considered “the continuous variables”: number of hospitalisations; number of visit to
emergency room and OPD; and the cost amount of hospitalisations and emergency
room visits. Unfortunately, participants disclosed they found it difficult to recall the
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data of the exactly number and were only able to answer “yes” or “no”. Therefore, the
“continuous variables” were changed to “categorical variables”. This change may
influence those results of this study.
Finally, this study did not measure HbA1c as a physiological indicator. Many
international studies of outcome measures used glycosolated hemoglobin levels
(HbA1c), a test indicating a three-month average blood glucose level. A systemic
review of evidence-based interventions study conducted by DeCoster and Cummings
(2005) found that of those 73 intervention articles more than one-third (40%) used
HbA1c as an outcome measure. This present study fails to measure HbA1c as a
physiological indicator which may will be explained by the fact that diabetes patients
in the Taiwanese medical system lack routine HbA1c testing. HbAc1 data was
difficult to measure in the present study. However, the majority of patients with
diabetes in Taiwan still do not control their disease appropriately recently, for
example, only 9.4 % of patients < 65 years and 14.0% of patients >65 years had
HbA1c values within the optimal range (HbA1c < 6.5 %) (Tai et al., 2006). Further
studies need to consider the HbA1c indicator to measure long-term physiological
health outcomes in the intervention studies of diabetes.
8.6 Recommendations
1. The above evidence of reliability and validity strengthens confidence in using the
C-DMSES and C-PTES, however, validation of a measurement tool is an ongoing
process. Both the C-DMSES and C-PTES thus need future studies to confirm their
psychometric properties.
2. Some participants found it difficult to disclose their personal circumstances or
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difficulties. A qualitative research study is required to clarify their individual needs.
Replication of this study in various settings or with other populations and adding
other outcome measures (such as HbA1c) would also be suggested in further studies.
3. We suggest interventions or patient education for Taiwanese people with type 2
diabetes incorporate the concept of self-efficacy in their design and implementation
and that they provide support-based interventions to groups rather than individuals.
Actually, health providers can be trained to provide relevant diabetic interventions
based on self-efficacy theory and can introduce self-efficacy enhancing strategies into
their nursing interventions. Overcoming cost barriers could be undertaken through
reimbursement of attendance at the SEEIP from the National Health Insurance. For
example, “diabetes quality-based payment programs” could be granted to medical
providers, reimbursing them for providing the SEEIP intervention. Health providers
have traditionally cared for diabetes clients on an individual basis and thus their use of
interventions has been considered costly and time prohibitive. However, the findings
of the present study provide evidence of effectiveness of the use of group activity
through the SEEIP and may influence the national policy makers to consider adding
or modifying the reimbursement criteria.
4. Health providers can be trained to recognise psychosocial problems and incorporate
the concept of self-efficacy in the design of diabetic interventions. According to
Peyrot et al. (2005), the majority of patients with type 2 diabetes suffer from
diabetes-related psychological problems and many have poor psychological
well-being (41%). However, many providers can not manage patients’ problems. So,
only a few patients receive diabetes-related psychosocial services (10%). Peyrot et al.
(2005) advocated the need for increased training for providers to enhance their
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confidence and skills in managing patients’ problems. Integrating mental health
professionals into the diabetes care team or training health providers to recognise and
provide psychosocial services could help patients with diabetes to manage their
disease.
5. Educational programs should be regularly held and evaluated in nursing schools
and clinical practices. The usefulness of self-efficacy in patient education should be
incorporated into nursing curricula for nursing students and into continuing education
for practicing nurses.
6. This is a cross-discipline approach in the fields of nursing care and counselling, and
it conforms the trend of caring for patients physically and mentally. It is worth
promoting this application on clinical cases and encouraging related research to
integrate physical and mental health care for chronic patients through a series of
group intervention strategy.
8.7 Summary
In conclusion, this chapter has overviewed the main results and information related to
the thesis. The implications for nursing practice, education and research have been
highlighted. Study limitations and recommendations have been considered.
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Appendix 1. REFERENCES Aalto, A. M., & Uutela, A. (1997). Glycemic control, self-care behaviours, and
psychosocial factors among insulin treated diabetics: A test of an extended health belief model. International Journal of behavioural Medicine, 4 (3), 191-214.
Aalto, A. M., Uutela, A., & Kangas, T. (1996). Health behavior, social integration, perceived health and dysfunction. A comparison between patients with type 1 and 2 diabetes and controls. Scandinavian Journal of Social Medicine, 24, 272-281.
Ahroni, J. H., Davignon, D., Boyko, E. J., & Pecoraro, R. E. (1994). The health and functional status of verterans with diabetes. Diabetes Care, 17(4), 318-321.
Alberti, K. G., & Zimmet, P. Z. (1998). Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: Diagnosis and classification of diabetes mellitus. Provisional report of a WHO Consultation. Diabetes Med, 15, 539-553.
Ambler, G. R., Fairchild, J., Craig, M. E., & Cameron, F. J. (2006). Contemporary Australian outcomes in childhood and adolescent type 1 diabetes: 10 years post the Diabetes Control and complications Trail. Journal of Paediatrics and Child Health, 42 (7-8), 403-410.
American Diabetes Association (1996a). Nutrition recommendations and principles for people with diabetes mellitus. Diabetes Care, 19(Suppl1), S16-S19.
American Diabetes Association (1996b). Clinical practice guidelines, foot care in patients with diabetes mellitus. Diabetes Care, 19, S23-S24.
American Diabetes Association (1996c). Consensus Statement. The pharmacological treatment of hyperglycemia in NIDDM. Diabetes Care, 19(Suppl1), S54-S61.
American Diabetes Association (1998a). Economic consequences of diabetes mellitus in the United States in 1997. Diabetes Care, 21, 296-309.
American Diabetes Association (1998b). Type 2 diabetes: Causes, complications, and new screening recommendations. Geriatrics, 53(3), 46-52.
American Diabetes Association (2000a). Test of glycaemia in diabetes. Diabetes Care, 23 (supp1), S80-S82.
American Diabetes Association (2000b). Diabetes mellitus and exercise. Diabetes Care, 23 (supp1), S50-S56.
American Diabetes Association (2001). Nutrition recommendations and principles for people with diabetes mellitus (position statement) Diabetes Care, 24 (supp1), S44-S47.
American Diabetes Association (2002a). Implications of the United Kingdom prospective diabetes study. Diabetes Care, 25 (supp1), S33-S49.
American Diabetes Association (2002b). Standards of medical care for patients with diabetes mellitus. Diabetes Care, 25 (supp1), S33-S49.
Anderson, R. M. (1985). Is the problem of non-compliance all in our heads? Diabetes Educator, 11, 31-36.
Anderson, R. M., Funnell, M. M., Barr, P. A., Dedrick, R. F., & Davis, W. K. (1991). Learning to empower patients: Results of professional education program for diabetes educators. Diabetes Care, 15, 584-590.
Anderson, R. M., Funnell, M. M., Butler, P. M. Arnold, M. S., Fitzgerald, J. T., & Feste, C. C. (1995). Patient empowerment: Results of a randomized controlled trial. Diabetes care, 18, 934-949.
![Page 318: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/318.jpg)
A2
Anderson, R. M., Funnell, M., Carlson, A., Saleh-Statin, N., Cradock, S., & Skinner, C. (2000). Facilitating self-care through empowerment. In F. J. Snoke and T. C. Skinner (Eds.), Psychology in diabetes care (pp.69-97). England: John Wiley & Sons, Ltd.
Anderson, R. J., Freedeland, K. E., Clouse, R.E., & Lustman, P. J. (2001). The prevalence of comorbid depression in adults with diabetes. Diabetes Care, 24, 1069-1078.
Apelqvist, J., & Larsson, J. (2000). What is the most effective way to reduce incidence of amputation in the diabetes foot? Diabetes/Metabolism Research and Reviews, 16, suppl 1, S75-S83.
Aubert, R. (1997). Trends in the global burden of diabetes 1995-2025. Diabetes, 46(supp.1), 39A.
Bandura, A. (1977a). Self-efficacy: Toward a unifying theory of behavior change. Psychological Review, 84(2), 191-215.
Bandura, A. (1977b). Social Learning Theory. Englewood Cliffs, NJ: prentice Hall. Bandura, A. (1982). Self- efficacy mechanisms in human agency. American
Psychologist, 37(2), 122-147. Bandura, A. (1986). Social foundations of thought and action: A social cognitive
theory. Englewood Cliffs, NJ: Prentice-Hall Inc. Bandura, A. (1989). Human agency in social cognitive theory. American psychologist,
44 (9), 1175-1184. Bandura, A. (1991). Self-efficacy mechanism in physiological activation and health-
promoting behavior. In J. Madden (Ed.), Neurobiology of learning, emotion and affect (pp.229-269). New York: Raven Press, Ltd.
Bandura, A. (1995). Exercise of personal and collective efficacy in changing societies. In A. Bandura (Ed.), Self- efficacy in changing societies (pp.1-45). New York: Press Syndicate of the University of Cambridge.
Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H. Freeman and Company.
Bandura, A., & Cervone, D. (1983). Self-evaluative and self-efficacy mechanisms governing the motivational effects of goal systems. Journal of Personality and Social Psychology, 45, 1017-1028.
Barlow, J. H., Wright, C. C., Sheassby, J. E., Turner, A. P. & Hainsworth, J. E. (2002). Self-management approaches for people with chronic conditions: A review. Patient education and Counselling, 48, 177-187.
Barlow, J. H., Wright, C. C., Turner, A. P., & Bancroft, G. V. (2005). A 12-month follow-up study of self-management training for people with chronic disease; are changes maintained over time? British Journal of Health Psychology, 10 , 589-599.
Barrera, M. Jr., Glasgow, R. E., McKay, H. G., Boles, S. M., & Feil, E. G. (2002). Do internet-based support interventions change perceptions of social support?: An experimental trial of approaches for supporting diabetes self-management. American Journal of Community Psychology, 30 (5), 637-654.
Bartels, D. (2004). Adherence to oral therapy for type 2 diabetes: Opportunities for enhancing glycemic control. Journal of the American Academy of Nurse Practitioners, 16(1), 8-16.
Belgrave, F. Z., & Lewis, D. M. (1994). The role of social support in compliance and other health behaviours for African Americans with chronic illnesses. Journal of Health and Social Policy, 5, 55-68.
![Page 319: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/319.jpg)
A3
Bell, D. S., & Ala, B. (2002). Chronic complications of diabetes. Southern Medical Journal, 95(1), 30-34.
Berk, R.A. (1990). Importance of expert judgment in content related validity evidence. Western Journal Nursing Research, 12 (5), 659-671.
Bijnen, E. J., Van Der Net T. Z. J., & Poortinga, Y. H. (1986). On cross-cultural comparative studies with the Eysenck Personality Questionnaire. Journal of Cross-Cultural Psychology,17(1), 3-16.
Birrer, R.B., & Sedaghat, V.D. (2003). Exercise and diabetes mellitus. Physician & Sportsmedicine, 31(5), 29-39.
Bland, J. M., & Altman, D. G. (1986). Statistical methods for assessing agreement between two methods of clinical measurement. Lancet, i (8476), 307–310.
Bodenheimer, T., Lorig, K., Holman, H., & Grumbach, K. (2002). Patient self-management of chronic disease in primary care. The Journal of the American Medical Association, 288(19), 2469-2475.
Bourdel-Marchasson, I., Dubroca, B., Manciet, G., Dechamps, A., Emeriau, J. P., Dartigues, J. F. (1997). Prevalence of diabetes and effect on quality of life in older French living in the community: The PAQUID epidemiological survey. Journal American Geriatr Soc, 45, 295-301.
Braddon, J. (2001). Oral hypoglycemics: A guide to selection. Current Therapeutics, Suppl 13, 42-47.
Bradley, C. (1989). Adherence with treatment regimens among adult rheumatoid arthritis patients: Current status and future directions. Arthritis Care and Research, 2 (3), S33-S39.
Bradley, C. (1994). Translation of questionnaires for use in different languages and cultures. In C. Bradley (Ed.), Handbook of Psychology (pp.43-55). The Netherlands: OPA Amsterdam.
Braun, B., Zimmermann, M. B., & Kretchmer, N. (1995). Effects of exercise intensity on insulin sensitivity in women with non-insulin-dependent diabetes mellitus. Journal Applied Physiology, 78(1), 300-306.
Brislin, R. W. (1986). The wording and translation of research instruments. In W. L. Lonner & J. W. Berry (Eds.) Field methods in cross-cultural research (pp.137-164). Newbury Park, CA: Sage.
Brod, M. (1998). Quality of life issues in patients with diabetes and lower limb extremity ulcers: Patients and caregivers. Quality Life Research, 7, 365-372.
Brown, S. A. (1990) Studies of educational interventions and outcomes in diabetes adults: A meta-analysis revisited. Patient Education and Counseling, 16, 189-215.
Brown, S. T. (1999). Interventions to promote diabetes self-management: State of the science. Diabetes Education, 25, 52-61.
Bureau of National of Health Insurance (2002, Mar 8). A brief introduction to the Republic of China (Taiwan) 2002 public health. Retrieved 2004, July 8, from http://www.gio.tw/taiwan-website/5-gp/brief/health.htm.
Burns, N., & Grove, S. (1993). The practice of nursing research, conduct, critique & utilization. Philadelphia: W.A. Saunders.
Campbell, A., Converse, P. E., & Rodgers, W. L. (1976). The quality of American life. New York: Sage.
Caravalho, J. Y., & Saylor, C. R. (2000) An evaluation of a nurse case-managed program for children with diabetes. Pediatric Nursing ,26(3), 296-328.
![Page 320: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/320.jpg)
A4
Chandalia, M., Gary, A., & Lutjohann, K. V. (2000). Benefical effects of high dietary fiber intake in patients with type 2 diabetes mellitus. North England Journal Medicine, 342 (19), 1392-1398.
Chang, C., Lu, F., Yang, Y. C., Wu, T. J., Chen, M. S., Chuang, L. M., & Tai, T. Y.(2000). Epidemiologic study of type 2 diabetes in Taiwan. Diabetes Research Clinical Practice, 50(suppl 2), 49-59.
Chang, F. T., & Lin, C. C. (1997). Using self-efficacy in assessing self-care to the IDDM patients. The Kaohsiung Journal of Medical Sciences, 13(6), 31-359.
Chang, S.H., Huang, L.H., & Lee, Y. T. (1996). Effects of an individual health education program on hyperlipidemia clients’ knowledge, health belief, self-efficacy and behavior. Chinese Journal of Public Health, 15 (3), 188-193.
Chantelau, E., & Haage, P. (1994). An audit of cushioned diabetic footwear: Relation to patient compliance. Diabetic Medicine, 11,114-116.
Chen, H. D., Shaw, C. K., Tseng, W. P., Chen, H. I. & Lee, M. L. (1997). Prevalence of diabetes mellitus and impaired glucose tolerance in Aborigines and Chinese in eastern Taiwan. Diabetes Research Clinical practice, 38,199-205.
Chen, H. H., Yen, M. F. & Tung, T. H. (2001). A computer simulation model for cost-effectiveness analysis of mass screening for type 2 diabetes mellitus. Diabetes Research Clinical Practice, 39(supp.1), S43-46.
Chen, Z. T., Chang, M. & Lin, Y. C. (1998). The relationship between self-efficacy, social support and self-care behaviours in diabetes mellitus patients. Nursing Research (Taiwan), 6(1), 31-43.
Chiou, S.Y. (2002). The study of the relationship between self-care behaviour and health beliefs among community type 2 diabetes clients. Unpublished master dissertation, National Taiwan University College of Medicine Graduate Institute, Taipei.
Chou, P., Li, C. L., Kuo, H. S., Hsiao, K. J., & Tsai, S. T. (1997). Comparison of two diabetes surveys between 1987-88 and 1991-92 in Pu-Li, Taiwan. Diabetes Research Clinical Practice, 38, 61-67.
Chou, P., Li, C. L., & Tsai, S. T.(2001). Epidemiology of type 2 diabetes in Taiwan. Diabetes Research Clinical Practice, 39(supp1), S29-35.
Chou, P., Liao, M. J., Kuo, H. S., Hsiao, K. J., & Tsai, S. T. (1994). A population survey on the prevalence of diabetes in Kin-Hu, Kinmen. Diabetes Care, 17, 1055-1058.
Chuang, L. M., Lin, B. J., Wu, T. J., Chen, T. H., & Tai, T. Y. (1989). The effect of health education for diabetics in the community. Journal Formosan Medical Association, 88, 1143-1146.
Chuang, L. M., Tsai, S. T., Huang, B.Y., & Tai, T. Y.( 2001). The DIABCARE (Taiwan) study group. The current state of diabetes management in Taiwan. Diabetes Research Clinical Practice, 54(supp1), S55-65.
Chueng, S. K., & Sun, S.Y. K. (1999). Assessment of optimistic self-beliefs: Further validation of the Chinese version of the general self-efficacy scale. Psychological Reports, 85(3), 1221-1224.
Ciechanowski, P., Katon, W., & Russo, W. (2000). Impact of depressive symptoms on adherence, function and costs. Archives of Internal Medicine, 160, 3278-3285.
Cincinnati, R., & Veliko, J. (2001). Oral medications. RN, 64(8), 30-36. Clarke, P., Gray, R., Legood, R., Briggs, A., & Holman, R. (2003). The impact of
diabetes-related complications on healthcare costs: Results from the United Kingdom Prospective Diabetes Study (UKPDS Study No. 65). Diabetes UK. Diabetic Medicine, 20, 442-450.
![Page 321: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/321.jpg)
A5
Clement, S. (1995). Diabetes self-management education. Diabetes Care, 18 (8), 1204-1214.
Cohen, J. (1977). Statistical power analysis for the behavior sciences. New York: Academic Press.
Cohen, S., & Wills, T.A. (1985). Stress, social support and the buffering hypothesis. Psychological Bulletin, 98, 310-357.
Cohen, J. (1988). Statistical power analysis for the behavioural science. New Jersey: L. Erlbaun Associates.
Connelly, C. (1987). Self-care and the chronically ill patient. Nursing Clinics of North America, 22 (3), 621-628.
Conner, M., & Sparks, P. (1995). The theory of planned behavior and health behaviours. In M. Conner, & P. Norman (Eds.), Predicting Health Behavior. Buckingham: Open University Press.
Corbett, C. F. (1999) Research-based practice implications for patients with diabetes. Home Healthcare Nurse, 17(9), 587-596.
Courtney, M., McDowell, J., Edwards, H., Powell, E., & Shortridge-Baggett, L. (2006). Effectiveness of a diabetes self-management program in improving health-related quality of life: A pre-post trial. International Journal of Nursing Studies. (Under review September, 1, 2006)
Couzos, S., Metcalf, S., Murray, R., & O’Rourke, S. (1998). Systematic review of existing evidence and primary care guidelines on the management of non-insulin-dependent diabetes. Australia: Commonwealth of Australia.
Currie, C. J., Williams, D.R., & Peters, J. R. (1996). Patterns of in andout-patient activity for diabetes: A district survey. Diabetes Medicine, 13, 273-280.
Dahl-Jorgensen, K., Brinchmann-Hansen, O., Bangstad, H. J. & Hanssen,K. F. (1994). Blood glucose control and microvascular complications- what do we know? Diabetologia, 37, 1172-1177.
Davidson, M. B. (1998). Diabetes mellitus: Diagnosis and Treatment (4th ed). Philadelphia: Saunders.
DeCoster, V. A., & Cummings, S. M. (2005). Helping adults with diabetes: A review of evidence-based interventions. Health and Social Worker, 30 (3), 259-264.
deGoot, M., Anderson, R., Freedland, K. E., Clouse, R. E., & Lustman, P. J. (2001). Association of depression and diabetes complications: A meta-analysis. Psychosom Medicine, 63 (4), 619-630.
DeGroot, M., Jacobson, A. M., Samson, J. A., & Welch, G. (1999). Glycemic control and major depression in type 1 and type 2 diabetes mellitus. Journal of Psychosomatic Research, 46, 425-435.
Delamater, A. M., Jacobson, A. M., & Anderson, B., Cox, D., Fisher, L., Lustman, P., Rubin, R., & Wysocki, T. (2001). Psychosocial therapies in diabetes: Report of the psychosocial therapies working group. Diabetes Care, 24(7), 1286-1292.
DeRekeneier, N., Resnick, H. E., & Schwartz, A. V. et al. (2003). Diabetes is associated with subclinical functional limitations in nondisabled older individuals. The health, aging, and body composition study. Diabetes Care, 26 (12), 3257-3263.
Dimkovic, N., & Oreopoulos, D. G (2000). Chronic peritoneal dialysis in the elderly: A review. Peritoneal Dialysis International, 20, 276-283.
Dongbo, F., Hua, F., McGowan, P., Yi-E, S., Lizhen, Z., Huiqin, Y., Tianguo, M., Shitai, Z., Yongming, D., & Zhihua, W. (2003) Implementation and quantitative evaluation of chronic disease self-management program in
![Page 322: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/322.jpg)
A6
Shanghai, China: Randomized Controlled Trail. Bulletin of the World Health organization, 81(3), 174-182.
Dornhorst, T. (2001). Insulinotropic meglitinide analogues. Lancet, 17 (358), 1709-1716.
Downer, G. (2001). Nutritional self-management in diabetes. Healthy Weight Journal, September/October, 74-75.
Drury, M. I. (1979). Diabetes Mellitus. London: Blackwell. Dunbar-Jacob, J. (2000). Perceived Therapeutic Efficacy Scale (PTES). Pittsburgh:
Division of Nursing, University of Pittsburgh. Dunn, S. (1986). Reactions to educational techniques: Coping strategies for diabetes
and learning. Diabetes medicine, 3(5), 419-429. Dunning, T. (2003). Care of People with Diabetes-A manual of nursing practice.
Melbourne: Blackwell Publishing. Edlman, D., Olsen, M. K., Dudley, T. K., Harris, A. C., & Oddone, E. Z. (2002).
Impact of diabetes screening on quality of life. Diabetes Care, 25(6), 1022-1026.
Egan, G. (1994). The skilled helper: A problem management approach to helping. CA: Pacific Grove.
Egede, L. E., Zheng, D., & Simpson, K. (2002). Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes. Diabetes Care, 25(3), 464-470.
Ewart, C. K., Taylor, C. B., Reese, L. B., & Debusk, R. F. (1983) Effects of early postmyocardial infarction exercise testing on self-perception and subsequent physical activity. The American Journal of Cardiology, 51, 1076-1080.
Expert committee on the Diagnosis and Classification of Diabetes Mellitus (1997). Report of the expert committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, 20, 1183-1197.
Fain, J., Nettles, A., Funnell, M., & Charron, D. (1999). Diabetes patient education research: An integrative literature review. The Diabetes Educator, 25 (6 suppl), 7-15.
Fanning, E. L. (2002). Outcomes and cost effectiveness of treating type 2 diabetes with a nurse case manager following treatment algorithms versus primary care physicians. Unpublished doctoral dissertation, University of Texas.
Feist, J. (1994). Theories of personality. Madison: Brown & Benchmark Publishers. Ferrans, C. E. (1990). Quality of life: Conceptual issues. Seminars in Oncology
Nursing, 6(4), 248-254. Ferrell, B. R., Grant, M., Funk, B., Otis-Green, S., & Garcia, N. (1998). Quality of life
in breast cancer-part two: Psychological and spiritual well-being. Cancer Nursing, 21 (1), 1-9.
Finkelstein, E. A., Bray, J. W., Chen, H., Larson, M. J., Miller, K., Tompkins, C., Keme, A., & Mandersheid, R. (2003). Prevalence and costs of major depression among elderly claimants with diabetes. Diabetes Care, 26, 415-420.
Fisher, L., Chesla, C. A., Mullan, J. T., Skaff, M., & Kanter, R. A.(2001). Contributors to depression in Latino and European-American patients with type 2 diabetes. Diabetes Care, 24(10), 1751-1757.
Fisher, S. J., Lekas, M. C., McCall, R.H., Shi, Z., QQ., Giacca, A., & Vranic, M. (1996). Determinants of glucose turnover in the pathophysiology of diabetes: An in vivo analysis in diabetes dog. Diabetes Metabolism, 22(2), 111-121.
![Page 323: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/323.jpg)
A7
Fitzgerald, J. T., Gruppen, L. D., Anderson, R. M., Funnell, M. M., Jacober, S. J., Grunberger, G., & Aman, L. C. (2000). The influence of treatment modality and ethnicity on attitudes in type 2 diabetes. Diabetes Care, 23(3), 313-318.
Ford, M. E., Tilley, B.C., & McDonald, P. E. (1998). Social support among African-American adults with diabetes, part two: A review. Journal of the National Medical Association, 90 (7), 425-432.
Foreyt, J. P., & Poston, W. S. (1999). The challenge of diet, exercise, and life style modification in the management of the obese diabetic patient. International Journal of Obesity, 23 (suppl 7), S5-S11.
Franch, L. (1999). Quality of life and therapy in type 2 diabetes. The Journal of Family Practice, 48(10), 747-748.
Fu, D., Fu, H., McGowan, P., Shen, Y., Zhu, L., Yang, H., Mao, J., Zhu, S., Ding, Y., & Wei, Z. (2003). Implementation and quantitative evaluation of chronic disease self-management program in Shanghai, China: Randomised controlled trial. Bulletin of the World Health Organization, 81, 174-182.
Funnell, M. M., & Anderson, R. M. (2000). The problem with compliance in diabetes. The Journal of the American Medical Association, 284(4), 13.
Funnell, M. M., Anderson, R. M., Arnold, M. S., Barr, P.A., Donnelly, M., Johnson, P.D., Taylor-Moon, D., & White, N. H. (1991). Empowerment: An idea whose time has come in diabetes education. The Diabetes Educator, 16 (5), 394-400.
Funnell, M. M., Donnelly, M. B., Anderson, R. M., Johnson, P.D., & Oh, M. S. (1992). Perceived effectiveness, cost, and availability of patient education methods and materials. Diabetes Educator, 18 (2), 139-145.
Funnell, M. M., & Meritt, J. H. (1993). The challenges of diabetes and old adult. Nursing Clinics of North America, 28(1), 45-53.
Gaede, P., Vedel, P., Larsen, N., Jensen, G.V., Parving, H.H., & Pedersen, O. (2003). Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. The New England Journal of Medicine, 348, 383-393.
Gallant, M. (2003). The influence of social support on chronic illness self-management: A review and directions for research. Health Education and behaviour, 30 (2), 170-195.
Garg, S. K., Campbell, R. K., Delahanty, L., & Halvorson, M. (2000). The role of frequent glucose monitoring in intensive diabetes management. Diabetes Educators, 26 (5), S3-S17.
Gavard, J. A., Lustman, P. J., & Clouse, R. E. (1993). Prevalence of depression in adults with diabetes. Diabetes Care, 16(8), 1167-1178.
Gecas, V. (1989). The social psychology of self-efficacy. Annual Reiew Sociology, 15, 291-316.
Glasgow, R. E. (1994). Social environment factors in diabetes: Barriers to diabetes self-care. In C. Bradley (Ed.), Handbook of Psychology and Diabetes Research and Practice (pp. 335-349). England: Hardwood Academic.
Glasgow, R. E., Dryfoos, J., Ruggiero, L., Chobanian, L., & Elizabeth, E. (1997). Quality of life and associated characteristics in large national sample of adults with diabetes. Diabetes Care, 20(4), 562-567.
Glasgow, R. E., Fisher, E. B., Anderson, B. J., LaGreca, A., Marrero, D., Johnson, S. B., Rubin, R. R., & Cox, D. J. (1999). Behavioral science in diabetes. Diabetes Care, 22 (5), 832-843.
Glasgow, R. E., Hampson, S. E., Strycker, L. A., & Ruggiero, L. (1997). Personal-model beliefs and social –environment barriers related to self-management. Diabetes Care, 20, 556-590.
![Page 324: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/324.jpg)
A8
Gasgow, R. E., La Chance, P., Toobert, D. J., Brown, J., Hampson, S. E., & Riddle, M. C. (1998). Long term effects and costs of brief behavioral dietary intervention delivered in the medical office. Patient Education and Counseling, 32, 175-184.
Gasgow, R. E.,& McCaul, K. D.(1982). Psychological issues in diabetes: A different approach. Diabetes care, 5, 645-646.
Glasgow, R. E., & Osteen, V. L. (1992). Evaluating diabetes education. Are we measuring the most important outcomes? Diabetes Care, 15(10), 1423-1432.
Glasgow, R. E., & Toobert, D. J. (1988). Social environment and regimen adherence among type II diabetic patients. Diabetes Care, 11, 277-286.
Glasgow, R. E., Toobert, D. J., & Gillette, C. D. (2001). Psychosocial barrier to diabetes self-management and quality of life. Diabetes Spectrum, 14(1) 33-47.
Glasgow, R. E., Toobert, D. J., Hampson, S. E., Brown, J. E., Lewinsohn, P. M., & Donnelly, J. (1992). Improving self-care among older patients with type II diabetes: The “ sixty something…” study. Patient Education and Counseling, 19, 61-74.
Glasgow, R. E., Toobert, D. J., Riddle, M., Donnelly, J., Michell, D., & Calder, D. (1989). Diabetes-specific social learning variables and self-care behaviors among persons with type II diabetes. Health Psychology, 8 (3), 285-303.
Glasgow, R. E., Wilson, W., & McCaul, K. (1985). Regimen adherence: A problematic concept in diabetes research. Diabetes Care, 4, 96-98.
Gleeson-Kreig, J., Bernal, H., & Wooley, S. (2002). The role of social support in the self-management of diabetes mellitus among a Hispanic population. Public Health Nursing, 19 (3), 215-222.
Goldstein, M. (2002). Promoting self-management primary care settings: Limitations and opportunities a commentary. In R. Williams, W. Herman, A. L. Kinmonth and N.J. Wareham (Eds.), The Evidence Base for Diabetes Care. U.K.: John Wiley & Sons, Ltd.
Gonzalez, V. M., Goeppinger, J., & Lorig, K. (1990). Four psychosocial theories and their applicationto patient education and clinical practice. Arthritis Care, 3, 132-143.
Goodall, T., & Halford, K. (1991). Self-management of diabetes mellitus: A critical review. Health Psychology, 10. 1-8.
Government Information Office, Taiwan (2004). About Taiwan. Retrieved 2 October, 2004, from http://www.gio.gov.tw/taiwan-website/aboutroc/index.htm
Grant, J. S., & Davis, L. L. (1997). Selection and use of content experts for instrument development. Research Nurs Health, 20 (3), 269-274.
Green, S. B., & Salkind, N. J. (2005). Using SPSS for windows and macintosh analysing and understanding data (4 th ed.). New Jersey: Pearson Education, Inc.
Greenfield, S., Kaplan, S. H., Ware, J. E., Yano, E. M., & Frank, H. (1988). Patients’ participation in medical care: Effects on blood sugar control and quality of life in diabetes. Journal General Internal Medicine, 3, 448-457.
Grey, M., Boland, E. A., Davidson, M., & Tamborlane, W. V. (2000). Coping skills training for youth with diabetes mellitus has long-lasting effects on metabolic control and quality of life. Journal of Pediatrics, 137 (1), 107-113.
Grey, M., Boland, E. A., Davidson, M., Yu, C., Sullivan-Bolyai, S., & Tamborlane, W. V. (1998). Short-terms effects of coping skills training as adjunct to intensive therapy in adolescents. Diabetes Care, 21 (6), 902-908.
![Page 325: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/325.jpg)
A9
Grigg, A., Thommasen, H. V., Tildesley, H., & Michalos, A. C. (2006). Comparing self-rated health, satisfaction and quality of life scores between diabetics and others living in the bella coola valley. Social Indicators Research, 76, 263-281.
Gross, D., Fogg, L., & Tucker, S. (1995). The efficacy of parent training for promoting positive parent-toddler relationships. Research in Nursing & Health, 18, 489-499.
Guo, P. L., Tsay, S. L., & Yen, C. (2002). The effectiveness of empowerment training on the HbA1c, self-efficacy and self-care among diabetes patients. Formosan Jornal Medicine, 6(6), 848-856.
Guthrie, D. W., & Guthrie, R. A. (2002). Nursing management of diabetes mellitus: A guide to the pattern approach. New York: Springer publishing company.
Guttwann-Bauman, I., Flaherty, B.P., Strugger, M., & McEevoy, R.C. (1998). Metabolic control and quality of life self-assessment in adolescents with IDDM. Diabetes Care, 21(6), 915-918.
Hanchak, N.A., Schlackman, N., & Harmon-Weiss, S. (1996). U.S. healthcare’s quality-based compensation model. Health Care Financing Review, 17(3), 143-1159.
Hanninen, J. A., Takala, J. K., & Keinanen-Kiukaanniemi, S. N. (1999). Depression in subjects with type 2 diabetes: Predictive factors and relation to quality of life. Diabetes Care, 22(6), 997-998.
Harris, M. D. (2003). Psychosocial aspects of diabetes with an emphasis on depression. Current Diabetes Reports, 3 (1), 49-55.
Harris, M. I., Cowie, C.C., & Howie, I. J. (1993). Self-monitoring of blood glucose by
adults with diabetes in the United States population. Diabetes Care, 16, 1116-1123.
Hebert, R., Robichaud, L., Roy, P.M., Bravo, G., & Voyer, L. (2001). Efficacy of a nurse-led multidimensionality preventive programme for older people at risk of functional decline: A randomised controlled trial. Age and ageing, 30, 147-153.
Heisler, M.(2004). Glycemic self-monitoring and insurance coverage. Canadian Medical Association Journal, 171(1), 48-49.
Herpertz, S., Albus, C., & Wagener, R. (1998). Cormorbidity of eating disorders. Does diabetes control reflect disturbed eating behaviour? Diabetes Care, 21(7), 1110-1116.
Hickman, M., Drummond, N., & Grimshaw, J. (1994). The operation of shared care for chronic disease. Health Bull, 52, 118-126.
Ho, P. M. (2006). Effect of medication nonadherence on hospitalation and mortality among patients with diabetes mellitus. Archives Internal Medicine, 166, 1836-1841.
Hornquist, J. O. (1982). The concept of quality of life. Scandinavian Journal of Social Medicine, 10, 57-61.
Hornquist, J. O., Wikby, A., Stenstrom, U., Andersson, P. O., & Akerlind, I. (1995). Type 2 diabetes and quality of life: A review of the literature. PharmacoEconomics, 8(1), 12-18.
Hornsby, W. G., Boggess, K. A., Lyons, T. J., Barnwell, W. H., Lazarhick, J., & Colwell, J. A. (1990). Hemostatic alterations with exercise conditioning in NIDDM. Diabetes Care, 13(2), 87-92.
Hosker, J. P., Kumar, S., Gordon, C., Bhatnagar, D., France, M., & Boulton, A. J. (1993). Diet treatment of newly presenting type 2 diabetes improves insulin
![Page 326: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/326.jpg)
A10
secretory capacity, but has no effect on insulin sensitivity. Diabetes Medicine, 10(6), 509-513.
Howells, L., Wilson, A. C., Skinner, T. C., Newtont, R., Morrist, A. D., & Greene, S. A. (2002). A randomized control trial of the effect of negotiated telephone support on glycaemic control in young people with type 1 diabetes. Diabetes UK. Diabetic Medicine, 19, 643-648.
Humphrey, A. R. G., Dowse, G. K., Thoma, K., & Zimmet, P. Z. (1996). Diabetes and nontraumatic lower exteremity amputations. Incidence, risk factors and prevention- a 12 year follow-up study in Nauru. Diabetes Care, 19 (7), 710-714.
Hung, L. L., & Kao, S. F. (1997). The self-efficacy and health-promoting lifestyles of the nursing students in a nursing institute. The Nursing Journal of Chang Gung, 8 (3), 52-65.
Hunt, L., Arar, N., & Larme, A. (1998). Contrasting patient and practitioner perspectives in type 2 diabetes management. Western Journal of Nursing Research, 20 (6), 656-682.
Hurley, A. C., & Shea, C.A. (1992). Self-efficacy: Strategy for enhancing diabetes self-care. The Diabetes Educator, 18(2), 146-150.
Ikeda, K., Aoki, H., Saito, K., Muramatsu, Y., & Suzuki, T. (2003). Associations of blood glucose control with self-efficacy and rated anxiety/depression type 2 diabetes mellitus. Psychological Report, 92 (2), 540-545.
Ingersoll, G. M., & Marrero, D. G. (1991). A modified quality-of-life measure for youths: Psychometric properties. The diabetes educator, 17 (2), 114-118.
Ismail, K., Winkley, K., & Rabe-Hesketh, S. (2004). Systematic review and meta-analysis of randomised controlled trial of psychological interventions to improve glycaemic control in patients with type 2 diabetes. The Lancet, 363(15), 1589-1597.
Iveson, G., & Ratner, H. (1990). Problem to solution. London: Brief Therapy Press. Jack, Jr., L., Airhihenbuwa, C. O., Namageyo-Funa, A., Owens, M. D., Vinicor, F.
(2004). The psychosocial aspects of diabetes care: Using collaborative care to manage older adults with diabetes. Geriatrics, 59 (5), 26-32.
Jacobson, S. F. (2004).Evaluating instruments for use in clinical nursing research. In F. Marilyn, & J. O. Sharon (Eds.), Instruments for Clinical Health-Care Research (pp.73-80). London: Jones and Bartlett.
Jarret, R. J. (1984). The epidemiology of coronary heart disease and related factors in the context of diabetes mellitus and impaired glucose tolerance. In R.J. Jarret, (Ed.) Diabetes and Heart Disease (P1-23). Amsterdam: Elsevier Science Publishers BV.
Jones, E. G., & Kay, M. (1992). Instrumentation in cross-cultural research. Nursing Research, 41 (3), 186-188.
Johnson, J. A. (1996). Self-efficacy theory as a framework for community pharmacy based diabetes education programs. The Diabetes Educator, 22, 237-241.
Jones, P. S., Lee, J. W., Phillips, L. R., Zhang, X. E., & Jaceldo, K. B. (2001). An adaptation of Brislin’s translation model for cross-cultural research. Nursing Research, 50 (5), 300-304.
Kaplan, R. M., Chadwick, M. W., Schimmel, L. E. (1985). Social learning intervention to promote metabolic control in Type 1 diabetes mellitus: Pilot experiment results. Diabetes Care, 8, 152-155.
Kavanagh, D. J., Gooley, S., & Wilson, P. H. (1993). Prediction of adherence and control in diabetes. Journal Behavior Medicine, 16, 509-522.
![Page 327: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/327.jpg)
A11
Kibourne, A. M., Justice, A. C., Rollman, B. L., Kathleen, A., Rabeneck, L., Weissman, S., Smola, S., Schultz, R., Whittle, J., & Rodriguez-Barradas, M. (2002). Clinical importance of HIV and depression symptoms among veterans with HIV infection. Journal of General Internal Medicine, 17, 512-520.
Kim, M. T., & Han, H.R. (2004). Cultural considerations in research instrumentation development. In F. Marilyn, & J. O. Sharon (Eds.), Instruments for Clinical Health-Care Research (pp.73-80). London: Jones and Bartlett.
King, H., Aubert, R. E., & Herman, W. H. (1998). Global burden of diabetes, 1995-2025: Prevalence, numerical estimate, and projections. Diabetes Care, 21, 1414-1431.
Kingery, P. M., & Glasgow, R. E. (1989). Self-efficacy and outcome expectations in the self-regulation of non-insulin dependent diabetes mellitus. Health Education, 20 (7), 13-19.
Kirsch, I., & Wickless, C. V. (1983). Concordance rates between self-efficacy and approach behavior are redundant. Cognitive Therapy & Research, 7, 179-188.
Krichbaum, K., Aarestadt, V., & Buethe, M. (2003). Exploring the connection between self-efficacy and effective diabetes self-management. Diabetes Educator, 29 (4), 653-662.
Kuijer, R.G., & deRidder, D.T. (2003) Discrepancy in illness-related goals and quality of life in chronically ill patients: The role of self-efficacy. Psychology and Health, 18 (3), 313-330.
Kuo, P. L. (2002). The Effectiveness of Empowerment Training in Self-Efficacy, Self-Care and Depression among Diabetes Patients. Unpublished Master thesis, National Taipei College of Nursing, Taipei.
Kvam, S. H., & Lyons, J. S. (1991). Assessment of coping strategies, social support, and general health status in individuals with diabetes mellitus. Psychological Reports, 68, 623-632.
Lai, M. F., & Liu, J. S. (2003). Effect of the intervention of social support and empowerment for diabetes patients. Journal of Health Education, 20, 1-28.
Laine, C., & Davidoff, F. (1996). Patient-centered medicine. The Journal of the American Medical Association, 275, 152-156.
Leith, L. M. (1992). Behavior modification and exercise adherence: A literature review. Journal Sport Behavior, 15, 60-74.
LeRoith, D., Taylor, S. L., & Olefsky, J. M. (2000). Diabetes Mellitus: A Fundamental and Clinical Text (2 nd ed). Philadelphia: Lippincott Williams & Wilkins.
Lev, E. L., & Owen, S. T. (2000). Counselling women with breast cancer using principles developed by Albert Bandura. Perspectives in Psychiatric Care, 36 (4), 131-138.
Liebert, R., & Spiegler, M. (1994). Personality: Strategies and issues (7th ed.). Pacific Grove: Brooks/Coles Publishing Company.
Lin, J. D., Shieh, W. B., Huang, M. J., & Huang, H. S. (1993). Diabetes mellitus and hypertension based on the family history and 2-h postprandial blood sugar in the Ann-Lo district (Northern Taiwan). Diabetes Research Clinical Practice, 20, 75-85.
Lin, J. H. (2003). Effects of aerobic exercise training on physical parameters, quality of life, and depression in patients with type 2 diabetes. Unpublished master dissertation, National Defense Medical Center, Taipei.
Lin, R. S., & Lee, W. C. (1992). Trends in mortality from diabetes mellitus in Taiwan, 1960-1988. Diabetologia, 35, 973-979.
![Page 328: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/328.jpg)
A12
Lin, T., Chou, P., Lai, M. S., Tsai, S. T., & Tai, T. Y. (2001). Direct cost of illness of patients with diabetes mellitus in Taiwan. Diabetes Research Clinical Practice, 54, (supp1), 43-46.
Locke, E. A., Saari, L. M., Shaw, K. N., & Latham, G. P. (1981). Goal setting and task performance: 1969-1980. Psychological Bulletin, 90 (1), 125-152.
Logminene, Z., Norkus, A., & Valius, L. (2004). Direct and indirect diabetes costs in the world. Medicina (Kaunas), 40 (1), 16-26.
Lorig, K. (1995). Patient education: Treatment or nice extra (editorial). British Journal of Rheumatology, 34, 703-706.
Lorig, K., Sobel, D., Ritter, P., Laurebt, D., & Hobbs, M. (2001). Effect of a self-management program on patients with chronic disease. Effective Clinical Practice, 4 (6), 256-262.
Lu, F. H., Yang, Y. C., Wu, J. S., Wu, C. H., & Chang, C. J. (1998). A population-based study of the prevalence and associated factors of diabetes mellitus in Southern Taiwan. Diabetic Medicine, 15 (7), 564-572.
Lustman, P. J., Anderson, R. J., Freedland, K. E., edGroot, M., Carney, R. M., & Clouse, R. E. (2000). Depression and poor glycacmic control : A meta-analytic review of the literature. Diabetes Care, 23, 934-942.
Lustman, P. J., Clouse, R. E., Alrakawi, A., Rubin, E., & Gelenberg, A. J. (1997). Treatment of major depression in adults with diabetes: A primary care perspective. Clinical Diabetes, 15, 122-126.
Lustman, P.J., Griffith, L.S., Gavard, J.A., & Clouse, R.E. (1992). Depression in adults with diabetes. Diabetes Care, 15(11), 1631-1639.
Lustman, P. J., & Harper, G. W. (1987). Nonpsychiatric physicians’ identification and treatment of depression in patients with diabetes. Comprehensive Psychiatry, 28 (1), 22-27.
Lynn, M.R. (1986). Determination and quantification of content validity. Nursing Research, 35(6), 382-385.
Maddigan, S. L., Majumdar, S. R., Guirguis, L. M., lewanczuk, R. Z., Lee, T. K., Toth, E. L., & Johnson, J. A. (2004). Improvements in patient-reported outcomes associated with an intervention to enhance quality of care for rural patients with type 2 diabetes. Diabetes Care, 27, 1306-1312.
Maddux, J., Sherer, M., & Rogers, R. (1982). Self-efficacy expectancy and outcome expectancy: Their relationship and their effects on behavioural intentions. Cognitive Therapy and Research, 6 (2), 207-211.
Maddux, J. E., Lewis, J. (1995). Self-efficacy and adjustment; basic principles and issues. In J. E. Maddux (Eds.), Self-efficacy, adaptation and adjustment: Theory, research, and application. New York: Plenum Press.
Maibach, E., & Murphy, D. A. (1995) Self-efficacy in health promotion research and practice: Conceptualization and measurement. Health Education Research Theory & Practice, 10 (1), 37-50.
Malone, J. M., Snyder, M., Anderson, G., Bernhard, V. M., Holloway, G. A., & Bunt, T. J., (1989). Prevention of amputation by diabetic education. American Journal Surgery, 158, 520-524.
Marin, G., & VanOss, M, B. (1991). Research with Hispanic populations. Newbury Park: Sage publications.
Marlatt, G. A., & Gorden, J. R. (1985). Repapse prevention: Maintenance strategies in the treatment of addictive behaviours. New York: The Guilford press.
![Page 329: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/329.jpg)
A13
Martin, M., Grunendahl, M., & Martin, P. (2001). Age differences in stress, social resources, and well-being in middle and older age. Journal of Gerontology: B Social Sciences, 56(4), 214-222.
Mason, J., O’keeffet, A., Mclntosht, A., Hutchinsont, A., & Young, R. J. (1999). A systematic review of foot ulcer in patients with type 2 diabetes mellitus. 1: prevention. Diabetic Medicine, 16, 801-812.
Maxwell, A. E., Hunt, F. F., & Bush, M. A. (1992). Effects of a social group as an adjunct to diabetes training on metabolic control and psychosocial outcomes. Diabetes Educator, 18, 303-309.
McAuley, E., Lox, C., & Duncan, T. (1993). Long-term maintenance of exercise, self-efficacy, and physiological change in older adults. Journal of Gerontology, 48 (4), 218-224.
McCarty, D., & Zimmet, P. (1994). Diabetes 1994 to 2010: Global estimates and projections. Melbourne: International Diabetes Institute.
McCaul, K. D., Glasgow, R. E., & Schafer, L. C. (1987) Diabetes regimen behaviors: Predicting adherence. Medical Care, 25, 868-881.
McClendon, J. J. (1996). Effect of treatment for depression on diabetes self-efficacy. Unpublished doctoral dissertation, University of Colorado.
McDowell, J., Courtney, M., Edwards, H., & Shortridge-Baggett, L. M. (2005). Validation of the Australian/English version of the Diabetes Management Self-Efficacy Scale. International Journal of Nursing Practice, 11, 177-184.
McDowell, J., Courtney, M., & Edwards, H (2005). Validation of the perceived therapeutic self-efficacy scale in Australians with type 2 diabetes. ICN 23 rd Quadrennial Congress “Nursing on the move: Knowledge, innovation and vitality” 21-27 May, Taipei, Taiwan (Oral Paper).
McGuire, W. J. (1984). Public communication as a strategy for inducing health promoting behavioral change. Preventive Medicine, 13, 299-319.
Miller, C. K., Edwards, L., Kissling, G., & Sanville, L. (2002). Evaluation of a theory-based nutrition intervention for older adults with diabetes mellitus. Journal of the American Dietetic Association, 102 (8), 1069-1081.
Moens, A., Grypdonck, M. H. F., & van der Bijl, J.J. ( 2001). The development and psychometric testing of an instrument to measure diabetes management self-efficacy in adolescents with type 1 diabetes. Scholarly Inquiry for Nursing Practice: An International Journal, 15(3), 223-233.
Morrish, N. J., Stevens, L. K., Fuller, J. H., Jarret, R. J., & Keen, H. (1991). Risk factors for macrovascular disease in diabetes mellitus: The London follow-up to the WHO Multinational Study of Vascular Disease in Diabetics. Diabetologia, 34 (8), 590-594.
Munro, B.H. (2000). Statistical methods for health care research (4th ed). Philadelphia: Lippincott Williams & Wilkins.
Murphy, D. J., Williamson, P.S., & Nease, D. E. (1994). Supportive family members of diabetes adults. Family Practice, 14, 323-331.
Murray, M. T. (2003). The importance of reducing after-meal elevations in blood sugar in diabetes and weight loss. Total Health, 25(5), 14-15.
Nakahara, R., Yoshiuchi, K., Kumano, H., Hara, Y., Suematsu, H., & Kuboki, T. (2006). Prospective study on influence of psychosocial factors on glycemic control in Japanese patients with type 2 diabetes. Psychosomatics, 47 (3), 240-246.
National Center for Health Statistics (1993). Healthy people 2000 review. Health and Human Service, United States, Hyattsville, MD: Public Health Service.
![Page 330: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/330.jpg)
A14
Nichols, G. A., & Brown, B. (2004). Functional status before and after diagnosis of type 2 diabetes. Diabetes Medicine, 21, 793-797.
Norris, S. L., Engelgau, M. N., & Narayan, K. M. (2001). Effectiveness of self-management training in type 2 diabetes: Systematic review of randomised controlled trials. Diabetes Care, 24, 561-587.
Nunnally, J.C., & Bernstein, R. L. (1994). Psychometric theory (3rd ed.). New York: McGraw-Hill.
Oetker-Black, S. L., Teeter, D. L., Cukr, P. L., & Rininger, S. A. (1997). Self-efficacy enhanced preoperative instruction. Association of periOperative Registered Nurses (AORN)-Journal, 66 (5), 854-862.
Padgett, D. K. (1991). Correlates of self-efficacy beliefs among patients with non-insulin dependent diabetes mellitus in Zagreb, Yugoslavia. Patient Education and counselling, 18, 139-147.
Pagano, E., Brunette, M., Tediosi, F., & Garattini, L. (1999). Costs of diabetes: A methodological analysis of the literature. Pharmacoeconomics, 15, 583-595.
Panzram, G. (1987). Mortality and survival in type 2 (non-insulin-dependent) diabetes mellitus. Diabetologia, 30 (3), 123-131.
Patrick, D. L., & Erickson, P. (1988). Assessing health-related quality of life in general population surveys. Series 2 report from the National Center for Health statistics. Hyattsville: NCHS.
Pasavic, E. (1980) Evaluations of patient education programs: A meta-analysis. Evaluation and the Health Profession, 3, 47-62.
Pennings-van der Eerden L. (1992). Self-care behavior in the treatment of diabetes mellitus. Unpublished doctoral dissertation, University of Utrecht, Amsterdam.
Peterson, T., Lee, P., Young, B., Newton, P., & Dornan, T. (1998). Well-being and treatment satisfaction in older people with diabetes. Diabetes Care, 21, 930-935.
Peyrot, M. (1999). Behavior change in diabetes education. Diabetes education, 25, 62-73.
Peyrot, M., & Rubin, R. R. (1997). Levels and risks of depression and anxiety symptomatology among diabetic adults. Diabetes Care, 20, 585-590.
Peyrot, M., Rubin, R. R., Lauritzen, T., Snoek, F. J., Matthews, D. R., & Skovlund, S. E. (2005). Psychosocial problems and barriers to improved diabetes management: Results of the cross-national diabetes attitudes, wishes and needs (DAWN) study. Diabetic medicine, 22, 1379-1385.
Phillips, P. (2000). Tablet tops for type 2 diabetes. Current Therapeutics, 41(9), 71-77. Piette, J., Weinberger, M., & McPhee, S. (2000). The effect of automated calls with
telephone nurse follow-up on patient-centered outcomes of diabetes care: A randomized, controlled trial. Med Care, 38 (2), 218-230.
Plotnikoff, R. C., Brez, S., & Brunet, S. (2003). Are exercise social-cognitive factors and behaviours different for adults with diabetes? A randomised community sample. Psychology, Health & Medicine, 8 (4), 465-471.
Plummer, E. S., & Albert, S. G. (1995). Foot care assessment in patients with diabetes: A screening algorithm for patient education and referral. Diabetes Educator, 21 (1), 47-51.
Polit, D. F., & Beck, C. T. (2004). Nursing Research Principle and Methods (7th ed.), Philaselphia: Lippincott Williams & Wilkins.
Polit, D. F. & Hungler, B. P. (1999). Nursing Research Principle and Methods (6th ed.), Philaselphia: Lippincott Williams & Wilkins.
![Page 331: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/331.jpg)
A15
Poradzisz, M. (2001). Variables affecting quality of life and adherence in adults with type 2 diabetes. Unpublished doctoral dissertation, University of Illinois, Chicago.
Prochaska, J., & DiClemente, C. (1983). Stages and processes of self-change of smoking: Towards an integrative model of change. Journal of Consultant Clinical Psychology, 51, 390-395.
Quittan, M., Sturm, B., Wiesinger, G.. F., Pacher, R., & Fialka-Moser, V. (1999). Quality of life in patients with chronic heart failure: A randomized controlled trial of changes induced by a regular exercise program. Scandinavian Journal of Rehabilitation Medicine, 31, 223-228.
RAND Health (2006, April 04). MOS- Social Support Survey Instrument. Retrieved July 3, 2006, from http://www.rand.org/health/surveys_tools/mos/mos_socialsupport.html.
Rapley, P. (1990). Adapting to diabetes: Metabolic control and psychosocial variables. Australian Journal of Advanced Nursing, 8(2), 41-47.
Rapley, P. (1991). Adapting to diabetes: Metabolic control and psychosocial variables. The Australian Journal of Advanced Nursing, 8 (2), 41-47.
Reiber, G. E., Pecoraro, R. E., & Koepsell, T. D. (1992). Risk factors for amputation in patients with diabetes mellitus. A case-control study. Annals of Intern Med, 117 (2), 97-105.
Renders, C. M., Valk, G. D., Griffin, S. J., Wagner, E. H., Eijk Van, J. T., & Assendelft, W. J. J. (2001). Interventions to improve the management of diabetes in primary care, outpatient, and community settings. Diabetes Care, 24, 1821-1833.
Rollnick, S., Mason, P., & Bulter, C. (2003). Health Behavior Change: A guide for practitioners. New York: Churchill Livingstone.
Rose, M., Fliege, H., Hildebrandt, M., Schirop, t. & Klapp, B. F. (2002). The network of psychological variables in patients with diabetes and their importance for quality of life and metabolic control. Diabetes Care, 25(1), 35-42.
Rotter, J. B. (1975). Some problems and misconceptions related to the construct of internal versus external control of reinforcement. Journal of Counseling and Clinical Psychology, 43, 56-67.
Rubin, R. R. (2000a). Diabetes and quality of life. Diabetes Spectrum, 13 (1), 21-23. Rubin, R. R. (2000b). Psychotherapy and counselling in diabetes mellitus. In F. J.
Snoek, & T. C. Skinner (Eds.). Psychology in Diabetes Care (pp.235-263.). England: John Wiley& Sons Ltd.
Rubin, R. R., & Peyrot, M. (1999). Quality of life and diabetes. Diabetes Metabolism Research and Review, 15, 205-218.
Rubin, R. R., & Peyrot, M. (2001). Psychological issue and treatments for people with diabetes. Journal of Clinical Psychology, 57 (4), 457-478.
Rubin, R. R., Peyrot, M., & Saudek, C.D. (1989). Effect of diabetes education on self-care, metabolic control, and emotional well-being. Diabetes Care, 12(10), 673-679.
Rubin, R. R., Peyrot, M., & Saudek, C.D. (1993).The effect of a diabetes education program in corporating coping skills training on emotional well-being and diabetes self-efficacy. The Diabetes Educator, 19 (3), 210-214.
Savoca, M., & Miller, C. (2001). Food selection and eating patterns: Themes found among people with type 2 diabetes mellitus. Society for Nutrition Education, 33, 224-233.
![Page 332: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/332.jpg)
A16
Schlundt, D. G., Rea, M.R., Kline, S. S., & Pichert, J. W. (1994). Situational obstacles to dietary adherence for adults with diabetes. Journal American Dietetic Association, 94, 874-876.
Schultz, D., & Shultz, S. (1998). Theories of personality (6th ed.). Pacific Grove: Brooks/Cole publishing Company.
Schunk, D., & Carbonari, J. (1984). Self-efficacy models. In J. Matarazzo, S. Weiss, J. Herd, N. Miller, & S. Weiss (Eds.), Behavioral health: A handbook of health enhancement and disease prevention (pp.230-247). New York: John Wiley & Sons.
Schwarzer, R. (1992). Self-Efficacy: Thought control of action. Washington, DC: Hemisphere.
Searle, M., & Ready, A. (1992). Survey of exercise and dietary knowledge and behavior in persons with type 2 diabetes. Canadian Journal of Public Health, 82, 344-348.
Seeman, T., & Chen, X. (2002). Risk and protective factors for physical functioning in older adults with and without chronic conditions: MacArthur studies of successful aging. Journal of Gerontology: B Social Sciences, 57 (3), S135-S144.
Shannon, B., Bagby, R., Wang, M. Q., & Trenker, L. (1990). Self-efficacy: A contributor to the explanation of eating behavior. Health Education Research, 5 (4), 395-407.
Sherbourne, C., & Stewart, A. (1991). The MOS Social Support Survey. Social Science and Medicine, 32(6), 705-714.
Shih, S. N., & Shih, F. J. (1999). Health needs of lone elderly Chinese men with heart disease during their hospitalisation. Nursing Ethics: An International Journal for Health Care Professionals, 6, 58-72.
Shortridge-Baggett, L. M. (2001). Self-efficacy: Measurement and intervention in nursing. Scholarly Inquiry for Nursing Practice: An International Journal, 15 (3), 183-188.
Shortridge-Baggett, L. M., & van der Bijl, J. J. (1996). International collaborative research on management self-efficacy in diabetes mellitus. Journal of the New York State Nurses Association, 27 (3), 9-14.
Sigurardóttir, A.R., & Árún, K. (2005). Self-care in diabetes: model of factors affecting self-care. Journal of Clinical Nursing, 14(3), 301-314.
Skelly, A. H., Marshall, J. R., Haughey, B. P., Davis, P. J., & Dunford, R.G. (1995). Self-efficacy and confidence in outcomes as determinants of self-care practices in inner-city, African-American women with non-insulin-dependent diabetes. Diabetes Educator, 21, 38-46.
Snoek, F. J. (2000). Quality of life: A closer look at measuring patients’ well-being. Diabetes Spectrum, 13 (1), 24-28.
Snoek, F. J. (2002). Breaking the barriers to optimal glycemic control-what physicians need to know from patients’ perspectives. International Journal of Clinical Practice, 129, 80-84.
Stevens, A., & Raftery, J. (1994). Health Care Needs Assessment: The epidemiologically based needs assessment reviews. Great Britain: T.J. Press.
Stewart, A. L., Greenfield, S., Hays, R. D., Wells, K., Rogers, W.H., Berry, D. D., McGlynn, E. A., & Ware Jr., J. E. (1989). Functional status and well-being of patients with chronic conditions: Results from the Medical Outcomes Survey. The Journal of the American Medical Association, 262, 907-913.
![Page 333: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/333.jpg)
A17
Sturt, J., & Hearnshaw, H. (2002). UK validation of the International Diabetes Management Self-efficacy Scale (DMSES) and the Perceived Therapeutic Efficacy Scale (PTES). UK: Center for Primary Health Care Studies, University of Warwick.
Sturt, J., & Hearnshaw, H. (2003). Measuring outcomes: Self-management, empowerment and self-efficacy. Diabetic Medicine, 20 (supplement 2), 78.
Taal, E., Rasker, J. J., Seydel, E. R. & Weigman, O. (1993) Health status, adherence with health recommendations, self-efficacy and social support in patients with rheumatoid arthritis. Patient Education and Counseling, 20, 63-76.
Talbot, F., & Nouwen, A. (2000). A review of the relationship between depression and diabetes in adults: Is there a link? Diabetes Care, 23(10), 1556-1562.
Tai, T. Y., Yang, C. L., Chang, C. J., Chang, S. M., Chen, Y. H., Lin, B. J., Ko, L. S., Chen, M. S., & Chen, C. J. (1987). Epidemiology of diabetes mellitus among adults in Taiwan, ROC. Journal Medical Association Thai, 70 (suppl 2), 42-48.
Tai, T. Y., Chuang, L. M., Tsai, S. T., & Huang, B. Y. The Diabcare (Taiwan) Study Group. (2006). Treatment of Type 2 diabetes mellitus in a primary care setting in Taiwan: Comparison with secondary/ tertiary care. Journal of the Formosan Medical Association, 105 (2), 105-112.
Taiwan Department of Health (2000). Taiwan Public Health Report 2000. Retrieved Octcber 11, 2003, from http://www.doh.gov.tw/english/900820/900820-4.htm.
Taiwan Department of Health (2001). Core Health Policies, 2001 Taiwan Government. Retrieved March 16, 2004, from http://www.doh.gov.tw/english/core%20health%20policies%202001.htm
Taiwan Department of Health (2006). The ten leading causes of death in Taiwan. Retrieved March 10, 2006, from http://www.doh.gov.tw/statistic/english/2/1.xls.htm.
Taiwan Department of Health (2004). Department of Health, Executive Yuan: Goals and Priorities for 2003. Retrieved March 10, 2004, from http://www.doh.gov.tw/dohenglish/overview/Plan_Content.asp?No=14&ClassNo=P04.htm
Taiwan Health and Vital Statistics (2003). Health and National Health Insurance annual statistics information service. Retrieved April 10, 2005, from http://www.doh.gov.tw/EN/Webpage
Tanaka, J. S. (1987). How big is big enough? Sample size and goodness of fit structural equation models with latent variables. Child Development, 58, 134-146.
Tasi, S. T., Wong, C. H., Lin, R. S., & Chang, S. H. (2002). A report of diabetes quality care. Annual Report of Taiwanese Association of Diabetes Educator. Taipei: Taiwanese Association of Diabetes Educator.
Thomson, F. J., & Masson, E. A. (1992). Can elderly diabetic patients cooperate in routine foot care? Age Ageing, 21, 333-337.
Toljamo, M., & Hentinen, M. (2001). Adherence to self-care and social support. Journal of Clinical Nursing, 10, 618-627.
Toobert, D. J., & Glasgow, R. E. (1899). Assessing diabetes self-management: The summary of diabetes self-care activities questionnaire. In C. Bradley (Ed.), Handbook of Psychology and Diabetes (pp.351-375). The Netherlands: OPA Amsterdam.
Toobert, D. J., & Glasgow, R. E. (1994). Assessing diabetes self-management: The summary of diabetes self-care activities questionnaires. In C. Bradley (Ed.),
![Page 334: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/334.jpg)
A18
Handbook of Psychology and Diabetes (pp. 351-375). The Netherlands: OPA Amsterdam.
Toobert, D. J., Hampson, S. E., & Glasgow, R. E. (2000). The summary of diabetes self-care activities measure. Diabetes Care, 23 (7), 943-950.
Tseng, C. H., Chong, C. K., & Heng, H. L. (2000). The incidence of diabetes mellitus in Taiwan. Diabetes Research Clinical Practice, 50 (suppl 2), S61-S64.
Tseng, C. H. (2002). The cost of diabetes. Taipei: The Workshop on Diabetes Economics.
Tseng, C. H. (2003). Prevalence and risk factor of peripheral arterial obstructive disease in Taiwanese type 2 diabetes patients. Angiology, 54(3), 331-338.
Tseng, C. H., Tseng, C. P., Chong, C. K., Huang, T. P., Song, Y. M.,Chou, C. W., Lai, S. M., Tai, T. Y., & Cheng, J. C. (2006). Increasing incidence of diagnosed type 2 diabetes in Taiwan: Analysis of data from a national cohort. Diabetologia, 49 (8), 1755-1760.
Tseng, F. Y., Lai, M. S. , Syu, C. Y., & Lin, C. C. (2006). Professional accountability for diabetes care in Taiwan. Diabetes Research and Clinical Practice, 71, 192-201.
UKPDS (United Kingdom Prospective Diabetes Study)(1998). Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with Type 2 diabetes(UKPDS 33). Lancet, 352, 837-853.
van der Bijl, J. J & Shortridge-Baggett, L. M.( 2001). The theory and measurement of the self-efficacy construct. Scholarly Inquiry for Nursing Practice: An International Journal, 15(3), 189-207.
van der Bijl, J.J, van Poelgeest-Eeltink, A., & Shortridge-Baggett, L. M.(1999). The psychometric properties of the diabetes management self-efficacy scale for patients with type 2 diabetes mellitus. Journal of Advanced Nursing, 30(2), 352-358.
van der Laar, K. E.W., & van der Bijl, J. J ( 2001). Strategies enhancing self-efficacy in diabetes education: A review. Scholarly Inquiry for Nursing Practice: An International Journal, 15(3), 235-248.
van der Ven, N. C. W., Hogenelst, M. H. E., Tromp-Wever, A. M. E., Twisk, J. W. R., van der Ploeg, H. M., Heine, R. J., & Snoek, H. J. (2005). Short-term effects of cognitive behavioural group training (CBGT) in adult Type 1 diabetes patients in prolonged poor glycaemic control. A randomized controlled trial. Diabetic Medicine, 22, 1619-1623.
Via, P. S., & Salyer, J. (1999). Psychosocial self-efficacy and personal characteristics of verterans attending a diabetes education program. The Diabetes Educator, 25 (5), 727-737.
Varricchio, C. G. (2004). Measurement issues concerning linguistic translations. In F. Marilyn, & J.O. Sharon (Eds.), Instruments for Clinical Health-Care Research (pp.73-80). London: Jones and Bartlett.
Varroud-Vial, M., Simon, D., Attalit, J., Durand-Zaleski, I., Bera, l., Attali, C., Letondeur, C., Strauss, K., petit, C., & Charpentier, G. (2004). Improving glycaemic control of patients with type 2 diabetes in a primary care setting: A French application of the staged diabetes management program. Diabetes UK. Diabetic Medicine, 21, 592-598.
Walford, S., Gale, E. A., Allison, S. P., & Tattersall, R. B. (1978). Self-monitoring of blood-glucose: Improvement of diabetic control. Lancet, 1, 732-735.
![Page 335: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/335.jpg)
A19
Walker, S. R., & Rosser, R. M.(1987). Quality of life: Assessment and application. CMR Workshop. England: MTP Press Ltd.
Walters, D. A., Gatling, W., Mullee, M. A., & Hill, R. D. (1992). The distribution and severity of diabetic foot disease; a community based study with comparison to a non-diabetic group. Diabetes medicine, 9, 354-358.
Wandell, P. E. (1998). Risk factors for microvascular and macrovascular complications in men and woman with type 2 diabetes. Scand Journal Prim Health Care, 17, 116-121.
Wang, C. Y., Abbott, L., Goodbody, A. K., Hui, W. T. Y., & Rausch, C. (1999). Development of a community-based diabetes management program for pacific islanders. The Diabetes Educator, 25(5), 738-746.
Wang, J. Q., & Shiu, T. Y. (2004). Diabetes self-efficacy and self-care behavior of Chinese patients living in Shanghai. Journal of Clinical Nursing, 13, 771-772.
Wang, J. S., Wang, R. H., & Lin, C. C. (1998). Self-care behaviors, self-efficacy, and social support effect on the glycemic control of patients newly diagnosed with non-insulin-dependent diabetes mellitus. The Kaoshiung Journal of Medical Science, 14(12), 807-815.
Wang, R. S., & Chiou., C. J. (1996). The participation of physical activity and its associated factors in the elderly. The Kaoshiung Journal of Medical Science, 12(6), 348-358.
Ware, J. E. (1987). Standards for validating health measures: Definition and content. Journal of Chronic Disease, 40(6), 473-480.
Ware, J. E., & Sherbourne, C. D. (1992). The MOS 36-items short-form health survey (SF-36) I: Conceptual framework and item selection. Medical Care, 30, 473-483.
Ware, J. E., & Kosinski, M. (2001). SF-36 Physical & Mental Health Summary Scale: A Manual for User of Version 1(2nd ed.). Lincoln: Quality Metric.
Ware, J. E., Kosinski, M., & Keller, S. D. (1996). A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3), 220-233.
Ware, J. E., Kosinski, M., & Keller, S. D. (1998). SF-12: How to score the SF-12 physical and mental health summary scales. Lincoln RL: Quality Mrtric Inc.
Ware, J. E., Losinski, M., & Keller, S. D. (1994). SF-36 Physical and Mental Health Summary Scale: A User’s Manual. Boston, Massachusetts: The Health Institute, New England Medical Center.
Wei, J. N., Chuang, L. M., Lin, R. S., Chao, C. L., & Sung, F. C. (2002). Prevalence and hospitalisation rates of diabetes mellitus in Taiwan, 1996-2000. Chinese Journal of Public Health, 21(3), 173-179.
Wei, M., Gibbon, L. W., Kampert, J. B., Nichaman, M. Z., & Blair, S. N. (2000). Low cardiorespiratory fitness and physical inactivity as predictors of mortality in men with type 2 diabetes. Ann intern Medicne, 132, 605-611.
Welch, G., Dunn, S., & Beeney, L. (1994). The ATT39: A measure of psychological adjustment to diabetes. In C. Bradley (Ed.), Handbook of psychology and diabetes (pp.223-245). Singapore: Harwood Academic Publishers.
Wexler, D. J., Grant, R. W., Wittenberg, E., Bosch, J. L.,Cagliero, E., delahanty, L., Blais, M. A., & Meigs, J. B. (2006). Correlates of health-related quality of life in type 2 diabetes. Diabetologia, 49, 1489-1497.
White, N. E., Richter, J. M., & Fry, C. (1992). Coping, social support, and adaptation to chronic illness. Western Journal of Nursing Research, 14, 211-224.
![Page 336: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/336.jpg)
A20
Wierenga, M. E. ( 1994). Life-style modification for weight control to improve diabetes health status. Patient Education and Conseling, 23, 33-40.
Williams, K. E., & Bond, M. J. (2002). The roles of self-efficacy, outcome expectancies and social support in the self-care behaviors of diabetes. Psychology, Health & Medicine, 7(2), 127-141.
Wing, R. R., Epstein, L. H., Nowalk, M. P., Koeske, R., & Hagg, S. (1985). Behavior change, weight loss, and physiological improvements in type 2 diabetic patients. Journal of consulting and Clinical Psychology, 53 (1), 111-122.
Wing, R. R., Epstein, L. H., Bayles, P. M., Kriska, A., Nowalk, M. P., & Gooding, W. (1988). Exercise in behavioural weight control programmed for obese patient with type 2 diabetes. Diabetologia, 31, 902-909.
Wing, R. R., Epstein, L. H., Nowalk, M. P., & Lamparski, D. (1986). Behavioral self-regulation in the treatment of patients with diabetes mellitus. Psychology Bulletin, 99, 78-89.
World Health Organization (1986). Ottawa Charter for health promotion. Canadian Journal of Public Health, 77, 425-427.
World Health Organization (2003). Adherence to long-term therapies: Evidence for action. Switzerland: World Health Organization.
World Health Organization (2004, 25 Aug 2004). Diabetes estimates and projections. Retrieved 2004, from http://www.who.int/ncd/dia/databases4.htm.
Wright, C. C., Barlow, J. H., Turner, A. P., & Bancroft, G. V. (2003). Self-management training for people with chronic disease: An exploratory study. British Journal of Health Psychology, 8, 465-476.
Yu, D. S., Lee, D. T., & Woo, J. (2004). Psychometric testing of the Chinese version of the medical outcomes study social support survey. Research Nures Health, 27(2), 135-143.
Zgibor, J. C., Simmons, D. (2002). Barriers to blood glucose monitoring in a multiethnic community. Diabetes Care, 25 (10), 1772-1777.
Zhang, J. X., & Schwarzer, R. (1995). Measuring optimistic self-beliefs: A Chinese adaptation of the General Self-efficacy Scale. Psychologia, 38, 174-181.
Zimmet, P., McCarty, D. J., & deCourten, M. P.(1997). The global epidemiology of non-insulin-dependent diabetes mellitus and the metabolic syndrome. Journal Diabetes Comp. 11, 60-68.
Zinker, B.A., Allison, R.G., & Lacy, D.B. (1997). Interaction of exercise, insulin, and hypoglycemia studied using euglycemic and hypoglycaemic insulin clamps. American Journal Physiology, 272(4 pt l), E530-E542.
![Page 337: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/337.jpg)
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Appendix 5. Study information sheet (Study I)
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STUDY INFORMATION SHEET (STUDY I)
This study is the basis of a dissertation in a Doctor of Philosophy qualification at Queensland University of Technology (QUT) and will be performed by Shu-Fang Wu under the guidance of a team of experienced researchers from QUT and NTCN (National Taipei College of Nursing). The names and contact details of the research team are listed below. Please call Shu-Fang Wu for all initial inquires. Contact details
Chief investigator: Shu-Fang Wu NTCN Ph: 886-2-28227101~3164 Co- investigator: Prof. Mary Courtney QUT Ph: 61-7-38643887
Prof. Helen Edwards QUT Ph: 61-7-38643884 Dr. Jan McDowell QUT Ph: 61-7-38643882
Associate Prof. Pei-Jen Chang
NTCN Ph: 886-2-28227101~3192
Purpose of the study The aim of this study is to translate and test the validation and reliability of two diabetes-specific self-efficacy: DMSES: the Diabetes Management Self-Efficacy Scale; and PTES: the Perceived Therapeutic Efficacy Scale in a Taiwanese population. Rational of the study Diabetes Mellitus (DM) in adults is a global health problem and is associated with long-term complications and poor health-related quality of life. A self-efficacy enhancing intervention program offers a basis for improving the effectiveness of diabetes education because it focuses on behavioral change. It is different from the
Title: Effectiveness of self-management for persons with type 2 diabetes following the implementation of a self-efficacy (confidence) enhancing
intervention program in Taiwan
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Appendix 5. Study information sheet (Study I)
A25
traditional diabetes education which focuses only on the transformation of information or skills. The DMSES and PTES scales are important tools to evaluate the effectiveness of the intervention. The tools have been translated into several languages and psychometrically tested with diabetes populations in several countries, such as The Netherlands, Switzerland, Belgium, UK, the USA and Australia. This is first time these questionnaires have been used in Taiwan and therefore it is necessary to test the validity and reliability of the Chinese versions in a Taiwanese population. Procedures Prior to commencement, I will verbally inform you about the research study, explain the study and then ask you to provide written consent to participate. If you agree to participate in this study, it will take you for about 20 minutes. However, you are free to withdraw from this study at any time, if it is not convenient for you, without comment or penalty.
At the beginning, you will complete the questionnaire and provide feedback on the questions. The questionnaire is composed of two scales: 20 items for DMSES and 10 items for PTES
1 month after the initial survey, a random sample of at least 35 participants from this study will be asked to fill in the same questionnaire to check the accuracy of the questionnaires.
Expected outcomes Develop two Chinese diabetes-specific self-efficacy questionnaires, the DMSES and PTES, in order to enable other researchers to use these in the Taiwanese population.
Risks and discomforts No major risks to you have been identified due to your participation in this project. You may become tired when completing the questionnaire. If you are unable to complete the questionnaire yourself then you may complete the questionnaire with the assistance of the data collector through an interview. If you feel tired, the interview will be ceased and resumed at a later time. Confidentiality All information you provide for the project will be treated in confidence and securely stored during the study period. Your results will only be revealed to the investigators and yourself. When the results of the study are published we will ensure that you will remain anonymous.
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Appendix 5. Study information sheet (Study I)
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Inquiries Questions related to this study are welcome at any time. Please direct them to Shu-Fang Wu (phone: 28227101~3164). If at any time you are not satisfied with my response, you may direct your inquires to Professor Mary Courtney (Director of Research Center for Health Research (Nursing), Queensland University of Technology, Australia; on 61-7-38643887). Acknowledgment Thank you for your agreement to participate in this study. Your help is greatly appreciated in the completion of my Doctor of Philosophy degree. Please ensure that you have read and understood the previous information. When you have come to a final decision as to whether or not you will participate in this study, I would greatly appreciate it if you could inform me of your decision on 28227101~3164 or I will contact you to ask your final decision after one week. Thank you very much Shu-Fang Wu No.365, Ming Te Road, 112 , Taipei, Taiwan, R.O.C. Phone: 28227101~3164
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Appendix 6. Study information sheet (Study II) (Intervention group)
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STUDY INFORMATION SHEET (STUDY II) (Intervention group)
This study is the basis of a dissertation in a Doctor of Philosophy qualification at Queensland University of Technology (QUT) and will be performed by Shu-Fang Wu under the guidance of a team of experienced researchers from QUT and NTCN (National Taipei College of Nursing). The names and contact details of the research team are listed below. Please call Shu-Fang Wu for all initial inquires. Contact details
Chief investigator: Shu-Fang Wu NTCN Ph: 886-2-28227101~3164 Co- investigator: Prof. Mary Courtney QUT Ph: 61-7-38643887
Prof. Helen Edwards QUT Ph: 61-7-38643884 Dr. Jan McDowell QUT Ph: 61-7-38643882
Associate Prof. Pei-Jen Chang
NTCN Ph: 886-2-28227101~3192
Purpose of the study The aim of this study is to examine the effects of a self-efficacy enhancing intervention program, which is designed to improve self-efficacy in managing type 2 diabetes; diabetes self-care activities, quality of life, psychosocial well-being and reduce health service utilization. Rational of the study Diabetes Mellitus (DM) in adults is a global health problem and is associated with long-term complications and poor health-related quality of life. A self-efficacy enhancing intervention program offers a basis for improving the effectiveness of
Title: Effectiveness of self-management for persons with type 2 diabetes following the implementation of a self-efficacy (confidence) enhancing
intervention program in Taiwan
![Page 344: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/344.jpg)
Appendix 6. Study information sheet (Study II) (Intervention group)
A28
diabetes education because it focuses on behavioural change. It is different from the traditional diabetes education which focuses only on the transformation of information or skills. So, it is important to develop educational programs based on self-efficacy theory for the self-management of diabetes. In addition, up to now there is a lack of literature on self-efficacy enhancing programs used in diabetes education in Taiwan. Further studies on nursing interventions for diabetes are particularly crucial in the future. Procedures Prior to commencement, I will verbally inform you about the research study, explain the study and then ask you to provide written consent to participate. If you agree to participate in this study, your involvement will be for a six month period. However, you are free to withdraw from this study at any time, if it is not convenient for you, without comment or penalty.
At the beginning, you will complete a baseline assessment questionnaire. And then you will receive the standard diabetes educational program provided by nurse educators, including: 1) view a videotape; 2) attend 4 weekly focused practice sessions, lastly approximately 1 hour; 3) receive information booklet; and 4) participate in follow-up survey by telephone twice: 8weeks and 16 weeks after
commencement At 3 month and 6 month after commencement you will be asked to complete
follow-up questionnaires. Expected outcomes If the study is found to be effective, then the expected outcomes of the research include: Enhancing your efficacy (confidence) in your ability to manage the disease, and The potential to reduce the risk of complications and improve quality of life and psychosocial well-being, and
Reducing the risk of complications and health care usage, and improving quality of life for you and will indirectly lower health care costs.
Risks and discomforts No major risks to you have been identified due to your participation in this project. You may become tired when completing the questionnaire. If you are unable to complete the questionnaire yourself then you may complete the questionnaire with the
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Appendix 6. Study information sheet (Study II) (Intervention group)
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assistance of the data collector through an interview. If you feel tired, the interview will be ceased and resumed at a later time. Confidentiality All information you provide for the project will be treated in confidence and securely stored during the study period. Your results will only be revealed to the investigators and yourself. When the results of the study are published we will ensure that you will remain anonymous. Inquiries Questions related to this study are welcome at any time. Please direct them to Shu-Fang Wu (phone: 28227101~3164). If at any time you are not satisfied with my response, you may direct your inquires to Professor Mary Courtney (Director of Research Center for Health Research (Nursing), Queensland University of Technology, Australia; on 61-7-38643887). Acknowledgment Thank you for your agreement to participate in this study. Your help is greatly appreciated in the completion of my Doctor of Philosophy degree. Please ensure that you have read and understood the previous information. When you have come to a final decision as to whether or not you will participate in this study, I would greatly appreciate it if you could inform me of your decision on 28227101~3164 or I will contact you to ask your final decision after one week. Thank you very much Shu-Fang Wu No.365, Ming Te Road, 112 , Taipei, Taiwan, R.O.C. Phone: 28227101~3164
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Appendix 7. Study information sheet (Study II) (Control group)
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STUDY INFORMATION SHEET (Study II) (Control group)
This study is the basis of a dissertation in a Doctor of Philosophy qualification at Queensland University of Technology (QUT) and will be performed by Shu-Fang Wu under the guidance of a team of experienced researchers from QUT and NTCN (National Taipei College of Nursing). The names and contact details of the research team are listed below. Please call Shu-Fang Wu for all initial inquires. Contact details
Chief investigator: Shu-Fang Wu NTCN Ph: 886-2-28227101~3164 Co- investigator: Prof. Mary Courtney QUT Ph: 61-7-38643887
Prof. Helen Edwards QUT Ph: 61-7-38643884 Dr. Jan McDowell QUT Ph: 61-7-38643882
Associate Prof. Pei-Jen Chang
NTCN Ph: 886-2-28227101~3192
Purpose of the study The aim of this study is to examine the effects of a self-efficacy enhancing intervention program, which is designed to improve self-efficacy in managing type 2 diabetes; diabetes self-care activities, quality of life, psychosocial well-being and reduce health service utilization. Rational of the study Diabetes Mellitus (DM) in adults is a global health problem and it’s associated with long-term complications and poor health-related quality of life. A self-efficacy enhancing intervention program offers a basis for improving the effectiveness of
Title: Effectiveness of self-management for persons with type 2 diabetes following the implementation of a self-efficacy (confidence) enhancing
intervention program in Taiwan
![Page 347: Effectiveness of self-management for persons with type 2 diabetes](https://reader037.vdocuments.us/reader037/viewer/2022110221/587f6c411a28ab4a148c0590/html5/thumbnails/347.jpg)
Appendix 7. Study information sheet (Study II) (Control group)
A31
diabetes education because it focuses on behavioral change. It is different from the traditional diabetes education which focuses only on the transformation of information or skills. So, it is important to develop educational programs based on self-efficacy theory for the self-management of diabetes. In addition, up to now there is a lack of literature on self-efficacy enhancing programs used in diabetes education in Taiwan. Further studies on nursing interventions for diabetes are particularly crucial in the future. Procedures Prior to commencement, I will verbally inform you about the research study, explain the study and then ask you to provide written consent to participate. If you agree to participate in this study, your involvement will be for a six month period. However, you are free to withdraw from this study at any time, if it is not convenient for you, without comment or penalty.
At the beginning, you will complete a baseline assessment questionnaire. At 3 month and 6 month after commencement you will be asked to complete
follow-up questionnaires. Expected outcomes If the study is found to be effective, then the expected outcomes of the research include: The potential to reduce the risk of complications and improve quality of life and psychosocial well-being, and
Reducing the risk of complications and health care usage, and improving quality of life for you and will indirectly lower health care costs.
Risks and discomforts No major risks to you have been identified due to your participation in this project. You may become tired when completing the questionnaire. If you are unable to complete the questionnaire yourself then you may complete the questionnaire with the assistance of the data collector through an interview. If you feel tired, the interview will be ceased and resumed at a later time. Confidentiality All information you provide for the project will be treated in confidence and securely stored during the study period. Your results will only be revealed to the investigators and yourself. When the results of the study are published we will ensure that you will remain anonymous.
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Appendix 7. Study information sheet (Study II) (Control group)
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Inquiries Questions related to this study are welcome at any time. Please direct them to Shu-Fang Wu (phone: 28227101~3164). If at any time you are not satisfied with my response, you may direct your inquires to Professor Mary Courtney (Director of Research Center for Health Research (Nursing), Queensland University of Technology, Australia; on 61-7-38643887). Acknowledgment Thank you for your agreement to participate in this study. Your help is greatly appreciated in the completion of my Doctor of Philosophy degree. Please ensure that you have read and understood the previous information. When you have come to a final decision as to whether or not you will participate in this study, I would greatly appreciate it if you could inform me of your decision on 28227101~3164 or I will contact you to ask your final decision after one week. Thank you very much Shu-Fang Wu No.365, Ming Te Road, 112, Taipei, Taiwan, R.O.C. Phone: 28227101~3164
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Appendix 8. Study consent form (Study I & II)
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STUDY CONSENT FORM (STUDY I & II)
Chief investigator: Shu-Fang Wu Phone number: 28227101~3164 The investigator will conduct this study using the principles governing the ethical conduct of research, and at all times, will protect the interests, comfort and safety of all participants. My signature below will indicate that: 1. The procedures involved in this study have been explained to me and I have been
given the opportunity to ask questions regarding this study. 2. I acknowledge that:
a) The possible effects of procedures have been explained to me. b) The study is only for purpose of research. c) I have been informed that I am free to withdraw from this study at any time
and without comment or penalty. d) I have been informed that the confidentiality of the information I provide will
be safeguarded. 3. I consent to participate in this research study. Participant: Signature: Date: I have explained the purpose of this study to the above participant and have given the opportunity to ask questions and answer their questions regarding this study. Investigator: Date:
Title: Effectiveness of self-management for persons with type 2 diabetes following the implementation of a self-efficacy (confidence) enhancing
intervention program in Taiwan
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Appendix 9. The questionnaire in English Effectiveness of self-management for persons with type 2 diabetes following
the implementation of a self-efficacy (confidence) enhancing intervention program in Taiwan
- INSTRUCTION -
This questionnaire asks for your views about managing issues associated with living
with type 2 diabetes.
Answer every question by responding as indicated. Your individual answers will remain confidential and not be shared with anyone else.
Certain questions may look alike but each one is different. Some questions ask
about problems you may not have. That’s great, but it’s important for us to know. Please answer each question.
There are no right or wrong answers. If you are unsure how to answer a question
please give the best answer you can.
Check the completed questionnaire. Occasionally a question can be accidentally missed when completing the questionnaire so it would be really helpful if you could take an extra couple of minutes to check that every question has been answered as indicated.
Hand in the completed questionnaire. When you are satisfied that all questions have
been answered, please hand in to the data collector or later the data collector will contact you to collect it.
Nursing School Centre for Health Research (Nursing) Queensland University of Technology
Victoria Park Road KELVIN GROVE QLD 4059
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Sample No.
Hospital Code Serial Number (This page will be filled by the interviewer)
Effectiveness of self-management for persons with type 2 diabetes following the implementation of a self-efficacy (confidence) enhancing intervention program
in Taiwan
(The followings are reserved to the interviewer)
Completeness of this questionnaire: □All questions are completed □Other situation (Please
describe)
Had you called to make interview appointment? □Yes □No □Other situation(Please describe)
Who fill up this form:□Interviewee □Interviewer filled up for interviewee(Please describe the
reason) □ Others filled up for the
interviewee(Please describe the reason) Interview duration: mins Name of interviewer: Interview date:
Name:
Sex: □M □F
Date of Birth: / / (dd/mm/yy) Current Address:_______________________________________________
Street City Zip code TEL:(Day) (Night) Mobile: Name of core cohabit person: Relationship: Tel:
Permanent Address:□ Same as current address
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Demographics 1. Sex: □(1)Male □(2)Female 2. Age: ____ Date of birth:____/____/____(dd/mm/yy) 3. Height is_______ cm 4. Family register province:□(1)Southern part of Fukien Province □(2)Mainland □(3)Hakka □(4)
Others (Please describe) 5. Religion: □(1)Buddhist □(2)Taoist or social religious □(3)Christian
□(4)Catholicism □(5) Others (Please describe) 6. Education:□(1)Illiteracy □(2)Primary school □(3)Junior high school
□(4)Senior high school □(5)College above 7. Marital status:□(1)Single □(2)Married □(3) Divorced □(4)Widower/Widow 8. Career:□(1)None □(2)yes 9. Living arrangement: □(1)Living alone □(2)Living with family
□(3) Others (Please describe 10. / (mm/yy) were you diagnosed with diabetes, therefore, you have been with
diabetes for years.
11. Co-morbidity:□(1)No □(2)Yes; Disease:
12. Since you are with diabetes, have you received any health education of diabetes
provided by health care worker (Each time at least 10 minutes above) □(1)None
□ (2)Yes, □ (1)Group health education _____times
(Names of the hospitals:________________________) and/or □ (2)Individual health education _____times
(Names of the hospitals:________________________) 13. Your weight is_______ kg.
14. Do you regularly go to outpatient clinic:
□(1)No □ (2)Yes, Name of the hospital: ___________________(How often:_____weeks
or ____months per time) 15. In the past 3 months, have you ever received emergency treatment:
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□(1)No □(2)Yes, totally _____times , you have totally spent NTD$ (After deducted the expense paid by health insurance) 16. Have you ever been hospitalized in the latest 3 months: □ (1)No □ (2)Yes, _____ times, total hospitalized days (Please continue the following questions) -From the past hospitalizations, you have totally spent NTD$
(After deducted the expense paid by health insurance) -Due to the hospitalization, you can’t go to work for days, the average
pay per day is NTD$ (If applicable) -Your family or friend who accompanied you in the hospital can’t go to work for - days, his/her average pay per day is NTD$ (□For accompanier who doesn’t have job □or who doesn’t have accompanier
can skip this question) 17. The current treatment is (Can be multiple chose): □(1)Oral hypoglycemic drugs: Medication:_________________ □(2)Insulin injection: Medication:_________________ □ (3)Controlled by diet □(4)Controlled by physical exercise □(5)Others (Please describe)
18. Do you have any complications of diabetes: □(1)None □ (2)Yes, □(1)Retinopathy (Eye) problem □(2)Kidney disease □(3)Nerve problem (4)Diabetic foot problem □(5)Hypertension □(6)Heart disease □(7)Hyperlipidaemia □(8)Others (Can be multiple chose)
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Diabetes Management Self-Efficacy Scale (DMSES)
Circle one number on each line I am confident that: Cannot do
at all Maybe Yes
Maybe No
Certainly can do
1. I am able to check my blood sugar if necessary
0 1 2 3 4 5 6 7 8 9 10
2. I am able to correct my blood sugar when the sugar level is too high (e.g. eat different food)
0 1 2 3 4 5 6 7 8 9 10
3. I am able to correct my blood sugar when the sugar level is too low (e.g. eat different food)
0 1 2 3 4 5 6 7 8 9 10
4. I am able to choose foods that are best for my health
0 1 2 3 4 5 6 7 8 9 10
5. I am able to choose different foods and maintain a healthy eating plan
0 1 2 3 4 5 6 7 8 9 10
6. I am able to control my body weight and maintain it within the ideal weight range
0 1 2 3 4 5 6 7 8 9 10
7. I am able to examine both of my feet (e.g. for cuts or blisters)
0 1 2 3 4 5 6 7 8 9 10
8. I am able to do enough physical activity (e.g. walking the dog; yoga; gardening; stretching exercise)
0 1 2 3 4 5 6 7 8 9 10
9. I am able to maintain my eating plan when I am ill
0 1 2 3 4 5 6 7 8 9 10
10. I am able to follow a healthy eating plan most of the time
0 1 2 3 4 5 6 7 8 9 10
Below is a list of activities your may have to perform to manage your diabetes. Please read each one and then circle the number that best describes how confident you usually are that you could carry out that activity. For example, if you are completely confident that you are able to check your blood sugar levels when necessary, circle 10. If you feel that most of the time you could not do it, circle 1 or 2. If you feel that all of the time you could not do it, circle 0
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Circle one number on each line
I am confident that: Cannot do at all
Maybe Yes Maybe No
Certainly can do
11. I am able to do more physical activity if the doctor advises me to
0 1 2 3 4 5 6 7 8 9 10
12. When doing more physical activity I am able to adjust my eating plan
0 1 2 3 4 5 6 7 8 9 10
13. I am able to follow a healthy eating plan when I am away from home
0 1 2 3 4 5 6 7 8 9 10
14. I am able to choose different foods and maintain my eating plan when I am away form home
0 1 2 3 4 5 6 7 8 9 10
15. I am able to follow a healthy eating plan during festive periods
0 1 2 3 4 5 6 7 8 9 10
16. I am able to choose different foods and maintain a healthy eating plan when I am eating out or at a party
0 1 2 3 4 5 6 7 8 9 10
17. I am able to maintain my eating plan when I am feeling stressed or anxious
0 1 2 3 4 5 6 7 8 9 10
18. I am able to visit my doctor four times a year to monitor my diabetes
0 1 2 3 4 5 6 7 8 9 10
19. I am able to take my medication as prescribed
0 1 2 3 4 5 6 7 8 9 10
20. I am able to maintain my medication when I am ill
0 1 2 3 4 5 6 7 8 9 10
DMSES (cont): Below is a list of activities your may have to perform to manage your diabetes. Please read each one and then circle the number that best describes how confident you usually are that you could carry out that activity. For example, if you are completely confident that you are able to check your blood sugar levels when necessary, circle 10. If you feel that most of the time you could not do it, circle 1 or 2. If you feel that all of the time you could not do it, circle 0
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Perceived Therapeutic Efficacy Scale (PTES)
Circle one number on each line
No
Confidence
Highest confidence
1. My level of confidence in the ability of my diabetes medication to control my blood sugar is:
0 1 2 3 4 5 6 7 8 9 10
2. My level of confidence in the ability that my diabetes medication can keep my blood sugar at a stable level and prevent it from becoming elevated is:
0 1 2 3 4 5 6 7 8 9 10
3.My level of confidence in the ability of my diabetes medication to limit the severity of complications (e.g. eye or foot problems) is:
0 1 2 3 4 5 6 7 8 9 10
4.My level of confidence in the ability of my diabetes medication to prevent me getting (more) complications is:
0 1 2 3 4 5 6 7 8 9 10
5.My level of confidence in the ability that the maintenance of the dose of my medication can control my diabetes effectively is:
0 1 2 3 4 5 6 7 8 9 10
6.My level of confidence in the need to take my medication each day exactly as prescribed to control my diabetes is:
0 1 2 3 4 5 6 7 8 9 10
7.My overall level of confidence in the value of the diabetes medication that I am prescribed is:
0 1 2 3 4 5 6 7 8 9 10
8.My level of confidence in the ability of medication in general to control my diabetes is:
0 1 2 3 4 5 6 7 8 9 10
9.My level of confidence in my health professionals’ advice that experts such as doctors or nutritionists give me in my diabetes treatment is:
0 1 2 3 4 5 6 7 8 9 10
10. My overall level of confidence in my ability to cope with my diabetes is:
0 1 2 3 4 5 6 7 8 9 10
For each statement listed below you are asked to circle the number that best describes your level of confidence. For example: 0 = no confidence and 10 = highest confidence.
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SDSCA (the Summary of Diabetes Self-Care Activities)
1. How many of the last SEVEN DAYS have you followed a healthy eating plan
0 1 2 3 4 5 6 7
2. On how many of the last SEVEN DAYS did you eat more than 5 plates of vegetables and fruits a day (such as: you have taken 3 plates of vegetables, 2 plates of fruits.) (a plant of fruits is about one tangerine, 1/3 of papaya… and so on, a plate of vegetables is about 100g. Interviewer will illustrate more examples according to food exchange list).
0 1 2 3 4 5 6 7
3. On how many of the last SEVEN DAYS did you eat high fat foods such as red meat or full-fat dairy produce (such as: fried foods, high-fat meat, chick skin)?
0 1 2 3 4 5 6 7
4. On how many of the last SEVEN DAYS did you participate in at least 30 minutes of physical activity? (Total minutes of continuous activity, including walking, and housework)
0 1 2 3 4 5 6 7
5. On how many oft he last SEVEN DAYS did you participate in a specific exercise session (such as: jogging, mountain climbing, Taijiquan, dancing, etc.) other than what you do around the house or as part of your work?
0 1 2 3 4 5 6 7
6. On how many of the last SEVEN DAYS did you take hypoglycemic drugs prescribed by your physicians?
0 1 2 3 4 5 6 7
7. On how many of the last SEVEN DAYS did you test your blood sugar?
0 1 2 3 4 5 6 7
8. On how many of the last SEVEN DAYS did you test your blood sugar the number of times recommended by your health care provider?
0 1 2 3 4 5 6 7
9. On how many of the last SEVEN DAYS did you check your feet?
0 1 2 3 4 5 6 7
10. On how many of the last SEVEN DAYS did you inspect the inside of your shoes (such as: if there are any stones inside shoes? If they are flat, no any tears, sharp edges or wet)?
0 1 2 3 4 5 6 7
11. On how many of the last SEVEN DAYS did you dry your foots carefully after washing, especially between toes?
0 1 2 3 4 5 6 7
12. On how many of the last SEVEN DAYS did you put on your appropriate shoes when you go out?
0 1 2 3 4 5 6 7
The questions below ask you about your diabetes self-care activities during the past 7 days. If you were sick during the past 7 days, please think back to the last 7 days that you were not sick.
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SF-12v2™ Health Survey © 1994, 2003 Health Assessment Lab, Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved. SF-12® is a registered trademark of Medical Outcomes Trust. (IQOLA SF-12v2 Standard, Australia (English))
HRQOL Short Form-12
This questionnaire asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. Thank you for completing this survey! For each of the following questions, please mark an in the one box that best describes your answer.
1. In general, would you say your health is:
2. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
Yes, limited
a lot
Yes, limited a little
No, not limited at all
a Moderate activities, such as moving a table, pushing
a vacuum cleaner, bowling, or playing golf .......................... 1............. 2............. 3
b Climbing several flights of stairs........................................... 1............. 2............. 3
Excellent Very good Good Fair Poor
1 2 3 4 5
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SF-12v2™ Health Survey © 1994, 2003 Health Assessment Lab, Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved. SF-12® is a registered trademark of Medical Outcomes Trust. (IQOLA SF-12v2 Standard, Australia (English))
3. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
4. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
Not at all A little bit Moderately Quite a bit Extremely
1 2 3 4 5
All of the time
Most of the time
Some of the time
A little of the time
None of the time
a Accomplished less than you would like...................................... 1 ............. 2............. 3 ............. 4............. 5
b Were limited in the kind of work or other activities ................. 1 ............. 2............. 3 ............. 4............. 5
All of the time
Most of the time
Some of the time
A little of the time
None of the time
a Accomplished less than you would like...................................... 1 ............. 2............. 3 ............. 4............. 5
b Did work or other activities less carefully than usual ................ 1 ............. 2............. 3 ............. 4............. 5
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SF-12v2™ Health Survey © 1994, 2003 Health Assessment Lab, Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved. SF-12® is a registered trademark of Medical Outcomes Trust. (IQOLA SF-12v2 Standard, Australia (English))
6. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks…
7. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?
All of the time Most of the time
Some of the time
A little of the time
None of the time
1 2 3 4 5
All of the time
Most of the time
Some of the time
A little of the time
None of the time
a Have you felt calm and
peaceful? ....................................... 1 ............. 2............. 3 ............. 4............. 5
b Did you have a lot of energy? ....... 1 ............. 2 ............. 3 ............. 4 ............. 5
c Have you felt downhearted and depressed? .............................. 1 ............. 2............. 3 ............. 4............. 5
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SF-12v2™ Health Survey © 1994, 2003 Health Assessment Lab, Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved. SF-12® is a registered trademark of Medical Outcomes Trust. (IQOLA SF-12v2 Standard, Australia (English))
MOS-SSS (the Medical Outcomes Study - Social Support Survey tool)
None of the time
A little of the time
Some of the time
Most of the time
All of the
time
1. Someone to help you if you were confined to bed
1 2 3 4 5
2. Someone you can count on to listen to you when you need to talk
1 2 3 4 5
3. Someone to give you good advice about a crisis
1 2 3 4 5
4. Someone to take you to the doctor if you needed it
1 2 3 4 5
5. Someone who shows you love and affection 1 2 3 4 5
6. Someone to have a good time with 1 2 3 4 5
7. Someone to give you information to help you understand a situation
1 2 3 4 5
8. Someone to confide in or talk to about yourself or your problems
1 2 3 4 5
9. Someone who hugs you 1 2 3 4 5
10. Someone to get together with for relaxation 1 2 3 4 5
11. Someone to prepare your meals if you were unable to do it yourself
1 2 3 4 5
12. Someone whose advice you really want 1 2 3 4 5
13. Someone to do things with to help you get your mind off things
1 2 3 4 5
14. Someone to help with daily chores if you were sick
1 2 3 4 5
15. Someone to share your most private worries and fears with
1 2 3 4 5
16. Someone to turn to for suggestions about how to deal with a personal problem
1 2 3 4 5
17. Someone to do something enjoyable with 1 2 3 4 5
18. Someone who understands your problems 1 2 3 4 5
19. Someone to love you and make you feel wanted
1 2 3 4 5
People sometimes look to others for companionship, assistance, or other types of support. How often is each of the following kinds of support available to you if you need it? Circle one number on each line
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SF-12v2™ Health Survey © 1994, 2003 Health Assessment Lab, Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved. SF-12® is a registered trademark of Medical Outcomes Trust. (IQOLA SF-12v2 Standard, Australia (English))
Center for Epidemiologic Studies Depression (CES-D) Scale
Questions
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
All of the time (5-7 days)
1. I was bothered by things that usually don't bother me.
0 1 2 3
2. I had trouble keeping my mind on what I was doing.
0 1 2 3
3. I felt depressed.
0 1 2 3
4. I felt that everything I did was an effort.
0 1 2 3
5. I felt hopeful about the future.
3 2 1 0
6. I felt fearful.
0 1 2 3
7. My sleep was restless.
0 1 2 3
8. I was happy.
3 2 1 0
9. I felt lonely.
0 1 2 3
10. I could not get "going."
0 1 2 3
Below is a list of some of the ways you may have felt or behaved. Please indicate how often you have felt this way during the past week by checking the appropriate box for each question.
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Appendix 10. The questionnaire in Chinese
樣本編號(研究員填寫)
醫院代碼 序號
台灣第二型糖尿病個案實行自我效能增進措施方案後之自我管理改善成效
戶籍地址:□同現在地址
□ 縣市 鄉鎮市區 村里
路街 段 巷
弄 號 樓
(研究員填寫)
本問卷填寫結果:□全部完成 □其他狀況(請說明)
有無事先電話通知?□有 □無 □其他狀況(請說明)
姓名: 性別: □男 □女
出生日期: 年 月 日
現在地址: 縣市 鄉鎮市區 村里
路街 段 巷
弄 號 樓
電話:(日) (夜)
行動電話:
重要同住者姓名: 關係: 電話:
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填寫狀況:□自填 □訪員代填(原因請說明) □其他人代填(請說明)
完成時間: 分鐘
訪員姓名: 完訪日期:
複閱者: 複閱日期:
資料輸入: 輸入日期:
- 問卷說明 –親愛的先生女士您好:
我們是昆士蘭科技大學及台北護理學院,為了糖尿病個案的健康,提供一連串的健康促進系列活動,以期增進大家對疾病的預防和管理能力,希望您能全程參與,因為您的全程參加將是我們最大的動力。這是一份請教您個人對糖尿病看法的一份問卷,回答問題時您不用和其他人做比較,也沒有所謂的「對」和「錯」,請您放心回答。
請您耐心填完這份問卷,以下內容分為幾個部分:糖尿病管理自我效能表、自覺治療效能表、日常生活自我照顧活動、生活品質、社會支持及憂鬱狀態。您個人的回答或基本資料絕對安全及保密,除了工作人員知道之外,資料不會外洩。
您參加的這個健康促進方案的目的是:希望藉由提供您對疾病管理的自信心(自我效能)進而增加自我照顧能力,減少潛在性合併症之發生,最後可以間接改善生活品質、心理社會安適狀態及降低醫療成本。若是您因為個人的因素想要中途停止參與,您有權力提出並告訴我們。
您在回答這份問卷時,有些問題看起來會很像,但事實上每一題都不一樣且都很重要。或許有些題目中,您可能沒有這些症狀或困擾,還是請您一題一題作答,選擇最合您個人情況的答案,因為您真實的答案對我們而言非常非常寶貴的,也是我們很想知道的研究資料。若是您對於讀或寫有困難,我們工作同仁將逐一唸給您聽,並提供書寫問卷之協助。
回答後請檢查是否填妥了每一題答案及確保整份問卷是完整的。因為有時某些題目在填寫過程中會不小心被遺漏,請您多花幾分鐘檢查一下,確定每一題都填妥了答案。
檢查完問卷後請您交給研究人員或稍後工作人員會來向您收取。最後要感謝您的合作及用心地填寫這份問卷,您的資料提供有助於糖尿病領域相關研究的發展,期待研究結果能提供及落實更好、更完整的糖尿病照護。
昆士蘭科技大學及台北護理學院研究小組敬上
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基本資料
1.性別:□(1)男 □(2)女 2.年齡:____歲 出生:____年____月____日 3.身高: 公分 4.籍貫:□(1)閩南 □(2)外省 □(3)客家 □(4)原住民 □(5)其他 (請說明) 5.宗教信仰:□(1)佛教 □(2)道教或燒香、拜拜民間傳統信仰 □(3)基督教
□(4)天主教□(5)一貫道 □(6)其他 (請說明)
6.教育程度:□(1)不識字 □(2)小學 □(3)國中 □(4)高中職
□(5)專科 □(6)大學 □(7)研究所以上 7.婚姻狀況:□(1)未婚 □(2)已婚 □(3)分居 □(4)離婚 □(5)喪偶
□(6)同居 □(7)其他 (請說明) 8.職業狀況:□(1)無 □(2)有, (請說明) 9.居住狀況: □(1)獨居 □(2)與家人同住 □(3)其他 (請說明) 10.民國 年 月醫生診斷我罹患糖尿病,所以患病時間到現在為止已經 年了
11.除了糖尿病外,有無其他疾病史:□(1)無 □(2)有,病因: (請說明)
12.自從患病後,有無曾經接受過醫護人員提供的糖尿病衛生教育(至少每次接受 10 分鐘以上的衛
生教育) □(1)無 □(2)有,團體衛教_____次(那些醫療院所名稱: ) 個人衛教_____次(那些醫療院所名稱: ) 13.體重是_______公斤
14.有無固定到醫療院所門診看醫生: □(1)無 □(2)有,醫療院所名稱: ___________________;
平均多久看一次醫生:_____週/月一次 15.最近三個月內有無到醫院掛急診:□無 □有;總共_____次, 結帳時,醫藥費用總共花了我
元新台幣 (扣除健保金額後)
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16.最近三個月內有無到醫院住院過: □(1)沒有 □(2)有,總共_____次,全部住院總天數共_____天(續答); ‧□這幾次住院結帳時,醫藥費用總共花了我 元新台幣 (扣除健保金額後) ‧□自己因住院而無法上班的天數_____天,一天平均工資約_____元新台幣(無工作者免填) ‧□主要照顧我的親友因照顧我而無法上班的天數_____天,他一天平均工資約 元新
台幣(□主要照顧者無工作或 □無主要照顧者則免填) 17.目前治療方法(可複選):
□(1)口服降血糖藥;用藥名稱: □(2)注射胰島素;用藥名稱: □(3)飲食控制 □(4)運動控制 □(5)其他 (請說明)
18.有無糖尿病合併症
□(1)無 □(2)有:(□(1)視網膜(眼睛)病變 □(2)腎臟病變 □(3)神經病變 □(4)糖尿病足□(5)高血壓 □(6)心臟病 □(7)高血脂 □(8)其他 )(可複選)
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中文版糖尿病管理自我效能量表 (Chinese version Diabetes Management Self-Efficacy Scale; C-DMSES)
第一部分: 以下為你在糖尿病自我管理中可能要做的事項。請仔細閱讀每一個項目,然後選出最能代表你自己執行這件事的信心程度。例如:如果你認為自己在「有需要時我有能力自行檢測血糖」非常有自信的話,請圈選 10; 如果你覺得大部份時間你無法做到的話(很少自信的話),請圈選 1 或 2;完全無法做到(完全沒自信的話)請圈選 0。
請在每一列中圈選出一個數字
我有自信: 完全無
法做到
也許可以
也許不可以
完全可
以做到
1. 有需要時,我有能力自行檢測血糖
0 1 2 3 4 5 6 7 8 9 10
2. 當我的血糖太高時,我有能力自己調整我的血糖值(例如:食用不同種類的食物)
0 1 2 3 4 5 6 7 8 9 10
3. 當我的血糖太低時,我有能力自己調整我的血糖值(例如:食用不同種類的食物)
0 1 2 3 4 5 6 7 8 9 10
4. 我有能力選擇最有利於我的健康的食物
0 1 2 3 4 5 6 7 8 9 10
5. 我有能力選擇不同種類的食物來維持健康的飲食計畫
0 1 2 3 4 5 6 7 8 9 10
6. 我有能力將我的體重控制在理想範圍內
0 1 2 3 4 5 6 7 8 9 10
7. 我有能力自行檢查我的腳(例如:傷口或起水泡)
0 1 2 3 4 5 6 7 8 9 10
8. 我有能力做足夠的身體活動(例如:溜狗、瑜珈、園藝、或伸展運動等)
0 1 2 3 4 5 6 7 8 9 10
9. 當我生病時,我仍然能維持我的飲食計畫
0 1 2 3 4 5 6 7 8 9 10
10. 大部份的時間內,我都能確實遵從我的健康飲食計畫
0 1 2 3 4 5 6 7 8 9 10
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請在每一列中圈選出一個數字
我有信心: 完全無
法做到
也許可以
也許不可以
當然可以
11. 當醫師建議我多做一些身體活動,我有能力確實做到
0 1 2 3 4 5 6 7 8 9 10
12. 當我身體活動量增加時,我有能力自行調整我的飲食計畫
0 1 2 3 4 5 6 7 8 9 10
13. 當我外出時,我仍然能遵行健康的飲食計畫
0 1 2 3 4 5 6 7 8 9 10
14. 當我外出時,我有能力選擇不同的食物種類,並維持我的飲食計畫
0 1 2 3 4 5 6 7 8 9 10
15. 在特殊節日時,我仍然能遵守健康飲食計畫
0 1 2 3 4 5 6 7 8 9 10
16. 當我在外用餐或參加聚會時,我有能力選擇不同種類的食物並維持我的健康飲食計畫
0 1 2 3 4 5 6 7 8 9 10
17. 當我面對壓力或焦慮時,我仍然能維持我的飲食計畫
0 1 2 3 4 5 6 7 8 9 10
18. 我能每年至少去看醫生四次,以監測我的糖尿病狀況
0 1 2 3 4 5 6 7 8 9 10
19. 我能夠依醫師處方按時服藥 0 1 2 3 4 5 6 7 8 9 10
20. 當我生病時,我仍然能維持我的糖尿病藥物治療
0 1 2 3 4 5 6 7 8 9 10
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日常生活自我照顧活動
此部分題目試想瞭解您對自我的日常生活照顧活動,請依據過去七天(包含今天)的實際情況
回答以下問題,若是過去七天您洽好在生病當中, 請您依據這次生病之前的實際情況回答
1.在過去 7 天中,您有多少天,按照健康的飲食計畫來進食
1 2 3 4 5 6 7 天
2.在過去 7 天中,您有多少天,一天所吃的蔬菜水果加起來超過 5 份〈如:吃蔬菜 3 碟、 水果 2 個。(水果一份約橘子一個,木瓜 1/3 個‧‧‧等;蔬菜一份 100 公克,約 1 碟, 研究者會依照食物代換表逐一舉例〉?
1 2 3 4 5 6 7 天
3.在過去 7 天中,您有多少天吃油脂多的食物〈如:油炸食物、肥肉、雞皮等〉?
1 2 3 4 5 6 7 天
4.在過去 7 天中,您有多少天,有做 30 分鐘以上的活動〈指身體持續活動超過 30 分鐘,包括:走路、做家事〉?
1 2 3 4 5 6 7 天
5.在過去 7 天中,除了工作及做家事以外,您有多天,有另外撥時間的去做運動〈如:慢跑、爬山、太極拳、土風舞等〉?
1 2 3 4 5 6 7 天
6.在過去 7 天中,您有多少天,有照醫師指示定時定量服用降血糖的藥?〈醫囑不需服降血糖藥者,不用回答此題〉
1 2 3 4 5 6 7 天
7.在過去 7 天中,您有多少天,在家自己(或家人幫忙)量血糖?
1 2 3 4 5 6 7 天
8. 在過去 7 天中,您有多少天,依照醫師指示的血糖測量標準次數(例如ㄧ天量血糖兩次)在家按時自己(或家人幫忙)量血糖?
1 2 3 4 5 6 7 天
9.在過去 7 天中,您有多少天,檢查您的雙腳〈包括腳趾、腳板與腳底〉?
1 2 3 4 5 6 7 天
10.在過去 7 天中,您有多少天,在穿鞋之前有先檢查鞋內的情形〈如:鞋內有無小石頭,是否平整、有無破損或潮濕等〉?
1 2 3 4 5 6 7 天
11.在過去 7 天中,您有多少天在洗完腳後將腳擦乾,並保持腳趾間乾燥?
1 2 3 4 5 6 7 天
12. 在過去 7 天中,您有多少天在出門時,都有穿合適的鞋子(例如沒有穿露腳趾得拖鞋或涼鞋而穿包鞋)?
1 2 3 4 5 6 7 天
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中文版自覺治療效能量表 (Chinese version the Perceived Therapeutic Efficacy Scale; C-PTES)
第二部份: 請在以下每個題目右方數字中,圈選出最能代表你的信心程度。例如:0 代表完全沒有信心,10 代表非常有信心。
請再每一列中圈選出一個數字
沒有信心
非常有信
心
1. 我的糖尿病藥物能夠控制我的血糖值,我對這件事的信心程度是
0 1 2 3 4 5 6 7 8 9 10
2. 我的糖尿病藥物能夠穩定血糖,減少高血糖發作,我對這件事的信心程度是:
0 1 2 3 4 5 6 7 8 9 10
3. 我的糖尿病藥物能夠減少併發症的嚴重程度(例如:眼睛或腳的併發症) ,我對這件事的信心程度是:
0 1 2 3 4 5 6 7 8 9 10
4. 我的糖尿病藥物能夠預防我得到(更多)併發症,我對這件事的信心程度是:
0 1 2 3 4 5 6 7 8 9 10
5. 維持我的藥物劑量可以有效控制我的糖尿病,我對這件事的信心程度是:
0 1 2 3 4 5 6 7 8 9 10
6. 每天需要依照處方正確服藥可以控制我的糖尿病,我對這件事的信心程度是:
0 1 2 3 4 5 6 7 8 9 10
7. 醫師處方開給我的糖尿病藥物是有療效, 對於這件事我的整體信心程度是:
0 1 2 3 4 5 6 7 8 9 10
8. 一般來講,藥物治療能夠有效控制我的糖尿病
0 1 2 3 4 5 6 7 8 9 10
9. 在我的糖尿病治療中,專家如醫師或營養師所給的專業建議,我對這件事的信心程度是:
0 1 2 3 4 5 6 7 8 9 10
10. 我能應付自己的糖尿病,對於這件事我的整體信心程度是
0 1 2 3 4 5 6 7 8 9 10
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生活品質量表
本調查目的在探討您對自己健康的看法。這些資訊將能幫助您記錄您的感受,以及您在執行日
常生活的能力。 敬請回答下列各問題並圈選一適當答案。如您對某一問題的回答不能確定,還
是請您盡可能選一個最適合的答案。在本部份所指過去一個月內﹐係指從今天往前算三十天內。
1. 一般來說,您認為目前的健康狀況是:
極好的 很好 好 普通 不好
1 2 3 4 5
2. 下面是一些您日常可能從事的活動,請問您目前健康狀況會不會限制您從事這些活動?如果會,到底限制有多少?
活動 會 受到很多限制
會 受到一些限制
不會 完全不受限制
a. 中等程度活動,例如搬桌子、拖地板、打保齡球或打太極拳
1 2 3
b. 爬數層樓樓梯 1 2 3
3.在過去一個月內,您是否曾因為身體健康問題,而在工作上或日常活動方面有下列任何的問題?
一直
都是
大部
分時間
有時 很少 從不
a. 完成的工作量比您想要完成的較少 1 2 3 4 5
b. 可以做的工作或其他活動種類受到限制 1 2 3 4 5
4.在過去一個月內,你是否曾因為情緒問題 (例如,感覺沮喪或焦慮),而在工作上或日常活動方面有下列任何問題?
一直 大部 有時 很少 從不
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都是 分時間
a. 做工作或其他活動的時間減少 1 2 3 4 5
b. 做工作或其他活動時不如以往小心 1 2 3 4 5
5. 在過去一個月內,身體疼痛對您日常工作 (包括上班及家務) 妨礙程度如何?
完全沒有妨礙 有一點妨礙 中度妨礙 相當多妨礙 妨礙多到極點
1 2 3 4 5
6. 下列各項問題是關於過去一個月內,您的感覺及對您周遭生活的感受,請針對每一問題選一最接您感覺的答案。
一直都
是
大部分
時間
有時 很少 從不
a. 您覺得心情平靜? 1 2 3 4 5
b. 您精力充沛? 1 2 3 4 5
c. 你覺得悶悶不樂憂鬱? 1 2 3 4 5
7. 在過去一個月內,您的身體健康或情緒問題有多少時候會妨礙到您的社交活動(如拜訪親友等)?
一直都是 大部分時間 有時 很少 從不
1 2 3 4 5
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社會支持量表
本部分想要瞭解您的友誼、幫助或其他形式的支持情況。請您依據個人實際情形及想法,在適當的答案打勾或圏選,請勿遺漏,非常謝謝您! ◎以下題目所提的「人」是指親人、朋友、鄰居、醫護人員或其他 「1=從來沒有」 表示不曾如此; 「2=很少」表示大部分時候不是如此; 「3=有時」表示約一半的時候是如
此; 「4=經常」表示大部分時候是如此; 「5=總是」表示幾乎每次都是如此
項目 從來沒有
很少 有時 經常 總是
1. 假如你臥病在床時,有會幫助你的人。 1 2 3 4 5
2. 當你需要與人談話時,有能傾聽你講話的人。 1 2 3 4 5
3. 當你面臨難關時,有給你良好意見的人。 1 2 3 4 5
4. 假如你需要有人帶你去看病時,有可以帶你去的人。
1 2 3 4 5
5. 有會向你表達喜愛及好感的人。 1 2 3 4 5
6. 有讓你覺得和他相處時很愉快的人。 1 2 3 4 5
7. 有提供資訊來幫助你了解所處情況的人。 1 2 3 4 5
8. 有值得信任或談論關於你本身或你難題的人。 1 2 3 4 5
9. 有與你很親近的人。 1 2 3 4 5
10. 有能陪伴你而讓你覺得身心很放鬆的人。 1 2 3 4 5
11. 假如你無法準備三餐時,有可以為你準備的人。 1 2 3 4 5
12. 有會供你真正想要之意見的人。 1 2 3 4 5
13. 有會做一些事情,讓你除去心中煩念的人
14. 假如你生病了,有可以協助你例行工作的人。 1 2 3 4 5
15. 有可以與你分享你個人苦惱和害怕的人。 1 2 3 4 5
16. 如果你需要一些建議以處理個人問題,有可以求助的人。
1 2 3 4 5
17. 有會做一些事令你愉快的人。 1 2 3 4 5
18. 有了解你煩惱的人。 1 2 3 4 5
19. 有疼愛且讓你感到被需要的人。 1 2 3 4 5
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憂鬱量表 這部分是有關想了解您有無憂鬱狀況之調查,請您仔細閱讀每一題中的敘述,然後圏選一項最能描述您最近七天〈包括今天〉的感受,在適當的答案打勾或圏選。
項目 一點也不 (少於一
天)
有時是 (1-2 天)
大部份是 (3-4 天)
總是 (5-7 天)
1. 原本不介意的事,最近竟然會困擾我。 0 1 2 3
2. 我做事無法專心。 0 1 2 3
3. 我覺得悶悶不樂。 0 1 2 3
4. 我做任何事都覺得費力。 0 1 2 3
5. 我對未來充滿希望。 0 1 2 3
6. 我覺得恐懼。 0 1 2 3
7. 我睡得不安寧。 0 1 2 3
8. 我是快樂的。 0 1 2 3
9. 我覺得寂寞。 0 1 2 3
10. 我缺乏幹勁。 0 1 2 3
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A 10-minute Videotape or DVD