THESIS

TYPE II DIABETES MELLITUS SELF-MANAGEMENT: RELATING DIABETES

DISTRESS, SOCIAL SUPPORT, SELF-EFFICACY, AND PERFORMANCE OF DIABETES

SELF-CARE ACTIVITIES

Submitted by

Christine Dawson

Department of Occupational Therapy

In partial fulfillment of the requirements

For the Degree of Master of Science

Colorado State University

Fort Collins, Colorado

Spring 2020

Master’s Committee:

Advisor: Matthew Malcolm

Karen Atler
Anne Williford
Copyright by Christine Dawson 2020

All Rights Reserved

 ABSTRACT

TYPE II DIABETES MELLITUS SELF-MANAGEMENT: RELATING DIABETES

DISTRESS, SOCIAL SUPPORT, SELF-EFFICACY, AND PERFORMANCE OF DIABETES

SELF-CARE ACTIVITIES

Type 2 Diabetes Mellitus (T2DM) is a widespread chronic disease that negatively impacts an

individual’s health and well-being, particularly when uncontrolled. Due to the nature of T2DM,

individuals are responsible for the challenge of self-managing the disease. Several factors act as

barriers and facilitators to self-management, but the literature has failed to establish consensus

about how these factors interact with one another. The present study utilized a correlational

design to examine the relationships among diabetes distress, social support, self-efficacy, and

performance of diabetes self-care activities. A total of 33 adults with T2DM participated in the

study by completing a battery of surveys regarding performance of diabetes self-care activities

and psychosocial factors. Self-efficacy was associated with diabetes distress (r = -.419). Support

satisfaction was related to both self-efficacy (r = .495) and diabetes distress (r = -.431), although

relationships were not found with other aspects of social support. We did not find any significant

relationships among the psychosocial variables and performance of diabetes self-care activities,

though both psychosocial factors and performance of diabetes self-care activities were linked to

key health indicators like A1C and BMI. Our findings suggest that these psychosocial factors

should be areas of interest for healthcare practitioners, researchers, and individuals with T2DM.

Diabetes distress, self-efficacy, and social support should be assessed and monitored, in addition

to performance of diabetes self-care activities. Future research should continue to explore

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relationships among psychosocial and contextual factors and their potential impact on ability to

successfully self-manage T2DM.

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 ACKNOWLEDGEMENTS

First, I would like to express my gratitude to my advisor, Dr. Matthew Malcolm for his

guidance, support, and patience throughout this process. I sincerely thank you for encouraging

me to truly take ownership of my thesis and for giving me the freedom to design and execute my

own study. I appreciate all the support you provided me along the way from navigating an IRB

amendment to statistical analysis, and everything in between.

I would also like to thank my committee members, Dr. Karen Atler and Dr. Jennifer

Portz. In particular, I would like to thank Dr. Karen Atler for helping me improve my academic

writing skills and critical thinking abilities not only through her role on my committee, but also

as my professor. Thank you to Dr. Anne Williford for providing support, even on short notice.

And to Dr. Jennifer Portz for your support and insight during the beginnings of this project.

Next, I would like to thank the Department of Occupational Therapy for providing

Wanda Mayberry Research Funding, which allowed me to incentivize participation in the study.

I also wish to recognize my professors and peers, who always challenged me to think critically

and in novel ways.

Finally, I would like to thank all of my family and friends who provided endless support

and encouragement throughout this journey. To my family, thank you for always believing in

me. To Erin Miramontes, thank you for helping me stay balanced. To the Raskins, thank you for

your pep talks and for helping me gain insight into the experience of living with a chronic

condition. Finally, to Dorothy Kalmbach, Justine Cawthorne, Meghan Dunnigan, and Sydney

Pelster, thank you for being the absolute best support system I could ask for, during graduate

school and beyond.

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 TABLE OF CONTENTS

ABSTRACT ............................................................................................................................... ii
ACKNOWLEDGEMENTS ....................................................................................................... iv
Chapter 1 - Introduction.............................................................................................................. 1
Background ..................................................................................................................... 1
Literature Review............................................................................................................ 3
T2DM Self-Management ..................................................................................... 3
Stress ................................................................................................................... 5
Diabetes distress ...................................................................................... 5
Social Support ..................................................................................................... 6
Self-Efficacy ....................................................................................................... 9
Theoretical Framework ................................................................................................. 11
Purpose of the Study ..................................................................................................... 12
Statement of the Research Question .............................................................................. 13
Chapter 2 - Methods ................................................................................................................. 14
Methods ........................................................................................................................ 14
Recruitment ....................................................................................................... 14
Procedures and Measures ................................................................................... 15
Demographics ........................................................................................ 15
Diabetes self-care activities .................................................................... 15
Diabetes distress .................................................................................... 16
Social support ........................................................................................ 17
Self-efficacy........................................................................................... 19
Statistical Analysis ............................................................................................ 19
Chapter 3 - Results ................................................................................................................... 21
Results .......................................................................................................................... 21
Diabetes Self-Care Activities ............................................................................. 21
Diabetes Distress ............................................................................................... 22
Social Support ................................................................................................... 23
Self-Efficacy ..................................................................................................... 24
Chapter 4 - Discussion and Conclusion ..................................................................................... 26
Discussion..................................................................................................................... 26
Future Directions ............................................................................................... 31
Limitations .................................................................................................................... 32
Conclusion .................................................................................................................... 33
Tables and Figures .................................................................................................................... 35
References ................................................................................................................................ 42
Appendices ............................................................................................................................... 57
Appendix A................................................................................................................... 58
Appendix B ................................................................................................................... 60
Appendix C ................................................................................................................... 64
Appendix D................................................................................................................... 65
Appendix E ................................................................................................................... 68

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 CHAPTER 1 INTRODUCTION

Background

Type II Diabetes Mellitus (T2DM) is a chronic disease affecting approximately 30

million individuals in the United States, or 9.4% of the population (Centers for Disease Control

and Prevention [CDC], 2017). When uncontrolled, T2DM can lead to multiple adverse health

complications, including cardiovascular disease, diabetic retinopathy, diabetic neuropathy, and

diabetic nephropathy (World Health Organization [WHO], 2016). Diabetes self-management

(DSM) is key to prevent the progression of the disease, however individuals struggle to

consistently perform diabetes self-care activities (WHO, 2016). Research demonstrates that

adherence is related to a multitude of interpersonal and contextual factors (Ahola & Groop,

2013), however the complexity of these interactions warrants further study. Failing to better

understand why individuals struggle with DSM prevents provision of appropriate interventions

to address those factors (Nagelkerk et al., 2006). This means that individuals will experience

continued disease progression, ultimately resulting in a host of unfavorable health and lifestyle

outcomes (WHO, 2016).

In addition to negative health outcomes, T2DM can negatively impact the ability to

participate in desired and meaningful daily activities. Studies suggest a significant link between

diabetes and functional disability (Gregg et al., 2002; Marinho et al., 2016). Individuals with

T2DM have reported problems with mobility, self-care, and domestic life (Marinho et al., 2016).

Additionally, complications of diabetes such as vision impairment and neuropathy can negatively

impact performance of home management tasks, driving, and community mobility (Estes, 2016).

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T2DM can also complicate common tasks like self-care by introducing a host of new activities

like blood glucose monitoring, foot care, and medication management (Estes, 2016).

Because of T2DM’s nature as a lifelong chronic disease, individuals with T2DM are

primarily responsible for T2DM management. In order to promote successful T2DM self-

management, healthcare associations recommend attending DSM classes and participating in

preventive care practices (CDC, 2017; American Diabetes Association [ADA], 2018a). In

support of this recommendation, approximately 4,100 DSM education and support programs

exist in the United States. However, despite the availability of these support programs, only

54.4% of adults with diagnosed diabetes reported attending a self-management class after

diagnosis (CDC, 2017). The CDC (2017) also reported that only 63% of diabetic adults perform

daily glucose monitoring, while another examination of DSM activities found that only 52% of

individuals with T2DM follow a diet and 26% follow an exercise regimen (Shultz et al., 2001).

Although decreased attendance of self-management classes offers one explanation for decreased

adherence in DSM, exploration of other factors influencing DSM is needed.

Psychosocial factors have been implicated as one such group of significant and influential

factors impacting DSM (Gonzalez et al., 2016). Psychological factors like self-discipline, locus

of control, coping and stress management skills, and self-efficacy may be barriers to successful

and consistent performance of diabetes self-care activities (Ahola & Groop, 2013; Aljasem et al.,

2001; Brown et al., 2002; Gazmararian et al., 2009; Nagelkerk et al., 2006). Social relationships

have also been identified as a potential barrier to one’s ability to fulfill complex self-

management requirements (Wiebe et al., 2016). The present study’s aim was to expand upon our

current knowledge regarding psychosocial factors by focusing on three specific psychosocial

factors – diabetes distress, social support, and self-efficacy. The literature suggests that these

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three constructs are relevant to DSM, but studies have seldom examined them in conjunction

with one another and have failed to establish consensus regarding their impact.

We examined correlational relationships among diabetes distress, social support, self-

efficacy, and performance of diabetes self-care activities. Gaining a better understanding of these

relationships is beneficial to guide future research in this area and to help healthcare practitioners

better understand barriers preventing their patients from successfully self-managing.

Literature Review

T2DM Self-Management

DSM is required to maintain optimal blood glucose levels and reduce the risk of

secondary complications, with the ultimate goal of improving both longevity and quality of life

(Ahola & Groop, 2013). DSM requires significant time and involves nearly all aspects of an

individual’s life (Nagelkerk et al., 2006). To be successful, individuals need to integrate DSM

into their lifestyle by modifying established routines and habits to include recommended diabetes

self-care activities (Fritz, 2014).

The American Association of Diabetes Educators (AADE) identified and published a

summary of seven self-care behaviors deemed “essential for successful and effective diabetes

self-management” (Tomky et al., 2008, p. 445). These behaviors—known as the AADE7Ô –

consist of the following: healthy eating, being active, monitoring, taking medication, problem

solving, healthy coping, and reducing risks. This framework is meant to provide guidelines for

DSM education and provide standardized nomenclature to facilitate better communication

among healthcare providers to improve coordination of care (Tomky et al., 2008).

The AADE7Ô is not the only set of guidelines available to inform practitioners. The

ADA annually publishes “Standards of Medical Care in Diabetes,” an extensive document

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delineating the current best practices in diabetes care. Within this document, the ADA states that

“ongoing patient self-management education and support are critical” (ADA, 2018a, p. S1) and

advocates for the provision of Diabetes Self-Management Education and Support (DSMES)

services as part of a comprehensive plan of care. The ADA recommends that DSM education be

provided “at diagnosis, annually, when complicating factors arise, and when transitions in care

occur” (ADA, 2018b, p. S38). DSMES services are also recommended by the AADE and the

Academy of Nutrition and Dietetics, with the goal of supporting individuals’ ability to make

decisions regarding their own healthcare and to effectively self-manage T2DM (Powers et al.,

2015).

Despite the promotion of DSM guidelines, negative outcomes persist and T2DM

continues to be the 7th leading cause of death in the United States (CDC, 2017). These outcomes

imply a disconnect between our knowledge about DSM and an individual’s ability to implement

that knowledge in daily life. A significant portion of the research on DSM has focused on

identifying interpersonal, intrapersonal, and large scale contextual factors that may be barriers to

successful T2DM management. However, we still do not fully understand the relationships

among those factors or whether they are predictive of performance of diabetes self-care

activities. This issue is not unique to T2DM. Bos-Touwen et al. (2015) examined multiple

factors contributing to patient activation for self-management among four chronic health

conditions, including T2DM. However, they were only able to explain 16% of the variance

between levels of activation. Similarly, a study seeking to identify predictors of self-care for

patients with chronic heart failure was only able to explain about 10% of the variance in self-care

(Rockwell & Riegel, 2001). These results support the need for further exploration of barriers and

predictive factors impacting DSM.

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Stress

The relationship between stress and health has been researched extensively, revealing a

complex but well-established relationship between chronic, excessive stress and negative effects

on overall health that contribute to the development of chronic disease (Acabchuk et al., 2017;

Hart, 2009). Although we understand how stress can be a risk factor for development of disease,

we know less about how stress plays a role post-diagnosis. The literature suggests that there are

multiple avenues by which stress can impact diabetes health outcomes. One key understanding

that has emerged is that stress and diabetes appear to have a reciprocal relationship. That is,

stress impairs the ability to self-manage, while difficulty with self-management can result in

increased stress (Nomura et al., 2000). Stress can be detrimental to DSM through both

physiological pathways and through disruption of life roles or ability to perform necessary

diabetes self-care activities (Cox & Gonder-Frederick, 1992). The present study was specifically

interested in this proposed relationship between stress and performance of diabetes self-care

activities. However, we examined this relationship from a disease-specific lens by specifically

measuring diabetes distress.

Diabetes distress. Diabetes distress has been defined as “a range of negative emotional

responses…to aspects of living with and managing diabetes balanced against an appraisal of

available coping resources” (Dennick et al., 2017, p. 899). Gonzalez et al. (2011) further

specified that emotional reactions may be in response to “the diagnosis of diabetes, threat of

complications, self-management demands, unresponsive providers, and/or unsupportive

interpersonal relationships” (p. 236).

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 The construct of diabetes distress emerged as researchers began to question whether a

diagnosis of depression accurately represented the unique psychosocial complications of having

diabetes. Diabetes distress is related to depressive symptoms (Fisher et al., 2007; Schmitt et al.,

2015), however multiple studies have been able to distinguish between the two, specifically by

examining their relationship to outcomes such as glycemic control (Aikens, 2012; Fisher et al.,

2010; Schmitt et al., 2015). Diabetes distress is correlated with glycemic control (Aikens, 2012;

Fisher et al., 2010) whereas no significant correlations were found between depression and A1C

(Fisher et al., 2010), suggesting that diabetes distress has its own unique role to play independent

of depressive symptoms.

In terms of T2DM, most inquiries have focused on the transaction between diabetes

distress and glycemic control with less focus on performance of diabetes self-care activities

(Jannoo et al., 2017; Lee et al., 2018). However, some research has found that diabetes distress is

predictive of medication adherence (Aikens, 2012; Jannoo et al., 2017). If diabetes distress is

associated with poor medication adherence, it is likely that it is also associated with other

diabetes self-care activities. The present study sought to close this gap by looking at diabetes

distress in relation to performance of diabetes self-care activities. The study also contributes to

the growing body of research on the potential role of social support as a mediating factor

between distress and DSM (Baek et al., 2014; Lee et al. 2018). Current research in this area has

also primarily focused on glycemic control, as opposed to performance of diabetes self-care

activities.

Social Support

Social support plays a significant role in chronic disease management, including DSM

(Chen et al., 2018; Gomes et al., 2017; Koetsenruijter et al., 2016; Rotberg et al., 2016). Social

6
support is defined as the perception that assistance is available (Ahola & Groop, 2013). The

word “perception” is key as some researchers have suggested that an individual’s perceived

social support is more important than the actual support received (Sherbourne & Stewart, 1991).

Social support may be categorized as structural or functional. Structural refers to the quantifiable

aspects of a network, while functional encompasses the qualitative dimensions of social support

(Schiøtz et al., 2012). Functional support can be broken down into subcategories of support

including emotional, tangible, and informational (Ahola & Groop, 2013; Chen et al., 2018;

Koetsenruijter et al., 2016).

Because T2DM impacts nearly every aspect of an individual’s daily life (Nagelkerk et al.,

2006), an individual’s social network will inevitably become involved in their disease.

Furthermore, many of the lifestyle changes that individuals with T2DM are required to make

involve activities that occur in a social context, like eating, exercising, and healthy coping

(Rotberg et al., 2016). Therefore, social supports may be called upon to provide emotional

support or assistance with tasks like healthy eating and exercise. The social network may also

become involved by providing assistance with seeking out information and resources

(Koetsenruijter et al., 2016; Newton-John et al., 2017).

Social networks will vary in size and include multiple sources like family, friends,

spouse, community, and healthcare providers. The literature suggests that size and source of

support matter (Ahola & Groop, 2013; Gomes et al., 2017; Koetsenruijter et al., 2016; Rotberg et

al., 2016; Shaw et al., 2006). For instance, Koetsenruijter et al. (2016) suggest that the size of the

social network is of particular importance for those who have a limited education, with larger

support networks positively influencing performance of diabetes self-care activities. Because

individuals with less than a high school education are at a higher risk for developing T2DM

7
(CDC, 2017), this relationship is notable. Some evidence implies that familial (Ahola & Groop,

2013; Gomes et al., 2017) and spousal (Henry et al., 2013) support are particularly important to

successful DSM while others emphasize the benefit of interacting with other individuals who

share a T2DM diagnosis (Rotberg et al., 2016). In an assessment of performance of diabetes self-

care activities, Shaw et al. (2006) found that family and friends were particularly helpful for

maintaining diet and performing foot care whereas community resources played a larger role in

monitoring and exercise.

Shaw et al.’s (2006) study implies that social support can influence performance of

diabetes self-care activities. Significant associations have been found between social support and

healthy eating (Bouldin et al., 2017; Rosland et al., 2014; Schiøtz et al., 2012; Shaw et al., 2006),

physical activity (Nicklett et al., 2013; Rosland et al., 2014), and medication adherence (Nicklett

et al., 2013; Osborn & Egede, 2012). However, the literature lacks consensus about some of

these relationships. Other studies failed to find a significant relationship between social support

and physical activity (Bouldin et al., 2017; Schiøtz et al., 2012) and between social support and

medication adherence (Rosland et al., 2014; Schiøtz et al., 2012). Similar discrepancies exist

regarding the influence of social support on foot care (Nicklett et al., 2013; Rosland et al., 2014;

Schiøtz et al., 2012; Shaw et al., 2006). and attendance of medical appointments (Nicklett et al.,

2013; Rosland et al., 2014). One meta-analysis suggested a correlation between social support

and monitoring (Song et al., 2017), but this claim requires further research.

Although some studies have demonstrated little or no relationship between social support

and DSM (Chlebowy & Garvin, 2006; Gleeson-Kreig et al., 2002), most of the research that is

currently available illustrates a relationship between the two. However, the nature of this

relationship is unclear as the literature demonstrates conflicting results. Identification of this

8
discrepancy indicates that further research is required to better understand the transaction

occurring between social support and DSM.

Additionally, little research has focused on satisfaction with social support despite

implications that it is an important consideration for performance of diabetes self-care activities.

Tang et al. (2008) reported that satisfaction was predictive of monitoring. Gleeson-Kreig et al.

(2002) found high levels of dissatisfaction with the amount of social support received for

performance of diabetes self-care activities. The present study examined not only type and

quantity of support, but also considered an individual’s satisfaction with perceived support.

Despite conflicting results regarding the relationship between social support and DSM,

there is consensus that DSM interventions should target social support (Nicklett et al., 2013;

Zhang et al., 2007). Evidence suggests that interventions targeting social support have been

successful in improving outcomes (Banbury et al., 2017; McEwen et al., 2010; Spencer-Bonilla

et al., 2017). Gaining a better understanding of social support’s role in DSM will contribute to

our understanding of why individuals struggle to integrate and will allow practitioners to design

effective social support interventions.

Self-Efficacy

Broadly, self-efficacy may be defined as “an individual’s perception of his/her own

ability to perform a specific task in a given situation” (Krichbaum et al., 2003, p. 657). As it

pertains to DSM, self-efficacy is the belief in one’s ability to “exercise control over one’s health

habits” (Bandura, 2004, p. 144). Self-efficacy is also a primary component of Social Cognitive

Theory (SCT), which serves as the theoretical basis for this study and will be discussed in a later

section.

9
 Self-efficacy has been identified in the literature as a key facilitator, or potential barrier,

to DSM. Because the individual with T2DM is typically the principal provider of care, it is

imperative that they feel confident in their ability to successfully complete tasks associated with

the complex challenge of DSM. One review even suggests that low self-efficacy is one of the

“strongest and most consistent barriers to effective self-management” (Krichbaum et al., 2003, p.

658). However, the certainty of this statement should not negate the complicated nature of the

relationship between self-efficacy and DSM. Schunk and Usher (2012) explain that self-efficacy

has positive effects on motivation, learning, achievement, and self-regulation but caution that

self-efficacy can be incredibly fragile, as failing to cope with, and solve, problems associated

with T2DM complications can lead to a decline in self-efficacy. Conversely, successfully

navigating problems has the potential to increase self-efficacy.

A substantial amount of research has been conducted regarding the relationship between

self-efficacy and DSM. There is a general consensus in the literature that self-efficacy directly

impacts DSM, with multiple authors concluding that self-efficacy is a strong predictor of

performance of diabetes self-care activities (Devarajooh & Chinna, 2017; Jiang et al., 2019;

Schinckus et al., 2018; Walker et al., 2015). Research has also established a positive relationship

between self-efficacy and glycemic control (Cherrington et al., 2010; D’Souza et al., 2017; Gao

et al., 2013). Furthermore, self-efficacy’s effect on DSM has been investigated in conjunction

with other common influential factors like social support (Lee et al., 2019; Mladenovic et al.,

2014; Peimani et al., 2018), health literacy (Sarkar et al., 2006; Schinckus et al., 2018), and

psychosocial factors. Associations between self-efficacy and performance of diabetes self-care

activities have been documented, but these findings are less prevalent in the literature than

examinations of outcomes like glycemic control. Researchers have found correlations between

10
self-efficacy and exercise (Allen, 2004; Heiss & Petosa, 2016; Sarkar et al., 2006), diet and

blood glucose monitoring (Mishali et al., 2011; Sarkar et al., 2006), and foot care (Sarkar et al.,

2006).

Self-efficacy may also be impacted by certain demographic factors. D’Souza et al. (2017)

reports a positive association between age and duration of diabetes and level of self-efficacy.

Cherrington et al. (2010) suggest differences between genders, finding significant relationships

among self-efficacy, depression, and glycemic control for men but not women.

Although the relationship between self-efficacy and DSM is well-established, further

research is needed to examine how self-efficacy influences performance of diabetes self-care

activities (Mishali et al., 2011). The present study worked to close this gap by utilizing measures

that allowed for exploration of these more specific relationships. Additionally, while multiple

studies have examined self-efficacy in relation to social support, diabetes distress, and

performance of diabetes self-care activities, there is a lack of research examining all factors

simultaneously.

Theoretical Framework

Social Cognitive Theory (SCT) is a multifaceted theory of behavior that seeks to explain

how individuals acquire and maintain behaviors within a social context (Bandura, 1998). More

specifically, its goal is to “explain how people change their behavior through self-control and

reinforcement in order to start goal-directed behavior which can be maintained over time”

(Thojampa & Sarnkhaowkhom, 2019, p. 1251). The question of how individuals maintain goal-

directed behavior is largely what researchers are concerned with when trying to understand

DSM. As a result, research has frequently tested the utility of SCT for explaining or predicting

performance of diabetes self-care activities in order to further support and encourage SCT’s use

11
in developing interventions (Allen, 2004; Plotnikoff et al., 2008; Thojampa & Sarnkhaowkhom,

2019).

SCT revolves around the key concept of reciprocal determinism, which posits that

personal, behavioral, and social or environmental factors are constantly and dynamically

interacting with one another to facilitate or impede a given behavior (Schunk & Usher, 2012).

The variables of interest in the present study can be sorted into each of these three categories:

self-efficacy and diabetes distress are personal factors, performance of diabetes self-care

activities is the behavioral factor, and social support is the environmental factor.

SCT was selected as the theoretical framework to guide the present study as its central

concept aligns with, and supports, this study’s fundamental interest in how various constructs

interact with one another within the context of DSM. In conjunction with a thorough review of

the literature, SCT provides a well-researched, theoretical basis to inform and support the study

hypotheses.

Purpose of the Study

As demonstrated in the existing literature, receiving a diagnosis of T2DM requires a

significant lifestyle adjustment. Multiple psychosocial factors have been presented as barriers

and facilitators of that adjustment, but the relationship between DSM and critical psychosocial

factors is not well-established. Identifying how such factors relate may reveal unknown barriers

to DSM. Gaining more information will move us toward solving the larger problem of why

individuals struggle to integrate despite our knowledge about how to successfully manage this

disease. Without a better understanding of why individuals struggle to integrate DSM into their

daily routines, it is likely that we will see the current negative healthcare trends associated with

T2DM (CDC, 2017) continue. We posited that diabetes distress, social support, and self-efficacy

12
were especially important factors to examine. Although research has previously demonstrated

connections between these constructs and DSM, the existing literature lacks consensus and fails

to adequately consider interactions occurring among all constructs simultaneously.

The purpose of this study was to examine relationships among diabetes distress, social

support, self-efficacy, and performance of diabetes self-care activities. This research project was

an extension of the Taking On Diabetes to Advance You (TODAY) Project, which examined the

experiences and challenges of managing T2DM with a focus on individuals with low

socioeconomic status.

Statement of the Research Question

To address these gaps, this study answered the following research question: What are the

relationships between diabetes distress, social support, self-efficacy, and performance of diabetes

self-care activities in adults diagnosed with T2DM?

We hypothesized that we would find the following significant correlations between the

four variables of interest: (1) Increased levels of diabetes distress will be associated with

decreased levels of social support, (2) Increased self-efficacy will be associated with decreased

diabetes distress, (3) Increased social support will be associated with increased self-efficacy, and

(4) Increased social support, increased self-efficacy, and decreased diabetes distress will be

associated with increased performance of diabetes self-care activities.

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 CHAPTER 2 METHODS

Methods

The study employed a correlational design to explore the relationships between diabetes

distress, social support, self-efficacy, and performance of diabetes self-care activities. The study

included a combination of objective and subjective self-report measures to ascertain the

relationships between the variables of interest. Each measure is summarized in Table 1.

Recruitment

The study utilized a convenience sample of adults with T2DM. Participants were

recruited using a combination of flyers and online postings to diabetes-specific forums. When

required, permission was obtained from forum moderators. Flyers and forum postings provided

basic information about the study, including the inclusion criteria. Inclusion criteria were: (1)

adults aged 18 and above, (2) diagnosed with T2DM, and (3) able to read and write English.

Individuals who determined that they met inclusion criteria and were interested in participating

in the study were directed to a survey link. Prior to starting the survey, participants were required

to read and agree to a consent form. The study procedures were approved by the Institutional

Review Board of Colorado State University and all participants provided informed consent.

To incentivize participants, they were offered a chance to win an iPad. At the end of the

survey, participants were asked if they would like to be entered into a raffle to win an iPad. If

participants indicated “yes,” Qualtrics sent them to a second survey where they were able to

provide their contact information. This information was not in any way linked to their responses.

If participants indicated “no,” they received the standard end of survey message.

14
Procedures and Measures

The battery of paper-based assessments was manually converted into an electronic format

and delivered via Qualtrics, an online survey platform. The Qualtrics survey was formatted to

prevent individuals from taking the survey multiple times, although they were able to stop and

resume the survey if they were unable to complete it in one sitting. The time required to

complete the survey was approximately 15 minutes. Participants were required to provide an

answer to each question before moving on, thus preventing skipped responses.

Raw data were downloaded to an Excel spreadsheet and visually inspected for missing or

incomplete responses. Missing and non-numerical data on cholesterol and blood pressure were

removed from the spreadsheet before statistical analysis. Participants’ scores for each measure

were calculated within the spreadsheet, following scoring directions. When applicable, subscale

scores were calculated within the spreadsheet as well.

Demographics. All participants completed a modified version of the Health History and

Demographics Questionnaire, which was developed as part of the TODAY project. The

questionnaire gathered information on the following: gender, age, ethnicity, race, employment

status, income level, cholesterol, and blood pressure. Height and weight were collected in order

to calculate body mass index (BMI). Participants also reported their A1C, a measure of an

individual’s average blood glucose over a 3-month period (ADA, 2020). Participants were also

asked if they have ever attended diabetes education sessions.

Diabetes self-care activities. Data on participants’ performance of diabetes self-care

activities was obtained by administering the Summary of Diabetes Self-Care Activities (SDSCA)

(Appendix A). The SDSCA was originally developed in 1994 but was revised in 2000 following

a review of studies utilizing the SDSCA. The “specific diet” subscale was removed as it was

15
found to be unreliable. The revised version includes questions that reflect current practices in

DSM like carbohydrate counting and reducing the risk of cardiovascular disease (Toobert et al.,

2000).

The SDSCA is a self-report measure requiring individuals with T2DM to answer

questions about performance of diabetes self-care activities over the past week. The measure

examines the following domains: diet, exercise, blood sugar testing, foot care, smoking, and

medication management. These categories are reflective of several AADE7Ô self-care

behaviors, including healthy eating, being active, monitoring, taking medication, and reducing

risks. A total score is obtained by calculating the mean of all responses. Subscale scores are

obtained by calculating the mean of responses within each subscale. Possible scores range from 0

to 7 days.

Although not all-encompassing, the SDSCA was chosen for this study because it is a

widely used and accepted measure of performance of diabetes self-care activities. The SDSCA

has been compared to other diabetes self-care measures to determine concurrent validity,

resulting in high correlations for exercise and modest correlations for diet and monitoring

(Weinger et al., 2005). Additionally, the SDSCA has good internal consistency with average

inter-item correlations of r = 0.47 (Toobert et al., 2000).

Diabetes distress. The Diabetes Distress Scale (DDS) (Appendix B) is a 17-item self-

report measure created to assess psychosocial distress related to diabetes. The measure may be

broken down into four separate subscales: emotional burden (EB), physician-related distress

(PD), regimen-related distress (RD), and diabetes-related interpersonal distress (ID). Participants

read each statement and utilize a Likert scale to indicate how problematic that particular domain

has been over the past month. Responses range from 1 to 6, where 1 = not a problem and 6 = a

16
very serious problem (Jannoo et al., 2017; Lee et al., 2018). A total score is obtained by

calculating the mean of all responses. Subscale scores are obtained by finding the mean of the

responses to the component items of that scale. This process yields a mean item score ranging

from 1 to 6. Mean items score of 3 or higher indicates a moderate level of distress and warrants

further clinical attention. The DDS has good internal consistency overall (a = 0.93) and for each

subscale (aEB = 0.88, aPD = 0.88, aRD = 0.90, aID = 0.88). It also has strong validity with higher

overall scores being “associated with being younger and more depressed, using insulin, poorer

self-care, and having elevated lipid levels” (Polonsky et al., 2005, p. 629).

Social support. Because of the complexity of social support, research suggests that

administering more than one social support measure is preferred in studies examining the effects

of social support (Al-Dwaikat & Hall, 2017). Multiple aspects of social support can be measured;

the present study included measures of functional support, structural support, and satisfaction

with support. The Medical Outcomes Study Social Support Survey (MOS-SSS) (Sherbourne &

Stewart, 1991) is a self-administered 19-item measure designed to measure functional social

support. Since its development, the MOS-SSS has been modified to reduce the number of items

and alter the subscales that are measured (Priede et al., 2018). For the purposes of this study, the

modified Medical Outcomes Study Social Support Survey (mMOS-SSS) (Appendix C) was used

to decrease time burden on participants. The mMOS-SSS is an 8-item self-administered measure

that includes the first 8 items of the MOS-SSS, covering instrumental and emotional support

subscales. Although it was initially created for use with women with breast cancer (Ganz et al.,

2003), it has since been evaluated for use in primary care and with more diverse populations

(Gómez-Campelo et al., 2014; Togari & Yokoyama, 2016). Similar to the original measure,

participants rate how often someone in their network would be available to assist them with each

17
item. Participants provide a rating on a 5-point Likert scale, where from 1 = none of the time and

5 = all of the time. A total raw score is obtained by summing all of the responses. Instrumental

support subscale scores are determined by summing the first four items, while emotional support

subscale scores are determined by the last four items. The raw scores will be converted to a 0-

100 scaled score, with higher scores indicating stronger social support. Neither the authors of the

original measure, nor the authors of the modified version offer defined cut-offs for interpretation

of scores. However, utilizing the published means obtained during the development of the

original measure is suggested (RAND Corporation, 2019; Sherbourne & Stewart, 1991).

Studies examining the psychometric properties of the mMOS-SSS have found good

internal reliability (a = 0.91) and construct and discriminant validity (Gómez-Campelo et al.,

2014; Moser et al., 2012; Priede et al., 2018). Its psychometric properties are comparable to the

original measure (Moser et al., 2012; Priede et al., 2018). Additionally, a study examining the

factor structure of the original measure and two abbreviated versions concluded that the mMOS-

SSS is the most efficient of all versions (Priede et al., 2018).

The Social Support Questionnaire Short Form (SSQ6) (Sarason et al., 1987) (Appendix

D) is a self-administered 6-item survey that measures perceived structural social support and

satisfaction (Al-Dwaikat & Hall, 2017). Participants rate each item on 2 dimensions – number of

perceived supports and satisfaction. For each statement, participants list how many individuals in

their network they perceive would support them ranging from 0 to 9 persons. Then, they rate

their satisfaction with that support on a 6-point Likert scale, where 1 = very dissatisfied and 6 =

very satisfied. Scoring is performed by determining the mean number of person-supports and

mean satisfaction. Possible mean person-supports scores range from 0 to 9, and possible mean

satisfaction scores range from 1 to 6.

18
 The SSQ6 is a derivative of the Social Support Questionnaire (SSQ) (Sarason et al.,

1983), developed to ease the time burden on participants. While the SSQ was initially developed

for college students, it has been used for individuals with T2DM (Chlebowy & Garvin, 2006).

Few studies have examined the psychometric properties of the SSQ6, but existing literature

suggests good reliability and validity (Al-Dwaikat & Hall, 2017; Sarason et al., 1987). When

compared to a battery of other social support measures, correlation coefficients were similar

between the SSQ and the SSQ6 suggesting that the abbreviated version is representative of the

original measure (Sarason et al., 1987).

Self-efficacy. The Diabetes Empowerment Scale – Short Form (DES-SF) (Appendix E)

is a measure of diabetes-related psychosocial self-efficacy. The DES-SF is an 8-item measure

derived from the full 28-item scale in order to ease time burden on participants (Anderson et al.,

2003). The abbreviated measure has good reliability (a = 0.84) and content validity.

The DES-SF asks participants to indicate their level of agreement with statements

regarding their attitudes toward their diabetes. Participants respond on a 5-point Likert scale,

where 1 = strongly disagree and 5 = strongly agree. Some sample statements include “I believe

that I can try out different ways of overcoming barriers” or “I believe that I know enough about

myself as a person to make diabetes care choices that are right for me.” (Anderson et al., 2003).

Scoring is completed by finding the mean of all responses. Possible mean scores range from 1 to

5, with higher scores indicating higher diabetes-related self-efficacy.

Statistical Analysis

Statistical analysis was completed using SPSS software. A Spearman’s correlation was

run to analyze the relationships between all of the domains being measured. Correlations of rs =

0.25 to 0.49 were considered to be weak, rs = 0.50 to 0.74 to be moderate, and rs = 0.75 and

19
above to be strong (Portney & Watkins, 2009). Uncorrected significance was set at p = 0.05.

However, because the total number of correlations is 120, setting the significance level to p =

0.05 means that about 6 correlations would be significant by chance. To address this issue of

multiple comparisons, the Bonferroni correction was used to adjust the significance level to p =

0.001. The following results section will report correlations at both p = 0.05 and p = 0.001.

20
 CHAPTER 3 RESULTS

Results

Of the 44 individuals who received the survey, 33 (75%) completed it. The average age

was 53.8 years (SD, 12.0; range, 34-79). The average A1C was 6.34 (SD, 1.0; range, 4.8 – 8.7),

with 23 (70%) participants reporting an A1C below the recommended level of 7.0. The average

BMI was 32.8 (SD, 10.7; range, 16.0 – 70.6), with 13 (39%) participants in the overweight range

(25.0 – 29.9) and 15 (45%) participants in the obese range (30.0+). Of the sample, 22 (67%)

participants indicated they were employed. About half the sample (n= 16) indicated they had

previously attended a diabetes education session. Further details about demographic variables are

summarized in Table 2. All correlations are represented in Table 3. The following sections

describe findings for each measure incorporated into the survey.

Diabetes Self-Care Activities

On the SDSCA, participants reported performance of diabetes self-care activities an

average of 4 of the past 7 days (mean, 4.2 days, SD, 1.0; range, 1.9 – 6.6). Mean subscale scores

are represented in Figure 1. Blood glucose monitoring was the most frequently performed

activity (mean, 5.6 days, SD, 2.3; range, 0 – 7), followed by foot care (mean, 4.2 days, SD, 1.5;

range, 1.4 – 7.0). The least frequent activities were exercise (mean, 3.8 days, SD, 2.4; range, 0 –

7) and adherence to a diet plan (mean, 3.5 days, SD, 1.3; range, 0.8 – 6.4). Total SDSCA scores

were moderately correlated with cholesterol, although only 18 (55%) out of 33 participants

reported usable data on cholesterol. For those 18 participants, increased performance of self-care

activities was moderately associated with decreased cholesterol levels. We also found

moderately strong correlations between cholesterol and exercise, with more frequent exercise

21
linked to lower cholesterol. Lower cholesterol was also moderately associated with more

frequent foot care. SDSCA scores were weakly associated with BMI and A1C; increased

performance of diabetes self-care activities was linked to lower BMI and lower A1C. A1C was

weakly correlated with diet and moderately correlated with exercise, signifying that more

frequent adherence to diet and exercise recommendations was associated with lower A1C.

Similarly, BMI was weakly correlated with diet indicating that participants who more frequently

followed dietary recommendations had lower BMI. SDSCA subscale correlations are represented

in Table 4. When correcting for multiple comparisons (p = .001), none of the correlations

remained statistically significant.

Diabetes Distress

The mean item score across all participants was 2.1 (SD, 1.0; range, 1.0 – 5.4) indicating

that, on average, the participants were experiencing minimal levels of distress. However, some

participants met or exceeded a mean score of 3, indicating that they were experiencing moderate

levels of distress. Of the 33 participants, 4 (12%) scored a 3 or above on the total scale, 6 (18%)

scored a 3 or above on the emotional burden subscale, 7 (21%) scored a 3 or above on the

physician-related subscale, 8 (24%) scored a 3 or above on the regimen-related subscale, and 7

(21%) scored a 3 or above on the diabetes-related interpersonal subscale. Subscale and total

scores are represented in Figure 2.

Diabetes distress was weakly correlated with age; younger participants tended to have

higher levels of distress. Increased levels of diabetes distress were moderately associated with

increased A1C. DDS scores were weakly correlated with BMI, with higher levels of distress

associated with higher BMI. We found moderate associations between A1C and emotional

burden and between A1C and physician-related distress, indicating that higher levels of

22
emotional burden and physician-related distress were associated with increased A1C.

Additionally, A1C was strongly correlated with regimen-related distress indicating that higher

levels of regimen-related distress was also associated with increased A1C (Figure 3). Age was

weakly associated with emotional burden and physician-related distress, and moderately

associated with diabetes-related interpersonal distress; younger participants reported higher

levels of distress on all three of these subscales. DDS subscale correlations are represented in

Table 5.

When correcting for multiple comparisons (p = .001), the moderate correlation between

diabetes distress and A1C remained statistically significant. Moderate to strong correlations

between A1C and diabetes distress subscales – emotional burden, physician-related distress, and

regimen-related distress – also remained statistically significant.

Social Support

The mean number of persons available to provide support was 2.9 persons (SD, 2.2;

range, 0 – 9). Mean satisfaction with available support was 4.6 (SD, 1.4; range: 1 – 6), indicating

that, on average, participants were slightly satisfied with the amount of support they have. Mean

number of person-supports and mean satisfaction ratings were weakly correlated with each other;

as the number of person-supports increased, satisfaction ratings increased as well. Mean number

of person-supports was moderately associated with BMI, with more person-supports associated

with decreased BMI. Mean satisfaction ratings were weakly correlated with systolic blood

pressure and age. On average, younger participants reported lower levels of satisfaction. Mean

satisfaction scores were weakly correlated with DDS scores; increased satisfaction ratings were

associated with lower levels of diabetes distress. Higher satisfaction ratings were also linked to

23
higher levels of diabetes-related self-efficacy, as evidenced by the moderate correlation between

mean satisfaction scores and DES-SF scores.

The mean scale score on the mMOS-SSS was 55 (SD, 26.4; range, 9 – 100). On the

instrumental support subscale, the mean scale score was 54 (SD, 32.7; range, 0 – 100), and on

the emotional support subscale, the mean scale score was 56 (SD, 25.6; range, 13 – 100). Each of

these mean scores indicate that participants reported below average availability of social support.

Mean scores on the total measure were weakly correlated with income; higher income was

associated with increased availability of social support. mMOS-SSS scores were also weakly

correlated with the mean number of person-supports, signifying a positive relationship between

perceived number of supports and perceived availability of support. A moderately strong

relationship was also found between mMOS-SSS scores and mean satisfaction ratings, with an

increase in perceived availability of support associated with higher satisfaction ratings.

When correcting for multiple comparisons (p = .001), only the moderate relationships

between mean number of person-supports and BMI and between satisfaction and mMOS-SSS

scores remained statistically significant.

Self-Efficacy

The mean score was 4.0 (SD, 0.9; range, 1.5 – 5.0), indicating average levels of diabetes-

related self-efficacy overall. Scores on the DES-SF were weakly associated with age and A1C.

Participants with higher self-efficacy tended to be older and have lower A1C. DES-SF scores

were weakly associated with total DDS scores, indicating that higher diabetes-related self-

efficacy was related to decreased distress. We also found relationships between DES-SF scores

and two DDS subscales: emotional burden and regimen-related distress. Higher diabetes-related

self-efficacy was moderately associated with a decrease in emotional burden and weakly

24
associated with a decrease in regimen-related distress. When correcting for multiple comparisons

(p = .001), only the moderate relationship between diabetes-related self-efficacy and emotional

burden remained statistically significant.

25
 CHAPTER 4 DISCUSSION AND CONCLUSION

Discussion

This study assessed the relationships among diabetes distress, social support, diabetes-

related self-efficacy, and performance of diabetes self-care activities in a sample of 33 adults

with T2DM. We found significant relationships between distress, self-efficacy, and social

support, but none of these variables were significantly correlated with performance of diabetes

self-care activities. However, diabetes distress, self-efficacy, and social support do appear to be

related to outcomes of performance of diabetes self-care activities in some capacity, as evidenced

by their relationships with health indicators like A1C and BMI.

Age emerged as a relevant demographic factor, especially regarding distress levels, self-

efficacy, and satisfaction with social support. Younger individuals reported higher levels of

distress, especially emotional burden and physician-related distress. The feelings of fear and

helplessness associated with emotional burden may be particularly prevalent in younger

individuals with shorter disease duration (Kasteleyn et al., 2015). Younger individuals may have

less experience with physicians and may feel less secure in their relationship with their

healthcare team (Hessler et al., 2011). The most significant source of distress for younger

participants was interpersonal distress. Younger individuals also reported lower support

satisfaction. Together these findings suggest that age plays a role in how individuals perceive the

support they receive from family or friends. A possible explanation is that quality of support

improves over time, or that individuals need less support as they gain experience living with the

disease. Similar to D’Souza et al. (2017), we found a positive relationship between age and self-

efficacy suggesting that individuals become more self-efficacious as they get older. This result is

26
likely linked to number of years spent managing the disease, although we did not collect data on

date of diagnosis.

Diabetes distress was associated with satisfaction but not other aspects of support,

providing partial support for Hypothesis 1. Social support has long been considered a potential

buffer against stress (Cohen & Wills, 1985), so our failure to find more correlation among

distress and social support is unexpected. Decreased distress was related to increased support

satisfaction highlighting the importance of individual assessments of support quality based on

personal preferences and needs. Newton-John et al. (2017) previously demonstrated that

individuals assess and respond differently to support; for instance, some view non-involvement

as positive and desirable while others view it in a negative light. While Tang et al. (2008)

similarly discovered an inverse relationship between satisfaction and diabetes distress, they did

not utilize a formal measure of satisfaction with social support. By utilizing a formal measure of

satisfaction, we were able to build upon and provide additional evidence to support Tang et al.’s

(2008) initial conclusions regarding satisfaction and diabetes distress. Baek et al. (2014) also

found a relationship between satisfaction and diabetes distress; however, unlike the present

study, Baek et al. (2014) also found that the size of support network was associated with diabetes

distress, and further posited that social support may be a protective factor against diabetes

distress.

Increased self-efficacy was linked to lower diabetes distress, supporting Hypothesis 2.

Self-efficacy specifically shared relationships with regimen-related distress and emotional

burden, suggesting that higher self-efficacy is associated with feeling less overwhelmed,

helpless, or incompetent in one’s ability to perform their DSM routine. In support of the

relationship between these variables, SCT suggests that feeling less stressed while performing a

27
task can help people feel more self-efficacious (Schunk & Usher, 2012). Both Jiang et al. (2019)

and Devarajooh and Chinna (2017) found a similar relationship between self-efficacy and

diabetes distress. Our study examined diabetes-related self-efficacy more globally, while Jiang et

al. (2019) and Devarajooh and Chinna (2017) each measured self-efficacy as it relates to specific

diabetes self-care activities like diet and exercise. Therefore, our findings build upon prior

research by highlighting the importance of a global sense of self-efficacy as it relates to diabetes

distress.

Higher self-efficacy was associated with increased satisfaction with social support, in

partial support of Hypothesis 3. Similar to our findings regarding distress and support,

satisfaction was the only support domain significantly linked to self-efficacy. Social support

intervention studies have generated evidence of a meaningful relationship between social support

and self-efficacy. Peimani et al. (2018) found that peer support improved self-efficacy, while

participants in Mladenovic et al. (2014) intervention reported a decline in exercise self-efficacy

once participation in a support group ceased. However, neither of these studies considered

satisfaction as a relevant domain of support. Though research has examined the impact of social

support on feelings of efficacy, support satisfaction has not been a common area of focus. Lack

of data about support satisfaction is likely due in large part to utilization of multiple social

support measures, many of which do not consider satisfaction. We utilized general measures of

social support alongside a diabetes-specific self-efficacy measure, which may explain why our

results did not exhibit a correlation between overall support and efficacy.

Lee et al. (2019) did examine satisfaction with support in conjunction with self-efficacy,

but only within the context of autonomy support from an informal health supporter. Lee et al.

(2019) reported that autonomy support and respect for the supporter were associated with self-

28
efficacy but, contrary to our findings, did not find a relationship between satisfaction and self-

efficacy. Future research regarding support and efficacy may need to take a more targeted

approach by using diabetes-specific measures. Currently, there is a lack of diabetes-specific

social support measures for use with adults with T2DM (Al-Dwaikat & Hall, 2017). The

Diabetes Social Support Questionnaire – Family Version (La Greca & Bearman, 2002) and the

Diabetes Social Support Questionnaire – Friends Version (Bearman & La Greca, 2002) have

been developed for use with adolescents with Type 1 Diabetes Mellitus. Future measure

development may benefit from taking a similar approach of focusing on one source of support at

a time like family, friends, or peers.

Contrary to the existing body of literature, we did not find a significant relationship

between performance of diabetes self-care activities and self-efficacy, diabetes distress, or social

support. This lack of significant findings may be due to measure selection or small sample size.

However, we did find relationships between all four variables of interest and select health

indicators. Performance of diabetes self-care activities was significantly associated with A1C,

BMI, and cholesterol, confirming the expectation that consistent and adequate performance of

diabetes self-care activities results in favorable health outcomes. In accordance with the

literature, increased self-efficacy (Cherrington et al., 2010; D’Souza et al., 2017; Gao et al.,

2013) and decreased diabetes distress (Aikens, 2012; Fisher et al., 2010) were associated with

lower A1C, indicating some relationship between these two factors and successful management.

A1C was specifically related to emotional burden, physician-related distress, and regimen-related

distress, suggesting that those who feel a sense of control over diabetes, have positive patient-

provider relationships, and feel confident in their performance of diabetes self-care activities

may be better equipped to meet glycemic targets. Such characteristics better equip these

29
individuals to take responsibility for their own care and overcome frequently cited barriers to

self-management like emotional challenges, provider factors, and low self-efficacy (Ahola &

Groop, 2013). Although we were unable to draw connections between diabetes distress and

performance of diabetes self-care activities, our findings relating diabetes distress to A1C

reaffirm the importance of managing diabetes distress to achieve and maintain glycemic control.

Social support was not linked to A1C but was associated with BMI, another important health

indicator that has been linked with increased risk of complications from T2DM (Gray et al.,

2015). Participants with larger social networks tended to have lower BMI. Diet and exercise

adherence are two components of achieving and maintaining a healthy BMI. Therefore, our

finding regarding support and BMI suggests that there may a relationship between social support

and diet and exercise adherence that was not captured in our results.

Failing to obtain support for Hypothesis 4 is an unexpected result. The lack of correlation

between performance of diabetes self-care activities and psychosocial variables, in conjunction

with findings relating both performance of diabetes self-care activities and psychosocial

variables to glycemic control and BMI, raises questions about the utility of our diabetes self-care

measure and its ability to accurately capture an individual’s ability to self-manage. Even though

the SDSCA is a valid and reliable measure of performance of diabetes self-care activities, the

present findings suggest that it has its limitations. Although this measure encompasses many

diabetes self-care activities, it fails to measure problem-solving and healthy coping, two critical

self-care behaviors outlined within the AADE7Ô (Tomky et al., 2008). Furthermore, it is not

sensitive to individualized recommendations that study participants may be following per their

healthcare team. For example, some may need to check their blood sugar multiple times a day

while others may not need to adhere to a similar frequency (Association of Diabetes Care &

30
Education Specialists [ADCES], 2020). The SDSCA attempts to consider such individual

differences by including the question, “on how many of the last seven days did you test your

blood sugar the number of times recommended by your health care provider?” (Toobert et al.,

2000); however, the overall mean score will still be affected by responses about blood sugar

testing regardless of attempts to acknowledge the nuances in self-care. Researchers continue to

explore both the utility and the limitations of the SDSCA (Caro-Bautista et al., 2014; Lu et al.,

2016; Schmitt et al., 2016). Some research has begun highlighting the need for further

psychometric testing on the revised measure (Lu et al., 2016), while other research emerges to

suggest that an alternative diabetes self-care measure may be superior (Schmitt et al., 2016).

Future Directions

The results of this study contribute to the larger body of literature seeking to understand

how contextual and psychosocial factors interact with one another as both facilitators and

barriers to successful performance of diabetes self-care activities. Conflicting and unexpected

findings confirm the need for additional research. However, our findings in conjunction with

prior research can be used to support development of targeted interventions to help people

become more successful with DSM.

Additional research is needed among minority groups, including non-English speaking

communities and those living in rural areas. Research will benefit from further efforts to develop

and establish standardized sets of diabetes-specific measures. The current body of literature

contains a multitude of measures for every variable of interest, making it difficult to compare

results. Future research should also work toward establishing causality between variables. In

particular research should focus on variables strongly correlated with one another, like A1C and

diabetes distress.

31
 Limitations

The present study has several limitations. One significant limitation was a small sample

size. Furthermore, the sample lacked diversity in certain areas. The sample was not racially or

ethnically diverse and the majority of participants (70%) reported well-controlled A1C. The

sample also represented higher income brackets, with a median income between $70,000-

$89,999 and 45% of participants reporting an income above $90,000. We did not collect data on

education level, disease duration, or diabetes severity, which limited our picture of the sample.

Measures were only provided in English, precluding non-English speakers from

participating in the study. The battery of surveys was delivered solely online, so individuals

without access to the Internet or individuals who are not proficient in using the Internet may have

been unable to participate. Because surveys were delivered online, the researcher also did not

have the ability to clarify questions for participants or provide additional guidance. Data on

cholesterol and blood pressure was incomplete due to a lack of more direct instruction on how to

report this information. This problem may have been remediated by restricting non-numerical

survey responses for these items. An additional limitation was the amount of correlations that

were no longer statistically significant at the more conservative p-value. Including fewer

variables or a larger sample size to provide more data or inclusion of fewer variables may have

resulted in more significant findings.

Although most of our measures were diabetes-specific, the study may have benefited

from a diabetes-specific social support measure in order to better test hypotheses surrounding

social support. While our self-efficacy measure was diabetes-specific, it focused on global

feelings of efficacy and empowerment in terms of coping with and managing diabetes as

opposed to being focused on specific self-management behaviors. A different measure of self-

32
efficacy may have allowed us to better assess its relationship to performance of diabetes self-care

activities. Unexpected results also raise questions about the utility of our diabetes self-care

measure. Difficulty selecting appropriate measures is not unique to our study. DSM research as a

whole lacks standardization of measures, which is likely a significant contributor to differing

results.

Conclusion

This study found relationships among three psychosocial factors associated with DSM

but was not able to establish a direct connection between those factors and performance of

diabetes self-care activities. Our findings contribute to a growing body of literature seeking to

understand how psychosocial and contextual variables facilitate or inhibit successful integration

of DSM into a daily routine.

Our findings contain several implications for healthcare practitioners developing

effective interventions for individuals working to self-manage this chronic condition. Findings

surrounding diabetes distress suggest a need for increased focus on stress management.

Additionally, our results suggest that the source of stress changes over time, indicating that

practitioners may need to focus on targeting more specific stressors depending on factors like

age. Given its relationship to distress and A1C, self-efficacy should continue to be an area of

focus for healthcare practitioners. Practitioners must be sensitive to the fragility of self-efficacy

and frequently reassess patients’ feelings of efficacy. Our findings imply that practitioners

should pay closer attention to patients’ satisfaction with their support network. When addressing

social support, practitioners must take a patient-centered approach that focuses on establishing

support that maximizes an individual patient’s satisfaction instead of assuming that a certain type

of social support will be most effective. Future research should continue to examine the

33
dynamics among factors impacting DSM in order to gain additional understanding, establish

consensus, and provide guidance for DSM intervention.

34
 TABLES AND FIGURES

Table 1

List of Measures
Measure Domains/Subscales Units Time Frame

1. Diet
2. Exercise
Summary of Diabetes
3. Blood sugar testing
Self-Care Activities Number of days 7 days
4. Foot care
(SDSCA)
5. Smoking
6. Medication management
Diabetes distress
Subscales:
Likert scale 1 to 6
1. Emotional burden
Diabetes Distress 1 = not a problem
2. Physician-related 1 month
Scale (DDS) 6 = a very serious
3. Regimen-related
problem
4. Diabetes-related
Interpersonal

Modified Medical Social support

Likert scale 1 to 5
Outcomes Study Subscales:
1 = none of the time None
Social Support Survey 1. Instrumental
5 = all of the time
(mMOS-SSS) 2. Emotional

Social support 0 to 9 supports

Social Support
Subscales: Likert scale 1 to 6
Questionnaire Short None
1. Number of supports 1 = very dissatisfied
Form (SSQ6)
2. Satisfaction 6= very satisfied

Diabetes Likert scale 1 to 5

Diabetes-related
Empowerment Scale – 1 = strongly disagree None
self-efficacy
Short Form (DES-SF) 5 = strongly agree

35
Table 2

Demographics
Factor n
Gender (n=33)
Female 18
Male 15
Age (n=33)
18-34 1
35-54 18
55-74 13
75+ 1
A1C (n=33)
<7.0 23
>7.0 10
BMI (n=33)
<18.5 (underweight) 1
18.5-24.9 (normal) 4
25.0-29.9 (overweight) 13
30.0+ (obese) 15
Cholesterol (n=18)
<140 8
140-200 6
200-240 2
240+ 2
Systolic blood pressure (n=30)
100-120 9
120-140 21
Diastolic blood pressure (n=30)
45-70 6
70-95 24
Ethnicity (n=33)
Hispanic or Latino 0
Non-Hispanic or Latino 33
Race (n=33)
White 31
Asian 1
Other 1
Diabetes education (n=33)
Yes 16
No 17
Employment status (n=33)
Yes 22
No 11
Income (n=33)
<$10,000 2
$10,000-$29,999 3
$30,000-$49,999 4
$50,000-$69,999 5
$70,000-$89,999 4
$90,000-$149,999 10
>$150,000 5

36
37
Table 4

Summary of Diabetes Self-Care Activities Subscale Correlations

Cholesterol BMI A1C
1. Diet -.357 -.370* -.440*
2. Exercise -.589* -.296 -.464**
3. Blood sugar testing .172 -.055 -.252
4. Foot care -.480* -.199 -.137

Note: *p<0.05; **p<0.01

Table 5

Diabetes Distress Scale Subscale Correlations

Age A1C DES-SF
1. Emotional burden -.444** .617*** -.565***
2. Physician-related -.350* .534*** -.167
3. Regimen-related -.252 .756*** -.399*
4. Diabetes-related interpersonal -.521** .272 -.197

Note: *p<0.05; **p<0.01; ***p<.001 deemed significant after Bonferroni correction

38
 7

6
Average number of days

0
Diet Exercise Blood Glucose Foot Care
Testing
Subscales

Figure 1. Summary of Diabetes Self-Care Activities Subscale Scores. Figure 1 displays the
average number of days participants reported performance of self-care activities within each
subscale. Blood glucose testing was the most frequently performed activity (mean, 5.6 days),
followed by foot care (mean, 4.2 days), exercise (mean, 3.8 days), and diet (mean, 3.5 days).

39
 6

5.5

4.5

4
Mean Score

3.5

2.5

1.5

1
EB PD RD ID TOTAL
Scale

Figure 2. Diabetes Distress Scale Scores. Figure 2 displays mean total and subscale scores on
Diabetes Distress Scale for all participants. Each circle represents an individual mean score to
demonstrate overall distribution of scores for total measure and each subscale. Abbreviations are
defined as follows: EB = emotional burden; PD = physician-related distress; RD = regimen-
related distress; ID = diabetes-related interpersonal distress. Total indicates mean scores on the
full measure. Mean scores of 3 or higher indicate moderate levels of distress. Of the 33
participants, 12% scored 3 or above on the total scale, 18% scored 3 or above on EB, 21% scored
3 or above on PD, 24% scored 3 or above on RD, and 21% scored 3 or above on ID.

40
 9
8.5
8
7.5
7
A1C

6.5
6
5.5
5
4.5
4
0 1 2 3 4 5 6
Regimen-Related Distress Score

Figure 3. A1C vs. Regimen-Related Distress Scores. Figure 3 displays the line of best fit for the
relationship between A1C and regimen-related distress scores (r = .756, p <.001).

41
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APPENDICES

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Appendix A

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Appendix B

60
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Appendix C

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Appendix D

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 Appendix E

I am going to read you some statements about diabetes. Each statement finishes the sentence “In
general, I believe that…” The response categories are: Strongly Disagree, Somewhat Disagree,
Neutral, Somewhat Agree, and Strongly Agree.
It is important that you answer every statement.

Attitudes Toward Diabetes – DES

Strongly Somewhat Neutral Somewhat Strongly

Disagree Disagree Agree Agree

In general, I believe that I:

1. ...know what part(s) of

taking care of my diabetes
that I am dissatisfied with. ( ) ( ) ( ) ( ) ( )

2. ...am able to turn my

diabetes goals into a
workable plan. ( ) ( ) ( ) ( ) ( )

3. ...can try out different ways

of overcoming barriers
to my diabetes goals. ( ) ( ) ( ) ( ) ( )

4. ...can find ways to feel

better about having
diabetes. ( ) ( ) ( ) ( ) ( )

5. ...know the positive ways

I cope with diabetes-related
stress. ( ) ( ) ( ) ( ) ( )

6. ...can ask for support for

having and caring for my
diabetes when I need it. ( ) ( ) ( ) ( ) ( )

7. ...know what helps

me stay motivated to
care for my diabetes. ( ) ( ) ( ) ( ) ( )

8. ...know enough about my-

self as a person to make
diabetes care choices that
are right for me. ( ) ( ) ( ) ( ) ( )

68