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Correlates of expected success at adherenceto health regimen of people with IDDM
Ruth Lo PhD RN
Lecturer, School of Nursing and Health Care Practices,
Southern Cross University, PO Box, 157, Lismore, NSW 2480, Australia
Accepted for publication 5 October 1998
LO R. (1999)LO R. (1999) Journal of Advanced Nursing 30(2), 418±424
Correlates of expected success at adherence to health regimen of people
with IDDM
Patient non-adherence is a well-recognized although poorly understood
phenomenon that affects patients in all areas of health care. Failure to comply
with health regimens is extremely costly both in economic terms and the health
status of individuals. This study assesses factors which correlate with the
expected success of health regimen adherence in 146 insulin-dependent
diabetes mellitus (IDDM) subjects. The results indicate that success in com-
plying with a health regimen is associated with good family support and rapport
with health professionals, an absence of chronic stress and the capacity to take
up the challenges posed by the disease. Health professionals have a role in
engendering optimism, in maintaining enthusiasm, and facilitating and
encouraging maintenance in health behaviours.
Keywords: compliance, diabetes mellitus, family support,
health professionals, intention and ef®cacy, stress
INTRODUCTION
The longer the duration of diabetes mellitus (DM), the
greater the likelihood of developing symptoms and signs
of degenerative complications (Shillitoe 1988) such as
heart disease, peripheral vascular disease, neuropathy,
retinopathy and renal disease. One of the most common
complications of DM is retinopathy (Harris & Linn 1985).
This is a degenerative disease of the small blood vessels in
the retina that can cause visual impairment and blindness.
Research has shown that diabetes is the leading cause of
blindness, lower extremity amputations and kidney trans-
plants in the United States (Cox & Gonder-Frederick
1992).
Apart from being a serious medical and social problem,
DM is a large economic burden on individuals and
society. Rubin et al. (1992) have stressed the economic
impact of insulin-dependent diabetes mellitus (IDDM),
including the costs associated with complications (e.g.
vascular, visual and renal). A retrospective analysis of
short-term baseline and follow-up clinical, economic, and
member and provider satisfaction data from approximately
7000 people with diabetes being treated by a comprehen-
sive diabetes management programme (Rubin et al. 1998)
showed that implementation of a comprehensive health-
care management programme for people with diabetes can
lead to substantial improvements in costs and clinical
outcomes in the short term. The authors inferred that
improvements will increase over time, with continuing
improvements in health status and a reduction in the
number of future diabetic complications.
The impact of non-adherence with recommended treat-
ment regimens on health status is staggering (Jacoby et al.
1990, Leese 1992, Olsson et al. 1994). For example, Baer
(1986) outlined the economic impact non-adherence has
on society as a whole. He cited an increase in medical
costs because of the need for additional care due to
complications of disease, exacerbations and prolongation
of illnesses, and incidence of usually preventable diseases.
Many individuals with diabetes do not adhere to their
health regimen. Research has indicated that rates of
non-compliance or non-adherence to health regimens
Journal of Advanced Nursing, 1999, 30(2), 418±424 Issues and innovations in nursing practice
418 Ó 1999 Blackwell Science Ltd
range from one-third to about three-quarters despite the
fact that the disease along with its many complications
presents life-threatening prospects (Wing et al. 1986).
Individuals are more likely to adhere to their diabetic
health regimen if the quality of their interaction and
relationship with their health providers is good and if the
individuals have a good social support system (Bernard &
Krupat 1994). Several studies have demonstrated that
positive feelings, appointment keeping, and a perception
that one's physician is warm, caring and communicating,
have been associated with medication adherence (DiMat-
teo et al. 1986, DiMatteo 1998). Conversely, actions that
anger patients and lead to dissatisfaction, such as requir-
ing people to wait a long time, are associated with lower
levels of adherence (Linn et al. 1982). Of particular
importance for people with chronic conditions is that
physicians who involve their patients as active partici-
pants in the treatment process generate a signi®cantly
higher rate of adherence than those who do not (Bernard &
Krupat 1994, Golin et al. 1996). These studies suggest that
compliance could be enhanced by warm and caring
physicians who take an interest in their patients' health
and regard patients as partners in the treatment and
prevention processes.
Social support, a component of the psychosocial envi-
ronment, is also an important determinant of individual
compliance (Tillotson & Smith 1996). The support of
family and friends has been found to be related to
compliance with diabetes regimen (Glasgow & Toobert
1988, Tillotson & Smith 1996). A study by Pham et al.
(1996) involving 76 amputation patients with non-insulin-
dependent diabetes mellitus (NIDDM) examined the rela-
tionship between their beliefs regarding diabetes and its
treatment and their self-evaluation of adherence to diabe-
tes self-care behaviours. Their ®ndings support the
importance of giving attention to patients' needs regarding
adherence to diet and exercise, improving social support,
and removing barriers to patients' treatment.
Two general viewpoints have been offered on the way in
which support works. The ®rst, known as the buffering
model, suggests that social support could serve as a source
of protection (that is, a buffer) against the harmful effects
of stress (Cohen & McKay 1984), allowing people to
appraise a stressor as less threatening and possibly
enhancing coping. The second model, known as the main
effects model (Cohen & Syme 1985), deals with the value
of social support independent of stress. It asserts that
support is a positive and useful resource, and it suggests
that its bene®ts are great even when people are not
exposed to stress.
A number of theorists ranging from Lewin (1936) to
Ajzen (1991) employ a value expectancy framework which
may be viewed as a chain of events model (Lawler 1971)
where behaviour is the outcome of a series of psycholog-
ical events, beginning with an assessment of possible
consequences or outcomes associated with each behaviour
under consideration (Glanz et al. 1997). The concern of
this paper is to identify those variables which may play a
part in the chain of events which lead to success in
complying.
This report is derived from a larger study (n� 387),
which investigated the psychosocial concomitants
of insulin-dependent diabetes mellitus (IDDM) and
non-insulin-dependent diabetes mellitus (NIDDM) by the
nature of treatment (diet alone, diet and hypoglycaemic
tablets, and diet and insulin). The theoretical model
which guided the author's efforts was derived from a
number of concepts taken from seven theories and models
of health behaviour including the Health Belief Model
(Rosenstock 1974), Lazarus' Stress and Coping Model
(Lazarus & Folkman 1984), the Theory of Reasoned
Action (Ajzen 1991), Rosenberg's Self-Esteem Inventory
(Rosenberg 1965) and Bandura's Social Learning Theory
(Bandura 19771 ). Individuals were asked to: (i) retrospec-
tively identify their lifestyle beliefs prior to the diagnosis;
(ii) indicate the degree of threat posed by a diabetes
diagnosis; (iii) indicate the stress experienced when
diagnosed with DM; (iv) identify how they coped and
lived with this initial diagnosis; and (v) indicate the ways
they currently managed the disease. This study focuses on
those IDDM (n� 146) subjects as the NIDDM subjects have
been reported elsewhere (MacLean & Lo 1998).
The study aims to address the following questions:
· What factors are associated with compliance with a
health regimen in patients with IDDM?
· What factors are related to intention to comply with a
health regimen?
· Does self-ef®cacy in¯uence compliance or intention to
comply with a health regimen?
THE STUDY
Instruments
In this study, a 5-point Likert (strongly agree Ð strongly
disagree) 11-item scale was created to measure self-ef®ca-
cy, which is the con®dence of the individual to do
exercise (3), the testing of blood sugar (3), diet (2), and
medication (3) (Cronbach a� 0á67; n� 146).
Examples of these items are: I am con®dent that I can
exercise at least three times per week, ¼ that I will test my
blood/urine for glucose regularly, ¼ that I will follow my
prescribed diet daily. The items used were similar to those
used in the intentions scale except that the pre®x was
I intend to ¼ (a� 0á91).
Ef®cacy item scores tended to be lower than the equiv-
alent intentions item scores together with a greater vari-
ability in scores. The correlation between ef®cacy and
intention was r� 0á57 (P� 0á000). Ef®cacy item scores
Issues and innovations in nursing practice Adherence to health regimen
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(2), 418±424 419
were multiplied by the appropriate intention item score.
The multiplicands were summed to create the dependent
variable used as a measure of intention to succeed in
complying. Thus, there was a recognition that con®dence
that a task can be accomplished is not suf®cient unless
there is also the intention to carry out the task.
The 12-item version of the General Health Question-
naire (GHQ) (Goldberg 1978) was used to measure
individuals' psychological health. MacLean (1990) and
Duncan-Jones et al. (19862 ) found in their studies that the
GHQ measured two types of stresses: chronic and tran-
sient. The Rosenberg (1965, Rosenberg et al. 1995) Self
Esteem Inventory was used to measure positive self-
esteem (®ve items, e.g. I feel that I have a number of good
qualities; I take a positive attitude towards myself) and
negative self-esteem (®ve items, e.g. All in all, I am
inclined to feel that I am a failure; I feel useless at times).
Both the GHQ and Rosenberg inventories are well-known,
reliable and valid measures. All instruments used in this
study with this sample were internally consistent with
Cronbach alpha's in excess of a� 0á80 (see Table 3). It
would be expected that those with high positive self-
esteem would be more likely to adhere to health regimens
than those with low self-esteem. Those with negative self-
esteem are more likely to experience dif®culty in main-
taining healthy behaviour. Similarly, whilst people with
diabetes may suffer from more transient stress from time to
time, it would be expected that those with chronic stress
(longer term stress) are those experiencing dif®culty with
their health regimens.
Ferraro et al.'s (1987) instrument, the Diabetes Locus of
Control (LOC) Scale, a disease speci®c scale, which
generates three sub-scales, namely Internal (LOC), Others
(LOC) and Chance (LOC) (Cronbach a� 0á82á75 and 0á80,
respectively), was used to identify individuals' degree of
control that could be exercised in relation to the manage-
ment of their diabetes. It was hypothesized that those with
a high internal LOC are more likely to take greater
responsibility for their illness and to adhere to their diet,
exercise and medication routines.
The ATT39 (Dunn et al. 1986) scale purports to measure
the emotional component of attitudes to diabetes. Cron-
bach a's for all the scales were quite low, except for factor
1 which comprised 11 items (a� 0á83) with highest
loadings (principal axes extraction, varimax rotation) on
items: there is little hope of leading a normal life with
diabetes (0á65); being told you have diabetes is like being
sentenced to a lifetime of illness (0á62). These 11 items
made up the Stress scale.
Three individual items of the Anderson et al. (1990)
Diabetes Attitude Scale were used in this study. The
others were discarded because of relatively low internal
inconsistency attributes. Those included for the purposes
of this study were scales concerned with good communi-
cation between health care professionals and individuals
(Relate, a� 0á80), NIDDM (a� 0á76), a scale concerned
with the apparent seriousness of non-insulin dependent
diabetes, and a scale concerned with good blood glucose
control (Control 1, a� 0á79). It was expected that high
scorers on these scales would manifestly have better
control over their diabetes.
Family support was measured by Procidano & Heller's
(1983) Perceived Social Support from Family Scale (Fam-
sup, a � 0á92), and the inconvenience and barriers to
adherence were measured by Glasgow et al.'s (1986)
questionnaire (eight items, a� 0á66).
Lazarus & Folkman's (1984) Ways of Coping Instrument
consists of a 68-item checklist containing a wide range of
actions and thoughts that individuals use to deal with
stressful situations. Refer to MacLean & Lo (1998) on how
these four scales (Avoidance, Effort, Advice and Growth)
were developed. In this present study, two scales were
generated, an avoidance scale (a� 0á88) and the proactive
scale (a� 0á89), which is the combination of the three
scales, Effort, Advice and Growth.
Sample selection
The sample of this study consisted of people with diabetes
who attended the Community Health Centres (CHCs) or
Diabetes Education Centres (DECs) throughout New South
Wales, Australia. The criteria for selection of subjects were
given to diabetes educators and dieticians to be used when
choosing appropriate subjects: (i) subjects consent
to participate; (ii) subjects speak and read English;
(iii) subjects have IDDM or NIDDM; (iv) subjects have
had DM for a period of 1±10 years since diagnoses; and
(v) subjects are aged between 18 and 65 years.
Ethics clearance from the university and the participat-
ing hospitals throughout the region was obtained prior to
distribution of the questionnaires. Diabetes educators and
dieticians in 37 CHCs and DECs in New South Wales,
Australia distributed questionnaires to 657 individuals. Of
the 657 questionnaires that were distributed by the
diabetes educators and dieticians, there was a response
rate of 59% (387 usable data). There were no signi®cant
differences between respondents and non-respondents in
terms of their gender, age, treatment and types of diabetes,
as the diabetes educators and dieticians also collected
non-respondents' data. There were eight (1%) incomplete
responses, and the rest (262) did not reply. This paper will
concentrate on the 146 IDDM respondents.
Procedures
All variables were entered into the regression model and
stepwise procedures were used to eliminate variables of
little relevance to the dependent variable under scrutiny
(Diekhoff 1992). This procedure gives all variables the
opportunity to emerge in the regression, whereas under a
R. Lo
420 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(2), 418±424
purely stepwise procedure only those variables which
typically correlate with the dependent variable emerge in
the equations. The variables which emerged as predictors
of `success' became the pool of items used in the ®nal
analysis.
FINDINGS
The majority of respondents were aged between 46 and
55 years of age. The 146 respondents consist of 65 males
(44á5%) and 81 females (55á5%). There were progressively
more subjects at each succeeding age group, i.e. the
smallest group of subjects was in the age group 18±25 and
there was about an equal number of subjects in age
groups, 26±35 and 36±45. Chi-squared analysis (Diekhoff
1992) of the data indicates that there is no relationship
between gender and age group. Whilst 71% of subjects are
married (excluding those who are widowed), there are
more males divorced (7%) than females (3%). Chi-square
analysis of the data indicates no signi®cant differences
between sex and marital status. The highest level of
education achieved by the majority of males (39%) and
females (61%) was secondary education up to Year 10.
There were about the same number of males and females
who completed certi®cates, undergraduate and postgrad-
uate studies. The mean duration of diabetes is 7 years.
Chi-square analysis of this data indicates no signi®cant
differences between males and females with regard to
educational level. Biographical factors such as the age,
gender, marital status and level of education of respon-
dents had no statistical signi®cance or in¯uence in any of
the analyses.
Table 1 presents the statistically signi®cant correlation
coef®cients among the variables. The stress associated
with being a person with diabetes as measured by the
`stress' scale, as described earlier, is signi®cantly corre-
lated (P < 0á000) with long-term chronic stress as
measured by the GHQ, with low probability of compliance
success. Stress was found to be negatively correlated with
proactive behaviour (seeking information and advice from
health professionals and family members), family support
and other locus of control.
A recognition of the challenge posed by the disease Ð
proactive Ð was correlated with good family support,
high probability of success, good relationship with health
providers and some chance with regard to LOC. The
strong proactive component is in line with other work
(Lazarus 1981, Armstrong 1987) in this area, coupled with
family support, good relationships with helping profes-
sionals and other LOC.
In many respects, the `success' variable re¯ects the more
positive aspects of the above variables. Intention to
perform self-care procedures was associated with good
family support and relationship with health providers, an
absence of chronic stress and the capacity to take up the
challenges posed by the disease.
Table 2 identi®es those variables which best predict
success in complying as measured by a combination of
intentional behaviour and feelings of con®dence of being
able to comply with their diabetic regime. The multiple
correlation (R2� 0á64) is substantial, accounting for
approximately 55% of total variance.
Table 1 Table giving statisti-
cally signi®cant Pearson pro-
duct moment correlations
(P < 0.05) and probability
levels among all variables
(n = 146)
Success
Chronic
stress Proactive
Others
LOC
Family
support
Professionals'
quality
Success 1á00 )0á31 0á45 0á18 0á47 0á34
P = 0á000 0á000 0á033 0á000 0á000
Chronic stress 1á00 )0á23 ± )0á29 ±
P = 0á006 0á000
Proactive 1á00 0á18 0á35 0á24
P = 0á033 0á000 0á003
Others' LOC 1á00 ± ±
P =
Family support 1á00 0á14
P = 0á084
Professionals' quality 1á00
P =
Table 2 Regression of dependent variables on independent
variables (n = 146). Dependent variable: success in complying
(multiple R = 0á64; R2 = 40)
Independent variables Beta R2
Chronic stress )0á17* 0á10
Family support 0á31** 0á22
Professionals' quality 0á26** 0á12
Others LOC 0á14* 0á03
Proactive 0á21** 0á20
*Indicate P < 0á05 and ** indicate P < 0á01.
Issues and innovations in nursing practice Adherence to health regimen
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(2), 418±424 421
In the equation R2� 0á64, having less chronic stress
emerges ®rst in the equation. This is followed by family
support, which is important in complying with the health
regimen. Positive attitudes to the quality of training of
diabetes professionals emerges in this equation as predic-
tive of the intention to and con®dence in the capacity to
comply with their diabetes regimen. `Other' LOC seems
also to predict compliance. Proactive, positive stance
towards the disease, and having the capacity to accept its
challenges aids in the success in complying with the
health regimen.
Table 3 shows the mean, standard deviation, minima,
maxima, and Cronbach's alpha of scales used in this
study.
CONCLUSION
The results of this study indicate that there are a number
of factors which affect success in adhering to one's health
regimen. The ®rst is stress related speci®cally to diabetes
(and associated with it are the syndrome of other stress
measures, most notably longer term chronic stress as
measured by the GHQ). Lazarus & Folkman (1984 p. 19)
de®ned psychological stress as:
a particular relationship between the person and the environment
that is appraised by the person as taxing or exceeding his or her
resources and endangering his or her well-being.
The results in this study clearly indicate that those who
experienced less stress, regardless of the source, are more
likely to follow their health regimen. The last decade has
revealed that the relationship between psychological stress
and diabetes is more complex than previously believed.
Relationships between stress and diabetes are bi-direc-
tional. Psychological stress can affect diabetes and diabetes
can affect stress levels (Cox & Gonder-Frederick 1991).
The results of this study also indicated that the quality of
rapport of patients with their health professionals is
crucial to the success of patients adhering to their health
regimens. This is in line with the results from other
researchers (Brannon & Feist 1992, DiMatteo 1998). Bartlett
et al. (19903 ) noted that when patients inform their doctors
of problems with adherence, many doctors assume that
their patients simply lack knowledge or motivation. They
launch into lengthy technical explanations, explaining the
pathophysiology of hypertension or motivate their patients
through the use of scare tactics, although neither of these
techniques have been proven to be effective. Health
professionals are in an educative as well as a supportive
role. Good quality communication can deepen the under-
standing the patient has of the disease, not only in general
terms, but more speci®cally and personally for them.
Family support has been identi®ed in the results as a
variable affecting individual's adherence. This has been
substantiated by the work of other researchers (Barnhoorn
& Adriaanse 1992, Sherbourne et al. 1992; Tillotson &
Smith 1996). These studies indicated that social support
may modify perception of stressful events by providing
the individuals with additional resources for coping with
particular stressors and thus lead to better glycaemic
control in diabetics.
`Other' LOC seems also to have an input into the success
of adhering to health regimens. A study by Schlenk & Hart
(1984) found a statistically signi®cant relationship
between compliance and social support, powerful other
health locus of control (PHLC) and internal health locus of
control (IHLC). A multiple regression analysis (Schlenk &
Hart 1984) found that social support and PHLC accounted
for at least 50% of the variance in compliance scores.
IMPLICATIONS FOR NURSING PRACTICE
Data analysis demonstrated that individuals who experi-
ence less stress, and who have a good social support, a
good relationship with health professionals and a capacity
to take up the challenges posed by diabetes have signi®-
cant bearings on the success of the individuals' compli-
ance with a health regimen.
The treatment or management of stress can be
approached in a number of ways by health professionals.
One of these is to offer individuals the opportunity to
examine the sources of their stress in present or childhood
experiences, and to consider ways of modifying their
responses to that stress. This kind of therapy can be
provided by a psychotherapist, clinical psychologist or
quali®ed counsellor. It is important to recognize that with
persistent or recurrent stressors, multiple techniques of
stress management may be required (Thoits 1986).
The individuals suffering from stress can also learn a
number of techniques that will assist them to reduce or
manage their stress in day-to-day life. Techniques such as
relaxation, yoga, biofeedback, visualization and medica-
tion have all gained in credibility and popularity in recent
years. When taught well and followed-up with continuing
support, courses in such techniques can help people to
take a new approach to the problems of stress.
Health professionals need to be aware of individuals'
needs and desires concerning social support. They may
Table 3 Means, standard deviations, minima, maxima, Cronba-
ch's alpha of scales
Variable Mean SDSD Min. Max.
Items in
scale a
Chronic stress 12á47 4á04 6 24 6 0á91
Proactive 51á66 9á26 22 71 18 0á89
Others' LOC 20á07 3á36 9 29 6 0á80
Family support 53á90 11á84 15 75 15 0á96
Professionals' quality 13á42 1á56 4 15 3 0á80
R. Lo
422 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(2), 418±424
intervene either by focusing on changing an inadequate
level of support from the informal network to a more
adequate level by in¯uencing structure, function or use of
a person's existing network or by providing direct emo-
tional and formal support to an individual.
With regard to the relating skills of health professionals
in enhancing adherence to health regimens, clinical and
research evidence suggests that a therapeutic relationship,
regardless of theoretical orientation, can contribute signif-
icantly to the process of behavioural change (Benfari et al.
1981). The health professional and patient can work
effectively together in the setting of speci®c behavioural
goals, the assessment of relevant personal and environ-
mental variables, and in the selection and implementation
of appropriate behavioural strategies to facilitate the
attainment of stated goals.
Health professionals can facilitate the process of proac-
tivity in the challenges posed by diabetes by encouraging
self-assessment of motivational factors and consulting with
individuals about strengthening positive motivators and
limiting or altering avoidance motivators. Receiving advice
and feedback from health care professionals will assist in
motivating individuals to adhere to their health regimens.
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