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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