Effectiveness of self-management for persons with type 2 diabetes ...

SCHOOL OF NURSING

CENTRE FOR HEALTH RESEARCH (NURSING)

Effectiveness of self-management for persons with type 2 diabetes following the implementation of a self-

efficacy enhancing intervention program in Taiwan

Shu-Fang (Vivienne) Wu

RN, BN, MSc (Nursing)

This dissertation is submitted to fulfil the requirement for the award of the doctor of

Philosophy of Nursing at Queensland university of Technology

November 2007

STATEMENT OF ORIGINALITY

This work contained in this dissertation has not been previously submitted for a

degree at any other tertiary education institution. To the best of my knowledge and

belief, the dissertation contains no material previously published or written by another

person, except where due reference is made.

Name: Shu Fang Vivienne Wu

Signed:

Date :

ACKNOWLEDGEMENTS

I wish to gratefully acknowledge all the people who assisted me in varied ways during

my doctorate. Completion of this thesis would have been impossible without the

assistance and guidance of the following people.

The person who was primarily instrumental throughout the entire course of this thesis

in bringing it to a successful conclusion was Prof. Mary Courtney, my principal

supervisor and someone I consider a great mentor. I would like also to express my

gratitude to each member of my supervisory team- Prof. Helen Edwards, Dr. Jan

McDowell, Prof. Lillie M. Shortridge-Baggett and Associate Prof. Pei-Jean Chang,

for their guidance, caring support, encouragement and instruction throughout my

academic career.

Thanks also to the faculty and my nursing colleagues at the National College of

Nursing who always encouraged me to keep going. I am grateful to the Queensland

University of Technology for the two-year scholarship, the QIDS which has been

extremely helpful to my financial situation. I am deeply indebted to the people,

research team members and participants who were involved in my research project.

Without their joint, support and cooperation, my thesis would not have been possible.

A big thank you to my PhD colleagues at QUT campus. We have laughed, cried,

provoked and debated with one another. Our shared experiences made this journey

easier.

Finally, it is very difficult to imagine how I would have completed this thesis without

the love and support of my family; especially my husband, Ming-I Venson. He has

given me his complete support, patience, acceptance and love. My family all have

made my life more meaningful by sustaining me during my PhD journey.

KEYWORDS

Type 2 diabetes, Randomised controlled trial, Self-management, Self-efficacy, Outcome expectations, Self-efficacy enhancing intervention program (SEEIP), Self-care, Health-related quality of life, Psychosocial well-being, Social support, Depression, Health care utilisation

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ABSTRACT

Objective The aim of this study firstly, was to translate and test the validity and reliability of two diabetes-specific self-efficacy instruments (the Diabetes Management Self-Efficacy Scale; DMSES and the Perceived Therapeutic Efficacy Scale; PTES) in a Taiwanese population. The main aim of this study was then to develop an intervention based on self-efficacy theory that was appropriate for the Taiwanese population and to examine the effects of a self-efficacy enhancing intervention program (SEEIP). Background In Taiwan, the prevalence, mortality rate and healthcare cost of diabetes has dramatically increased. People with diabetes have low participation rates in performing self-care activities, with some two-thirds of diabetic patients not controlling their disease appropriately. Moreover, few studies in Taiwan have conducted randomised controlled trials or had improvement in patient self-care or self-management as their primary goal and no instruments that measure self-efficacy related to the management of diabetes (especially for outcome expectations) have yet been found and appropriately used to measure the effectiveness of self-management. Therefore, there is a particular need for research on self-efficacy enhancing intervention programs for people with type 2 diabetes. Design A convenience sample survey (n=230) was used in order to test the validity and reliability of C-DMSES and C-PTES in a Taiwanese population. Moreover, a randomised controlled trial (RCT) (n=145; the intervention group (72); the control group (73)) design was conducted in the main study with pre (baseline) and post-testing (undertaken at 3 months and 6 months following baseline collection). Intervention Both the control group and intervention group received the standard diabetic educational program in the outpatient clinic. The intervention group participants received the standard diabetic educational program and the following additional interventions: (1) viewed a 10-minute DVD (2) received a “Diabetes Self-Care” booklet (3) participated in four efficacy- enhancing counselling intervention sessions, and (4) participated in telephone follow-up. The self-efficacy model was adapted from

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Shortridge-Baggett & van der Bijl (1996). Diabetes self-management principles were used in program development and evaluation. Main outcome measures Instruments used in data collection included 1) Self-efficacy towards management of type 2 diabetes (as measured by the Chinese version of the Diabetes Management Self-Efficacy Scale; C-DMSES and the Chinese version of the Perceived Therapeutic Efficacy Scale; C-PTES); 2) self management behavior (as measured by the Summary of Diabetes Self-Care Activities; SDSCA); 3) health-related quality of life for diabetes (as measured by the Short Form-12; SF-12); 4) psychosocial well-being (as measured by the Medical Outcomes Study (MOS), Social Support Survey (SSS) tool and the Center for Epidemiology Studies Short Depression Scale; CES-D) and 5) health care utilisation (as measured by health care utilisation self report instrument). Data analysis

Data were double-entered for verification using SPSS® statistical software. Study I:

Descriptive statistics, regression analysis, Pearson’s correlation, Cronbach’s alpha-coefficients, factor analysis and Bland-Altman plots with 95% limits of agreement (LOA) were performed to evaluate validity and reliability of C-DMSES and C-PTES.

Study II: Descriptive analysis was used to examine demographic variables and outcome variables. T-tests were used to analyse differences on continuous data between mean scores for the intervention and control groups. Categorical data were analysed using Chi-square statistics to test the significance of different proportions. To assess the group differences of dependent variable changes, repeated measures ANOVA/ ANCOVA were used.

Results Study I: Convergent validity showed that C-DMSES correlated well with the validated measure of the General Self-Efficacy Scale (GSE) in measuring self-efficacy. Criterion-related validity showed that the C-DMSES was a significant predictor of the Summary of Diabetes Self-Care Activities (SDSCA) scores. Factor analysis supported the C-DMSES being composed of four subscales with good internal consistency (Cronbach’s alpha=.77 to .93) and stability (ICC=.82). Similarly, significant criterion-related validity was demonstrated between the C-PTES and SDSCA scores. Convergent validity was confirmed as the C-PTES converged well with the GSE Scale in measuring self-efficacy. Construct validity of the C-PTES was confirmed through factor analysis and a single subscale formed. Internal

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consistency with a Cronbach’s alpha was .95 and the test-retest reliability (ICC) was .77 and a Bland-Altman plot showed 97% of the subjects were within 2 standard deviations of the mean. Study II: The 3- and 6-month benefits of the intervention over usual care were increases in self-efficacy, outcome expectation, self-care activities, and social support. However, the results of the health-related quality of life and depression scores indicated that the change over time was not different in the two groups. A smaller proportion of the participants significantly in the intervention group, had been hospitalised and visited the emergency room than participants who were in the control group at the 6-month period. However, health-related quality of life and depression were not significantly increased in the intervention group at the 3- and 6-month compared to the control group.

Conclusion Results of Study I support the psychometric properties of C-DMSES and C-PTES in providing a measure for self-efficacy specific to persons with type 2diabetes in Taiwan. The main study revealed that the SEEIP for type 2 diabetes based on self-efficacy theory was culturally acceptable to Taiwanese people with diabetes and that the SEEIP was effective in the self-management of people with type 2 diabetes.

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List of publications related to this thesis Title Status

TAIWANESE JOURNALS

Wu, S. F., Li, Y. C., Chang, J. R., & Courtney, M (2007). The Application of Self-Efficacy Counselling Skills in Health Education for Patients with Diabetes, The Journal of Nursing (Taiwan), 54(1), 70-77 .

Published

Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, J. R. (2006). Application of the Self-Efficacy Model in Nursing Practice, VGH Nursing Journal (Taiwan), 23(2), 181 -186.

Published

Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, J. R. Hong, S. T. (2006). Self-efficacy-enhancing intervention training and application for patients with diabetes mellitus. Formosan Journal of Medicine (Taiwan), 10(1), 115-122.

Published

Wu, S. F. (2006). A two-stage translation and test the validity and reliability of a foreign instrument. The Journal of Nursing (Taiwan), 53 (1), 65-71.

Published

INTERNATIONAL JOURNALS (WITH SCI IMPACT FACTOR)

Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, J. R. (2006). Development and validation of the Chinese version Diabetes Management Self-Efficacy Scale, International Journal of Nursing Studies, doi:10.1016/j.ijnurstu.2006.08.020 (SCI, Impact Factor=0.692).

Accepted &

In press

Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, J. R. (2006). Psychometric properties of the Chinese version of the Perceived Therapeutic Efficacy Scale, Journal of the Formosan Medical Association, (SCI, Impact Factor= 0.453).

Accepted

Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, J. R. (2006). Self-efficacy, outcome expectations, and self-care behavior in people with type 2 diabetes in Taiwan, Journal of Clinical Nursing, (SCI, Impact Factor=0.867 )

Accepted &

In press

CONFERENCE PRESENTATIONS (PEER-REVIEWED) *denotes presenter

*Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, P.J. (20-22 July 2006). Evaluation of a Self-Efficacy Enhancing Intervention for Taiwanese Persons' Self-Management of Type 2 Diabetes. in The Sigma Theta Tau International 17th International Nursing Research Congress: Advancing Knowledge and Community

Published

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Globally Through Collaboration, Le Centre Sheraton Montréal, Québec, Canada: Sigma Theta Tau International Honor Society of Nursing

*Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M.,

Chang, P.J. (2005, Nov.).Understanding diabetes mellitus in Taiwan: Evaluation of the validity and reliability of a diabetes-specific self-efficacy instrument in a Taiwanese population. in The 3rd Pan-Pacific Nursing Conference & The 5th Hong Kong Nursing Symposium on Cancer Care. Shatin, N.T., Hong Kong: The Nethersole School of Nursing

Published

*Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, P. J. (2005, May). Translation and validation of a diabetes-specific self-efficacy instrument in a Taiwanese population. in ICN 23rd Quadrennial Congress, Nursing on the move: Knowledge, innovation and vitality. Taipei, Taiwan: Taiwan International Conference Centre (TICC)

Published

CONFERENCE POSTERS (PEER-REVIEWED) *denotes presenter

*Wu, S. F., Courtney, M, Edwards, H., McDowell, J. Shortridge-Baggett, L. M., Chang, P. J. (2005, May). Improving Taiwanese persons’ self-efficacy towards self-management of type 2 diabetes. in International Network for Doctoral Education in Nursing, A global agenda for nursing doctoral education. Taipei, Taiwan: The Howard Plaza Hotel Taipei.

Published

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TABLE OF CONTENTS Contents page ABSTRACT.................................................................................................................i LIST OF PUBLICATIONS RELATED TO THIS THESIS..........................................iv TABLE OF CONTENTS.............................................................................................vi LIST OF APPENDICES..........................................................................................xvi LIST OF TABLES ....................................................................................................xviii LIST OF FIGURE ...................................................................................................xxi

Chapter 1 Introduction ........................................................................ 1

1.1 Introduction .........................................................................................................1 1.2 Background and significance of the study ...........................................................2 1.3 The aim, objectives, and research questions, hypotheses, and definitions .........10

1.3.1 Two research studies in three phases ....................................................10 1.3.2 The aim ................................................................................................11 1.3.3 Objectives .............................................................................................12 1.3.4 Research questions................................................................................12 1.3.5 Research Hypotheses ............................................................................13 1.3.6 Definitions of terms ..............................................................................14

1.4 Assumptions ........................................................................................................18 1.5 Expected outcomes ..............................................................................................18

1.5.1 Study I...................................................................................................18 1.5.2 Study II outcome...................................................................................18

1.6 Summary .........................................................................................................20

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Chapter 2 Review of literature on the burden of diabetes mellitus and on current health care in Taiwan ............................. 21

2.1 Introduction..........................................................................................................21 2.2 Population profile of Taiwan including its health characteristics ........................21

2.2.1 A profile of Taiwan ...............................................................................21 2.2.2 Health care expenditure ........................................................................22 2.2.3 National Health Insurance in Taiwan....................................................23 2.2.4 Core health policies in Taiwan..............................................................23 2.2.5 Chronic diseases in Taiwan...................................................................24

2.3 The prevalence, mortality rate and cost burden of diabetes mellitus in Taiwan ..25

2.3.1 High prevalence rate of diabetes mellitus in Taiwan ............................26 2.3.2 High mortality rate of diabetes mellitus in Taiwan...............................28 2.3.3 The high proportion of health expenditure for the treatment

of diabetes mellitus ...............................................................................29 2.3.4 Conclusions...........................................................................................31

2.4 Current situation for diabetes health care services in Taiwan..............................31

2.4.1 Community-base approach ...................................................................31 2.4.2 Hospital-base approach.........................................................................33

2.5 Diabetes in Taiwan: self management issues.......................................................35 2.6 Literature on diabetes care interventions in Taiwan ............................................37 2.7 International cooperation .....................................................................................40 2.8 Summary ..............................................................................................................40

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Chapter 3 Review of literature on diabetes, self-care, quality of life, and psychosocial issues ............................. 46

3.1 Introduction .........................................................................................................46 3.2 Diabetes Mellitus .................................................................................................46

3.2.1 Diagnosis and definition ......................................................................46 3.2.2 Classifying diabetes .............................................................................48 3.2.3 Complications .....................................................................................50

3.3 Self-care of diabetes ............................................................................................53

3.3.1 Blood glucose monitoring.....................................................................55 3.3.2 Nutrition................................................................................................57 3.3.3 Exercise ................................................................................................59 3.3.4 Medication ............................................................................................61 3.3.5 Foot care................................................................................................64

3.4 Quality of life and diabetes ..................................................................................68

3.5 Psychosocial issues and diabetes .........................................................................71

3.5.1 Diabetes and social support ....................................................................72 3.5.2 Diabetes and depression..........................................................................74

3.6 Summary…. .........................................................................................................78

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Chapter 4 Framework ......................................................................... 81 4.1 Introduction .........................................................................................................81 4.2 Self-efficacy model .............................................................................................81

4.2.1 Self-efficacy (efficacy expectations) ....................................................84 4.2.2 Outcome expectations...........................................................................87 4.2.3 Information sources ..............................................................................90

4.2.3.1 Performance accomplishments .................................................90 4.2.3.2 Vicarious experience.................................................................91 4.2.3.3 Verbal persuasion......................................................................92 4.2.3.4 Self-appraisal ............................................................................93

4.2.4 Behaviour..............................................................................................94

4.3 Self-efficacy and diabetes self-management .......................................................95 4.4 Self-efficacy and health outcome variables .........................................................102

4.4.1 Self-efficacy and quality of life ............................................................102 4.4.2 Self-efficacy and psychosocial-well-being ...........................................105

4.4.2.1 Self-efficacy and social support................................................105 4.4.2.2 Self-efficacy and depression .....................................................108

4.4.3 Self-efficacy and health care expenditure.............................................110

4.5 An intervention program based on self-efficacy theory ................................113 4.5.1 The rationale for developing SEEIP .....................................................113

4.5.1.1 To test the self-efficacy model requires establishing a comprehensive intervention program.....................................114

4.5.1.2 A new conceptual framework: the empowerment approach.....117 4.5.1.3 Traditional patient educational programs in Taiwan

are insufficient for people’s diabetic control.............................118 4.5.2 Development of self-efficacy for people with diabetes ........................121

4.5.2.1 Counselling skills to develop self-efficacy ..............................121 4.5.2.2 Self-efficacy enhancing strategies according to

Bandura’s information sources .................................................128

4.6 Summary ..............................................................................................................138

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Chapter 5 Methods .............................................................................. 140 5.1 Introduction..........................................................................................................140 5.2 Study I: Translation, testing of validity and reliability of two diabetes-specific

self-efficacy instruments in a Taiwanese population .......................141 5.2.1 Research design ....................................................................................141

5.2.1.1 Stage one: translation and instruments development................142 5.2.1.2 Stage two: validation and reliability of instruments .................146

5.2.2 Population and sample ..........................................................................149 5.2.3 Setting and procedure ...........................................................................149 5.2.4 Research concept and instruments/measurement strategies .................150 5.2.5 Data Analysis ........................................................................................154 5.2.6 Ethical considerations ...........................................................................155

5.3 Study II (Pilot Study): Development of an intervention based on self-efficacy

theory and piloting of the intervention ..........................................156 5.3.1 Research design ....................................................................................158 5.3.2 Population and sample ..........................................................................158 5.3.3 Setting and procedure ...........................................................................159 5.3.4 Ethics considerations ............................................................................159 5.3.5 Results: Study II (Pilot Study) ..............................................................160

5.3.5.1 Viewing a 10-minute DVD .......................................................162 5.3.5.2 Receiving the “Diabetes Self-Care” booklet.............................163 5.3.5.3 Participating in four efficacy- enhancing counseling

intervention sessions .................................................................164 5.3.5.4 Participating in telephone follow-up.........................................165

5.4 Study II (Main Study): Randomised controlled trial to evaluate the

efficacy of an intervention ..........................................167 5.4.1 Research design ....................................................................................167 5.4.2 Population and sample ..........................................................................167 5.4.3 Sample size ...........................................................................................168 5.4.4 Setting and procedure ...........................................................................170 5.4.5 Research concept and instruments/measurement strategies .................173 5.4.6 Data management and analysis.............................................................178

5.4.6.1 Data management......................................................................179 5.4.6.2 Data analysis .............................................................................180

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5.4.7 Ethical considerations ...........................................................................181 5.5 Summary ..............................................................................................................182 Chapter 6 Results ................................................................................. 184 6.1 Introduction..........................................................................................................184 Result of Study I.......................................................................................................184 6.2 Description of sample ..........................................................................................184 6.3 Result of the Chinese version of the DMSES (C-DMSES).................................187

6.3.1 Result of Stage one: translation and development of the C-DMSES .............................................................................................187

6.3.2 Result of Stage two: validation and reliability of the C-DMSES .............................................................................................188 6.3.2.1 The content validity of the C-DMSES............................................189 6.3.2.2 The criterion validity of the C-DMSES..........................................191 6.3.2.3 The convergent validity of the C-DMSES......................................193 6.3.2.4 The construct validity of the C-DMSES.........................................193 6.3.2.5 Internal consistency of the C-DMSES............................................196 6.3.2.6 Stability of the C-DMSES ..............................................................197

6.4 Result of the Chinese version of the PTES (C-PTES).........................................199

6.4.1 Result of Stage one: translation and development of the C-PTES ................................................................................................199

6.4.2 Result of Stage two: validation and reliability of the C-PTES ................................................................................................199 6.4.2.1 The content validity of the C-PTES................................................199 6.4.2.2 The criterion validity of the C-PTES..............................................201 6.4.2.3 The convergent validity of the C-PTES..........................................203 6.4.2.4 The construct validity of the C-PTES.............................................203 6.4.2.5 Internal consistency of the C-PTES................................................205 6.4.2.6 Stability of the C-PTES ..................................................................205

6.5 Summary result of Study I ...................................................................................207

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Result of Study II (Main study) .............................................................................208 6.6 Introduction..........................................................................................................208 6.7 Description of sample ..........................................................................................209 6.8 Checking differences between groups .................................................................212

6.8.1 Sociodemographics and illness history...................................................212 6.8.2 Key variables of participants ...................................................................214

6.9 Question 2: Can an intervention (SEEIP) based on self-efficacy theory improve

self-management in people with type 2 diabetes in Taiwan? .............................216 6.9.1 Question 2.1: Is there a difference in the self-efficacy of people

with type 2 diabetes following implementation of the SEEIP? .................217 6.9.2 Question 2.2: Is there a difference in the self-care activities of people

with type 2 diabetes following implementation of the SEEIP? .................221 6.9.3 Question 2.3: Is there a difference in health-related quality of life of

people with type 2 diabetes following implementation of the SEEIP? ......223 6.9.4 Question 2.4: Is there a difference in the psychosocial well-being of

people with type 2 diabetes following implementation of the SEEIP? ......226 6.9.5 Question 2.5: Is there a difference in health care utilisation of people

with type 2 diabetes following implementation of the SEEIP? ..................233

6.10 Summary result of Study II................................................................................237

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Chapter 7 Discussion ........................................................................... 239 7.1 Introduction..........................................................................................................239 Discussion of Study I................................................................................................240 7.2 Discussion of the Chinese version of the DMSES (C-DMSES)..........................240

7.2.1 Discussion of Stage one: translation and development of the C-DMSES .............................................................................................240

7.2.2 Discussion of Stage two: validation and reliability of the C-DMSES ............................................................................................242 7.2.2.1 The content validity of the C-DMSES............................................242 7.2.2.2 The criterion validity of the C-DMSES..........................................244 7.2.2.3 The convergent validity of the C-DMSES......................................244 7.2.2.4 The construct validity of the C-DMSES.........................................245 7.2.2.5 Internal consistency of the C-DMSES............................................248 7.2.2.6 Stability of the C-DMSES ..............................................................249

7.3 Discussion of the Chinese version of the PTES (C-PTES) .................................250

7.3.1 Discussion of Stage one: translation and development of the C-PTES .................................................................................................250

7.3.2 Discussion of Stage two: validation and reliability of the C-PTES ................................................................................................251 7.3.2.1 The content validity of the C-PTES................................................251 7.3.2.2 The criterion validity of the C-PTES..............................................252 7.3.2.3 The convergent validity of the C-PTES..........................................253 7.3.2.4 The construct validity of the C-PTES.............................................254 7.3.2.5 Internal consistency of the C-PTES................................................254 7.3.2.6 Stability of the C-PTES ..................................................................255

7.4 Summary discussion of Study I ...........................................................................256

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Discussion of Study II (Main Study) ......................................................................258 7.5 Description of sample, sociodemographics, and illness history

of participants......................................................................................................258

7.6 Research Question 2: Can an intervention (SEEIP) based on self-efficacy theory improve self-management in people with type 2 diabetes in Taiwan?.....259 7.6.1 Hypothesis 1: People who receive the intervention will have

greater self-efficacy towards managing their type 2 diabetes than people who do not receive the intervention .......................................259

7.6.2 Hypotesis 2: People who receive the intervention will undertake diabetes self-care activities more frequently than people who do not receive the intervention ................................................263

7.6.3 Hypothesis 3: People who receive the intervention will have better HRQOL than people who do not receive the intervention ...............266

7.6.4 Hypothesis 4: People who receive the intervention will have better psychosocial well-being than people who do not receive the intervention...................................................................268

7.6.5 Hypothesis 5: People who receive the intervention will have a lower usage of health services than people who do not receive the intervention....................................................................273

7.7 Summary discussion of Study II (Main Study) ...................................................275

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Chapter 8 Conclusions and Recommendations ................................. 277 8.1 Introduction..........................................................................................................277 8.2 Conclusion and significance of Study I ...............................................................279 8.3 Conclusion and significance of Study II..............................................................280 8.4 Implications..........................................................................................................283 8.5 Limitations ...........................................................................................................286 8.6 Recommendations................................................................................................287 8.7 Summary ..............................................................................................................289

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LIST OF APPENDICES Contents page Appendix 1. REFERENCES ................................................................................ A1 Appendix 2. The letter of approval from University Human Ethics Committee,

Queensland University of Technology............................................ A21

Appendix 3. The letter of approval from the Research Degree Committee,

Queensland University of Technology ............................................ A22 Appendix 4. A study consent form from Tri-Service general Hospital

in Taipei city, Taiwan ...................................................................... A23 Appendix 5. Study information sheet (Study I) ................................................... A24 Appendix 6. Study information sheet (Study II) (Intervention group) ................. A27 Appendix 7. Study information sheet (Study II) (Control group)......................... A30 Appendix 8. Study consent form (Study I & II) .................................................. A33 Appendix 9. The questionnaire in English .......................................................... A34 Appendix 10. The questionnaire in Chinese ......................................................... A47 Appendix 11. The approval of DMSES scale ..................................................... A59 Appendix 12. The approval of PTES scale ......................................................... A60 Appendix 13. The approval of SDSCA scale........................................................ A61 Appendix 14. The approval of SF-12 scale ......................................................... A62 Appendix 15. The approval of MOS-SSS scale .................................................. A63

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Appendix 16. The approval of GSE scale ........................................................... A64 Appendix 17. The approval of CES-D scale ........................................................ A65 Appendix 18. A certificate of participation for 10 sessions of the “get to

know your blood glucose level” program .................................... A66

Appendix 19. A certificate of participation for 24-hour chronic disease counseling skills program ........................................................... A67

Appendix 20. Intervention suite of the SEEIP .................................................... A68

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LIST OF TABLES Contents page Table 2.1 Ten leading causes of death in Taiwan in 2004..................................... 24 Table 2.2: Total Diabetes Population .................................................................... 27 Table 2.3 Results of diabetes care ........................................................................ 35 Table 2.4 Publications related to self-efficacy or interventions for diabetes

care in Taiwan ........................................................................................ 44 Table 3.1Diagnostic criteria for diabetes based on the fasting plasma

glucose (venous) .................................................................................... 47

Table 4.1 Goals, strategies and targets: from the general to the specific .............. 126 Table 5.1 Instrument/ measurement strategies (Study I) ...................................... 150 Table 5.2 Comparison of traditional patient education in Taiwan and

the SEEIP............................................................................................... 156 Table 5.3 Intervention suite of the SEEIP ............................................................ 161 Table 5.4 Instrument/ measurement strategies (Study II: Main Study) ................ 173 Table 6.1 Characteristics of participants (Study I) ............................................... 185

Table 6.2 Characteristics of participants of the total and retest sample (Study I) ................................................................................................................ 186 Table 6.3 Results of the translation and the back-translation of the C-DMSES .. 188 Table 6.4 Expert panel for content validity .......................................................... 189

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Table 6.5 Content validity score of C-DMSES .................................................... 190 Table 6.6 A regression analysis summary for the C-DMSES predicting

the SDSCA ............................................................................................ 193 Table 6.7 The result of the principal-component factor analysis for C-DMSES.. 194 Table 6.8 Rotated factor matrix of the C- DMSES. Principal-component

method with Varimax rotation ........................................................... 195 Table 6.9 Cronbach’s α value of C-DMSES ........................................................ 197 Table 6.10 The C-PTES after modification based on the experts’ comments ..... 200 Table 6.11 Content validity score for C-PTES...................................................... 200 Table 6.12 Rotated factor matrix of the C-PTES. Principal-component

method with Varimax rotation ............................................................ 204 Table 6.13 Pearson item-total coefficient of correlation of the C-PTES.............. 205 Table 6.14 Comparisons of sociodemographics and illness history between

intervention and control groups .......................................................... 212 Table 6.15 Differences between groups on the key variables of baseline ............ 215

Table 6.16 Differences between groups on health care utilisation of baseline .... 216 Table 6.17 The mean (SD) for the efficacy-expectation and

outcome-expectation scores ................................................................ 218 Table 6.18 The mean (SD) for the self-care activities scores ............................... 221 Table 6.19 The mean (SD) for the physical health and mental health scores....... 224 Table 6.20 The mean (SD) for the social support and depression scores ............. 226

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Table 6.21 Repeated measure analysis of variance for the outcome variables ..... 230 Table 6.22 Comparisons of outcome variables by time of groups

(Paired-t Test) ..................................................................................... 231 Table 6.23 Comparisons of outcome variables by time of groups

(Independent-t Test)............................................................................ 232 Table 6.24 Comparison of visits to emergency room between intervention

and control groups .............................................................................. 236 Table 7.1 Comparison of subscales in the Dutch and Chinese versions of DMSES

............................................................................................................. 247

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LIST OF FIGURES Contents page Figure1.1 The two research studies ...................................................................... 11 Figure 2.1 Total of People with Diabetes in the world ......................................... 26 Figure 2.2 The Prevalence of Diabetes in Taiwan ................................................ 28

Figure 2.3 Mortality Rate for Diabetes in Taiwan ................................................ 29 Figure 4.1 Self-efficacy Model adapted from Shortridge-Baggett

and van der Bijl (1996) ....................................................................... 83 Figure 4.2 Modified self-efficacy model for evaluation of the

self-efficacy enhancing intervention program (SEEIP) for persons with type 2 diabetes......................................................... 116

Figure 5.1 Two studies (or three phases) of the research ..................................... 141 Figure 5.2 Stage one of the development processes of the C-DMSES

& C-PTES .......................................................................................... 145

Figure 5.3 Stage two of the validation and reliability of instruments of

the C-DMSES & C-PTES.................................................................. 148

Figure 5.4 Sampling strategy and procedures to collect the study sample

in Study II (Main Study) .................................................................... 168 Figure 5.5 The result of repeated measures ANOVA power analysis................... 169 Figure 5.6 Research design- experimental study .................................................. 172 Figure 6.1 Scatter plot between SDSCA and C-DMSES for individual

observations ........................................................................................ 192

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Figure 6.2 Scree plot of the C-DMSES ................................................................ 195

Figure 6.3 Bland-Altman plot for reproducibility of C-DMSES scores............... 198 Figure 6.4 Scatter plot between SDSCA and C-PTES for individual

Observations ....................................................................................... 202

Figure 6.5 Scree plot of the C-PTES .................................................................... 204

Figure 6.6 Bland-Altman plot for reproducibility of C-PTES scores................... 206

Figure 6.7 Sample of the main study .................................................................... 211 Figure 6.8 Graph of the interaction between time and group for the

efficacy expectations........................................................................... 219

Figure 6.9 Graph of the interaction between time and group for the outcome expectations................................................................... 221

Figure 6.10 Graph of the interaction between time and group for the self-care activities ........................................................................ 223

Figure 6.11 Graph of the interaction between time and group for the

physical health-related quality of life .............................................. 224

Figure 6.12 Graph of the interaction between time and group for the mental health-related quality of life................................................. 225

Figure 6.13 Graph of the interaction between time and group for the

social support ................................................................................... 228

Figure 6.14 Graph of the interaction between time and group for the depression ........................................................................................... 229

Figure 6.15 The percentage of the hospitalisation between the intervention and control groups at Time 1, Time 2 and Time 3........................... 234

Figure 6.16 The percentage of visits to emergency room between the intervention

xxiii

and control groups at Time 1, Time 2 and Time 3........................... 235

Figure 6.17 The percentage of visits to OPD between the intervention and control groups at Time 1, Time 2 and Time 3........................... 235

Student number: n4513282 Shu-Fang Wu Chapter 1 Introduction

1

Chapter 1

1.1 Introduction

Diabetes Mellitus (diabetes) is a prevalent and costly condition with substantial

morbidity and mortality. Enhancing self-efficacy for persons with diabetes, improving

their self-management and quality of life, and reducing their utilisation of health

services is an ongoing challenge for health-care providers and the government. In

Taiwan, the prevalence, mortality rate and health care costs of diabetes have increased

dramatically. Previous research has shown that people with diabetes may lack

education or skills or have low participation rates in performing self-care activities

(Chuang et al., 2001; Lin et al., 2001). In addition, only a few studies have used

randomised trials and only a few studies have examined the improvement in patient

self-care or self-management as their primary goal in Taiwan. There is a particular

need for research on an intervention program to enhance the self-efficacy of people

with type 2 diabetes. The approach used for this study was to develop an intervention

that would be responsive to the needs of people with type 2 diabetes, and would

improve their self-efficacy and their self-management ability. This intervention was

evaluated in a randomised controlled trial (RCT) that included multiple measures of

outcomes, such as self-efficacy in managing type 2 diabetes, diabetes self-care

activities, health-related quality of life, psychosocial well-being and health service

utilisation. A 6-month follow-up and a pre- and post-test design was used to evaluate

the effectiveness of the intervention. This chapter will discuss the background and

significance of this study, and its purpose, objectives, research questions and

definitions and expected outcomes.


2

1.2 Background and significance of the study

Diabetes in adults is a global health problem. Diabetes mellitus is a disorder of the

endocrine system characterised by abnormal fluctuations in blood glucose levels,

usually related to a defect in insulin production and glucose metabolism (Dunning,

2003). Although its prevalence varies widely between different populations, the rate

has generally increased worldwide (Chang et al., 2000). The global number of

diabetes patients is estimated to rise significantly from 176 to 370 million between

2000 and 2030, with more than 80% of them living in developing countries (Aubert,

1997; King, Aubert & Herman, 1998; World Health Organization (WHO), 2003). In

Taiwan, the overall 5-year incidences for men and women were 187.1 and 218.4 per

100,000 populations, respectively (Tseng et al., 2006), of these 96.7% had type 2

diabetes (Tasi, Wong, Lin & Chang, 2002). It is estimated that there are about

540,000 patients with drug-treated diabetes, affecting around 1 million people (Tseng,

2003), out of a total population of 23 million people in Taiwan. Moreover, diabetes

mellitus has been ranked as the fourth leading cause of death in Taiwan (Taiwan

Department Of Health (DOH), 2006). It is associated with long-term complications,

including heart disease, peripheral vascular disease, neuropathy, retinopathy, renal

disease and poor health-related quality of life (Guthrie & Guthrie, 2002). In addition,

the mortality rate of diabetes has dramatically increased from 7.9 per 100,000

population in 1980, to 16.8 per 100,000 in 1985 and to 34.49 per 100,000 in 1998 (Lu,

Yang, Wu, Wu & Chang, 1998; Tseng, Chong & Heng, 2000). In 2002, there were

8,818 cases of mortality from diabetes mellitus. These statistics reflect the

considerable impact the disease has on the health care system; health care costs for

diabetic patients amount to 11.5% of the total health care expenditure in Taiwan

(Tseng, 2003). Diabetes, therefore, is not only a serious health problem but also has a

major impact on the National Health Insurance budget of Taiwan.


3

In Taiwan, several factors contribute to the poor control of diabetes. Firstly, lack of

education for diabetic patients, due to issues such as pressure of time; lack of

communication skills; lack of familiarity and confidence with appropriate education

strategies; and lack of counselling skills among health professionals. Secondly, people

who live in Taiwan typically do not obtain sufficiently comprehensive medical

information. Finally, while some people have poor control of their disease due to

shortfalls in self-care knowledge or skills, a large proportion of diabetic people do not

have the motivation to make any changes. Two epidemiological surveys showed that

only 30% of people with diabetes had performed self-monitoring of blood sugar or

urine sugar, indicating that people with diabetes may lack skills or have low

involvement in self-care activities (Chuang, Tsai, Huang & Tai, 2001; Lin, Chou, Lai,

Tsai & Tai, 2001). A recent Taiwanese study found that still only 9.4 % of patients <

65 years and 14.0 % > 65 years had HbA1c values within the optimal range (HbA1c

< 6.5 %) (Tai, Chuang, Tsai & Huang, 2006). Alarmingly, Tseng (2003) also stated

that 30% of people with diabetes were found to have an HbA1C level >10%. This

means more than two-thirds of diabetic patients do not control their disease

appropriately (Tasi et al., 2002) because it is difficult for them to change their

lifestyles.

In general, diabetes patient education programs can be found in some hospitals and

community health services in Taiwan. These traditional patient educational programs

may be conducted either by individuals or groups. Individual patient educational

program means one patient receives one professional’s health education. Group

patient educational program means many patients receive one professional’s health

education at one time. Normally nurses or diabetes educators will be involved in

delivering these patient education programs (either by individuals or groups), with a


4

few nutritionists or dieticians also contributing. In 2001, the Bureau of National

Health Insurance (BNHI) started some “quality-based payment programs” to improve

quality of care, including diabetes care. This reimburses medical care providers with

extra payments if they provide nutrition consulting and individual diabetic education.

It is estimated that, currently, there are about 139 diabetes educational promotion

institutions in Taiwan. Even though patient education is being widely promoted, there

remains a lingering doubt about how effective it is in achieving the desired

improvement in diabetic care. Previous studies have shown that, unfortunately, most

diabetic patients in Taiwan do not control their disease appropriately. Consequently,

assisting people with diabetes to change their behaviour is significant in implementing

self-management and reaching the highest possible level of health

(Shortridge-Baggett, 2001). For diabetes care to succeed, patients must be able to

make informed decisions about how they will live with their illness (Funnell &

Anderson, 2000).

It has been recognised for at least a decade that the treatment of diabetes and illness in

industrialised countries has moved from reliance on medical interventions alone to

involving also the development of personal skills to adapt to the process of illness

(Connelly, 1987). Management of diabetes is aimed at keeping blood sugar levels

within the normal range (Drury, 1979; Expert Committee on the Diagnosis and

Classification of Diabetes Mellitus, 1997); effective management depends on the

individual with diabetics undertaking a range of self-care behaviours that may include

insulin injections several times daily, oral hypoglycemics, a strict calorie-controlled

diet that is low in fat and high in fibre, and regular exercise (Wing, Epstein, Nowalk

& Lamparski, 1986). Diabetes is a disease for which treatment and prevention of

complications largely depends on the patient’s willingness to self-manage most of


5

their own care on a daily basis (Fitzgerald et al., 2000). Maintaining long-term

motivation and concordance are major issues; lowering blood sugar level requires

changes to lifelong behaviours related to diet and physical activities, a very difficult

and complex process (Prochaska & DiClemente, 1983). Patients’ self-management

depends heavily on their education and empowerment, and their self-monitoring of

the outcomes of self-care (Pasavic, 1980). However, Clement (1995) stated that more

than 50% of patients with diabetes receive limited education on diabetes

self-management, or none. Only through education and empowerment can people’s

awareness of their self-care abilities be improved, leading to a better quality of life

(Chuang et al., 2001).

Self-efficacy is a cognitive resource that enables an individual to adapt to and cope

with chronic illness; efficacious individuals are able to cope under diverse conditions

and are willing to meet new challenges (Bandura, 1997). Over the last 30 years,

Bandura’s social cognitive theory has been increasingly applied, both as a model of

health behaviour and as a framework for developing effective health interventions

(Bandura, 1977b; 1986). Self-efficacy is an important element of social cognitive

theory. Bandura has defined self-efficacy as “people’s judgment of their capabilities to

organise and execute the course of action which require designated types of

performances” (Bandura, 1986, p.391). WHO (1986) advocated the use of strategies

to enable people to make healthy lifestyle choices. Self-efficacy theory provides the

scientific rationale for strategies that have the potential to enhance people’s

self-confidence in their ability to undertake behaviour change.

Self-efficacy also offers a basis for improving the effectiveness of diabetes education

because it focuses on behavioural change (van der Bijl & Shortridge-Baggett, 2001).


6

Johnson (1996) suggested that it is important to develop educational programs based

on self-efficacy theory for the self-management of diabetes. These can improve upon

traditional diabetes education that focuses only on the transmission of information or

skills (Moens, Grypdonck & van der Bijl, 2001; van de Laa & van der Bijl, 2001).

Health care professionals view the facilitation of personal self-efficacy, in the

individuals’ ability to manage self-care regimens, as a primary health resource and an

effective solution for diabetes management. So, in order for individuals to take an

active role in their own health, people need an increased understanding of their illness

condition and of self-care regimens. Intervention strategies must involve building up

their personal self-efficacy in individual’s ability to manage self-care activities, as

well as the development of positive expectations about their health outcomes (Bradley,

1989).

A comprehensive literature review has revealed that there have been 92 Taiwanese

studies related to self-efficacy, in areas such as education, social learning, job

satisfaction, information management and exercise behaviours. However, few

researchers have engaged in self-efficacy research in relation to health period.

Nevertheless those who did so have demonstrated that self-efficacy is an important

predictor of health improvement (Chang, Huang & Lee, 1996; Wang & Chiou, 1996;

Hung & Kao, 1997; Chen, Chang & Lin, 1998; Wang, Wang & Lin, 1998; Guo, Tsay

& Yen, 2002). At the time of writing, only three correlational research studies that

relate to self-efficacy and diabetes were located (Chang & Lin, 1997; Chen, Chang &

Lin, 1998; Wang, Wang & Lin, 1998), and only two intervention studies relating to

empowerment and diabetes (Lai & Liu, 2003; Guo, Tsay & Yen, 2002). There are

other studies that have evaluated interventions to improve dietary behaviour, exercise

and glucose testing, but none was found that addressed all of these in one study.


7

No Taiwanese studies have used randomised trials as a methodology to trial new

interventions for diabetes; instead they have focused on how to produce

improvements in diabetes knowledge rather than on measures of self-management or

behaviour change (Chuang, Lin, Wu, Chen & Tai, 1989). Also, many studies lack a

comprehensive model and theory (Chang & Lin, 1997; Chen, Chang & Lin, 1998;

Wang, Wang & Lin, 1998). The present study made use of an intervention that

focussed on the effects on self-efficacy of relying on four sources of information that

have been adopted from Bandura (1977a) and the aim of this study was to develop,

trial and evaluate a theory-based nursing intervention program suitable for people

with type 2 diabetes in Taiwan. In Taiwan, no researchers have engaged in

self-efficacy studies on diabetes that incorporate interventions, and hence there is a

lack of results that could relate changes in self-efficacy for diabetics to their reliance

upon these sources. Furthermore, no instruments that measure self-efficacy related to

the management of diabetes (especially for outcome expectations) have yet been

found and appropriately used to measure the effectiveness of self-management. Since

there is such a lack of literature on self-efficacy interventions in diabetes education in

Taiwan, further studies on nursing interventions to improve self-management of

diabetes are particularly crucial in the future.

At the same time, this study presented a great opportunity to link up with international

research teams to develop and test the self-efficacy model in Taiwan. The

International Partnership in Self-management and Empowerment (IPSE) is a

collaborative group of researchers conducting studies on the role of self-efficacy in

the management of chronic disease, including diabetes. The IPSE is also involved in

constructing theory-based instruments that can measure the effectiveness of an


8

intervention intended to improve self-efficacy, and demonstrating their reliability and

validity. Such instruments include the Diabetes Management Self-Efficacy Scale

(DMSES) and the Perceived Therapeutic Efficacy Scale (PTES). The DMSES and

PTES have been translated into several languages and psychometrically tested with

diabetes populations in various countries, such as Netherlands, Switzerland, Belgium,

UK, USA and Australia.

Bolstering patient’s confidence in their ability to successfully care for themselves is a

critical step in promoting active self-management (Fu et al., 2003; Ismail, Winkley &

Rabe-Hesketh, 2004). The rationale for developing the intervention program based on

self-efficacy theory (Self-Efficacy Enhancing Intervention Program; SEEIP) included

the following:

• Firstly, to test the self-efficacy model adapted from Shortridge-Baggett & van

der Bijl (1996) in an experimental design required a comprehensive

intervention program to be established and then its effectiveness to be

evaluated.

• Secondly, patient empowerment has recently become an alternative to the

compliance-orientated approach to diabetes management. The intervention of

this study based on self-efficacy theory. Self-efficacy is a major component of

the empowerment approach and it plays an important role in behaviour

change.

• Finally, existing traditional patient educational programs in Taiwan are

insufficient to control people’s diabetes; a new diabetes service program needs

to be introduced into the Taiwanese healthcare system.

The SEEIP emphasises confidence enhancing and goal-setting skills in order to


9

increase self-efficacy and change people’s behaviours. Four sources of information

adopted from Shortridge-Baggett and van der Bijl (1996) and Bandura (1977a) were

applied in this intervention. The SEEIP given to diabetic people included: (1) viewing

a 10-minute DVD, (2) receiving a “Diabetes Self-Care” booklet, (3) participating in

four efficacy-enhancing counselling intervention sessions at weekly intervals, and (4)

participating in telephone follow-up. The SEEIP guided people in identifying their

problems and provided techniques to help people make decisions and take actions, as

they encountered changes in circumstances or disease and improve their health

outcomes.

This study proposed that educating people with type 2 diabetes, within a framework

that enhances self-efficacy, would improve self-management of this disease,

health-related quality of life and psychosocial well-being and would lower health care

costs. This study was divided into three phases. The first phase of this study, was to

translate the two instruments into Chinese, and then to test the validity and reliability

of the Chinese versions of each of them in a Taiwanese population. An intervention

based on self-efficacy theory was then developed. Finally, a randomised controlled

trial was conducted to evaluate the efficacy of the intervention. If significant

differences in the outcome variables were found between the intervention and control

groups, this would demonstrate that the intervention program was effective.


10

1.3 The aim, objectives, and research questions, hypotheses, and definitions

1.3.1 Two research studies in three phases

The study was divided into two research studies. Study I (Phase 1) translated two

diabetes-specific self-efficacy instruments (DMSES & PTES: the Diabetes

Management Self-Efficacy Scale and the Perceived Therapeutic Efficacy Scale) into

Chinese for use in a Taiwanese population, and tested their reliability and validity.

Study II covered two phases: Phase 2 consisted of development of an intervention

based on self-efficacy theory, and then Phase 3 was a randomised controlled trial to

evaluate the efficacy of the intervention in a Taiwanese population (see Figure 1.1).


11

Figure 1.1 The two research studies

1.3.2 The aim

The aim of this study was to develop, trial and evaluate a theory-based nursing

intervention program suitable for people with type 2 diabetes in Taiwan. The

evaluation focussed on the effects of enhancing self-management, health-related

quality of life, and psychosocial well-being for people, to determine if there was any

reduction in health service usage.

Study I (Phase 1)

Translation, testing of

validity and reliability of

two diabetes-specific

self-efficacy instruments in

a Taiwanese population

Translate DMSES and

PTES scales (English to

Chinese; Chinese to

English)

Content validity (CVI)

Construct validation: factor

analysis

Internal consistency:

Cronbach’s alpha

Stability: test-retest (after

2-4 weeks): ICC; a

Bland-Altman plot

Study II (Phase 2:

Pilot study) Development of an

intervention based on

self-efficacy theory &

piloting of the intervention

Developing a suitable

intervention in

Taiwanese: included

videotape (DVD),

“Diabetes Self-Care ”

booklet, efficacy-

enhancing counselling

intervention sessions and

telephone follow-up

•Validation of the

intervention: patient and

provider experts

• Pilot the intervention

Study II (Phase 3:

Main study) Randomised controlled trial

(RCT) to evaluate the

efficacy of the intervention

Pre-test / post-test/

experimental study

Baseline- 3months- 6 months

Outcome measure:

C-DMSES

C-PTES

SDSCA

SF-12

MOS-SSS

CES-D

Health Service utilisation


12

1.3.3 Objectives

The objectives of this research study were to:

• Translate and test the validity and reliability of two diabetes-specific

self-efficacy instruments (DMSES scale & PTES scale) in a Taiwanese

population.

• Develop an intervention based on self-efficacy theory that is appropriate for

the Taiwanese population; and

• Use a randomised controlled trial to evaluate the efficacy of the intervention in

a Taiwanese population in improving:

1. Self-efficacy towards management of type 2 diabetes;

2. Diabetes self-care activities, i.e., adherence to medication regime;

blood glucose testing; foot care;

3. HRQOL (health-related quality of life);

4. Psychosocial well-being; and

5. Health service utilisation.

1.3.4 Research Questions

Study I

Research Question 1: Are the two diabetes-specific self-efficacy instruments, the

DMSES and PTES, valid and reliable for a Taiwanese population?

Study II

Research Question 2: Can an intervention based on self-efficacy theory improve

self-management in people with type 2 diabetes in Taiwan?

Within Research Question 2, the following further questions were examined.


13

For people with type 2 diabetes, following implementation of the SEEIP, is there a

difference in their:

2.1: Self-efficacy?

2.2: Self-care activities?

2.3: Health-related quality of life?

2.4: Psychosocial well-being?

2.5: Health care utilisation?

1.3.5 Research Hypotheses

The following hypotheses were tested during Study II (Main study):

1. People who receive the intervention would have greater self-efficacy in managing

their type 2 diabetes than those who do not;

2. People who receive the intervention would undertake diabetes self-care activities

more frequently than those who do not;

3. People who receive the intervention would have better HRQOL than those who do

not;

4. People who receive the intervention would have better psychosocial well-being

than those who do not; and

5. People who receive the intervention would have a lower usage of health services

than those who do not.


14

1.3.6 Definitions of terms

For the purposes of classification, several key terms will be clearly defined here both

conceptually and operationally, including: type 2 diabetes, self-efficacy, self-efficacy

enhancing intervention program (SEEIP), self-care, diabetes self-management,

quality of life, psychosocial well-being and health care utilisation.

Type 2 diabetes

Conceptual definition: type 2 diabetes mellitus (formerly called type II, NIDDM or

adult-onset) is characterised by insulin resistance in peripheral tissue and an insulin

secretory defect of the beta cell (Expert Committee on the Diagnosis and

Classification of Diabetes Mellitus, 1997).

Operational definition: people were eligible for the study if they were diagnosed by a

doctor as having type 2 diabetes according to the clinical criteria.

Self-efficacy

Conceptual definition: self-efficacy is “people’s judgment of their capabilities to

organise and execute the course of action which require designated types of

performances” (Bandura, 1986, p.391).

Operational definition: self-efficacy is the variable “self-efficacy towards

management of type 2 diabetes”, as measured by DMSES (Diabetes Management

Self-Efficacy Scale) and PTES (Perceived Therapeutic Efficacy Scale).


15

Self-efficacy enhancing intervention program (SEEIP)

Conceptual definition: the self-efficacy enhancing intervention program (SEEIP) in

this study was different from traditional education programs. The SEEIP emphasised

confidence-enhancing and goal-setting skills with a view to increasing people’s

self-efficacy and changing their behaviours. The intervention of SEEIP was based on

self-efficacy model (Shortridge-Baggett and van der Bijl, 1996).

Operational definition: the SEEIP program designed by the researcher was used to

enhance diabetic people’s self-confidence and ability in caring for themselves. The

SEEIP program provided enhanced sources of development of self-efficacy. It

included: (1) viewing a 10-minute DVD, (2) receiving a “Diabetes Self-Care”

booklet, (3) participating in four efficacy-enhancing counselling intervention sessions

at weekly intervals, and (4) participating in telephone follow-up.

Self-care

Conceptual definition: self-care is defined in terms of “level of diabetes self-care”.

Glasgow, Wilson & McCaul (1985) proposed using the term “levels” of specific

self-care behaviours as they occur in relation to specific regimen areas.

Operational definition: this study used the term “level of diabetes self-care” for the

absolute frequency or consistency of regimen behaviours (e.g. number of days per

week on which subjects engage in physical activity). The Summary of Diabetes

Self-Care Activities (SDSCA) is a self-report measure of the frequency of completing

different regimen activities over the preceding seven days, which was used to measure

self-care of diabetic people in this study. Areas of regimen assessed were glucose

testing, diet, medication taking, exercise, and foot care.


16

Diabetes self-management

Conceptual definition: diabetes self-management is relevant because it is assumed

that adoption of a healthy lifestyle will produce better metabolic control of diabetes,

and in turn will aid in the avoidance of subsequent acute and long-term complications

of the disease (Toobert & Glasgow, 1994).

Operational definition: diabetes self-management in this study was defined in its

broadest terms and included all the self-care activities used by patients to maintain

their glycemic levels as close as possible to recommended target levels.

Self-management involves more than just self-care (following daily procedures as part

of a regimen). Effective self-management will produce better health outcomes,

including better self-efficacy, self-care behaviours, health-related quality of life,

psychosocial well-being, and lower utilisation of health services.

Health-related quality of life

Conceptual definition: health-related quality of life in the medical area has been

defined as “a concept encompassing a broad range of physical and psychological

characteristics and limitations, which describe an individual’s ability to function and

to derive satisfaction from doing so” (Walker & Rosser, 1987).

Operational definition: health-related quality of life was a variable for this study (as

measured by Short Form-12).


17

Psychosocial well-being

Conceptual definition: psychosocial well-being is defined as “seeking a sense of

control in the face of life-threatening illness characterised by emotional distress,

altered life priorities, and fears of the unknown, as well as positive life changes”

(Ferrell, Grant, Funk, Otis-Green & Garcia, 1998).

Operational definition: in this thesis, the variable of psychosocial well-being included

the factors of social support and depression, as measured by the Medical Outcomes

Study (MOS) Social Support Survey (SSS) tool and the Center for Epidemiology

Studies Short Depression Scale (CES-D).

Health care utilisation

Conceptual definition: health care utilisation includes direct and indirect costs. Direct

costs are the health system costs attributed to program costs for treatment, operational

expenses for fixed overhead costs, and utilisation costs for laboratory and medications.

Indirect costs are patient costs related to lost time from work or leisure (Fanning,

2002).

Operational definition: health care utilisation was an outcome variable for this study

as measured by a tool designed to collect: hospitalisations (yes or no), visit to OPD

(yes or no), and visit to ER (yes or no).


18

1.4 Assumptions:

1. Self-efficacy plays a significant part in self-management of diabetic people.

2. Self-care performances will be better among those people with diabetes who have

strong beliefs in self-efficacy (efficacy expectations or just self-efficacy).

3. Strong beliefs in the effectiveness of the regimen (outcome expectations) are likely

to produce better health outcomes.

4. Enhancing self-efficacy (confidence) towards self-management could enable people

with type 2 diabetes to better manage their disease and to produce better health

outcomes.

1.5 Expected outcomes

This study was divided into two research studies and included the following expected

outcomes:

1.5.1 Study I:

Demonstration of the validity and reliability of two diabetes-specific self-efficacy

questionnaires (the DMSES and PTES) in the Taiwanese population in order to enable

other researchers to use these in the future.

1.5.2 Study II:

Provision of a comprehensive diabetes education intervention: the self efficacy

enhancing intervention program and demonstration of the effectiveness of a nursing

intervention (SEEIP) when used in health care service delivery, as follows:


19

The nursing intervention (SEEIP) would enhance the ability of people with type 2

diabetes to manage the disease by increasing their efficacy (confidence);

The nursing intervention (SEEIP) would increase the self-efficacy (confidence) and

then improve the level of self-care for people with type 2 diabetes;

The intervention (SEEIP) when incorporated into existing diabetes educational

programs, would improve health-related quality of life and psychosocial well-being

for people with type 2 diabetes;

Reducing health care usage and improving health-related quality of life for people

with type 2 diabetes will indirectly lower health care costs;

Publication of results will provide nurses with knowledge and enable them to

practise safe and competent evidence-based care for people with chronic diseases

such as diabetes;

Publication of results will introduce a comprehensive theory and enrich a growing

body of international knowledge about self-efficacy and self-management of a

chronic disease in Taiwan.


20

1.6 Summary

In summary, the motivation for the research was based on the increasing trends of

diabetes prevalence, mortality and healthcare costs in Taiwan, low self-care abilities

and poor control by diabetics in Taiwan, few clear conceptualisations and empirical

studies related to self-efficacy and diabetes and lack of Randomised controlled trial

(RCT) research for diabetes and a great opportunity to link with international research

teams (IPSE). This study proposed that educating people with type 2 diabetes within a

framework that enhances self-efficacy would improve self-management of this

disease, their health-related quality of life, their psychosocial well-being and lower

health care costs.

Chapter 1 has outlined the background and significance of this study, presenting its

aims, objectives, research questions, hypotheses, definitions and outcomes. Chapter 2

will review the literature on the burden of diabetes mellitus and its impact on the

current health care service in Taiwan. Chapter 3 will review the literature on diabetes,

in respect of self-care, self-management, quality of life, and psychosocial issues.

Chapter 4 will describe the framework of the study, Chapter 5 will discuss its

methodology, Chapter 6 will report results, Chapter 7 will present discussions, and

Chapter 8 will present conclusions.

Student number: n4513282 Shu-Fang Wu Chapter 2 Burden of diabetes in Taiwan

21

Chapter 2

Review of the literature on the burden of diabetes

mellitus and on current health care in Taiwan

2.1 Introduction

In order to understand the background to this research study, this chapter provides

an overview of the population profile of Taiwan and of its health characteristics.

Over several decades, with changes in lifestyle and improvements in health care, the

leading causes of death have shifted from acute communicable diseases to chronic

diseases. For example, cerebrovascular diseases, heart diseases, and diabetes

mellitus have been the major causes of death recently. In 1980, diabetes was ranked

as the 13th leading cause of death; in 2002 it was the 4th and is expected to become

the second highest in the future (Taiwan DOH, 2006). Diabetes mellitus has a high

prevalence and mortality rate and is a great cost burden on the Bureau of National

Health Insurance. The rapid growth of health expenditure has presented the

government with greater financial difficulties. Finding solutions to reducing health

expenditure has now become a key issue for the future of Taiwan.

2.2 Population profile of Taiwan including its health characteristics

2.2.1 A profile of Taiwan

Taiwan is an island in East Asia. The total area administered by the Taiwan

government is about 36,188 Km2 (14,000 miles2). The largest city is the capital,

Taipei. In 2003, the population of Taiwan was 23 million. Of this, approximately 4

million live in two cities: 2 million in Taipei and 1.5 million in Kaohsiung. Most


22

people in Taiwan are ethnic Han Chinese and were either born on the mainland or

have ancestors from there. They are divided into three groups, based on their native

Chinese dialect: Taiwanese (those who speak Taiwanese, also called Min), Hakka

(those who speak Hakka, also called Kejia), and Mandarin (Government Information

Office, Taiwan, 2004). Because its economy has achieved such rapid growth

recently, Taiwan is known as one of Asia's "Four Tigers," along with Hong Kong,

Singapore, and South Korea. The per capita GNP is US$ 14,216 (Bureau of NHI,

2002). Taiwan thus has one of the highest standards of living in the world.

2.2.2 Health care expenditure

Shifting demographic patterns and recent changes in lifestyle have influenced health

care in Taiwan. The ageing population has brought pension issues to the fore, and

long-term care for the elderly and those with serious chronic disease problems have

triggered government concerns. The total healthcare budget of Taiwan’s Department

of Health in 2002 was US$1.41 billion, and the total expenditure of the Bureau of

National Health Insurance (BNHI) was US$8.5 billion (Bureau of NHI, 2002).

According to a Taiwan government report, 8.43% of the population were aged over

65 in 2002. The health of the general population has greatly improved over recent

decades; for example, life expectancy increased between 1951 and 2001 from 53.38

years to 72.8 years for males, and from 56.33 years to 78.48 years for females,

(Taiwan DOH, 2000). This large population and high percentage of older people

requires a large number of health service institutions to provide basic health services.

The Bureau of National Health Insurance (2002) stated that there were 669 hospitals

and 17,413 clinics in Taiwan. Of the hospitals, 96 (14%) are public and 573 (86%)

private; as for clinics, 483 (2.8%) are public and 16,930 (97.2%) private. These


23

facilities provide 127,676 short and long term care beds, averaging nearly 57 beds

per 10,000 people. However, most people use the services nearest to where they are

living, so the majority use private health providers.

2.2.3 National Health Insurance in Taiwan

Health insurance is another important health issue in Taiwan. Prior to March 1995,

only 59% of the population had health insurance. In view of the rapidly growing

medical care costs and the increasing numbers of older people, the government

launched a National Health Insurance (NHI) program on March 1, 1995, to provide

universal medical care (Bureau of NHI, 2002). In 2000, 21,400,826 people were

covered by the NHI program, representing 96.16% of the total 23 million population.

The NHI also signed contracts with 91% of the medical institutions nationwide to

provide medical services to all those insured, a critical point in the history of the

healthcare system in Taiwan. Although there is high public satisfaction with this

program, the rapid growth of health expenditure has placed the government in

greater financial difficulties. In 2001, the third priority of the core health policies in

Taiwan was to promote reform of NHI (Taiwan DOH, 2001). Reducing health

expenditure is the next key issue for the NHI department.

2.2.4 Core health policies in Taiwan

According to the Department of Health in Taiwan, nine core health policies were

proposed in 2001 (including several that are issues in this research study), namely

active promotion of health education to the public; extensive implementation of

community healthcare management programs; establishing a total medical

promotion service system from birth to old age; aiming to diminish medical care and


24

long term care; reform of the NHI system; strengthening the national health

information network; training health workers; upgrading standards of health and

medical research; and promoting international exchange in health and medical care

(Taiwan DOH, 2001). Further health policies released in 2003 continue trying to

solve urgent issues, such as strengthening the NHI management system, raising

citizens’ awareness of healthy lifestyles, developing health technology and

participating in international health organisations (Taiwan DOH, 2004).

2.2.5 Chronic diseases in Taiwan

In the last forty years, with changes in lifestyle and improvements in health and

medical care, the ten leading causes of death have shifted from acute communicable

diseases to chronic diseases. As the proportion of elderly people increases, chronic

cardiovascular diseases have replaced infectious diseases as the major causes of

death among adults. In 2004, for example, heart diseases, cerebrovascular diseases,

and diabetes mellitus were the second, third and fourth leading causes of death,

respectively. Hypertensive diseases also overtook bronchitis, emphysema, and

asthma as the tenth leading cause of death (Taiwan DOH, 2006) (see Table 2.1).

Table 2.1 Ten leading causes of death in Taiwan in 2004

Rank Cause of death Deaths per 100,000 population

Percentage of total deaths

1 Malignant tumours 160.54 27.20 2 Heart disease 56.79 9.62 3 Cerebrovascular diseases 54.48 9.23 4 Diabetes mellitus 40.58 6.88 5 Accidents and adverse effects 37.33 6.32 6 Pneumonia 24.44 4.14 7 Chronic liver disease and cirrhosis 23.63 4.00 8 Nephritis, nephritic syndrome, and

nephrosis 20.67 3.50

9 Suicide 15.31 2.59 10 Hypertensive conditions 7.97 1.35


25

Adapted from Taiwan Department of Health (2006). The ten leading causes of death in Taiwan.

Retrieved March 10, 2006, from http://www.doh.gov.tw/statistic/english/2/1.xls.htm.

According to the Department of Health (2000), Taiwan in the 21st century will face

the healthcare needs of an ageing population. Threats of cancers and cardiovascular

diseases have not abated; those chronic yet incurable degenerative diseases will

certainly generate a great burden on society and create a great drain on medical

resources. Diabetes mellitus is a chronic disease facing Taiwanese people now, the

fourth leading cause of death in Taiwan. The cerebrovascular diseases, and heart

disease, which were the second, and third leading causes of death in Taiwan, are

also serious complications of diabetes that can cause severe problems for affected

individuals and their families and a heavy burden on health services. Moreover,

diabetes is increasing to the point where health authorities are calling it an

“epidemic” requiring urgent attention (Stevens & Raftery, 1994); this is a problem

worldwide.

2.3 The prevalence, mortality rate and cost burden of diabetes mellitus in Taiwan

Diabetes mellitus in adults is a global health problem. Because it can cause a variety

of severe complications in many major organ systems, diabetes has become one of

the most costly and serious diseases. Although its prevalence varies widely between

different populations, it has generally increased worldwide (Chang et al., 2000). It is

estimated that the global number of diabetes patients will rise significantly from 176

to 370 million between 2000 and 2030 (see Figure 2.1), with more than 80% in

developing countries (Aubert, 1997; King, Aubert & Herman, 1998; WHO, 2003).

This increase has been attributed to longer life expectancy and the excess intake of


26

calories and reduced physical activity in modern societies (Zimmet, McCarty &

deCourten, 1997). In 2000, the three countries with the greatest number of diabetic

patients were India, China, and the USA, where the economic burden is enormous

(American Diabetes Association, 1998a; McCarty & Zimmet, 1994) (see Table 2.2).

176,525,312

370,023,002

2000 2030Year

Figure 2.1 Total numbers of people with diabetes in 2000 and 2030

2.3.1 High prevalence rate of diabetes mellitus in Taiwan

In Taiwan, the incidence of diabetes is 0.5-1% overall and 0.9-1.8% for those over

30 years; 96.7% of this is type 2 diabetes (Chou, Li & Tsai, 2001; Tasi, et al, 2002).

A recent study indicated that the overall 5-year incidences were 187.1 for men and

218.4 for women respectively per 100,000 population (Tseng et al., 2006). The

prevalence of diabetes mellitus for the total population in Taiwan is about 4%

(Taiwan Health and Vital Statistics, 2003; Tseng et al., 2006), and for the adult

population 6-12% (Chou, Li & Tsai, 2001). In more recent years, community-based

studies have found that the prevalence of diabetes increased steadily from 5.05% to

7.10% to 8.17% in the years 1970, 1979, and 1986 respectively, for those aged


27

above 40; in Taipei city, it was about 8% (Tai et al., 1987). In those aged 30 years or

more, diabetes has recently been recorded at about 12.4% (Tseng, Chong & Heng,

2000) (see Figure 2.2).

In fact, in Taiwan, the population 65 years and older is projected to grow rapidly

from 7.02% in 1993 to 14.72% in 2021 (Government Information Office, Taiwan,

2004); about one in seven Taiwan senior citizens currently suffer from diabetes

(Taiwan DOH, 2004). Taiwan’s rapid socio-economic development during the last

30 years has been accompanied by a substantial increase in the prevalence of

diabetes (Lin & Lee, 1992). It is estimated that in 2002 there were about 540,000

cases of drug-treated diabetes and that diabetes affected around one million people;

half of them being undiagnosed (Tseng, 2003; Taiwan Health and Vital Statistics,

2003; Tseng et al., 2006), out of a total population of 23 million people in Taiwan

(see Table 2.2). Although the number of diabetic patients seems to be small,

compared with other countries, the increasing trend over the past decades cannot be

ignored.

Table 2.2 Total Diabetes Population

Country 2000 2030 Rank World 176,525,312 370,023,002 India 31,705,000 79,441,000 1 China 20,757,000 42,321,000 2 United States of America 17,702,000 30,312,000 3 Indonesia 8,426,000 21,257,000 4 Japan 6,765,000 8,914,000 5 Pakistan 5,217,000 13,853,000 6 Russian Federation 4,576,000 5,320,000 7 Brazil 4,553,000 11,305,000 8 Italy 4,252,000 5,374,000 9 Bangladesh 3,196,000 11,140,000 10 Taiwan 1,000,000 1,800,000

Adapted from World Health Organisation (2004). Diabetes estimates and projections. Retrieved

Aug 25 2004, from http://www.who.int/ncd/dia/databases4.htm


28

5.05%7.10%

8.17%

12.40%

0.00%2.00%4.00%6.00%8.00%10.00%12.00%14.00%

1965 1970 1975 1980 1985 1990 1995 2000 2005Years

Figure 2.2 The Prevalence of Diabetes in Taiwan

2.3.2 High mortality rate of diabetes mellitus in Taiwan

Not only have the numbers of people with diabetes increased, mortality from

diabetes is also rising. The rank order of diabetes among the leading causes of death

in Taiwan rose from 13th in 1980, to 7th in 1985 and to 5th since 1987. A recent

statistic from the Department of Health in Taiwan has revealed that diabetes was the

fourth-highest cause of death among Taiwanese in 2002 and is expected to become

the second highest in the future (Taiwan DOH, 2006).

The mortality rate of diabetes has dramatically increased from 7.9 per 100,000

population in 1980 to 16.8 in 1985 and 34.49 in 1998 (Lu et al., 1998; Tseng, Chong

& Heng, 2000) (See Figure 2.3). In 2002, there were 8,818 deaths from diabetes

mellitus, representing 6.95% of total deaths. This contrasts significantly with 198

deaths, or 0.27% in 1960 (Lin & Lee, 1992).


29

7.9

16.8

34.49

0510152025303540

1975 1980 1985 1990 1995 2000Years

Figure 2.3 Mortality Rate for Diabetes in Taiwan

2.3.3 The high proportion of health expenditure for the treatment of diabetes mellitus

The number of deaths attributed to diabetes has been increasing over recent decades

and this also impacts on total healthcare expenditure. Diabetes is more prevalent in

older adults (Fitzgerald et al., 2000) and 97% of diabetic cases suffer from type 2

diabetes (Tasi, et al, 2002). Diabetes is associated with long-term complications,

including heart disease, peripheral vascular disease, neuropathy, retinopathy, and

renal disease, and poor health-related quality of life (Guthrie & Guthrie, 2002). In

Taiwan, the complication rates of diabetes are 31.8% for retinopathy, 26.6% for

peripheral vascular disease, 21.2% for neuropathy, and 0.8% for chronic renal

failure (Lin et al., 2001). Diabetic patients also represented 26.6% of those with end

stage renal disease requiring dialysis each year (Tseng, 2002). The level of diabetes-

related complications is impossible to reverse and will be a heavy financial burden

in the future. In a recent retrospective study (Tseng, 2002), the average total cost for

each diabetes patient was estimated to be NT (New Taiwan dollar) $52,532. Of this

cost, 85.5% was direct and 14.5% indirect. The per capita expenditure for diabetic


30

patients was 4.3 times higher than for non-diabetic patients (Chen, Yen & Tung,

2001; Lin et al., 2001). The average number per year of out-patient visits and in-

patient admissions were 10.1 and 0.21 respectively for each patient with diabtes.

The average work loss days were 2.7 and 2.1 days, for patients and their family

members, respectively (Chen, Yen & Tung, 2001). Also, Wei, Chuang, Lin, Chao

and Sung (2002) showed that among those with diabetes, 18.6-20.0% of males and

16.5-17.8% of females experienced at least one hospitalisation annually. These

statistics reflect the considerable impact that the disease has on the health care

system.

Diabetes is becoming one of the major public health problems because a large

proportion of the health care expenditure has been spent on its treatment, and

because of its associated morbidity and mortality. Most diabetes expenditure is used

to pay for inpatient services (60-85%); the biggest part of it (70%) because of late

diabetes complications; and diabetes accounts for 3-12% of total health care

expenditure in different countries (Logminene, Norkus & Valius, 2004). According

to Bureau of National Health Insurance data, the health care cost for diabetic

patients amounts to 11.5% of the total health care expenditure in Taiwan (Tseng,

2003) and consumed more than US$320 million in the year 2003 (Taiwan Health

and Vital Statistics, 2003; Tseng, et al, 2006). Of this total, approximately three-

fourths of expenditure has been used in the treatment of diabetes complications

(Tseng, 2003). Diabetes therefore, is not only a serious health problem in Taiwan

but also has a major impact on the National Health Insurance budget.


31

2.3.4 Conclusions

The global burden of diabetes is enormous, particularly in developing countries.

Taiwan, too, has increasing trends of diabetes prevalence, mortality and healthcare

costs. It is important to prevent complications and to prolong the life of the patients.

It is easy to become frustrated over these patients; studies have shown that diabetes

can be prevented by regular exercise and dietary control. In other words, preventing

the occurrence of chronic diabetes complications or diabetes itself would seem to be

the most efficient way to reduce the heavy burden of diabetes. Taiwan may need to

introduce different health care services or find a new strategy to address these tough

tasks.

2.4 Current situation for diabetes health care services in Taiwan

2.4.1 Community-based approach

The community-based approach to diabetes treatment and management is confined

to the public health service system. Diabetes is a chronic disease that needs to be

monitored. Health stations, staffed with physicians, pharmacists and nurses, are

community-oriented and form the basis of primary health care in Taiwan; on

average, each health station has one or two doctors. Surveys have shown that 70-

90% of the visits to these centres are for infant and child immunisations. Prior to

1990 the government did not provide any community health care services programs

specifically for diabetes. People who suffer from diabetes only half of them seek

medical treatment (Tseng, 2003) for example, private medical clinic or hospitals.

Between 1990-1999, epidemiological surveys were conducted in communities

across Taiwan, including Taipei, Jilung, Kinmen, Puli, Hualien, and Tainan (Tai et


32

al., 1987; Lin, Shieh, Huang & Huang, 1993; Chou, Liao, Kuo, Hsiao & Tsai, 1994;

Chou, Li, Kuo, Hsiao & Tsai, 1997; Chen, Shaw, Tseng, Chen & Lee, 1997; Lu, et

al, 1998); some of these were government funded. These surveys sought to achieve

was a better understanding of the prevalence and mortality rate of diabetes in

Taiwan, and they focused on exploring the morbidity of prediabetes or diabetes,

based on community evidence. Also, during that period, chronic disease control

institutions were asked to provide on-the-spot screening for blood pressure, blood

sugar and cholesterol in areas with poor communications and medical care resources,

in order to detect chronic disease patients early for referral for treatment and follow-

up management. However, no interventions or health programs were conducted in

communities at that time.

During 1999-2000, community diabetes policy gave rise to the shared care network

program conducted in the Ilan and Tao-Yuan areas. Hickman, Drummond &

Crimshaw (1994) defined the project as “the joint participation of hospital

consultants and general practitioners in the planned delivery of care for patients with

a chronic condition, informed by an enhanced information exchange over and above

routine discharge and referral notes”. The purpose was to combine the resources of

public health care systems, acute care systems, and medical professionals to form an

effective and efficient health care service (Chou, Li & Tsai, 2001). This

development is now being evaluated and plans are being made to extend it into

diabetes care in the public health system. At present, however, there is a lack of

concrete community health care programs or interventions related to diabetes.


33

2.4.2 Hospital-based approach

It is estimated that in 2002 there were about 540,000 cases of drug-treated diabetes,

and that diabetes mellitus was affecting around 1 million people in Taiwan (Tseng,

2003). That means that half of the people with diabetes were undiagnosed (Tasi et

al., 2002) and that the majority of people use private health services (Bureau of NHI,

2002).

Before the National Health Insurance program was launched in 1995, many people

with diabetes found medical care too expensive and some deliberately ignored their

disease. Hospital resources for diabetes patients were also very limited at that time.

Since 1995, the Bureau of National Health Insurance (BNHI) has improved access

to care for the Taiwanese people and provided them with greater financial risk

protection. This policy benefits most of the population in Taiwan, especially people

who suffer from chronic diseases, such as diabetes or cancer, which impose severe

financial, human and social burdens.

Recently, the rapidly growing costs of medical care and the increasing number of

medical complications from diabetes have attracted the attention of the BNHI. The

existing literature indicates that financial incentives have a significant influence on

provider behaviours (Hanchak, Schlackman & Harmon-Weiss, 1996). So in 2001,

BNHI introduced quality-based payment programs to improve quality of care. Since

October 2001, five major diseases, including cervical cancer, breast cancer, diabetes,

tuberculosis, and asthma were provided for by this program. Extra financial rewards,

in addition to the BNHI fee schedule, were granted to medical providers,

reimbursing them for providing nutrition advice and individual diabetes education. It

is estimated that there are about 139 diabetes educational promotion institutions in


34

Taiwan so far, including centres, classes, and outpatient clinics, usually divided into

three levels according to quality of care (Bureau of NHI, 2002). Diabetes quality-

based payment programs are only found in large hospitals, such as medical centres

or area hospitals, who can apply for just part of the extra fee from BNHI (Tasi et al.,

2002). So this program is not easy to extend into general diabetes health care; it

needs to be evaluated and improved continually in the future.

In 2001, another scheme of the Bureau of Health Promotion in the Department of

Health was piloted in many hospitals. A diabetes passport was freely provided for

people when they visited GPs (general practioners) in hospitals; it consisted of

simple medical records and diabetes education information. The government hoped

the passport would prompt people about this disease; however, hospitals or

providers have largely ignored this scheme, as it is not compulsory.

In a survey report (Tasi et al., 2002), conducted by the Taiwanese Association of

Diabetes Educators, data were collected from 53 hospitals that had joined the

quality-based payment programs for diabetes. Extra health services, including

nutritional or medication education, were supposedly provided to 5698 diabetes

patients. A randomised sampling design was used in this study. Results revealed that

96.7% of patients suffered from Type 2 diabetes. Of these, 54.8% were female and

45.2% male; average age was 63.4; average time since diagnosis was 11.8 years. In

terms of complications, 31.8% had retinopathy, 26.6% peripheral vascular disease,

21.2% neuropathy, 0.8% chronic renal failure, 1.5% were blind, and 1.0% had

suffered amputation (see Table 2.3). The results of the survey indicate that diabetes

has been poorly controlled in the medical care system in Taiwan even though an

extra payment program was introduced and applied for their routine care.


35

Table 2.3 Results of diabetes care

Categories Diabetes care Number of cases 5055 Female (%) 54.8 Age 63.4±12.4 Length of disease (years) 11.8±7.6 Type 2 (%) 96.7 BMI 25.2±3.5 BMI>25 (%) 47.6 Insulin treatment (%) 22.6 HbA1c (%) 8.9±2.2 Complications: Retinopathy, 31.8% Peripheral vascular disease 26.6% Neuropathy 21.2% Chronic renal failure 0.8% Blind 1.5% Amputation 1.0%

Adapted from Tasi et al. (2002).

A report of diabetes quality care. Annual Report of Taiwanese Association

of Diabetes Educators. Taipei: Taiwanese Association of Diabetes Educator.

2.5 Diabetes in Taiwan: self management issues

About 1 million people in Taiwan suffer from diabetes but only half of them seek

medical treatment (Tseng, 2003). Tseng (2003) stated that 30% of people with

diabetes were found to have an HbA1c level >10% in Taiwan. This means that two-

thirds of diabetic patients do not control their disease appropriately since it is

difficult for them to change their life style and diet habits. The normal range of

HbA1C is below 6%; because an average HbA1C higher than 7% is associated with a

higher risk of complications, the recommended glycemic goal for a diabetic

population is under 7% (ADA, 2002b). A recent study found that still only 9.4 % of

patients < 65 years and 14.0 % > 65 years had HbA1c values within the optimal


36

range (HbA1c < 6.5 %) (Tai et al., 2006). This means the disease is being very

poorly controlled.

Many people with diabetes in Taiwan do not visit their doctor regularly until serious

complications have occurred. Moreover, basic clinics and large hospitals do not trust

each other because of keen competition; small private clinics do not transfer patients

to large hospitals until the situation has become critical, resulting in higher medical

costs to treat a worsened situation. According to Tseng (2002), the average annual

number of clinic visits was 35.8 per patient, representing 6.2% of outpatient clinic

use. The average duration of each admission, for diabetic patients was 16.8 days and

for non-diabetic was 7.7 days, representing 22.1% of total admission days.

Admissions of diabetes patients were mostly due to diabetic complications.

People not only fail to change their life style and habits, but also lack information

about and confidence in health care settings. Many people with diabetes prefer to be

managed by their GP (Dunning, 2003), however GPs usually have no systematic

ways of providing education to their patients. For example in Taiwan, patients

expect doctors to offer detailed explanations of test results and self-care information,

but doctors are unlikely to do so because of limited consultation times. Sometimes,

also, people do not ask questions even when doctors are listening to them, because

they are unwilling to challenge doctors. In general, diabetes patient education can be

found in many hospitals and community health services in Taiwan. These traditional

patient educational programs can be conducted through either individual or group

education. Normally nurses or diabetes educators, and only a few nutritionists or

dieticians, will be involved in diabetes patient education programs. Several factors

contribute to the lack of provision of education for diabetic patients, such as pressure


37

of time, lack of communication skills, lack of familiarity and confidence with

appropriate education strategies, and lack of counselling skills. These circumstances

often make it more difficult for diabetic patients to cope with their disease. If

outpatient clinics do not provide professional information, people will remain

uninformed about strategies for controlling their illness. Many people with diabetes

in Taiwan do not receive enough medical information and frequently become

frustrated (Chuang et al., 2001).

In addition, while some people have poor control of their disease due to deficits in

self-care knowledge or skills, a large proportion of people with diabetes are not

motivated to make any changes. In Taiwan, two epidemiological surveys showed

that only 30% of people with diabetes have performed self-monitoring of blood

sugar or urine sugar; demonstrating that they either lack skills or have low

participation rates in performing self-care actives (Chuang et al., 2001; Lin et al.,

2001). It is necessary to develop local support groups for diabetes patients and

volunteers where the self-care motivation of patients can be raised with the

professional help of consultants and nutritionists. Only through education and

empowerment can people’s awareness of their self-care abilities be improved,

leading to a better quality of life (Chuang et al., 2001).

2.6 Literature on diabetes care interventions in Taiwan

This study was based on the supposition that educating people with type 2 diabetes

within a self-efficacy framework would enhance their self-management capabilities

for the disease. Early efforts focused on patient education for people with diabetes,

so many diabetes articles have been published in Taiwan, including issues of


38

educating patient as individuals and in groups (Chuang et al., 1989). But recently the

importance of psychological and behavioural interventions has been emphasised,

because of the growing recognition that knowledge alone is insufficient to produce

significant changes in behaviour (Peyrot, 1999). Brown (1999) has stated that

interventions combining behavioural techniques with the provision of information

were found to be more effective than those that only provided information.

In Taiwan, there have been 92 studies related to self-efficacy, in areas such as

education, social learning, job satisfaction, information management and exercise

behaviours. Few researchers have engaged in self-efficacy research in health, but

those who did so have shown that self-efficacy is an important predictor of

successful health promotion interventions (Chang, Huang & Lee, 1996; Wang &

Chiou, 1996; Chang & Lin, 1997; Hung & Kao, 1997; Chen, Chang & Lin, 1998;

Wang, Wang & Lin, 1998; Guo, Tsay & Yen, 2002;). Up to now, only three

correlational research studies relating to self-efficacy and diabetes (Chang & Lin,

1997; Chen, Chang & Lin, 1998; Wang, Wang & Lin, 1998), and two intervention

studies relating to empowerment and diabetes have been found (Guo, Tsay & Yen,

2002; Lai & Liu, 2003) (see Table 2.4).

Of these intervention studies, one article describes an empowerment-training

program in a hospital followed by evaluation of HbA1C and depression levels (Guo,

Tsay & Yen, 2002), while another describes a social support and empowerment

education course and evaluates its effect in a community (Lai & Liu, 2003). The

other two intervention studies were not related to self-efficacy theory. One article

evaluated the effects of an aerobic exercise-training program on diabetic patients’

physical parameters and psychosocial aspects (Lin, 2003) and the other study


39

evaluated a diabetic patient education program for its effects on weight and blood

glucose control (Chuang et al., 1989). Moreover, few studies used randomised trials,

since they were trying to produce improvements in diabetes knowledge but were less

concerned with measures of self-management or behaviour change. Also, many

studies lacked a comprehensive model and theory. Most current studies did not

include an intervention, and hence there is a lack of diabetes-related studies,

particularly in Taiwan, on changes to self-efficacy based on Bandura’s four sources

of efficacy information. The results of these studies are difficult to apply extensively

in clinical practice.

Glasgow et al. (1989) has highlighted the methodological defects of studies on

diabetes self-care correlates: the lack of clear conceptualisations and the fact that

many empirical studies lacked a comprehensive model and theory. WHO (2003)

pointed out that data from developing countries concerning correlates of adherence

of regimens in patients with diabetes are particularly scarce. Also, the absence of

standard measurement instruments prevents comparisons being made between

studies and real practice. Much work needs to be done to develop standardised,

reliable and valid measurement tools. One of the important epidemiological studies

in Taiwan (Chou, Li & Tsai, 2001) concluded that, once the epidemiological

situation of diabetes is understood, the next step should focus on the self-

management issues regarding diabetes, and that both patient education programs and

training for health professionals will be needed in the future.

Further studies on nursing interventions for diabetes will be particularly crucial in

the future. In addition, it is time to develop and evaluate an intervention that

includes clear conceptualisations and a basis in self-efficacy theory. Testing the


40

model in different countries and cultures will also result in important progress in

diabetes services. This could not only increase the self-management ability of

diabetic people to change their health behaviours, but also provide a large body of

knowledge, based on a comprehensive theory, for diabetes professionals in Taiwan.

2.7 International cooperation

According to the Department of Health in Taiwan, in the coming century it is

becoming increasingly important to promote international cooperation, to exchange

information, to share medical care services, and to research and train for the global

promotion of human well-being (Taiwan DOH, 2001). The priorities of core health

policies need to be articulated: to upgrade standards of health and medical research

and to promote international exchange in health and medical care. It can be seen that

international cooperation is an aim of Taiwan’s government at present. This study

provides an excellent opportunity to link with international research teams (the

International Partnership in Self-management and Empowerment; IPSE) and to

develop and test the self-efficacy model in Taiwan. Results of this study may be

compared internationally and will contribute to diabetes services in Taiwan.

2.8 Summary

Key issues facing people with diabetes are discussed below

Government

The National Health Insurance service was launched comparatively recently in

Taiwan, and its financial difficulties are growing, due in part to the high levels of

prevalence and mortality of diabetes mellitus, and the resulting high cost burden. So

far, there are few suitable strategies in place for addressing diabetes, and there are no


41

effective program evaluations being conducted. Care providers are not adequately

rewarded by the government.

Healthcare system (communities and hospitals)

The public health system does not manage chronic disease care effectively, even

though it is a priority core health policy. The public health system is not well

coordinated with the acute care system, so that public health and acute care

organisations do not pass on to the government useful suggestions or experiences

obtained from pilot programs. Hospitals are unable to choose appropriate

interventions or apply them effectively to people with diabetes. The quality of

diabetes care in the health care system is not very high, especially for people with

type 2 diabetes, representing 95-97 % of the total diabetes population in Taiwan.

Individual management

There is a gap in expectations, in terms of self-care issues, between health providers

and people with diabetes. People have mistaken ideas about diabetes, such as not

needing to visits their GPs regularly, and do not feel responsible for their own self-

care. They have a lack of knowledge, skills, motivation and willingness to change

lifestyles, and are short of confidence and feelings of empowerment.

There are five summary conclusions for Taiwan’s situation:

1) Epidemiological studies and vital statistics have revealed increasing trends in

prevalence, mortality and healthcare costs for diabetes. Diabetes in Taiwan is

not being effectively controlled, and the direct and indirect expenditures on


42

diabetes are very high; its control is vital to avoid complications and prolong

the life of patients.

2) The government and the healthcare systems are struggling with the

difficulties of the diabetes problem. For example, the government is

attempting to build up support networks, and trying to combine professional

resources to improve the accessibility to services for diabetic people in

communities. In addition, the NHI not only provides very high funding for

the healthcare system, but also provides quality-based payment programs to

assure the quality of care in hospitals. These need to be continuously

evaluated and improved.

3) An important key factor is the need to enhance the self-care abilities and

motivation of people with diabetes; otherwise the poor control of diabetes

will remain.

4) There are very few clear conceptualisations and empirical studies related to

self-efficacy in the areas of health and diabetes, and a lack of randomised

trial research for diabetes. Moreover, no researchers are engaged in self-

efficacy studies in relation to diabetes that rely on interventions, particularly

those based on the four sources of information identified by Bandura (1977a)

period, Clearly, much work needs to be done to develop standardised,

reliable and valid measurement tools and to develop a comprehensive self-

efficacy model and theory in Taiwan.

5) Promoting international cooperation is also a major aim of the Taiwan

government.

In summary, improving self-management, enhancing quality of life, and reducing

health service utilisation for persons with type 2 diabetes is an ongoing challenge for


43

health-care providers. An important way of addressing these problems is by

reinforcing their self-efficacy (confidence) in self-management.


21

Table 2.4 Publications related to self-efficacy or interventions for diabetes care in Taiwan Author Intervention

or correlation studies

Sampling method

/ sample size

Framework Comp-rehensive

theory base?

Result

Chang & Lin (1997)

Correlation A convenience sample/ n=72

Self-efficacy No -There was a strong correlation between the IMDSES scale and the Diabetes Self-Care scale (r=0.94, p<0.01)

Chen, Chang & Lin (1998)


Self-efficacy No - Subjects had the highest scores in self-efficacy of glucose testing and taking medicine. Also, subjects had the highest scores in self-care behaviours of glucose testing and taking medicine.

-Specific items in self-efficacy were significantly corrected with corresponding items in self-care behaviours (r=0.88, p<0.001).

Wang, Wang & Lin (1998)


Self-efficacy No -Social support and self-efficacy scores corrected significantly with self-care behaviours.

- Self-efficacy was found to explain 74.0% (a multiple stepwise) variance of self-care behaviours.

Guo, Tsay & Yen (2002)

Intervention (Empower-ment-training program)

A convenience sample/ n=67

Self-efficacy (empowerment)

No -The empowerment had a negative correlation with HbA1c and positive correlation with self-efficacy and self-care scores.

-Patients in the experiment group significantly improved their levels of empowerment, self-efficacy and self-care more than patients in the control group.

-There were no significant in blood sugar control and depressive mood between groups.

Lai & Liu (2003)

Intervention (Social support and empowerment module)


Social cognitive theory, social support, social belief and conception of empowerment

No -The social support and empowerment module (SSEM) education course could significantly increase social support of the experimental group.

-The SSEM education course could significantly increase empowerment of the experimental group and empowering patients with power, self-efficacy and self-care behaviour.

-After intervention, the experimental group was higher than the control group on social support and empowerment.

Chuang et al. (1989)

Intervention (patient education program)


Patient -education

No -The diabetic patient education had a significant influence with the weight control and blood glucose control.

44


22

Author Intervention or correlation

studies

Sampling method

/ sample size

Framework Comp-rehensive

theory base?

Result

Lin (2003) Intervention (an aerobic exercise-training program)


Aerobic exercise-training

No -OGTT glucose level, triglyceride (p<.05) were lower after adjusting possible confounding factors.

-Fasting glucose, HbA1C, body weight, BMI, heart rate, BP were decrease significantly (P<.0001)

-Quality of life (MCS of SF36) were elevated except bodily pain and PCS and more time of exercise training they received, the more their depression improved (p<.05)

45

Student number: n4513282 Shu-Fang Wu Chapter 3 Literature on diabetes and outcome variables

46

Chapter 3

Review of literature on diabetes, self-care, quality of

life, and psychosocial issues

3.1 Introduction

Diabetes mellitus is the main focus of this research study. The literature review in this

chapter examines the main issues related to diabetes mellitus. The first section

presents general information about diabetes, including its diagnosis and definition,

classification, and complications. The following sections relate to the outcome

variables of this study: self-care of diabetes, such as blood glucose monitoring,

nutrition, exercise, medication and foot care; the quality of life of people with diabetes;

and psychosocial issues.

3.2 Diabetes Mellitus

3.2.1 Diagnosis and Definition

Diabetes mellitus (diabetes) encompasses a heterogeneous group of diseases of

various aetiologies. It is defined as a symptomatic or asymptomatic state of altered

carbohydrate metabolism characterised by two or more fasting plasma glucose levels

of 126 mg/dL (7.0 mmol/L) or greater, or a value of 200 mg/dL (11.1 mmol/L) or

greater at 2 hr, on an oral glucose tolerance test. A diagnosis of diabetes can also be

made with a random blood glucose value of 200 mg/dL (11.1 mmol/L) or greater if it

is associated with symptoms (polydipsia, polyuria, polyphagia, unexplained weight

loss) (Guthrie & Guthrie, 2002; Expert Committee on the Diagnosis and

Classification of Diabetes Mellitus, 1997). However, some people may have even


47

been given a warning by a doctor that their “sugar was a bit high”, which they

mistakenly interpreted as a grace period before a diagnosis of diabetes. Impaired

Fasting Glucose (IFG) or Impaired Glucose Tolerance (IGT) are now known as “pre-

diabetes”, where the sugar levels are clearly no longer normal, but not yet at the level

required for the actual diagnosis of diabetes. The diagnosis of impaired fasting

glucose (IFG) as fasting plasma glucose between 110 mg/dL and 126mg/dL (6.1-

7.0mmol/L); and impaired glucose tolerance (IGT) as 2-hr post plasma glucose from

140/dL to <200mg/dL (7.8 to <11.1mmol/L). Both these categories, IFG and IGT, are

risk factors for future diabetes and cardiovascular disease (ADA, 2002b). Table 3.1

shows that diagnostic criteria for diabetes based on the fasting plasma glucose.

Table 3.1 Diagnostic criteria for diabetes based on the fasting plasma glucose (venous)

Stage Fasting plasma glucose (venous)

mmol/L (mg/dL)

Normal < 6.1 (<110)

Impaired Fasting Glycaemia (IFG) ≥ 6.1 and <7.0 (≥ 110 and <126)

Diabetes Mellitus ≥7.0 (≥ 126)

Another definition briefly states that diabetes mellitus is a metabolic disorder in which

the body’s capacity to utilise glucose, fat and protein is disturbed, due to insulin

deficiency or insulin resistance, both of which lead to an elevated blood glucose

concentration and glycosuria (Dunning, 2003). In addition, the American Diabetes

Association and WHO define diabetes as a group of metabolic diseases characterised

by hyperglycaemia resulting from defects in insulin secretion, insulin action, or both.

Common to all types of diabetes mellitus is chronic hyperglycaemia, which is

associated with long-term damage, dysfunction and failure of various organs,


48

especially the eyes, kidneys, nerves, heart and vessels (Alberti & Zimmet, 1998).

After defining diabetes, the American Diabetes Association (ADA) announced in

1997 a revised diabetes classification system and diagnostic criteria, described below.

3.2.2 Classifying diabetes

Since 1995, the American Diabetes Association’s expert group has convened to

review the literature and determine what changes to the diabetes classification system

and diagnostic criteria are necessary. New recommendations for the classification and

diagnosis of diabetes mellitus include the preferred use of the terms “type 1” and

“type 2” instead of “IDDM (Insulin Dependent Diabetes Mellitus)” and “NIDDM”

(Non-Insulin Dependent Diabetes Mellitus) to designate the two major types. In June

1997, an international expert committee released a report with new recommendations

for the classification and diagnosis of diabetes mellitus (Expert committee on the

Diagnosis and Classification of Diabetes Mellitus, 1997). These revised data resulted

from a joint activity between the American Diabetes Association (ADA) and the

World Health Organisation (WHO). The new classification system identifies four

types of diabetes mellitus: type 1, type 2, gestational diabetes and other specific types.

Arabic numbers are specifically used in the new system to minimise the occasional

confusion of type “II” as the number “11”. Moreover, the diagnostic criteria do not

require the oral glucose tolerance test (OGTT) (Guthrie & Guthrie, 2002).

Type 1 diabetes mellitus (formerly called type I, IDDM or juvenile diabetes) is

characterised by beta cell destruction caused by an autoimmune process, usually

leading to absolute insulin deficiency (Expert Committee on the Diagnosis and

Classification of Diabetes Mellitus, 1997). Over 95% of persons with type 1 diabetes


49

mellitus develop the disease before the age of 25. There are two forms of type 1

diabetes: immune-mediated diabetes mellitus, which results from autoimmune

destruction of the pancreatic beta cell; and idiopathic diabetes mellitus, referring to a

form of the disease that has no known aetiologies (Dunning, 2003).

Type 2 diabetes mellitus (formerly called type II, NIDDM or adult-onset) is

characterised by insulin resistance in peripheral tissue and an insulin-secretory defect

of the beta cell (Expert Committee on the Diagnosis and Classification of Diabetes

Mellitus, 1997). This disease was formerly called adult or maturity-onset diabetes, but

with the increasing prevalence of the disease in children, age related terminology can

no longer be used. The term NIDDM (Non-Insulin Dependent Diabetes Mellitus) was

also changed because many of these individuals require insulin for control. With these

problems in mind, in 1997 the Committee decided to simplify the terminology to type

2 diabetes. This form of disease occurs predominantly in adults (basically persons

older than 30), but may occur at any age (Guthrie & Guthrie, 2002) and is strongly

associated with a family history of diabetes in women, especially women with a

history of gestational diabetes, with old age (especially over 40 years of age), and

with obesity and lack of exercise; however, the prevalence of eating disorders is

similar in type 1 and type 2 diabetes (Herpertz, Albus & Wagener, 1998; Dunning,

2003). Previous research has shown that diabetes is a genetic disease, the gene or

genes being prevalent in all societies, but that the disease becomes manifest primarily

as societies industrialise, and as calorie intake increases and calorie expenditure

decreases (Guthrie & Guthrie, 2002). The majority of people with type 2 diabetes

require multiple therapies to maintain acceptable blood glucose goals, for example 50

to 70% require insulin, often in combination with oral medicine regimes. This means

that diabetes management is more complicated for people with type 2 diabetes, which


50

increases their likelihood of non-compliance, and the cost of managing the disease for

both the patient and the health system (Dunning, 2003).

Gestational diabetes mellitus is an operational classification (rather than a

pathophysiologic condition) referring to diabetes mellitus developed by women

during gestation. This definition of gestational diabetes mellitus and its diagnosis was

not altered in the new recommendations (Expert Committee on the Diagnosis and

Classification of Diabetes Mellitus, 1997).

Other specific types of diabetes mellitus include diabetes caused by other identifiable

disease processes: genetic defects of beta cell function such as Maturity Onset

Diabetes in the Young (MODY); genetic defects of insulin action; disease of the

exocrine pancreas, such as cancer and pancreatitis; endocrine diseases such as

Cushing’s disease and acromegaly; and drug or chemically induced diabetes (Expert

Committee on the Diagnosis and Classification of Diabetes Mellitus, 1997).

3.2.3 Complications

Diabetic complications contribute to the overall cost of health care for those with

diabetes and for health care providers; many people are admitted to hospital because

they have active diabetes. Complications can be classified as acute or long term; acute

complications may occur during temporary changes in blood glucose levels, while

long term complications usually accompany long duration of diabetes and persistent

hyperglycaemia (Dunning, 2003). Acute complications include hypoglycaemia;

hyperglycaemia; infection; fat atrophy or hypertrophy; and insulin allergy. In recent

years, vascular disease and neuropathy, long term complications of diabetes, have


51

become the leading cause of death among persons with diabetes (Guthrie & Guthrie,

2002).

Long term complications can be divided into macrovascular complications, including

increased atherosclerosis and cardiovascular disease, myocardial infarction and stroke

(Dunning, 2003; Guthrie & Guthrie, 2002) and microvascular complications,

including retinopathy, neuropathy, and nephropathy (Wandell, 1998; Dunning, 2003).

Coronary heart disease, a macrovascular complication of diabetes, is the greatest

cause of death in persons with type 2 diabetes in Caucasian and industrialised

countries. The estimated mortality rates of coronary heart disease range between 50%

and 60% (Panzram, 1987), conferring a 2 to 4 fold increase in mortality risk compared

with the non-diabetic population (Jarret, 1984). Small-vessel disease or

microangiopathy involves the small blood vessels all over the body; its clinical

manifestations occur in only two organs, the kidney and the eye. According to the

American Diabetes Association, diabetic retinopathy is the most frequent cause of

new blindness among adults aged 20 to 74; after 20 years with type 2 diabetes, nearly

60% of patients have some degree of retinopathy (ADA, 1998b).

The relationships between factors and the development of diabetes complications

must be clarified. A number of factors might play a role in the development of

diabetic complications. Studies have showed that the most important factors for

macrovascular complications were the duration of diabetes, age, hypertension,

hyperglycaemia and smoking (Morrish et al, 1991; Wandell, 1998). A study has also

showed that, for microvascular complications, the most important factors were the

duration of diabetes and age (Wandell, 1998). For microvascular complications the


52

risk factors include high blood pressure, high serum total and LDL cholesterol, low

serum HDL cholesterol and raised serum triglycerides, poor glucose control and

smoking. In 1998, the United Kingdom Prospective Diabetes Study demonstrated the

importance of controlling blood pressure to reduce the risk of cardiovascular disease

and of lowering blood glucose to reduce the incidence of microvascular complications

(UKPDS, 1998).

In Taiwan, the high complication rate of diabetes places a heavy financial burden on

the government. Recent complication rates for diabetes include: retinopathy (31.8%);

peripheral vascular disease (26.6%); neuropathy (21.2%); and chronic renal failure

(0.8%) (Lin et al., 2001). The prevalence of large vessel disease (LVD) in diabetic

and non-diabetic subjects has been found to be 20.0% and 12.9%, respectively.

Among diabetics, 15.8% have ischemic heart disease (IHD), 1.7% leg vessel disease,

and 2.5% stroke. Diabetics have a significantly higher prevalence of macrovascular

disease than non-diabetic subjects (Chang et al., 2000). Moreover, diabetes mellitus is

one of the chronic diseases facing Taiwanese people today; it is the fourth leading

causes of death in Taiwan, while the cerebrovascular diseases and heart diseases, the

second, and third leading causes of death in Taiwan respectively, are also the

complications of diabetes (see Chapter 2). Its complications can cause severe

problems for affected individuals and their families and are known to impose a heavy

burden on health services. The treatment of diabetes-related complications is a heavy

financial burden and needs to be considered seriously.

Interestingly, reducing the risk of developing most complications is preventable

through appropriate blood glucose control or by lowering factors that cause the

disease to progress. For example, the relationship between microvascular


53

complications and the level of metabolic control measured as HbA1C is firmly

established (Dahl-Jorgensen, Brinchmann-Hansen, Bangstad & Hanssen, 1994).

Moreover, the UKPDS has provided strong support for the American Diabetes

Association’s position that vigorous treatment of diabetes can decrease the morbidity

and mortality of the disease by reducing its chronic complications (American Diabetes

Association, 2002a). The chronic complications of diabetes can be avoided by striving

to achieve normal levels of serum glucose, blood pressure and lipids. They can be

effectively treated if they are detected early. Although aggressive therapy can prevent

or improve the progression of diabetic complications and should be started at the time

of diagnosis (Bell & Ala, 2002), establishing self-care responsibilities for people with

diabetes is a base solution for effective management of diabetes. According to

Anderson (1985), people with diabetes indicate that they consider the daily regimen of

self-care activities more difficult than the diagnosis of diabetes itself. The topic of

self-care of diabetes becomes an important role of effective management of diabetes

and will be described in the next section.

3.3 Self-care of diabetes

There is an increasing trend to have patients take an active role in regulating their

treatment and self-care (Downer, 2001). Effective management of diabetes requires a

team care approach that may include the following members: diabetologist; diabetes

nurse specialist or educator; dietician; podiatrist; social worker; psychologist; general

practitioner and the patient (Dunning, 2003); however, the person with diabetes is the

most crucial player in the team. In fact, diabetes is a self-managed disease; over 95%

of diabetes management is done by patients themselves. For diabetes care to succeed,


54

patients must be able to make informed decisions about how they will live with their

illness (Funnell & Anderson, 2000).

The aim of diabetes control is to maintain quality of life, to remain free from the

symptoms of diabetes, and to keep blood glucose in an acceptable range. The range is

determined on an individual basis, usually between 4 and 9 mmol/L. Also, people

with diabetes require the adoption and maintenance of multiple self-care behaviours to

achieve and sustain glycaemic control (Drury, 1979) that can include insulin

injections several times daily, oral hypoglycaemics, a strict calorie-controlled diet that

is low in fat and high in fibre, and regular exercise (Wing et al., 1986). Self-care

behaviours play an especially crucial role for the person with diabetes.

Self-care, following daily procedures as part of a regimen, is the minimum level of

competence required for people who have diabetes (Guthrie & Guthrie, 2002).

However, the procedures for self-management involve more than that. In this thesis,

self-care is defined as “level of diabetes self-care”, following Glasgow, Wilson &

McCaul (1985) who proposed using the term “levels” of specific self-care behaviours

as they occur in relation to specific regimen areas. Others have used the term

“diabetes self-management” similarly (Wing et al., 1986; Goodall & Halford, 1991).

According to Toobert and Glasgow (1899), it is difficult to formulate self-care

improvement strategies without a means to determine accurately the frequency or

consistency of a regimen of behaviours. This study uses the term “level of diabetes

self-care” for the absolute frequency or consistency of regimen behaviours (e.g.

number of days per week on which subjects engage in physical activity). The

Summary of Diabetes Self-Care Activities (SDSCA) (Toobert, Hampson & Glasgow,

2000) is a self-report measure of the frequency of completing different regimen


55

activities over the preceding seven days that was used to measure self-care of people

with diabetes in this study. Areas of regimen assessed were glucose testing, diet,

medication taking, exercise, and foot care; so the topics of blood glucose monitoring,

nutrition, exercise, medication and foot care therefore, will be described below.

3.3.1. Blood glucose monitoring

The self-monitoring of blood glucose (SMBG) is an important part of diabetes self-

care, as it is a way of evaluating therapy efficiency and adjusting treatment. SMBG

was popularised in 1978 (Walford, Gale, Allison & Tattersall, 1978); patient SMBG

has been available for 20 years since the introduction of blood glucose meters. In

order to maintain tight glycaemic control, blood glucose needs to be frequently

measured; the results of regular systemic testing not only form the basis for adjusting

medication, food intake and activity levels, but also help to prevent serious

complications, for example, the patient may check whether they are hypoglycaemic

during the evening or during intercurrent illness. However, patients must be taught the

correct technique to self-monitor their blood glucose, because studies have revealed

that up to 50% of patient-generated SMBG results are inaccurate (ADA, 2000a).

Maintaining motivation for SMBG is a constant problem in diabetes care, since many

people with diabetes find regular testing difficult to sustain in the long term. SMBG

requires motivation on the part of the patient; it also needs an understanding of the

correct use of the glucose meter. Some recommend a minimum schedule of 1-2 tests

per week pre and post meal (2 hr), or at different times of the day on 2-3 days each

week (Couzos, Metcalf, Murray & O’Rourke, 1998). Harris, Cowie and Howie (1993)

conducted a survey of 2405 patients with type 2 diabetes and found that among


56

subjects with type 1 diabetes, 40% monitored their blood glucose at least once per day.

Among subjects with type 2 diabetes treated with insulin, 26% monitored at least once

per day and among type 2 diabetes subjects not treated with insulin, only 5%

monitored blood glucose level. There are some barriers to persuading patients with

diabetes to perform SMBG. A recent study reported that cost was a barrier to self-

monitoring, leading to a low frequency of testing (Heisler, 2004). Zgibor and

Simmons (2002) showed that patient-reported barriers to diabetes care are associated

with blood glucose monitoring, especially in relation to financial (an external physical

barrier), and self-efficacy issues (an internal psychological barrier). Those reporting

personal barrier to diabetes care, especially those relating to finance and access to

community and family support and self-efficacy were less likely to monitor blood

glucose twice weekly.

In Taiwan, two epidemiological surveys have shown that only 30% of people with

diabetes have self-monitored their blood or urine sugar, demonstrating that they either

lack skills or simply have low rates of performing self-care activities (Chuang et al.,

2001; Lin et al., 2001). It is necessary to develop support groups for local diabetes

patients and volunteers to raise self-care motivation of patients with professional help

from consultants and nutritionists. Through education and empowerment, people’s

awareness of their self-care abilities can be improved leading to a better quality of life

(Chuang et al., 2001).

In summary, SMBG allows a profile to be found and treatment appropriately planned.

Accurate testing technique and appropriate maintenance of equipment are needed to

ensure treatment decisions are based on correct data. SMBG is a way to help people


57

with diabetes recognise the benefits of self-management of their disease and give

them greater insight into it.

3.3.2. Nutrition

Medical nutrition therapy is integral to diabetes care and management, and can be

achieved by maximizing the involvement of the person with diabetes in their self-

management (ADA, 2001). Diet control is the foundation of all therapy for type 2

diabetics, and is also the most natural and safe control mechanism. Through diet

control alone, one-thirds of patients can control their blood sugar at a satisfactory

level (Funnell, Donnelly, Anderson, Johnson & Oh, 1992). Effective nutrition

intervention in diabetes management results in improved self-monitoring of blood

glucose, blood lipids, glycated haemoglobin level, blood pressure, and weight

management, and can lead to reductions in medication, frequency of hypoglycaemia,

hospitalisation, and cost of overall health care; and most importantly, improved

quality of life for the patient (Downer, 2001). Thus, a nutrition intervention is

worthwhile to pursue for every person with diabetes.

It is currently accepted that the most appropriate diet in the treatment of type 2

diabetes is one that is high in carbohydrates and fibre and low in fat (ADA, 1996a).

Although weight loss is often desirable, the emphasis for dietary advice should be on

glycaemia and lipid control, (Couzos et al., 1998). Hosker et al. (1993) has trialled

food therapy (diets with 50% of the total caloric capacity in carbohydrates, low

saturated fatty acid, and high fibre) on newly diagnosed type 2 diabetics. After a 3-

month trial, they found that blood sugar was under control, and the secretion of

insulin increased. Similarly, Murray (2003) claims that fibre supplement can lower


58

blood glucose after a meal by approximately 20% and Chandalia, Gary and Lutjohann

(2000) found that a high-fibre diet improved glycaemia control and plasma lipid

levels. Diabetic diet control issues have recently been summarised by Dunning (2003).

Principles of dietary management for people with diabetes should involve a diet high

in complex carbohydrates (50-60 % of total intake), low in fat (<10 % of total energy

value), especially saturated fat, containing adequate protein (15 % of total intake), low

in simple sugar, less than 25 grams/day, and ensuring that a variety of food is eaten

daily from each of the five food groups and that carbohydrate is consumed at each

meal, especially for patients on insulin or diabetes medication (Dunning, 2003).

One way to encourage responsibility in people with type 2 diabetes and to help them

take an active role in improving their blood glucose is to provide dietary guidelines

(Downer, 2001) that can help people with the self-management of their blood glucose.

For example, weight loss of 10-20 pounds or maintenance of a constant weight; eating

six small meals instead of three large meals is recommended; no large meal late in the

day; spreading meals throughout the day; a light evening snack; and daily self-

monitoring of blood sugar (Downer, 2001). Moreover, according to Savoca and Miller

(2001), providing diet strategies was necessary to help people with type 2 diabetes to

adhere to recommended dietary guidelines. Three types of diet strategies were

suggested in their study. Firstly, food selection and preparation strategies, such as

reducing their dietary fat intake (e.g., grilling, baking, or broiling meat). Secondly,

meal planning strategies, such as preparing a packed lunch, and planning several

meals at one time. Finally, dining out strategies, such as carefully selecting the

restaurant, making sensible food choices, and controlling portions of food. However,

dietary recommendations should be as flexible as possible and individualised, and

education should consist of basic nutrition plus a goal-oriented treatment plan.


59

In summary, nutrition therapy should be individualised for people with diabetes,

giving consideration to their usual eating habits and other lifestyle factors. Nutrition

recommendations can then be developed to meet the goals and desired outcomes of

the treatment. Also, how to enhance individual’s level of understanding of the

common aspects of a dietary recommendation and how to encourage individuals to

adhere their dietary recommendations are the most significant issues for people with

diabetes.

3.3.3. Exercise

There are clinical benefits of incorporating a regular exercise program into the

management of diabetes; for type 2 diabetes, the earlier the exercise program is

started, the greater the benefits. Many type 2 diabetics are overweight or have obesity

problems, but they can lose weight by drawing on blood glucose as an energy source

during and after exercising (Fisher et al., 1996). An exercising muscle increases its

glucose uptake and oxygen consumption 20-fold, initiating glycogenolysis and

lipolysis, and stimulating hepatic glucose output (Zinker, Allison & Lacy, 1997). If

diabetics exercise for more than 30 minutes every day, insulin demands can decrease

about 30% to 40%, due to a 7- to 20-fold increase of the usage of glucose by the body

(Wing et al., 1988). Hence people with diabetes who exercise can generally reduce

their plasma glucose levels. Regular exercise will result in improved insulin

sensitivity and glucose usage. Moreover, a leaner body configuration and enhanced

psychological well-being will usually impart a positive effect to any patient (Birrer &

Sedaghat, 2003).


60

There are many benefits of exercise for those with diabetes, including increased

insulin sensitivity, improved blood sugars, reduced risk of coronary heart disease, and

decreased blood pressure and lipid levels. Moderate exercise for 30 minutes, five

times a week can result in a 10 to 20% improvement in HbA1C (ADA, 2000b).

Hornsby et al. (1990) conducted a study with type 2 diabetics in which exercise was

undertaken 3 times a week, 30 minutes per session, over a 12-14 week period, which

resulted in the fasting blood sugar and HbA1C readings decreasing significantly.

So regular exercise not only decreases blood sugar and increases insulin sensibility, it

also decreases the potential causes of circulatory problems (Braun, Zimmermann &

Kretchmer, 1995). Wei, Gibbon, Kampert, Nichaman and Blair (2000) conducted an

epidemiological study and found that low cardiorespiratory fitness and physical

inactivity are independent predictors of all-cause mortality in men with type 2

diabetes. The risk of dying from cardiovascular disease is 2-4 times greater among

those who have diabetes than among those who do not (National Center for Health

Statistics, 1993). Studies also show that diabetic patients have lower levels of activity

than those who do not have diabetes (ADA, 2000b). Physical activity is one of the

measures that can reduce the risk of coronary heart disease for people with diabetes

( Foreyt & Poston, 1999).

Even though the benefits of exercise have been documented so well, adherence to

exercise programs has been reported as low, while 50% of participants drop out in the

first 3 to 6 months (Leith, 1992). Also, Searle and Ready (1992) showed that over

50% of Canadians with diabetes fail to exercise more than once per week. Toljamo

and Hentinen (2001) showed that adherence rates of self-care generally vary from 3 to

80%, depending on the intervention and research methods used in the studies.


61

According to Glasgow, Hampson, Strycker and Ruggiero (1997) and Ruggiero et al.

(1997), patients with diabetes have more difficulty in adhering to suitable diet and

exercise than to their insulin medication.

The causes of low adherence have been investigated: A study was conducted to

determine whether there are differences in key social-cognitive determinants of

exercise between adults with diabetes and those without. Results showed that the

diabetes group reported significantly lower scores for self-efficacy and perceived

behavioural control. These data suggest that the low levels of self-efficacy and

perceived behavioural control among those with diabetes emphasise the importance of

designing specific strategies to increase their self-confidence in undertaking physical

activity (Plotnikoff, Brez & Brunet, 2003).

In brief, the benefits of exercise are physiological and psychological. Increased

activity and some exercise not only have a therapeutic value, but also increase

optimism and enhance self-confidence. It is time to help people discover and obtain

the feeling that comes with exercising and convert that feeling into internal gain

(Guthrie & Guthrie, 2002).

3.3.4. Medication

Although diet and exercise are important parts of type 2 diabetes self-care, most

patients require medication to maintain adequate glycaemia control. According to

Glasgow et al. (1999), various diabetes self-care behaviours are relatively independent

of one another. Dietary aspects of the regimen are experienced as the most difficult

(Schlundt, Rea, Kline & Pichert, 1994), followed by exercise, while most patients find


62

medication taking to be the area in which they have the least difficulty (Glasgow,

1994). This may be because this regimen area is perceived by the public as most

closely associated with “managing an illness” (Glasgow et al. 1997). However, while

most patients may take their medication, they are far less adherent with timing or

adjusting its administration (Ho, 2006). So understanding the regimen of medication

is an important issue in diabetes self-care.

Oral hypoglycaemic agents have added a new dimension to the treatment of diabetes

mellitus since tolbutamide became available in 1956 (Guthrie & Guthrie, 2002); they

are used to stimulate insulin secretion, but are not the same as insulin itself, neither

can they replace it. However, many patients have the misconception of oral agents as

“insulin pills”. In many cases control of blood sugar level cannot simply be achieved

only by diet and exercise and therefore medication is important for the treatment of

diabetes. The ADA (American Diabetes Association) recommends that if a trial diet

for 8 to12 weeks is unsuccessful in controlling blood sugar, oral hypoglycaemic

medication should be introduced (ADA, 1996c). Medication includes oral

hypoglycaemic drugs and insulin injection. Patients should take the exact medicine

and injection prescribed by their doctors. In this way medication can improve the

control of diabetes and decrease the occurrence rate of acute and chronic

complications (Davidson, 1998; LeRoith, Taylor & Olefsky, 2000).

Some new classes of OHA (oral hypoglycaemic agents) have been released in the last

few years. The newer OHAs might extend the life of the beta cells and delay the need

for insulin (Dornhorst, 2001); they do not contain insulin themselves, and should be

used to supplement dietary measures. Excessive dosages are not recommended, nor

are OHAs a substitute for proper dietary compliance. They are not suitable for type 1


63

diabetes or during pregnancy (Dunning, 2003). OHAs target the different metabolic

aspects of type 2 diabetes: (1) Biguanides reduce insulin resistance and fasting

glucose; (2) Sulphonylureas and Glitinides are secretagogues, agents that stimulate

insulin production; (3) Thiazolidinediones (TZI) decrease insulin resistance, reduce

daytime preprandial hyperglycaemia and have some effect on the fasting blood

glucose; (4) Alpha-glucosidase inhibitors slow carbohydrate digestion and reduce

postprandial glucose (Phillips, 2000; Braddon, 2001). These drugs can be effective

alone or can be used in combination. Multiple OHAs are often required because type

2 diabetes is a slow progressive multifactorial disease. OHAs can be also combined

with insulin. Adherence to prescriptions and blood glucose monitoring is essential to

assess and tailor the dose in order to maintain the desired level of glycaemia control.

The regularity required in taking medication presents a challenge both to people with

diabetes and to their treating clinicians. Studies have demonstrated that treatments

including multiple medications or frequent dosages have a negative impact on

adherence (Bartels, 2004). Funnell and Meritt (1993) also found that some older

diabetics have other chronic diseases, therefore, they often have to take many

different kinds of medications. Additionally, many older diabetics may have fading

memories, so they may sometimes forget to take the medicines, and there is also the

potential possibility of taking wrong dosages. It is important for people with diabetes

to receive proper education in how to take medication correctly in order to prevent

further progress of the disease and avoid complications.

In conclusion, an understanding of the action of the various oral agents should assist

people with diabetes to cope with their disease. Guidance and education provided by


64

health professionals should help individuals to use these medications more carefully

(Cincinnati & Veliko, 2001).

3.3.5. Foot care

Foot problems are the most commonly reported complication of diabetes; they may

result in hospitalisation and sometimes require surgical intervention, which can lead

to a lifetime of disability and low quality of life. Diabetic foot disease is a

heterogeneous disease entity defined as a group of symptoms that leads to tissue

breakdown. Infection, neuropathy and ischaemia are usually present and increase the

risk of infection (Apelqvist & Larsson, 2000). According to a recent report, 40 to 70%

of lower limb amputations occur in people with diabetes, most beginning with an

ulcer (Dunning, 2003); the amputation rate can be reduced by preventative foot care.

Foot disease and its management have an adverse impact on the well-being and

quality of life of people with diabetes (Brod, 1998).

Foot ulcers are common in people with diabetes and are costly in terms of both patient

morbidity and the use of healthcare resources. A study of 1077 people with diabetes

found that 7.4% of patients had past or present foot ulceration (Walters, Gatling,

Mullee & Hill, 1992). The economic burden of foot ulcers has been assessed as

widespread; one study found that patients with diabetes made up 5.5% of admissions,

6.4% of outpatient attendances and 9.4% of bed-days (Currie, Williams & Peters,

1996).

It is important that primary foot care for people with diabetes should incorporate

adequate monitoring and the opportunity to reinforce the message of self-care and


65

preventive strategies. Many patients are unable to do self-monitoring due to poor

eyesight, making it difficult for them to inspect their feet (Thomson & Masson, 1992).

Hence it is important for people with diabetes to maintain regular contact with health

professionals. In general, common neurological examinations in hospitals include

tests for vibration sensitivity threshold with a biothesiometer or tuning fork, or for

cutaneous pressure sensitivity with a 10-g monofilament (5.07) (Mason, O’Keeffet,

Mclntosht, Hutchinsont & Young, 1999). These examinations can signal the risk of

diabetes foot problems.

A summary of guideline recommendations for the examination of the foot in those

with diabetes was provided by ADA (1996b), and has been in common use in clinical

practice. The clinical practice guidelines, originally approved in 1990, recommended

basic foot care education for all health professionals regardless of risk category, with

a thorough inspection of the feet at each visit and a comprehensive assessment

annually. Vascular examination involved palpation of pulses and inspection. Tests for

sensorimotor examination are not specified. Range of movement is examined, as is

gait, and inspection for bony abnormality is included in the musculo-skeletal items

listed. The importance of continuing instruction until the patient can verbalise and

demonstrate proper foot care practice is emphasised (ADA, 1996b; Couzos et al.,

1998).

Many people with diabetes may not have sufficient skills or knowledge to properly

manage their condition, including foot care (Mason et al., 1999). Common elements,

such as foot hygiene and awareness of fungal infections, treatment of callous, and

actions required for cutaneous injuries should be included in patient education (Mason

et al., 1999). Epidemiological and clinical risk factors for ulceration also have been


66

reported; risk markers include old age, duration of diabetes, peripheral vascular

disease, renal disease, plantar callous, poor vision, poor footwear, cigarette smoking,

social deprivation and social isolation (Walters et al., 1992; Mason et al., 1999). In

addition, Plummer and Albert (1995) conducted research on 136 diabetics to examine

foot self-care behaviour in the high-risk population for amputation. They found that

those in the high-risk group had a high frequency of poor foot self-care behaviours. In

Germany, a 4-year follow-up study on diabetics found that the longer they wore a

protective insole and undertook more frequent foot care, the more significant was the

decrease in recurrence of foot ulcers (Chantelau & Haage, 1994). Consequently,

emphasis on foot care is an important nursing intervention when caring for people

with diabetes.

Education has been recommended as the most important contribution to the

prevention of foot problems in people with type 2 diabetes (ADA, 1996b).

Emphasising the importance of physical activity and of appropriate control of blood

sugar levels are essential components of this. Reiber, Pecoraro and Koepsell (1992)

showed that physical activity, defined as 20 minutes exercise three times per week has

also been found to be protective against amputation (OR 0.6; 95% CI 0.3-0.9). In

another study, fasting plasma glucose levels < 7.8 mmol/L at base line were protective

in a 12-year follow-up study. There were no amputations in this group, irrespective of

the duration of diabetes (Humphrey, Dowse, Thoma & Zimmet, 1996). Nevertheless,

other comprehensive recommendations about foot care should still be included in the

educational content.

Despite the evidence that foot care can prevent amputations, care of feet continues to

be a commonly neglected aspect of management of patients with diabetes. Foot care


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must be organised to provide monitoring, education or intervention and referral in a

manner acceptable to patients (Mason et al., 1999).

In conclusion, successful management of diabetes relies on the individual being able

to perform self-care activities designed to control symptoms and avoid complications.

Many complications arising from diabetes are preventable if rigorous attention is paid

to managing the disease, including following a prescribed medication regimen and

strict calorie-controlled diet, doing regular exercise, undertaking blood glucose checks

and caring for feet (McDowell, Courtney, Edwards & Shortridge-Baggett, 2005).

Addressing the task-related issues of self-management activities required by people

with diabetes is important and an ongoing challenge for health-care providers and the

health care system.


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3.4 Quality of life and diabetes

Quality of life has been recognised as an important health outcome (Snoek, 2000) and

even represented as the ultimate goal of all health interventions (Rubin & Peyrot,

1999). However, there is no universally accepted definition for quality of life, maybe

because the concept is a “vague and ethereal entity, something that many people talk

about, but which nobody very clearly knows what to do about” (Campbell, Converse

& Rodgers, 1976, p.471). In general, the terms “quality of life”, “well-being”, “health

status” and “satisfaction” are often used interchangeably (Snoek, 2000).

Hornquist defines quality of life as a broad spectrum of dimensions of human

experience, ranging from those describing the necessities of life, such as food and

shelter, to those associated with achieving a sense of fulfilment and personal

happiness (Hornquist, 1982). To narrow its extent to those aspects directly related to

disease or medical treatment, the term “health-related quality of life” (HRQOL) was

introduced (Patrick & Erickson, 1988); in the medical area it was defined as “a

concept encompassing a broad range of physical and psychological characteristics and

limitations, which describe an individual’s ability to function and to derive

satisfaction from doing so” (Walker & Rosser, 1987).

Furthermore, Ferrans (1990) defined five domains of the quality of life: normal life,

happiness and satisfaction, achievement of personal goals, social utility, and natural

capacity. Ware (1987) even combined different perspectives and concluded that

quality of life referred to the satisfaction level in an individual’s living environment

toward: physical function; role limitation due to physical problems; role limitation due

to emotional problems; social functions; pain; vitality; mental health and general


69

health. Overall, it can be divided into a physical component scale (PCS) and a mental

component scale (MCS) (Ware, 1987; Ware & Kosinski, 2001).

Most people understand what is meant by quality of life but it is a difficult concept to

measure. A number of instruments have been developed that measure the general

aspects of quality of life, and diabetes-specific quality of life tools are also available

(Dunning, 2003). According to Rubin and Peyrot (1999), two broad approaches to

health-related quality of life measurement have emerged: generic and disease-specific.

The generic approach involves the use of measures applicable across all health and

illness groups. The generic measure of quality of life most widely used in studies of

people with diabetes is the Medical Outcomes Study (MOS) Short-Form General

Health Survey, including several forms: SF-36; SF-20; and SF-12 (Stewart et al.,

1989). The MOS instrument includes physical, social and role functioning scales to

capture behavioural dysfunction caused by health problems. Measures of mental

health, perceptions of overall health, and pain intensity reflect more subjective

components of health and general well-being (Rubin & Peyrot, 1999). The MOS tool

comprises 8 subscales: physical function (PF); role-physical (RP); role-emotional

(RE); social function (SF); bodily pain (BP); vitality (VT); mental health (MH); and

general health (GH); and physical and mental component summary scores (PCS and

MCS scores) (Ware, Losinski & Keller, 1994). These instruments have been

translated into many languages and used in studies, including those on people with

diabetes (Ware & Sherbourne, 1992; Ware, Losinski & Keller, 1994).

In general, most studies report that quality of life among people with diabetes is worse

than that in the general population (Rubin & Peyrot, 1999). Several studies have

measured quality of life using the SF-36 and SF-20 versions. Ware and colleagues


70

published data based on responses to the 1990 National Health Survey of Functional

Status, finding that those with diabetes reported lower quality of life than the general

population on scales assessing physical functioning, role functioning and general

health; however differences were not significant on scales assessing social functioning

and mental health (Ware & Sherbourne, 1992; Stewart, Hays & Ware, 1988).

Similarly, a study that included patients with both types of diabetes but did not

distinguish subjects by complication status, found that those with type 2 diabetes

scored lower than controls on all quality of life scales (Aalto, Uutela & Kangas, 1996).

However, a recent study has found that for people with type 2 diabetes prior to

diagnosis, physical and mental functioning measured by SF-12 was already lower for

subjects who met the new criteria than for those in the comparison group, perhaps

because of obesity or other aspects of the insulin resistance syndrome (Nichols &

Brown, 2004).

Some demographic variables or psychosocial factors are related to quality of life

(Rubin, 2000a) and influence it for people with diabetes. In general, men report better

quality of life than women; younger people report better quality of life than older

people; those with more education or income generally report better quality of life

than those with less of either (Glasgow, Dryfoo & Ruggiero et al., 1997; Quittan et al.,

1999; Rubin & Peyrot, 1999; Rubin, 2000a; Dunning, 2003). Psychosocial factors,

including health-related beliefs, social support, coping style, and personality type

might have potent effects on quality of life (Rubin, 2000a). Other factors, such as

medication and physical exercise are all important indications (Glasgow, Dryfoo &

Ruggiero et al., 1997; Quittan et al., 1999). Having better glycaemic control is

associated with better quality of life; and complications of diabetes are the most

important disease-specific determinant of quality of life (Rubin & Peyrot, 1999;


71

Guttwann-Bauman, Flaherty, Strugger & McEevoy, 1998). However, many studies

have found that patients’ quality of life is not related to whether their diabetes is type

1 or type 2, rather, the most important factor is complications of diabetes (Ahroni,

Davignon, Boyko & Pecoraro, 1994; Franch, 1999; Edlman, Olsen, Dudley, Harris &

Oddone, 2002).

In conclusion, many studies have shown that people with diabetes have experienced a

lower quality of life compared with population norms, in aspects either of mental or

physical health. For example, Wexler et al. (2006) found that people with type 2

diabetes have a substantially decreased health-related quality of life in association

with symptomatic complications. Therefore, it is very important to know how to

improve the quality of life for people with diabetes. Rubin (2000a) recommended that

certain interventions, including the introduction of blood glucose-lowering

medications and educational and counselling interventions designed to facilitate the

development of diabetes-specific coping skills, can improve both glycaemic control

and quality of life in people with diabetes. Special education interventions initiatives

should be established to help people with diabetes to improve the health outcome of

health-related quality of life.

3.5 Psychosocial issues and diabetes

It is inevitable that nurses or other professionals will take on an increased clinical role

for diabetes care. Not only do they focus on the medical aspect of diabetes, but also

recognise its psychosocial impact for people with diabetes. Several studies have

shown that psychosocial factors play an integral role in diabetes management; the

impact of psychosocial factors is a stronger predictor of mortality in diabetic patients

than many physiological variables (Delamater et al., 2001). Psychosocial factors


72

include cognitive functioning, depression, stress, social support, and self-efficacy

(Seeman & Chen, 2002) and they help predict differences in Activities of Daily

Living (ADLs) (Martin, Grunendahl & Martin, 2001). Psychosocial well-being is

defined as “seeking a sense of control in the face of life-threatening illness

characterised by emotional distress, altered life priorities, and fears of the unknown,

as well as positive life changes” (Ferrell et al., 1998). In this thesis, the variable of

psychosocial well-being includes the factors of social support and depression which

will be discussed in the following sections.

3.5.1 Diabetes and social support

People with diabetes are encouraged to care for themselves in managing their illness.

Diabetes creates a need for increased support, as the demands of the regimen are

extensive (Guthrie & Guthrie, 2002). Social support has been found to be significantly

correlated with higher functional status (Shih & Shih, 1999) or diabetes health status

(Wierenga, 1994) and enhanced self-care (Dimkovic & Oreopoulos, 2000). Williams

and Bond (2002) conducted a survey and found that social support was associated

with the exercise of self-care, and the relationship between the two variables was

mediated by self-efficacy. Belgrave and Lewis (1994) examined the role of social

support in compliance and other health behaviours and found that social support was

significantly associated with the positive health behaviours of appointment keeping

and adherence to health activities. Of all the health activities chosen by the authors,

which included diet, exercise, having regular blood pressure tests, taking medication

as prescribed, and foot care, social support was found to have the greatest impact on

diet and foot care. However, a cross-sectional study was conducted with 95 insulin-

requiring Hispanic adults to explore social support and diabetes self-management. The


73

results showed that participants were least satisfied with the help they received for

diabetes-related self-care, personal care, and financial assistance and that social

support was not strongly related to diabetes self-management (Gleeson-Kreig, Bernal

& Wooley, 2002).

Social support has a positive influence on the overall psychosocial well-being of an

individual. Due to the growing recognition of this, health care interventions have

increasingly incorporated social support. As White, Richter and Fry (1992) have

shown, the greater the perceived social support, the better the psychosocial adjustment

to illness. The enhancing component bolsters the social support of chronically ill

patients (Hebert, Robichaud, Roy, Bravo & Voyer, 2001). In a randomised clinical

trial conducted by Maxwell, Hunt and Bush (1992), 204 patients with diabetes were

studied, randomly divided into two groups. The control group received the training

program only, whereas the experimental group was offered that program in addition to

eight support group meetings, at which they had the opportunity to receive

informational and emotional support. After 7 months of follow-up, patients in both

groups showed improved metabolic control (HBAIC), diabetes knowledge, frequency

of practising recommended diabetes management behaviours, and emotional

adjustment; however, no additional improvement was seen in the people in the

experimental group. Nevertheless, the authors suggested that a better understanding of

the possible contribution of support groups to health is necessary before such groups

are routinely recommended to patients with diabetes.

There has been some attention in the research literature on the role personal

characteristics play in the social support that is received by people with diabetes. Men

with diabetes have reported more support from family members, whereas women


74

received more from friends (Kvam & Lyons, 1991). Murphy, Williamson and Nease

(1994) conducted a cross-sectional research design using a telephone survey to

examine the role of social support among adult patients with type 2 diabetes, and

found that 51% of the men in the study identified their wives as the family health

monitor, but only 8% of the women identified their husbands as the family health

monitor. Moreover, people with a higher educational level were also found to have

greater feelings of support from family and friends (Kvam & Lyons, 1991). However,

Ford, Tilley and McDonald (1998) summarised a literature review for the African-

American population and concluded that socio-economic status was not emphasised

in the studies reviewed, although it might be expected that education and income

would positively influence health incomes and glycaemia control. So the relationship

between personal characteristics and social support needs to be explored in further

studies.

In conclusion, the rising incidence and prevalence of diabetes continues to be a major

health concern. Social support has been found to be a relevant factor in diabetes self-

management. The problem is further magnified among ethnic groups, including the

Taiwanese population. Further research should continue to examine the interaction of

social support and diabetes self-management in different populations.

3.5.2 Diabetes and depression

A number of studies have shown the association between diabetes and depression

(Gavard, Lustman & Clouse, 1993; Anderson, Freedland, Clouse & Lustman, 2001;

Lustman et al., 2000). This is an important public health issue because depressive

disorders generally have been associated with the outcomes of chronic disease such as


75

diabetes (Finkelstein et al., 2003). Causes underlying the association between diabetes

and depression are poorly understood (Jack Jr. et al., 2004), however, diabetes

increases the risk of depression, with prevalence rates from 15 to 40 % (Harris, 2003).

Depression can contribute to decreased physical and mental functioning that causes

individuals to be less likely to follow daily diabetes self-care routines, thus exposing

them to poor glycaemic control and increasing their risk for complications (Lustman

et al., 2000). Ciechanowski, Katon and Russo (2000) have stated that people who are

depressed are more likely to have inadequate self-care and to require specialist

intervention. The relationship of depression and self-care is interwoven (Talbot &

Nouwen, 2000); depressed people with diabetes may present with the typical

symptoms of low energy, worthlessness, hopelessness, and helplessness that manifests

in a ‘why bother’ attitude and poor follow-through. People with diabetes may get

labelled as noncompliant with the diabetes self-care regimen (Guthrie & Guthrie,

2002), while the underlying problem of depression may go undiagnosed. An effective

screening instrument needs to be used to detect the symptoms of depression earlier.

Depression remains unrecognised and untreated in a majority of cases, despite its

specific relevance to diabetes (Lustman et al, 1997). Most estimates suggest that only

about one-third of people with diabetes and major depression are recognised and

treated (Lustman & Harper, 1987). Many generic measures of emotional status have

been employed in studies that include people with diabetes. Psychometric instruments

include the Well-being Questionnaire; the Profile of Mood States, the Symptom

Checklist (SCL-90R); the Kellner Symptom Questionnaire and the Affect Balance

Scale. Depression in people with diabetes has been studied using the following scales:

the Beck Depression Inventory, the Zung Self-Rating Depression Scale and the Center


76

for Epidemiological Studies Depression Scale (CES-D) (Rubin & Peyrot, 1999). They

are also effective tools for detecting depression in people with diabetes.

The number of research articles that include information about depression in diabetes

has increased. In 1997, Lustman et al. adopted the Beck Depression Inventory in

surveying people with diabetes, and found that about 70% of 172 people with diabetes

had a depression problem, 3 to 4 times higher than in healthy individuals (Lustman et

al, 1997). Hanninen, Takala and Keinanen-Kiukaanniemi (1999) conducted a study on

people with type 2 diabetes and found that 28.8% of the subjects had a tendency to

depression. Also, studies have found that people with diabetes have higher levels of

depression than the norms derived from the general population (Gavard, Lustman &

Clouse, 1993; Bourdel-Marchasson et al., 1997; Lustman, Griffin, Gavard & Clouse,

1992; Rubin & Peyrot, 1999). For example, Peyrot and Rubin (1997) found that rates

of disturbance for depression (41%) and anxiety (49%) were higher than those typical

in the general population (< 10%). Egede, Zheng and Simpson (2002) found that the

average rate of people with diabetes with depression was twice higher than for healthy

individuals and for diabetes with depression disorder, the average medical expense

each year was 4.5 times higher than diabetes without depression disorder.

Depression is associated with the outcomes of diabetes and contributes to the high

economic burden of health care costs; deGoot, Anderson, Freedland, Clouse and

Lustman (2001) found that depressive symptoms were associated with an increase in

the severity or number of diabetes complications in 89% of 27 studies and there was a

significant relationship between depression and retinopathy, neuropathy, nephropathy

and sexual dysfunction. As for health care costs, DeRekeneier, Resnick and Schwartz


77

(2003) showed that depression was associated with an approximately five-fold

increase in health expenditure for diabetes.

In addition, psychological disturbance may be associated with the number of diabetes-

related complications and with certain demographic variables. Anderson et al.(2001)

and Fisher, Chesla, Mullan, Skaff and Kanter (2001) all indicated that depression

disorder in people with diabetes was significantly related to gender, education level,

marital status, blood sugar control, and multiple complications. There were higher

rates of depression in women, those who were unmarried, and those with lower levels

of education (Peyrot & Rubin, 1997; Rubin & Peyrot, 2001). Acute or chronic

complications caused by unstable blood sugar control are important factors of

depression (Hanninen et al., 1999; Fisher et al., 2001). Peyrot and Rubin (1997) found

a higher rate of depression in those with three or more diabetes related complications.

Additionally, glycaemic control was significantly worse in patients with depression

compared to those who were not depressed (DeGroot, Jacobson, Samson & Welch,

1999). Researchers also have indicated that appropriate blood sugar control can

improve the problem of depression in people with diabetes (Talbot & Nouwen, 2000;

Anderson et al., 2001). However, there is no significant association with diabetes

types (type 1 or type 2) or duration of disease (Peterson, Lee, Young, Newton &

Dornan, 1998; Rubin & Peyrot, 1999; Talbot & Nouwen, 2000).

From the above literature, it can be concluded that people with diabetes do have a

tendency for depression problems. Moreover, depression problems are also influenced

by many basic attributes, such as gender, age, education, marital status, physical

activity, complication, family diabetics history, and blood sugar. This issue has


78

engaged the attention of many researchers, and finding ways to improve the

depression problems in people with diabetes is obviously a critical factor.

3.6 Summary

The literature review on diabetes provides the main key points of this study. Five

issues related to diabetes mellitus have been explored, including: diagnosis and

definition, classification, and complications of diabetes. Diabetes is a chronic disease

that requires daily regimentation of all activities including:

(1) blood glucose monitoring;

(2) adhering to dietary restrictions;

(3) maintaining or increasing levels of physical activity;

(4) managing and administering medications; and

(5) active participation in self-care routines, such as foot care.

Although the Taiwanese health care system has persistently emphasised the

importance of patient health education (see Chapter 2.4.2), improvement in self-care

activities and control of diabetes has been limited. Two Taiwanese surveys showed

only 30% of people with diabetes had performed self-monitoring of blood sugar or

urine sugar demonstrating people with diabetes lack skills or have low participation

rates in performing self-care activities (Chuang et al., 2001; Lin et al., 2001).

Alarmingly, only 14.0% of patients > 65 years have HbA1c values within the optimal

range of < 6.5% (Tai et al. 2006). For diabetes care to succeed, patients must be able

to make informed decisions about how they will live with their illness (Funnell &

Anderson, 2000). Thus, improving self-management and prevention of diabetic

complications for people with diabetes is an ongoing challenge for health-care

providers and the government.


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Quality of life and psychosocial well-being are other very common and crucial

outcome variables for chronic diseases. Also, the variable of psychosocial well-being

including the factors of social support and depression is very important for people

with diabetes. The relationships between diabetes and quality of life and psychosocial

well-being have also been described above and most studies report that quality of life

and psychosocial well-being among people with diabetes are worse than those in the

general population (Rubin & Peyrot, 1999). However, in general, cross-sectional

designs are limited, in that causality cannot be established between the phenomena

being studied, for example, the effects of social support or depression on diabetes

control over time cannot be assessed in cross-sectional studies (Ford, Tilley &

McDonald, 1998). In terms of previous research studies, very few studies have been

conducted by way of well-designed randomised controlled trials. Clearly, more

research, particularly randomised trials, is needed regarding self-management, and

self-efficacy on quality of life and psychosocial well-being.

There is a doubt about how effective it is in achieving the desired effect of

improvement in the prevalence, mortality rate and health care costs of diabetes in

Taiwan. A gap between knowledge and behaviour change is evident in diabetic

studies that demonstrate patients with diabetes do not perform self-care although they

received diabetic patient education (Glasgow & Osteeen, 1992). Self-efficacy offers a

basis for improving the effectiveness of diabetes education because it focuses on the

capacity for behavioural change (van der Bijl & Shortridge-Baggett, 2001). The self-

efficacy approach to diabetes education seeks to enhance the self-care knowledge,

skills, self-awareness, and sense of personal autonomy of patients to encourage them

to take charge of their own diabetes care. Educating people with type 2 diabetes


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within a framework that enhances self-efficacy may improve self-management of this

disease, health-related quality of life, psychosocial well-being and may lower health

care costs. Thus the issue of self-efficacy and relevant outcome variables will be

discussed in the following chapter, Chapter 4.

Student number: n4513282 Shu-Fang Wu Chapter 4 Framework

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Chapter 4

Framework

4.1 Introduction

A model of self-efficacy adapted from Shortridge-Baggett and van der Bijl (1996) is

used as a framework for this study. The basic premise underlying self-efficacy theory,

according to Bandura (1977a; 1986), is that individuals’ expectations of self-efficacy

(efficacy expectations) and success (outcome expectations) determine whether they

will engage in a specific behaviour. There are two main parts of this chapter, an

overview of self-efficacy theory and a description of the intervention (SEEIP) used in

the study.

The self-efficacy model is discussed first, including its two main cognitive

components (self-efficacy and outcome expectations), information sources

(performance accomplishments, vicarious experience, verbal persuasion, and

self-evaluation) and behaviours, and then the issues of self-efficacy in diabetes

self-management are explored. Self-efficacy and outcome variables, such as quality of

life and psychosocial well-being issues, will be dealt with at the end of that section.

The second part of this chapter includes the rationale for the promotion of

self-efficacy, and a plan of SEEIP, the self-efficacy enhancing intervention program.

4.2 Self-efficacy model

Over the last decade and a half, Bandura’s social cognitive theory has been

increasingly applied, both as a model of health behaviour and as a framework for


82

developing effective health interventions (Bandura, 1977b; 1986). Self-efficacy is one

important part of social cognitive theory (SCT) (Bandura, 1977b), formerly known as

social learning theory. According to Bandura, self-efficacy was originally defined as

“a specific type of expectancy concerned with one’s beliefs in one’s ability to perform

a specific behaviour or set of behaviours required producing an outcome” (Bandura,

1977a). However, this definition has been expanded to refer to “people’s judgment of

their capabilities to organise and execute the course of action which require

designated types of performances” (Bandura, 1986, p.391). Thus, one’s self-efficacy

judgments are concerned, not with skills, but with one’s perceived competency in

using whatever skills one has (Bandura, 1986).

Self-efficacy theory is one theory of the behaviour of a person, her or his

characteristics, and the environment in which the behaviour occurs. The model of

self-efficacy used in this study is adapted from Shortridge-Baggett and van der Bijl

(1996) (see Figure 4.1). In this model, the main concepts include the characteristics of

a person, his or her behaviour and the outcomes of that behaviour. The basic premise

underlying self-efficacy theory, according to Bandura (1977a, 1986), is that

expectations of personal mastery (self-efficacy or efficacy expectations) and success

(outcome expectations) determine whether an individual will engage in a specific

behaviour (van der Bijl & Shortridge-Baggett, 2001).


83

Environment

Figure 4.1 Self-efficacy Model adapted from Shortridge-Baggett and van der Bijl (1996)

Self-efficacy theory has two cognitive components, the first being perceived efficacy

belief (efficacy expectations, or just self-efficacy). The second cognitive component

of self-efficacy is outcome expectation (Bandura, 1977a; 1982). Although

self-efficacy and outcome expectation are viewed as different mechanisms, their

influence on behaviour change is synergistic. Both self-efficacy (confidence in ability)

and outcome expectation (belief that the behaviour will have the desired effect) are

required for any given outcome. Both efficacy expectation and outcome expectation

Person -Characteristics -Perception -Self-referent

Behaviour -Initiation -Effort -Persistence

Outcome

Efficacy-Expectations -Magnitude -Strength -Generality

Outcome-expectations

Information sources -Performance accomplishment -Vicarious experience -Verbal persuasion -Self appraisal


84

are important determinants of behaviour and their differential influence is explained

in the following sections.

4.2.1. Self-efficacy (efficacy expectations)

The definition of self-efficacy is “people’s judgment of their capabilities to organise

and execute the course of action which require designated types of performances”

(Bandura, 1986, p.391). This description shows that people’s self-efficacy is not of a

general nature, but is related to specific situations. Individuals can judge themselves

to be very competent in a specific field and less competent in another field. For

example, a person can be convinced that she or he can walk 10 km in a flat area, but

be quite certain that he or she cannot do it in the mountains (van der Bijl, van

Poelgeest-Eeltink & Shortridge-Baggett, 1999). This concept emphasises not people’s

skills, but their judgments of what they can do (Bandura, 1986). So self-efficacy is not

a personality trait, but is related to specific situations (van der Bijl &

Shortridge-Baggett, 2001).

Because self-efficacy is strictly situational and task-related (van der Bijl, van

Poelgeest-Eeltink & Shortridge-Baggett, 1999), an expression of personal efficacy is

an assertion of confidence in one’s capability to overcome the difficulties inherent in

achieving a specified level of behavioural attainment (Maibach & Murphy, 1995).

Judgment about the specific task is built on past experiences and will vary according

to three factors that constantly interact: level (or magnitude), strength, and generality

of the efficacy belief (Bandura, 1977a; Bandura, 1986); magnitude considers the

difficulty of the task; strength looks at the conviction a person holds that the task can

be done; and generality considers how experiences of self-efficacy can either be


85

specific to one task in one situation or generalised to new or challenging situations

(Shortridge-Baggett & van der Bijl, 1996). Consequently, behavioural, cognitive and

social skills must be integrated if a person is to undertake a specific task.

Bandura (1986) claimed that self-efficacy is the most effective predictor of change in

behaviour. In other words self-efficacy influences how people think, feel, motivate

themselves and perform (van der Bijl & Shortridge-Baggett, 2001). People who have

a high level of self-efficacy are more persistent in the face of difficulties than those

with a lower level (Bandura & Cervone, 1983; Bandura, 1997). Motivation and

perseverance in performing behaviours depend on the individual’s evaluation of his or

her self-efficacy. If individuals do not believe they can perform a behaviour, their

performance in it will decline (Bandura, 1997); in contrast, people who believe in

their efficacy create benign environments in which they exercise some control; the

effects on their life choices are profound (Bandura, 1997). Self-efficacy is a crucial

determinant of performance that operates, in part, independently of underlying skills

(Bandura, 1986); for example, in patients recovering from a heart attack it has been

found that their perceived self-efficacy regarding physical capability is a better

predictor of resumption of an active life than their cardiovascular capacity (Ewart,

Taylor, Reese & Debusk, 1983; Bandura, 1986). In particular, lifestyle behavioural

changes are likely to be reliant on self-efficacy (efficacy belief) to overcome

perceived barriers to adopting the new behaviour (Schultz & Shultz, 1998).

Self-efficacy regulates human behaviour through cognitive, motivational, affective,

and selection processes (Bandura, 1997). These processes usually work together in

regulating actions. The first process is that efficacy beliefs affect thought patterns in

terms of promoting or destroying performance; for example, people with high


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self-efficacy are more likely to have high aspirations, and firmly believe in

themselves in meeting these challenges. The second process is motivational, by which

people motivate themselves by forming beliefs about what they can do, expecting

likely outcomes, and setting goals. The third process is affective, in that self-efficacy

regulates emotional states by supporting effective courses of action to transform the

environment in ways that alter its emotive potential (Bandura, 1997); this means that

the degree of stress or depression people experience in threatening or difficult

situations depends on how well they think they can deal with them; low self-efficacy

can lead to depression and reduce social support (Bandura, 1997). The final process is

selective, in that people with high self-efficacy prefer normatively difficult activities

and display high staying power in these pursuits. According to Bandura (1986), the

stronger their perceived efficacy beliefs, the more vigorous the efforts and the longer

the persistence.

The expectation that a certain behaviour will have a desired outcome serves as a

motivation to continue the behaviour (Bandura, 1995), so belief in one’s ability to

perform a task that will lead to the desired outcome is a strong predictor of one’s

performance of the task. Consequently, self-efficacy has been suggested to be one of

the most influential agents in human behaviour. It has been found that a strong sense

of personal efficacy is related to better health, higher achievement and better social

integration (Conner & Sparks, 1995).

However, having high self-efficacy does not imply that the behaviour can be

conducted without any anxiety (Feist, 1994). Bandura (1991) stated that self-efficacy

is able to mediate the relationship between stress or anxiety and a sense of the

controllability of an adverse situation; to resist threats, an optimistic sense of personal


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efficacy is required (Bandura, 1986). Individuals with a stronger efficacy belief may

feel anxious, but will have fewer self-doubts and will recover quickly (Bandura, 1997).

As to health, people with a higher self-efficacy were less likely to be depressed than

those with a low self-efficacy (Gecas, 1989; Bandura, 1997).

In conclusion, an efficacy expectation is about the confidence in one’s capability to

produce the behaviour. People are motivated to perform tasks they believe will

produce desired outcomes. Outcome expectations are highly dependent on efficacy

expectations. Therefore, efficacy expectations predict performance much better than

outcome expectations (Bandura, 1986). According to Shortridge-Baggett (2001), it is

hypothesised that self-efficacy plays an important role in predicting behaviour and its

outcomes (Bandura, 1986).

4.2.2 Outcome expectations

Perceived self-efficacy is a judgment of one’s ability to organise and execute given

types of performances, whereas an outcome expectation is a judgment of the likely

consequence such performances will produce (Bandura, 1997, p.21). Performance is

causally prior to outcomes. According to Bandura (1997), how one behaves largely

determines the outcomes that one experiences. Similarly, the outcomes people expect

depend largely on their judgments of how well they will be able to perform in given

situations. Outcomes, therefore, arise from actions.

Outcome expectation is a judgment about the result of enacting the behaviour in

question; it is about whether the recommended behaviour will have the desired effect

(Bandura, 1989). Bandura differentiates between efficacy expectation and outcome


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expectations, by the questions “Can you perform this task?” (efficacy expectations);

and “If you managed to perform this task, what would the outcome be?” (outcome

expectations). He also stated that individuals can believe that a particular course of

action will produce certain outcomes, but they may not act on that outcome belief if

they are doubtful that they can actually execute the necessary activities (Bandura,

1986).

An outcome expectation has been defined as a positive or negative expectation of a

physical, social or self-evaluative nature (Bandura, 1997). Positive forms of physical

expectations include pleasant sensory experiences and physical pleasures, and

negative ones include pain and physical discomfort. Positive forms of social effect

include social reactions of others as expressions of interest, approval, and social

recognition, while negative forms include disinterest, disapproval, and social rejection.

The third major class of outcomes includes positive and negative self-evaluative

reactions to one’s own behaviour. For example, an athlete’s anticipation of social

recognition, applause, monetary prizes, and self-satisfaction resulting from a

high-jump of two metres represent positive self-evaluative reactions, and a superior

feeling of attainment; whereas if the athlete anticipates social disappointment, loss of

rewards, and self-criticism, this represents a negative self-evaluation, and a deficient

level of attainment (Bandura, 1989; 1997).

Although Bandura (1986) and Shortridge-Baggett (2001) hypothesised that

self-efficacy plays an important role in predicting behaviour and its outcomes,

outcome expectations have nor been measured in many studies, and mixed results

were found (Shannon, Bagby, Wang & Trenker, 1990). Outcome expectations and

self-efficacy were found to be good predictors of intention to undertake breast


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self-examination. Conversely, outcome expectations were not predictive of intention

to lose weight (Shannon et al., 1990). Evidence of an association between

self-efficacy and self-care has recently appeared in diabetes literature (Kingery &

Glasgow, 1989; Hurley & Shea, 1992); a study conducted by Kingery and Glasgow

(1989), was part of a larger investigation of the behavioural aspects of type 2 diabetes

and one of its purposes was to determine whether outcome expectations alone, or the

interaction between self-efficacy and outcome expectations, added to the utility of

self-efficacy in predicting levels of self-care. The results of the study showed that

self-efficacy and outcome expectations were weakly intercorrelated (r = .21 and .19

for diet and .04 and .27 for glucose, at time one and time two respectively). The

addition of outcome expectations to self-efficacy and the other variables did explain

an additional two to four percent of the variance on exercise self-care, however,

despite low correlations (r = .42 at both assessments) between the two measures. Also,

Williams and Bond’s (2002) study showed that outcome expectations accounted for

an average 10% of the variance in self-care. Because the previous mixed results were

found, some researchers have argued that the variables are indeed redundant (Kirsch

& Wickless, 1983).

Bandura (1982) proposed that behaviour is best predicted by considering both

self-efficacy and outcome expectations; this is especially relevant when the

performance of an activity does not ensure positive outcomes (Bandura, 1977a) as in

the case of diabetes self-care, in which metabolic control is also influenced by

physiological and emotional factors. As a result, the inclusion of outcome expectancy

measures in diabetes research may improve the understanding of adherence. Few

studies have included both of these components, although Skelly, Marshall, Haughey,

Davis & Dunford (1995) presented a model including both self-efficacy and outcome


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expectancies that accounted for 22%, 24% and 56% of the variance in blood glucose

testing, diet and exercise adherence, respectively. As an independent predictor,

however, outcome expectancy reached significance only for blood glucose testing.

Therefore, the value of including outcome expectancy measures in studies of diabetes

self-care practice requires further investigation (Williams & Bond, 2002).

To sum up, when predictions are to be made of an individual’s likelihood of success

in a program, self-efficacy expectations and outcome expectations should both be

considered. Greater attention should be directed to examining the relationship

between self-efficacy and outcome expectations and the variables in future

interventions (Kingery & Glasgow, 1989; Johnson, 1996; Williams & Bond, 2002).

4.2.3 Information sources

The development of self-efficacy for a particular task requires four main sources of

information, from direct and indirect experiences; these are performance

accomplishments, vicarious experience, verbal persuasion, and self-evaluation

(Bandura, 1977a; van der Bijl & Shortridge-Baggett, 2001). These four sources of

information influence with a person’s self-efficacy in novel situations, and they affect

expectations about the magnitude and strength of one’s self-efficacy

(Shortridge-Baggett & van der Bijl, 1996). These four information resources are

described in the following sections.

4.2.3.1 Performance accomplishments

Performance accomplishments (practising and earlier experience) are the most

effective in developing one’s perception of self-efficacy (Shortridge-Baggett & van


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der Bijl, 1996). Performance accomplishments involve practising and experiencing

success in achieving goals; and this performance mastery experience is a composite of

prior experiences in carrying out the behaviour (McAuley, Lox & Duncan, 1993).

Successful achievements will strengthen self-efficacy (efficacy expectations) about

ability to perform specific tasks and generalise to similar tasks, while they will also

increase the individual’s ability to resist failure.

Experiences of success enhance self-efficacy, while frequent failure decreases it,

especially when the failure takes place early in the learning process. If a person has

developed a strong self-efficacy, a single failure does not have much influence

(Shortridge-Baggett, 2001); once a person has high self-efficacy, she or he tends to

generalise from one experience to another. Thus, the greater the perceived difficulty

of the task, the greater its contribution to self-efficacy when success in the behaviour

is achieved.

Successful direct performance of a behaviour results in higher, stronger self-efficacy

belief than vicarious experience or other behavioural feedback sources (Bandura,

1982). Therefore, accomplishing the behaviour has consistently explained a greater

percentage of self-efficacy belief than other sources (Bandura, 1986, Gecas, 1989).

4.2.3.2 Vicarious experience

Vicarious experience (observing others perform tasks successfully), obtained by

watching the desired behaviour, is another but less effective method to increase

self-efficacy (Shortridge-Baggett & van der Bijl, 1996). Vicarious experience enables

judgments based on the observation of another’s performance. Others can serve as


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examples and role models and provide information about the degree of difficulty of a

specific kind of behaviour (Shortridge-Baggett, 2001). The greater the perceived

similarity to oneself, the greater is the impact of the modelled success or failure

(Bandura, 1997).

The people serving as role models should be similar to the observer in those

characteristics that are relevant to the issue. The model in vicarious learning should be

able to convince the observer that the challenge can be met; a clear outcome is also

important, so that people can persuade themselves that, if others can do it, they can

too (Liebert & Spiegler, 1994). According to Schunk and Carbonari (1984), a

vicarious learning model, for young people with type 1 diabetes who are learning how

to control their blood glucose level, could illustrate the competing commitments of

the relevant age groups. This is an example of vicarious experience.

Although vicarious experience is the second most important source of enacting

behaviour, it cannot be relied upon as the sole source of efficacy information.

Furthermore, its effect can be negated by perceived personal failure (Bandura, 1997).

4.2.3.3 Verbal persuasion

Verbal persuasion can increase both self-efficacy and outcome expectation, leading to

change in behaviour intention (Maddux, Sherer & Rogers, 1982). Although verbal

persuasion is the most often used information source for self-efficacy, it is weaker

than the previous two sources as it is not related to one’s own experience or other

examples. Verbal persuasion (receiving positive verbal reinforcement from others),

the “you can do it” phenomenon, is limited, because it does not provide experimental


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knowledge of self-efficacy. This technique is useful when people have slipped into old

behaviours after accomplishing new ones (Shortridge-Baggett & van der Bijl, 1996).

Because verbal persuasion is easy to provide and readily available, it is also easily

countered by a subsequent less than ideal performance, and then may even discredit

the persuader. Thus, verbal persuasion is a weaker source of mastery expectation than

performance accomplishments and vicarious experience. However, Bandura (1977a)

has stated that, used in conjunction with other resources, rather than having just a sole

role, advice and suggestions by credible others can be effective.

4.2.3.4 Self-appraisal

Physiological information (self-evaluation of the physical and emotional effects of

sources, particularly if this occurs during the early learning phase) provides feedback

to the person of how well the task is being performed (Shortridge-Baggett & van der

Bijl, 1996). Information from the human body can affect someone’s judgment of their

capability to show a specific behaviour. In judging their own capacities, people use

information on their physiological and emotional situations (Shortridge-Baggett,

2001). Emotional arousal, expressed in physiological cues such as heartbeat and

breathing pattern, is used by individuals to judge their degree of anxiety and readiness

to act. Excessive levels of anxiety act as negative feedback that can decrease

self-confidence and performance, particularly for complex tasks (Bandura, 1986).

People experience stress, anxiety and depression as signs of personal deficiency. In

activities that need strength and perseverance, they may interpret fatigue, pain,

symptoms of hypoglycaemia as indicators of low physical efficacy. Persons expect to


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be more successful when they are not stressed than when they are (Shortridge-Baggett,

2001). In summary, the more positive the feedback, the greater is the enhancement of

self-efficacy (Bandura, 1997).

4.2.4 Behaviour

According to Bandura (1997), the behaviour adopted depends on three perspectives of

people’s understanding: their perceptions of the degree of risk, followed by an

expectation that the behaviour will reduce that risk, and their expectation that they are

able to make the behaviour change. The three perceptions together affect behaviour

intention; in general, they influence behaviour adoption from initiation through to

long-term maintenance (Bandura, 1986).

Many of the different models of behaviour change are overlapping and in conflict

with one another in their effects on confidence, which helps to explain a person’s

degree of motivation or readiness to change. However, Rollnick, Mason and Butler

(2003, p.18) conclude: “if a change feels important to you, and you have the

confidence to achieve it, you will feel more ready to have a go, and more likely to

succeed”. Self-efficacy concerns the confidence in one’s capability to produce the

behaviour; people are motivated to perform tasks they believe will produce desired

outcomes. Outcome expectations are highly dependent on efficacy expectations, so

efficacy expectations predict performance much better than expected outcomes

(Bandura, 1986).

Moreover, behaviour is as important in the aetiology of many chronic conditions as it

is to the self-care regimen (Gecas, 1989). Diabetes is a chronic illness that requires


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long-term self-management. Low levels of psychosocial support and self-efficacy

factors can be considered as barriers because a high level of self-efficacy is generally

facilitative of self-management (Glasgow, Toobert & Gillette, 2001). Diabetes

management is a specific behaviour domain; thus the issue of self-efficacy regarding

one specific behavioural domain, diabetes self-management, will be discussed in the

next section

4.3 Self-efficacy and diabetes self-management

Diabetes self-management is a concern because it is assumed that adopting a healthy

lifestyle will produce better metabolic control of diabetes, which in turn will help to

avoid subsequent acute and long-term complications of the disease (Toobert &

Glasgow, 1994). Self-management approaches depend on drawing on patient

judgments and values within the context of daily living to inform how a

comprehensive treatment plan can best be agreed and implemented (Goldstein, 2002).

The procedures for self-management involve more than self-care that merely follows

through on daily procedures as part of a regimen. Self-management requires

participation, teamwork and frequent glucose monitoring, especially for intensive

diabetes management (Garg, Campbell, Delahanty & Halvorson, 2000).

Self-management in this study therefore, is defined in its broadest terms and includes

all efforts by patients to maintain levels of glycaemia as close as possible to the

recommended targets. Better self-efficacy will produce effective self-management,

better health outcomes, including, self-care behaviours, health-related quality of life,

psychosocial well being, and lower utilisation of health services.

There has been a trend for the responsibility for day-to day disease management to


96

shift gradually from health care professionals to the individual; a recent review of the

self-management literature pertaining to chronic disease found that a large proportion

of these studies was published in the 1990s (Barlow, Wright, Sheassby, Turner &

Hainsworth, 2002). Persons with diabetes are responsible for decisions regarding food

intake, foot care, exercise, eye care, and adherence to a diabetes regimen to prevent

medical complications (Wang, Abbott, Goodbody, Hui & Rausch, 1999). According to

Fitzgerald et al. (2000), diabetes is a self-managed disease; treatment and prevention

of complications are largely a function of the patients’ willingness to care for

themselves on a daily basis. Because patients deliver most of their own diabetes care,

understanding the factors that affect self-management behaviour is important.

However, lowering blood sugar levels requires changing lifelong behaviours of diet

and physical activity and this is a very difficult and complex process (Prochaska &

DiClemente, 1983).

A patient’s self-management depends on patient education, empowerment, and their

self-monitoring of the results of self-care (Pasavic, 1980). Clement (1995) has stated

that more than 50% of patients with diabetes receive limited diabetes

self-management education or none. So, assisting people with diabetes to change their

behaviour is significant in effecting self-management and in reaching the highest

possible level of health (Shortridge-Baggett, 2001). Moreover, Lorig (1995) has

suggested that most effective self-management interventions use cognitive and

behavioural modification, in addition to providing information.

Low levels of psychosocial support and self-efficacy factors can be considered as

barriers to diabetes management, because a high level of self-efficacy is generally

facilitative of self-management (Glasgow, Toobert & Gillette, 2001). Johnson (1996)


97

suggested that developing an educational program based on self-efficacy theory for

the self-management of diabetes is important; it can improve upon the traditional

diabetes education that focuses only on the transformation of information or skills

(van de Laa & van der Bijl, 2001; Moens et al., 2001). Several studies of individuals’

perceptions of their ability to perform self-care behaviour have shown self-efficacy to

be an important variable in the self-management of diabetes (McCaul, Glasgow &

Schafer, 1987; Glasgow & Osteen, 1992; Hurley & Shea, 1992).

The early focus of diabetes research studies was on educational interventions to

improve diabetic knowledge, self-care behaviours and improvement in metabolic

control (Brown, 1990; Welch, Dunn & Beeney, 1994; Fain, Nettles, Funnel & Charron,

1999). However, over the last two decades the focus of diabetes research studies has

moved and expanded to recognise the importance of psychosocial factors (Dunn, 1986;

Hunt, Arar & Larme, 1998), and cognitive factors such as self-efficacy theory

(Glasgow et al., 1992; Anderson et al., 1995; Johnson, 1996; Bandura, 1997).

Physician-directed, compliance-oriented care is not an effective solution, since

patients in this context are more like passive recipients of medical knowledge. Brown

(1990) stated that patient education has a moderate to significant effect on improving

patient knowledge but is less effective in improving glucose control over time.

However, Bodenheimer, Lorig, Holman and Grumbach (2002) used a central concept

in self-management education, self-efficacy. Patients’ self-efficacy is enhanced when

they succeed in solving problems that they have identified themselves. This approach

to self-management education teaches problem-solving skills, allows patients to

identify their problems, offers techniques to help them make decisions, take

appropriate actions, and change their behaviours in their lives, whereas traditional


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patient education merely provides information and technical skills. Self-management

education, therefore, complements traditional patient education in supporting patients

to live the best possible quality of life along with their chronic condition.

Diabetes-related self-efficacy research has focused on predicting self-care ability. In

the United States of America (USA), self-efficacy was found to be a significant

predictor of adherence to self-care activity. Those in the low adherence group, as well

as those with longer duration of diabetes, had significantly lower self-efficacy and

higher illness demand than those in the high adherence group (Poradzisz, 2001). In

Japan, Nakahara et al. (2006) examined the causal relationship between psychosocial

factors and glyceamic control using structural-equation modelling and found that

self-efficacy directly reinforced self-care adherence. In the Netherlands, diabetic

patients with high self-efficacy show more compliance with self-care in their lives

than patients with low self-efficacy (van de Laar & van der Bijl, 2001). Efficacy

belief scores related to regimen-specific behaviours were found to predict self-care

behaviours such as blood glucose management, diet, exercise, and insulin use

(Kingery & Glasgow, 1989; Hurley & Shea, 1992). Also, systematic reviews

examining self-efficacy in patients with diabetes show that self-efficacy positively

influences the health behaviours of patients with diabetes (Norris, Engelgau &

Narayan, 2001; Krichbaum, et al., 2003).

In addition, diabetes-related self-efficacy research has focussed on predicting various

health status outcomes. The strengthening of diabetes-specific self-efficacy has been

associated with a reduction in glycated haemoglobin (Anderson et al., 1995) or in

weight (Glasgow et al., 1992). In those studies in which glycated haemoglobin has

been measured, blood glucose self-management (BGSM) behaviours were more often


99

found to be independent (Padgett, 1991; Glasgow et al., 1992). A large body of

behavioural science research in diabetes, reviewed by Glasgow and colleagues (1999),

demonstrated a strong relationship between patient participation in diabetes

self-management and several psychological constructs including self-efficacy,

empowerment, behavioural intentions and problem solving or coping skills.

In the USA, a 10-session, self-management training program was designed for people

over 60 years of age with type 2 diabetes (Glasgow et al., 1992). It targeted

problem-solving skills and self-efficacy; 102 adults were randomly assigned to

immediate or delayed intervention conditions. At post-test, subjects in the immediate

group showed significantly greater reductions in calorie intake (29% versus 10%, p

< .05) and percent of calories from fat (45% versus 29%, p< .05) than control subjects.

Correlations between changes on behavioural measures and change in physiological

measures were modest. The intervention group produced greater weight reductions

(r = .33, p< .01) and increased the frequency of glucose testing (r =- .21, p< .05)

compared to the control group. In contrast the improvement in exercise self-care

showed no significant changes from pre-test to post-test.

Anderson et al. (1995) conducted a randomised controlled evaluation of their

empowerment program in the USA, focusing on self-efficacy and its component skills.

These included the ability to identify satisfaction and dissatisfaction related to living

with diabetes and to achieve personal goals, to use problem-solving to eliminate the

barriers to goals, to manage stress, to obtain appropriate social support, to strengthen

motivation to perform and to make cost-benefit decisions about planned behaviours.

Forty-six volunteers, mainly overweight, well educated women, were randomly

assigned to immediate program attendance, or waiting list control, after a full


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induction into the study design and intervention approach. Participants were asked to

complete experiential worksheets, attend six sessions and participate in group

discussions. At 12 weeks from baseline, the intervention group demonstrated a

significantly greater improvement in glycosylated haemoglobin than the control group.

Self-efficacy was significantly increased among the intervention group in terms of

setting goals, managing stress, obtaining social support and making self-care

treatment decisions.

In Shanghai, mainland China, Fu et al. (2003) conducted a study to evaluate the

effectiveness of a chronic disease self-management program (CDSMP). A randomised

controlled trial was undertaken with six-month follow-up, comparing patients who

received treatment with those who did not. Participants in the treatment group

received education from a lay-led CDSMP leader and one copy of a help book. In

total, 954 volunteer patients with a medical record noting a confirmed diagnosis of

hypertension, heart disease, chronic lung disease, or diabetes, who were assigned

randomly to treatment (n=430) and control (n=349) groups. The results showed that

patients who received treatment had significant increases in the time of their weekly

periods of aerobic exercise (> 25 minutes, p= .01), and scores in their practice of

cognitive symptom management by .37 (p= .005), both measures of self-efficacy:

increase of .69 and .63 in self-efficacy to manage symptoms and in self-efficacy to

manage disease in general (both p= .001). Also, patients in the treatment group had

significant improvements in eight measures of health status (p < .05) and .12 fewer

hospitalisations than the control group (p= .04).

A recent systematic review and meta-analysis conducted by Ismail, Winkley and

Rabe-Hesketh (2004) analysed the randomised controlled trials of psychological


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interventions (supportive or counselling therapy; cognitive behaviour therapy,

psychodynamic psychotherapy and interpersonal psychotherapy) to improve

glycaemic control in patients with type 2 diabetes. Eight studies in the review had

outcome data on blood glucose. There was no evidence that psychological therapies

improved current blood glucose concentrations between patients assigned to a

psychological therapy and those in the control group; 25 trials were eligible for the

review and in 12 trials, the mean percentage of glycated haemoglobin was lower in

people assigned a psychological intervention than in the control group; the people

mean difference was -.32 (95% CI -.57 to -.07) equivalent to an absolute difference of

-.76%. However, the author made the criticism that most of the studies were of

moderate to poor quality in the reporting of potential biases, and had small sizes.

There is also inconsistent data in the literature between self-efficacy and

self-management for people with diabetes. Padgett (1991) found that glycaemic

control was not significantly correlated with either self-care ratings or with

self-efficacy for a type diabetic group. Rapley (1991) tested the association between

self-efficacy and glycaemic control, a type 1 diabetes group was found to have a

significant negative correlation (r= - .31) with glycosylated haemoglobin while no

association was found for the type 2 group.

Although most studies have shown that self-efficacy is a useful predictor for diabetic

self-management (Glasgow et al., 1992; Anderson et al., 1995; Glasgow et al., 1999;

Fu et al., 2003; Ismail, Winkley & Rabe-Hesketh, 2004), there has been limited and

inconsistent research in the literature into self-efficacy and self-management for

people with diabetes (Padgett, 1991; Rapley, 1991). The role of self-efficacy in

improving self-care behaviours and health outcomes, such as health-related quality of


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life, psychosocial well being is limited in Taiwanese research studies and health

service utilisation needs to be explored further in later studies.

4.4 Self-efficacy and health outcome variables

4.4.1 Self-efficacy and quality of life

Since implementing diabetes management lies largely with the patient’s daily effort,

patient education programs have placed increased emphasis on the patient’s role and

responsibility (Glasgow et al., 1999). Some patient activation interventions

(Greenfield et al., 1988; Grey, Boland, Davidson & Tamborlane, 2000) have reported

strong effects including promoting in self-efficacy, improvements in self-management,

and quality of life. Also, studies have investigated empowerment or self-efficacy

education as a conceptual framework for teaching diabetes self-management

(Caravalho & Saylor, 2000). Quality of life was recognised as a central outcome

measure of diabetes management in the landmark DCCT (The Diabetes Control and

Complications Trial) (Ingersoll & Marrero, 1991; Ambler, Fairchild, Craig &

Cameron, 2006).

Grey et al. (2000) conducted research to determine whether initial effects on

metabolic control and quality of life associated with a behavioural intervention

combined with intensive diabetes management (IDM) could be sustained over 1 year

in youth. Seventy-seven participants electing to initiate IDM were randomly assigned

to one of two groups: with or without coping skills training (CST), which consists of

6 small group sessions and monthly follow-up to help youth cope with their lives;

skills included social problem solving, cognitive behaviour modification, and conflict

resolution. The results showed that CST subject had lower glycosylated haemoglobin


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(p= .001) and better diabetes (p= .002) and medical (p= .04) self-efficacy, and less

impact of diabetes on their quality of life (p= .005) than youth receiving IDM alone

after 1 year.

Poradzisz (2001) stated that self-efficacy was found to be a significant predictor of

both adherence of self-care activities (R2= .35, p< .001) and QOL (R2= .40, p< .001).

Illness demand and family support contributed to QOL, but did not significantly

influence adherence for this sample. A moderate correlation (r= .50, p< .001) was

found between adherence and QOL. The results suggest that diabetes educators

should focus on efforts to improve self-efficacy, the individual’s perception of QOL

and adherence to diabetes regimen.

Bodenheimer, Lorig, Holman & Grumbach (2002) used a central concept in

self-management, which is self-efficacy. Confidence enables people to carry out a

behaviour necessary to reach a desired goal. Self-efficacy is enhanced when patients

succeed in solving patient identified problems. Self-management education

complements traditional patient education in supporting patients to live the best

possible quality of life with their chronic condition.

Fu, et al. (2003) conducted a chronic disease self-management program (CDSMP)

and found that after six months follow-up patients who received treatment (n=430)

had significant improvements in HRQOL (eight measures of health status) (p< .05),

and .12 fewer hospitalisations than the control group (p= .04).

Maddigan et al. (2004) argued that interventions aimed at improving the management

of diabetes have been somewhat successful in changing the processes for delivering


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care and have improved intermediate or surrogate outcomes, such as glycaemic

control and patient-reported outcomes, however, they have often been overlooked in

the evaluation of such interventions (Renders et al., 2001; Gaede et al., 2003). In a

review of 41 studies of community-based controlled interventions to improve

processes of care or outcomes in patients with diabetes (Renders et al., 2001), only

four studies evaluated patient-reported outcomes in a manner that would be

considered scientifically valid.

According to a literature review study (Hornquist, Wikby, Stenstrom, Andersson &

Akerlind, 1995), an attempt was made to describe how type 2 diabetes affects the life

of the ill person. A substantial proportion of patients are primarily affected with

fatigue, anxiety and depression. Some negative social circumstances have also been

noted. Social support appears to be helpful, although self-efficacy and health practices

seem to be as important. The author suggested that there was a great need for more

research on type 2 diabetes; broad prospective longitudinal follow-up studies

monitoring natural disease progression, as well as examining the predictive

significance of quality of life, would be welcome.

Fostering self-efficacy by helping the patient reach attainable goals and providing for

opportunities to develop self-management skills will bring the patient closer the

concept of patient empowerment (Via & Salyer, 1999). Rose, Fliege, Hildebrandt,

Schirop and Klapp (2002) using the structural equation model to derive a

mathematical model and confirm that if a patient reports strong beliefs in self-efficacy,

he/she is more likely to report a higher quality of life. HRQOL is important to

consider in further studies because the burden associated with diabetes may extend

beyond what is captured by clinical measures (Maddigan et al., 2004). Although


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several authors (Greenfield et al., 1988; Grey et al., 2000) have theorised that patient

activation or self-management interventions have shown significant effects of quality

of life. The effect of a self-efficacy enhancing intervention on quality of life was

studies in a few studies which designed with randomised controlled trial. Patient

reported outcome, measures such as health-related quality of life of patients with type

2 diabetes need to be involved in further experimental studies.

4.4.2 Self-efficacy and psychosocial well-being

Self-efficacy was found to provide a linking mechanism between psychosocial factors

and health outcomes. Psychosocial factors combined with cognitive functioning,

depression, stress, social support, and self-efficacy (Seeman & Chen, 2002) and they

help predict differences in Activities of Daily Living (ADLs) (Martin, Grunendahl &

Martin, 2001). In this thesis, the variable of psychosocial well being includes the

factors of social support and depression. It assumes that a self-efficacy enhancing

intervention program can improve psychosocial well being for people with diabetes in

this study. Both factors of social support and depression therefore are discussed as

follows.

4.4.2.1 Self-efficacy and social support

Diabetes is a largely self-managed disease with a major psychosocial impact on the

lives of patients and their family (Snoek, 2002). To understand patients’ self-care

behaviour, we need to take into account various psychological and social factors.

According to Snoek (2002), negative attitudes and low self-efficacy expectations are

common among people with diabetes. Cumulative negative experiences can result in a

state of “learned helplessness” or “diabetes burnout”. In diabetes care, a


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bio-psychosocial approach to the patient and his or her coping problems is warranted.

Social support has been reported to influence metabolic control through positive

effects on adherence (Glasgow & Toobert, 1988). Bandura (1977a) suggested that the

effects of social support are mediated by self-efficacy, while others may act as a

source of efficacy information relevant to the task at hand. A lack of social support

may lead to lower self-efficacy, which will in turn reduce the likelihood of a given

behaviour (Williams & Bond, 2002). Williams and Bond (2002) found that social

support was associated with exercise self-care and the relationship between the two

variables was mediated by self-efficacy. Moreover, Gallent (2003) and Nakahara et al.

(2006) stated there might be an indirect influence of social support on diabetes

self-management through self-efficacy.

Maxwell, Hunt, & Bush (1992) studied 204 patients with diabetes who were randomly

divided into two groups. The control group received only a normal diabetes training

program, whereas the experimental group was offered the same program in addition

to eight support group meetings, during which they had the opportunity to receive

informational and emotional support. After 7 months of follow-up, patients in both

groups showed improved metabolic control (HbA1C), diabetes knowledge, frequency

of practicing recommended diabetes management behaviours, and emotional

adjustment. However, no additional improvement was seen in those people in the

experimental group. The authors suggest that it is possible that sufficient social

support developed among the participants in the training group settings in which

individual self-disclosure, mutual comparison and support, interpersonal feedback,

and other elements that are thought to enhance in support groups may have been

facilitated.


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Aalto and Uutela (1997) tested a model of the Health Belief Model (HBM),

supplemented by other factors (locus of control, self-efficacy, health value, and social

support) and found that in multiple regression analyses both DA (diet adherence) (p<.

01) and SMBG (self-monitoring of blood glucose) were related to HbA1C.

Theoretically derived path models for the HBM (estimated using the LISREL

statistical model) required modifications. DA showed strong associations with

diabetes related social support (p< .001) and net benefits of DA (p< .001). SMBG

showed strong associations with self-efficacy in SMBG and net benefits of SMBG

(p< .001).

Seeman and Chen (2002) used data from the MacArthur Study of Successful Aging to

examine the impact of socio-demographics, health status, health behaviours, and

social and physical factors on patterns of change in physical functioning. The results

found that levels of functioning were not solely determined by clinical disease/health

status, but rather modifiable factors that respond best to environmental interventions,

such as increased levels of physical activity, access to a social support network, and

self-efficacy, to effectively overcome possible constraints.

Lai and Liu (2003) undertook a social support and empowerment education module

(SSEM) and evaluated the effect of social support for people with type 2 diabetes in a

community in Taiwan (n=49). The experimental group took part in a series of SSEM

courses, which was based on social cognitive theory, during a 4-week period. The

SSEM course significantly increased social support and empowerment of the

experimental group and gave patients support with power, self-efficacy and self-care

behaviour.


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All the previously mentioned studies have been applied with social support as a

mediator or outcome variable in diabetes care; however, studies which introduce a

self-efficacy enhancing intervention program and then examine the effect of social

support status are rare. Williams and Bond (2002) also suggested that programs

designed to increase confidence in self-care abilities are likely to be effective. As an

integrated model for self-efficacy is used that is supplemented with social

psychological factors, such as self-efficacy, health-related quality of life, social

support and depression, the test of the effectiveness will be explored in this thesis.

4.4.2.2 Self-efficacy and depression

People are interested in more immediate impacts of diabetes on their daily lives;

patient-centred outcomes increasingly are incorporated into the development of care

plans and the evaluation of treatment success (Laine & Davidoff, 1996; Piette,

Weinberger & McPhee, 2000). These outcomes include symptoms of depression and

anxiety, common in patients with diabetes, that can lead to poor glycaemic control

and may be at least as important in determining their health-related quality of life

(HRQOL) and service use (Piette, Weinberger & McPhee, 2000).

Piette, Weinberger and McPhee (2000) evaluated the impact of automated telephone

disease management calls, with nurse telephone follow-up, as a strategy for

improving outcomes such as mental health, self-efficacy, satisfaction with care, and

HRQOL among low-income patients with diabetes. A randomised controlled trial

involved 248 primarily English- and Spanish-speaking adults with diabetes in the U.S.

and patient-centred outcomes were measured at 12 months via telephone interview.


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The results showed that, compared with patients receiving the usual care, intervention

patients at follow-up reported fewer symptoms of depression (p= .023), greater

self-efficacy to conduct self-care activities (p= .006) and fewer days in bed because of

illness (p= .026). Intervention and control patients had roughly equivalent scores for

established measures of anxiety, diabetes-specific HRQOL, and general HRQOL.

A randomised controlled trial of self-management training for people with chronic

disease, including endometriosis, diabetes, osteoporosis and myalgic

encephalomyelitis, was conducted by Wright, Barlow, Turner and Bancroft (2003).

They determined the effectiveness of a community-based chronic disease

self-management course (CDC) for UK participants (n=232) with a range of chronic

diseases. The CDC comprised six weekly sessions (each of 2 hours) and aimed to

enhance self-efficacy through weekly action planning sessions that involved problem

solving, decision-making, role modelling, and persuasion. The result showed that no

significant changes were found at four-month follow-up for male participants (Ps=

.180) in depressive and anxious mood (Ps= .118), respectively; however, significant

reductions were found in these for female participants.

The latest meta-analysis conducted by Ismail, Winkley and Rabe-Hesketh (2004)

systematically reviewed and analysed the randomised controlled trials of

psychological interventions to improve specific psychological problems such as

depression in patients with type 2 diabetes. Five studies showed that psychological

distress was significantly lower in the intervention groups.

There are inconsistent data in the literature between self-efficacy and depression for

people with diabetes. Ikeda, Aoki, Saito, Muramatsu & Suzuki (2003) investigated the


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possible relations of HbA1c with scores on anxiety, depression, and self-efficacy for

113 outpatients with type 2 diabetes. The relation between the HbA1C level and the

self-efficacy scores as well as with ratings of anxiety and depression was evaluated. A

significant relationship was found for the HbA1C level with anxiety, depression, and

self-efficacy scores; however, self-efficacy and anxiety and depression showed no

association. These results suggest that HbA1C can be maintained at better levels by

increasing the self-efficacy of diabetic patients.

In conclusion, several studies have shown that psychosocial factors play an integral

role in diabetes management. Their impact is a stronger predictor of mortality in

diabetes patients than many physiological variables (Delamater et al., 2001).

Depression and diabetes self-efficacy have been found to be negatively correlated; the

higher the level of depression, the lower the self-efficacy (McClendon, 1996). Using a

psychological intervention may help people with diabetes to improve the depressive

mood. However, more studies related to self-efficacy and depression requires to be

explored in the future.

4.4.3 Self-efficacy and health care expenditure

Studies show that diabetes self-care education, especially interventions that use

counselling strategies to change behaviour, can lead to significant improvements in

glycaemic control as well as reductions in diabetes-related hospitalisations and health

care costs (Glasgow et al., 1992; Jack, Jr. et al., 2004). Health care utilisation includes

direct and indirect costs. Direct costs are the health system costs attributed to program

costs for treatment, operational expenses for fixed overhead costs, and utilisation

costs for laboratory and medications. Indirect costs are patient costs related to lost


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time from work or leisure (Fanning, 2002). Little is known about the impact of

disease management programs on medical costs for patients with diabetes (Fanning,

2002). Moreover, there are no prospective randomised trials measuring the impact of

diabetes self-management education on hospitalisation rates (Clement, 1995).

A study of an educational intervention was retrieved, involving 203 diabetic patients

with either uninfected ulcers or previous amputation (Malone et al., 1989). In addition

to usual care, the intervention group received a single 1-hour education session on

foot care that included a slide show of infected feet and amputated limbs and a patient

instruction checklist. The study showed a reduction in the combined endpoint of limbs

free of infection, ulcer or amputation, favouring education (education 90 %, control

72 %). Although there were no significant differences in infection or mortality during

follow-up, there was an excess of ulceration (education 5 %, control 15 %) and

amputation (education 4 %, control 12 %) in the control group.

Piette, Weinberger and McPhee (2000) evaluated the impact of automated telephone

disease management (ATDM) calls with telephone nurse follow-up as a strategy for

improving outcomes. The results showed that compared with patients receiving usual

care, intervention patients at follow-up reported fewer days in bed because of illness

(p= .026).

Fanning (2002) estimated the cost-effectiveness of HbA1C final endpoints of

treatment by a nurse case manager following a treatment algorithm for

hyperglycaemia management of patients with type 2 diabetes, compared to costs of

conventional diabetes care by a primary care physician in USA. The results showed

that the average total cost per patient for the community clinic site (CC-TA) in this


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12-month analysis was 26 % lower, although this reduction was not significantly

different from the conventional care site (PCP) ($997 ± 90 vs $1,344 ± 209, p= .08).

The CC-TA health system cost was significantly less expensive ($865 ± 84 vs $1,249

± 192, p= .05), but the patient cost was not significantly different (($112 ± 6 vs $95 ±

18, p= .3).

Fu, et al. (2003) conducted a study of the chronic disease self-management program

(CDSMP) in mainland China to evaluate the effectiveness of the Shanghai CDSMP.

Patients in the treatment group had significant improvements in eight measures of

health status (p< .05) and .12 fewer hospitalisations than the control group (p= .04).

Many costing studies have documented the total burden of diabetes to the health

system and society, with varying focus on the impact of diabetes-related

complications (Pagano, Brunette, Tediosi & Garattini, 1999). According to Clarke,

Gray, Legood, Briggs & Holman (2003), using a model for estimating the immediate

and long-term health care costs associated with seven diabetes-related complications

in patients with type 2 diabetes participating in the UK Prospective Diabetes Study

(UKPDS), results showed that the cost of first complications were as follows:

amputation ₤8459 (95 % confidence interval ₤5295, ₤13200); non-fatal myocardial

infraction₤4070 (₤3580, ₤4722); fatal myocardial infarction ₤1152 (₤941, ₤1396);

fatal stroke ₤3383 (₤1935, ₤5431); non-fatal stroke ₤2367 (₤1599, ₤3274); ischaemic

heart disease ₤1959 (₤1467, ₤2541); heart failure ₤2221 (₤1690, ₤2896); cataract

extraction ₤1553 (₤1320, ₤1855); and blindness in one eye ₤872 (₤526, ₤1299). Thus,

preventing complications related to type 2 diabetes is an important way to reduce

health care expenditure.


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Although people with type 2 diabetes have frequent contact with health care providers,

their health outcomes are often poor. Varroud-Vial et al. (2004) suggested that to

achieve the goals of reduction in complications and health care costs, it is probably

necessary to combine several strategies into an intervention, including educating the

providers and the patients. Therefore, this thesis will examine over a 6 month-SEEIP

intervention whether a theory-based nursing intervention program can improve

diabetic self-management and reduce health care utilisation in a primary care setting.

4.5 An intervention program based on self-efficacy theory

Studies into self-efficacy theory have demonstrated that it has the potential to

facilitate behaviour change and improve health outcomes in diabetes. Facilitating

personal self-efficacy in the person’s ability to manage therapeutic self-care is the

main idea of the self-efficacy model. In this section, the rationale for developing an

intervention program based on self-efficacy theory (Self-Efficacy Enhancing

Intervention Program: SEEIP) is described first. After justifying the choice of the

SEEIP program, the development of self-efficacy for people with diabetes and a plan

of the SEEIP are then described.

4.5.1 The rationale for developing SEEIP

The first reason is that, for this study, a comprehensive intervention program to

improve health related outcomes needs to be established and then tested to evaluate its

effectiveness. The second reason is that diabetes management requires a new

conceptual framework to inform the behavioural, educational and clinical treatment

approaches. The third reason is that traditional patient educational programs in

Taiwan are insufficient for people’s diabetic control; a new diabetes service program


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needs to be introduced into the Taiwanese health care system. Self-efficacy is the

main concept in the empowerment approach and it plays an important role in

successful behavioural change, consequently, the self-efficacy model of

Shortridge-Baggett and van der Bijl (1996) (see Figure 4.1), which was discussed in

Section 4.2, will be used as the basis for the intervention. These three reasons for

developing the SEEIP are explained further in the following sections.

4.5.1.1 To test the self-efficacy model requires establishing a comprehensive intervention program

Bolstering patients’ confidence about their ability to successfully implement care is a

critical step in promoting active self-management (Fu et al., 2003; Ismail, Winkley &

Rabe-Hesketh, 2004). Research affirms that people with higher diabetes self-efficacy

follow better care practices (Glasgow et al., 1989; Kingery & Glasgow, 1989). There

are many studies investigating self-efficacy in patients with diabetes, and these have

shown that self-efficacy positively influences their health behaviours and outcomes

(McCaul et al., 1987; Rapley, 1990; Padgett, 1991; Hurley & Shea, 1992; Glasgow &

Osteen, 1992; Johnson, 1996). The literature offers various examples of programs that

increase perceptions of personal control by enhancing self-efficacy (Bodenheimer et

al., 2002; Dongbo et al., 2003). As can be understood, enhancing patients’

self-efficacy programs in self-care can facilitate the improvement of patients’ health

outcomes (Corbett, 1999; Taal, Rasker, Seydel & Weigman, 1993).

The testing of self-efficacy theory’s role in behaviour change and health outcomes

relevant to chronic illness management has also been discussed (See Sections 4.3 and

4.4), however, most of the studies cited did not incorporate an intervention and hence,

lack results on behaviour changes relying upon Bandura’s four sources of efficacy


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information. In Taiwan particularly, no researchers are engaged in self-efficacy

research with interventions in relation to diabetes. In contrast, in this study, the four

sources of information adopted from Bandura (1977a) are applied in the intervention.

Bandura (1977a) recommended that strategies to build up self-efficacy belief not only

operate differently for each of the sources, but also that they have the potential to

increase the person’s sense of confidence in ability. The self-efficacy model and the

intervention of SEEIP (based on information resources, see Figure 4.2) is an

important part in this framework. Testing this model requires establishing a

comprehensive intervention program and then evaluating its effectiveness.


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Intervention (SEEIP) - Views a DVD - Receives the

“Self-Care behaviours” booklet

- Four efficacy-enhancing intervention sessions

- Telephone follow up

Person

-Demographic

variables: age, gender,

education, married

status, etc.

-illness history

Behaviour

-Self management

behaviour (SDSCA)

Outcome -Self-efficacy towards management of type 2 diabetes -Health-related quality of life (SF12) -Psychosocial well-being (MOS-SSS; CES-D) -Health care utilisation

Efficacy-Expectations

-DMSES scale Outcome-expectation

-PTES scale

Environment

Figure 4.2 Modified self-efficacy model for evaluation of the self-efficacy enhancing intervention program (SEEIP) for persons with type 2 diabetes


117

4.5.1.2 A new conceptual framework: the empowerment approach (increased self-efficacy is an integral part of an empowerment education program)

In recent years, patient empowerment has become an alternative to the

compliance-oriented approach to diabetes management. Empowerment incorporates

components of knowledge, behavioural skills and self-care responsibility (Anderson,

Funnel, Barr, Dedrick & Davis, 1991). The primary purpose of empowerment for

people with diabetes is to prepare them to make informed decisions about their

self-care, as a supplement to basic diabetes education.

In 1991 the education team at the University of Michigan Diabetes Research and

Training Centre (MDRTC) realised that diabetes self-management was radically

different from the treatment of acute illness and required a new conceptual framework

to inform the behavioural, educational and clinical approaches to be used. Called

‘patient empowerment’ this paradigm was contrasted with the more traditional

medical model approach to care and education (Anderson et al., 1991).

The team of MDRTC realised that patients with diabetes were fully responsible for

the self-management of their illness; this immutable responsibility rests on three

characteristics of the disease. Firstly, the most important choices affecting the health

and well being of a person with diabetes are made by the person, not by diabetes

educators or health professionals. Secondly, people with diabetes are in control of

their diabetes self-management. Finally, the consequences of the choices people make

every day about their diabetes care accrue, first and foremost, to the people

themselves (Anderson et al., 2000). Because the patient empowerment approach to

diabetes patient education seeks to maximise the self-management knowledge, skills,

self-awareness and sense of personal autonomy of patients to enable them to take


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charge of their own diabetes care, enhancing people’s responsibilities for their

self-management is crucial for people with diabetes. Moreover, the evaluation of the

patient empowerment approach should focus on patient achievement of self-selected

diabetes care goals, improved psychosocial adaptation and enhanced self-efficacy

(Anderson et al., 2000). As a result, self-efficacy is a main concept in the

empowerment approach and it plays an important role in successful behaviour change.

Increased self-efficacy is an integral part of an empowerment education program.

According to Anderson et al. (1995), increases in self-efficacy are linked to

empowerment and improved outcomes. Clement (1995) has claimed that diabetes

self-management education is effective only when behaviour change strategies are

extensively used. Also, Caravalho and Saylor (2000) state that whether a patient is

motivated to perform positive health behaviours may be decided by the patient’s

belief in his or her ability to succeed in a skill or to achieve self-selected goals. This

belief is known as self-efficacy. Also, they revealed that self-efficacy plays a central

role in behavioural interventions, because efficacy beliefs are dynamic and subject to

influence; they are ongoing cognitive, behavioural and communication processes.

Personal self-efficacy is changeable by different modes of influence. Enhancement of

efficacy beliefs increases motivation and success with behavioural efforts (Maibach &

Murphy, 1995). In brief, more studies are needed to focus on how to enhance

self-efficacy, especially for chronic illness, such as diabetes.

4.5.1.3 Traditional patient educational programs in Taiwan are insufficient for

people’s diabetic control

The traditional model of diabetes education has been ineffective in bringing about

desired outcomes (Funnell et al., 1991). Glasgow and Osteen (1992) have stated that


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changes in knowledge and attitude through information transfer and instruction are

not sufficient to realise the desired self-care behaviour; they also recommend that

diabetes education should include a patient perspective, such as the patient’s

self-efficacy. Self-efficacy, therefore, is an important component of diabetes

management and can be used for prediction of adherence to self-care behaviours

(Johnson, 1996).

Self-management approaches imply the involvement of patient judgments and values

within the context of daily living to inform how a comprehensive treatment plan can

be best agreed and implemented (Goldstein, 2002). Consistent with this

self-management perspective, the American and British Diabetes Association

(Diabetes UK) now refers to diabetes education as diabetes self-management

education (Goldstein, 2002). However, more than 50% of patients with diabetes

receive limited diabetes self-management education, or none (Clement, 1995; Johnson,

1996). Taal et al. (1993) claimed that to improve the self-management of disability

and adherence to health recommendations, patient education should be aimed at

strengthening self-efficacy expectations. Self-efficacy is one important part of social

cognitive theory, and offers a basis for improving the effectiveness of diabetes

education, because it focuses on behavioural change (van der Bijl &

Shortridge-Baggett, 2001). This can improve traditional diabetes education that relies

on just the transfer of information or skills (Brown, 1990; van de Laa & van der Bijl,

2001; Moens et al., 2001).

In general, diabetes patient education can be found in some hospitals and community

health services in Taiwan. These traditional patient educational programs can be

conducted as either individual or group education. Normally nurses or diabetes


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educators will be involved in patient education programs, and a few nutritionists or

dieticians may also be involved. In 2001, Bureau of National Health Insurance (BNHI)

commenced a few quality-based payment programs to improve quality of care, thus

diabetes was involved in a financial program. This allows extra payment for medical

care providers if they provide nutrition consulting and individual diabetic education. It

is estimated that there are about 139 diabetes educational promotion institutions in

Taiwan so far (see Section 2.4.2). Even though patient education has been widely

promoted, there remains a lingering doubt about how effective it can be in achieving

the desired effect of improve diabetic care. Unfortunately, previous literature has

shown most diabetic patients do not control their disease appropriately in Taiwan,

even though patient education has been provided (see Section 3.6). Moreover, no

researchers are engaged in self-efficacy research with interventions based on the four

sources of information adopted from Bandura (1977a) being applied in relation to

diabetes. A new diabetes service program needs to be introduced into the Taiwanese

health care system in order to improve the poor situation of diabetes care.

In Taiwan, individual or group diabetic education and nutrition consulting are offered

in many hospitals, especially in academic medical centres or local community

teaching hospitals. Traditional education in Taiwan usually gives out an educational

sheet and then explains the content of the sheet; normally, about 10-20 minutes is

spent on each session. Because of the importance that perceived self-efficacy can have

on performance of behaviours, this concept was selected for the present study. A

self-efficacy enhancing intervention program (SEEIP) is different from a traditional

education program. Traditional patient education emphasises disease-specific

information and technical skills, and health care professionals decide what

information and skills to teach (Bodenheimer et al., 2002) whereas the SEEIP teaches


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self-efficacy enhancing and goal-setting skills in order to enhance people’s confidence

and change people’s behaviours. While traditional patient education defines the

problems, the SEEIP guides people to identify their own problems and provides

techniques to help them make decisions, and take proper actions as they encounter

changes in circumstances or disease. The comparison of traditional patient education

and the SEEIP in this research study is demonstrated in the next chapter (pilot study)

(Table 5.2).

4.5.2 Development of self-efficacy for people with diabetes

Fostering self-efficacy by helping the patient reach attainable goals and providing for

opportunities for them to develop self-management skills will bring the concept of

patient empowerment closer (Via & Salyer, 1999). The follow-up literature of

counselling skills and self-efficacy enhancing strategies are guides to structure the

development of self-efficacy for people with diabetes. It requires application in other

diabetes-related interventions.

4.5.2.1 Counselling skills to develop self-efficacy

For practitioners, five practical principles of enhancing self-efficacy can be derived

from the work of Bandura and others (Egan, 1994). Firstly, self-efficacy is not an

all-or-none quality. One can provide encouragement for those situations where it is

high, and help the person look at different approaches for improving self-efficacy in

situations where he or she feels less confident. Secondly, doing is the best way to

enhance self-efficacy. Thirdly, people need to have skills to succeed but sometimes

these lie dormant; they need to be built up. Fourthly, feedback should be provided

about deficiencies in performance, not deficiencies in the person. Finally, people learn


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by modelling themselves on others, hence there is value in talking about friends and

patients who have succeeded, attending self-efficacy enhancing groups, and so on

(Rollnick, Mason & Butler, 2003).

According to Rubin (2000b), health care providers’ facilitation of the development of

diabetes-related coping skills in people with diabetes involves a number of specific

techniques. These techniques help patients to identify their problematic

diabetes-related issues, identify attitudes and beliefs underlying the problems and

establish self-care goals, and develop a plan for achieving these goals. These coping

skills training techniques include: ask questions; start with the patient’s agenda and

individualise the treatment plan for each patient; be as specific as possible in defining

the problem; take a step-by-step approach; and maintain contact with patients between

visits. Moreover, some strategies, based on Bandura’s social learning theory, includes:

do little more; scaling questions; brainstorm solutions; past efforts of successes and

failures; and reassessing confidence, dealing with specific changes in self-efficacy

about behaviour change (Rollnick, Mason & Butler, 2003). These are very important

points of information for enhancing self-efficacy in this study.

The skills and strategies to develop self-efficacy described below are derived from

Rubin (2000b) and Rollnick, Mason and Butler (2003) in order to provide an evidence

base to be used for the SEEIP in this study, especially for the self-efficacy counselling

intervention sessions of the SEEIP.

1. Ask questions

Asking questions like “what’s the hardest thing for you right now about dealing with

your diabetes?” “How often are you testing your blood sugar these days?” can


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actually save valuable time for the health care provider and the patient. Participants

begin the process by identifying their own regimen barriers or “sticking points”. The

more specifically the problem is defined, the easier it is to solve (Rubin, 2000b).

2. Start with the patient’s agenda and scaling questions

Starting with the patient’s agenda actually increases the likelihood that the health care

provider will accomplish his or her goals for the patient, because when patients see

that their needs are the provider’s primary concern, openness to the provider’s

suggestions will be likely to grow (Rubin, 2000b). Scaling questions are linked to the

numerical assessment of confidence. For example, “If you decided right now to

change (your diet) how confident do you feel about succeeding with this? If 0 was

‘not confident’ and 10 was ‘very confident’, what number would you give yourself?”

(Rollnick, Mason & Butler, 2003, p.64). The participant will do most of the thinking

and talking, while your role is to ask questions and help with clarifying the stumbling

blocks to change.

Having gained a numerical judgment from the participant about confidence to change,

try some simple advice, like: “So you gave yourself a score of 3/10 for confidence to

actually change your diet. What about cutting out those snacks between meals from

now on?” (Rollnick, Mason & Butler, 2003, p.96).

Having conducted an assessment of how confident the person feels to make a

particular change, providers have been told a rating, out of 10. Ask either or both of

the following questions and then follow them on with other open questions or

reflective listening statements. Ask why the participant scored a given number and not

a lower one: “You said that you were fairly confident about your ability to change.


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Why have you scored 4 and not 1?”. For example, “I am at 4 and not 1 because I

know that if the situation is right, if I can keep away from friends who push me in the

wrong direction, I can succeed.” This will allow providers to respond in ways such as,

“So you have got the confidence to succeed if only you could organise your social life

differently.” Providers can either pursue this in more detail, or keep the focus broad to

begin with, by asking a question like “What other reasons do you have for giving

yourself a score of 4 not 1?” (Rollnick, Mason & Butler, 2003, p.97)

However, there are other different questions, for example “You gave yourself a score

of 4. So you do have some confidence that you could succeed. How could you

become more confident, so that your score goes up to 5 or 6?” or “What would help

you to become more confident?” or “What stops you moving up from 4 or 5?”. These

questions need to be practised skilfully by providers and will be more effective for

participants.

3. Brainstorm solutions (decision making)

In most behaviour change consultations patients probably prefer greater autonomy in

decision-making. If clinical judgment tells you that a participant really wants you to

tell him or her what to do, then you should respond accordingly. However, most

patients, the authors believe, will react against simple advice-giving (Rollnick, Mason

& Butler, 2003). If a participant said “I don’t know what to do about…”, the providers

could answer “Have you thought about before….?” This simple strategy is usually

called brainstorming. There are some examples that can be practised: “There is

usually not one but many possible courses of action”; “You will be the best judge of

what works for you”; “Let’s go through some of the options together”. Try to avoid

spending too much time evaluating the options. If the participant says: “Yes! But, that


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won’t work because….”, say something like: “That’s fine, let’s not get too stuck on

one idea, let’s move on….what else could you do?”. However, let the participant

select the most suitable option, with questions like “Which one suits you the most?”

or “What makes the most sense to you?”. The provider’s task is to elicit and to

understand how the participant really feels about what to do (Rollnick, Mason &

Butler, 2003).

4. Set goals (take a step-by-step approach)

Caravalho and Saylor (2000) have stated that whether a patient is motivated to

perform positive health behaviours may be decided by the patient’s belief in his or her

ability to succeed in a skill or to achieve self-selected goals. No one can solve

problems all at once; many people can solve them one-step-at-a-time. Most

diabetes-related problems are daunting. Health care providers can help their patients

cut a problem down to size by taking a step-by-step approach (Rubin, 2000b). The

goals of a problem for people with diabetes also need to be taken by a step-by-step

approach. The strategy of selecting a goal needs to move from the general to the

specific, such as from a goal, through strategies, to targets. Help the participant set

small, achievable targets, if at all possible. Using weight loss as the example, getting

more exercise might be a goal for one person but it needs more detail about the

strategies and targets (see Table 4.1) (Rollnick, Mason & Butler, 2003). According to

Bodenheimer et al. (2002), an important concept in self-management education is

self-efficacy. An action plan usually a shorter duration, such as 1 or 2 weeks for

example, “This week I will walk around the block before lunch on Monday, Tuesday,

and Thursday”. The action plan should be realistic, proposing behaviour that patients

are confident they can accomplish. Confidence can be measured by asking, “On a

scale of 0 to10, how sure are you that you can walk around the block before lunch on


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Monday, Tuesday, and Thursday?” Experience shows that if the answer is 7 or higher,

the action plan is likely to be accomplished.

Table 4.1 Goals, strategies and targets: from the general to the specific

Goal→ Strategy→ Target

Lose weight 1. Eat less fatty food 1. Cut out fried potatoes 2. No red meat during the week 3. No full-fat milk

2. Start eating new food 1. Fruit once a day 3. Replace certain foods 1. Baked potatoes or rice instead of

chips 2. Fish instead of meat at weekends 3. Fruit instead of pudding 3/7 days 4. Poached egg or beans on toast instead

of bacon for breakfast 4. Get more exercise 1. Walk to work whenever possible 2.Arrange sport or dancing once a week 3. Use the stairs instead of the lift Adapted from Rollnick, S., Mason, P., & Butler, C. (2003). Health behaviour change: A guide for

practitioners. New York: Churchill Livingstone. P.94

Moreover, establishing a realistic timescale is also important. Changing habits takes

time and is a gradual process. A good timescale is one that is slow enough to be

manageable but fast enough to show some results so as to keep up the participant’s

motivation. A useful question like “one of the things you said you liked about

drinking was the socializing- would there be any advantage in waiting until after

Christmas before beginning to cut down?” (Rollnick, Mason & Butler, 2003, p.99).

5. Consider past efforts - successes and failures

According to Bandura (1977a), performance accomplishments (practising and earlier


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experience) are the most effective in developing one’s perception of self-efficacy in

the four information sources. Performance accomplishments mean practising and

experiencing success in achieving goals and this performance mastery experience is a

composite of prior experiences related to carrying out the behaviour. Successful

achievements will strengthen self-efficacy (efficacy expectations) about ability to

perform specific tasks and generalise to similar tasks (McAuley, Lox & Duncan,

1993).

From past experience, we can learn what we are good at and what we find most

difficult by looking back at previous attempts to change. This can be a good way of

learning. Helping someone to see the past as a valuable piece of information, to help

plan a more successful future is a skill. Use words like failure and frame the question

in terms of what the participant did wrong rather than in terms of a faulty plan or

adverse circumstances which could be altered if another attempt was made. For

example, “You have not been very successful in the past, have you? Perhaps we better

take a long, hard look at what you did wrong last time and see if you can make a

better go at it this time” (Rollnick, Mason & Butler, 2003, p.101).

Ask about the person’s most successful attempt to date. What made it different from

any other attempts? Are any of these differences things that could be built into a new

plan? Solutions-focused therapists emphasise the value of encouraging people to talk

about their strengths rather than their difficulties and to guide conversations towards

“solution talk” (Iveson & Ratner, 1990). If a participant acknowledges that he or she

did change, briefly, but discounts this, saying “Yes but it was dreadful, it nearly killed

me!”, he or she may be helped to reframe and the provider can say “Looking back on

it now you must be really impressed with yourself for coping with such a difficult


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situation!” Keep the discussion of past experience as a way of building confidence.

6. Reassess confidence

Levels of self-efficacy will vary across the specific strategies and targets for

confidence building them. For example, someone wishing to change his or her diet

might be more confident about eating more fruit. To return to an assessment of levels

of confidence can be very useful. That can be done formally, in numerical form, as

described on the previous strategy of scaling questions.

7. Maintain contact with patients between visits

According to Rubin (2000b), effective approaches to maintaining contact include:

phone calls, postcards, e-mail messages and office-based support groups. This

strategy can be difficult for many health care providers, but research and clinical

experience show that even brief, occasional contact with a health care provider can

powerfully affect people struggling with a chronic disease.

In conclusion, the strategies need to structure a conversation in a useful way that

encourages the participant to take the lead as much as possible. The above strategies

require application in other diabetes-related interventions. The following literature has

used self-efficacy enhancing strategies according to Bandura’s information sources;

these methods could apply in the intervention of SEEIP.

4.5.2.2 Self-efficacy enhancing strategies according to Bandura’s information sources

To develop self-efficacy beliefs (level/magnitude, strength, and generality of the

belief) for a specific task there are four information sources. A certain hierarchy exists


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in the four information sources of self-efficacy: performance accomplishment,

vicarious experience, verbal persuasion, and self-evaluation (Bandura, 1977a; van der

Bijl & Shortridge-Baggett, 2001).

1. Performance accomplishment

Performance accomplishment, the repeated execution of the task, is the most powerful

source, as it is based on direct information; people immediately experience success or

failure (van der Bijl & Shortridge-Baggett, 2001). When starting a task, people need

experience of success to improve their self-efficacy (Gonzalez, Goeppinger & Lorig,

1990). Rapid successes are beneficial to self-efficacy, while failure at an early stage is

disadvantageous. Repeating a single task until the patient has mastered it eventually

leads to success. Johnson (1996) has stated that persons with diabetes should be

allowed time and opportunity to try out a blood-glucose monitoring device until they

are successful. Furthermore, they should practice first in simple situations, and later in

more complex ones (Bandura, 1986).

Sometimes people interpret their successes negatively; they do not recognise them, or

underestimate their importance. In these cases, it is important to establish goal setting

in order to enhance self-efficacy (van der Laar & van der Bijl, 2001). Goals influence

achievement because they motivate people to exert themselves again and thus they

persevere longer in their task; goals, however, have to be realistic and achievable.

Short-term goals are more motivating than long-term ones (Locke, Saari, Shaw &

Latham, 1981). After each education session, the contract should be discussed and

new goals set by the client (Gonzalez, Goeppinger & Lorig, 1990).


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The combination of setting goals in a contract and giving feedback is important.

Before every education session, feedback should be given on the goals of the

preceding period, and clients should report their achievements (van der Laar & van

der Bijl, 2001). At least 30% of each education session should be used for discussing

contracts and feedback, and regular contact by phone to ask about the client’s

achievements can also be effective (Gonzalez, Goeppinger & Lorig, 1990). In

addition, a diabetes diary is another good source of feedback for persons with diabetes.

For example, blood glucose values, self-care actions and the prevailing circumstances

can be noted in the diary, and the client can thus gain insight into self-regulation (van

der Laar & van der Bijl, 2001).

When clients know what is expected of them, are conscious of what will happen to

them, and are able to choose behaviour strategies, their self-efficacy is enhanced (van


2. Vicarious experience

Vicarious experience (modelling), by seeing other people demonstrate the desired

behaviour, can offer very important self-efficacy information, but it is not based on

one’s own experiences (van der Bijl & Shortridge-Baggett, 2001). Comparability of

models is based on two criteria: shared experiences and similar personal

characteristics. People with a comparable lifestyle, like friends or colleagues, can

serve as models, and models can demonstrate skills for the intended behaviour (van

der Laar & van der Bijl, 2001). In group education, one possibility is to choose a

person with the same health problems, such as diabetes. For each problem the group

leader can ask the group members for solutions or ideas and thus group members can

be encouraged to help each other in solving their problems. They may offer


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innovative solutions that have not been thought of by professionals (Gonzalez,

Goeppinger & Lorig, 1990).

Moreover, modelling can also be used with other educational media like television,

videos, movie, brochures and textbooks. Some investigations have looked at movies

or videos as a strategy for vicarious learning because the desired behaviour can be

demonstrated using comparable models whenever possible. Results found an increase

in self-efficacy (Gross, Fogg & Tucker, 1995; Johnson, 1996). According to Johnson

(1996), the medium of video can show all aspects of diabetes care and specific role

models can be used for demographic groups, such as children, teenagers and older

persons with diabetes.

Another form of learning by observation is demonstration of specific skills or

behaviour. Nurses, educators or course leaders can demonstrate specific actions. For

example, skills of injecting insulin and measuring blood glucose can be demonstrated

by professionals (Johnson, 1996; Oetker-Black, Teeter, Cukr & Rininger, 1997).

3. Verbal Persuasion

Verbal persuasion is an easily used, but weak source, and is usually used to support

the other sources (van der Bijl & Shortridge-Baggett, 2001). Verbal persuasion may

stimulate persons to set higher goals than they would have done by themselves.

Positive feedback is another important reward to induce people to show a specific

behaviour and keep it up (van der Laar & van der Bijl, 2001). The more reliable the

person who is communicating the message, the greater is the success in changing

attitudes or learning a new behaviour.


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Bandura (1997) has emphasised the importance of the credibility and expertise of the

educator. Confidence can also arise from observed equality with the educator,

whereas patients can also stimulate each other. Patients who are experiencing

difficulties in a specific area can often be influenced by a group (Gross, Fogg &

Tucker, 1995; Johnson, 1996). For people with diabetes, verbal persuasion primarily

consists in the transfer of knowledge. Once patients have insight into the reasons why

they have to change their behaviour, they need to be stimulated to start making those

changes, such as changes in diet and physical exercise. Instructions can be given on

blood glucose monitoring and on the use of the blood-glucose monitoring device;

explanations can then be given on the recommended frequency of monitoring.

Patients, therefore, have to be observed and encouraged in their behaviour (Johnson,

1996).

In conclusion, positive feedback on the actions they have taken and a positive

interpretation of possible faults can enhance self-efficacy (van der Laar & van der

Bijl, 2001).

4. Self-evaluation

Self-evaluation is the least concrete source of information for self-efficacy. People

rely on their physical and emotional states to judge their capabilities (Bandura, 1997;

van der Bijl & Shortridge-Baggett, 2001). Self-efficacy can be increased by

improving the patient’s physical situation, reducing stress, and decreasing negative

emotions, as well as by correcting false interpretations of the patient’s physical

situation. Maddux and colleagues (1995) claim that persons have more confidence in

their own abilities when they feel relaxed. Strategies that reduce and control

emotional tension can thus enhance self-efficacy, particularly when learning new


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behaviour.

Physical symptoms can be seen as indicators of personal ineffectiveness, and

changing these interpretations is important. Health care professionals need to

determine what people believe and why they believe it, and if possible, help people

change their beliefs (van der Laar & van der Bijl, 2001). Stress can influence diabetes

regulation and lead to metabolic disorders; physiological stressors like pain and

trauma produce heightened insulin intolerance, and so do psychological stressors like

undesired life events and daily worries. Suffering with diabetes inevitably leads to

some level of stress.

Johnson (1996) claimed that having patients feel relaxed is crucial. Education,

therefore, should be given in a relaxed and stress-free environment, because fear and

distress have a negative effect on self-efficacy. Clearly, physiological indicators of

self-efficacy play a large part in healthy functioning. However, this source of

self-efficacy should be seen in the context of the other three sources, which are more

concrete and can be better measured (Bandura, 1977a; van der Laar & van der Bijl,

2001).

5. Combination of sources

Combining different sources of self-efficacy is best for enhancement of self-efficacy,

and combining all four sources is the most effective (Maddux & Lewis, 1995;

Bandura, 1997). However, the influence of the different sources can differ in each

situation and for each person, and few investigations have looked at multidimensional

efficacy information (Bandura, 1997). The following studies have demonstrated

evidence and effects for self-efficacy enhancing interventions.


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Wing, Epstein, Nowalk, Koeske and Hagg (1985) examined the effects of a

behavioural program on weight loss for patients with type 2 diabetes, using elements

of the first three sources of self-efficacy information. The patients received

information on nutrition and physical exercise and learned a number of strategies for

enhancing their behaviour. Participants had to set their goals and keep a diary;

meetings were used to practice and discuss progress; also role-play allowed

observation of others. The result was a significant loss of body weight during the first

four months; however, this was poorly sustained. After 16 months the effects of the

program had disappeared.

Padgett (1991) examined factors related to self-efficacy and found that persons with

higher self-efficacy shared a number of characteristics. Younger persons, males, and

higher educated persons usually have higher self-efficacy than older persons, women

and persons with less education. Persons with higher depression tend to have lower

self-efficacy. Thus, identifying individual risk factors can increase the effectiveness of

interventions to enhance self-efficacy.

According to Johnson (1996), self-efficacy could be used as a framework to enhance

the effectiveness of community pharmacy-based diabetes education programs. All

four information sources of self-efficacy can be used with different learning methods.

For example, when people are learning to measure and interpret blood glucose, the

educator first has to explain the advantages and supply the necessary knowledge. The

equipment and procedure then can be demonstrated, after which the persons with

diabetes have an opportunity to practice at home. This author recommended that a

videotape of patients with diabetes successfully performing specific self-care


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behaviours and incorporating such behaviours into their daily routine could be

provided for patients to view at their convenience. This medium would provide

additional vicarious experience in a low-stress environment; fear can have a negative

effect on self-efficacy. Practitioners should routinely monitor self-efficacy for

adherence and self-care behaviours among patients with diabetes (Kavanagh, Gooley

& Wilson, 1993); one questionnaire of SDSCA is recommended for use (Johnson,

1996). However, to conquer the weakness of this scale, converging measures of

self-management should be collected when possible. For example, patients may be

encouraged to maintain diaries of self-care behaviours (e.g. food records or a

blood-glucose monitoring dairy).

Grey et al. (1998) found that training in coping skills had a positive effect on

self-efficacy among teenagers with diabetes. The training was aimed at avoiding

inappropriate coping and establishing more positive coping and behaviours.

Participants were trained based on the elements of modelling, verbal persuasion and

practicing skills. When people change behaviour, maintenance of the desired

behaviour is critical. Absence of a coping response will lead to lower self-efficacy and

relapse. Correct use of a coping response will lead to success, which enhances

self-efficacy (Marlatt & Gorden, 1985).

According to Rubin (2000b), psycho-education incorporating a coping skills training

component could have contributed to several outcomes in different ways. Diabetes

self-efficacy could have been affected directly, and other outcomes such as

self-esteem, depression, anxiety, self-care behaviour and glycaemia control could

have been affected indirectly (Rapley, 1991;Ismail, Winkley and Rabe-Hesketh,2004).

The addition of coping skills training seems financially feasible for most diabetes


136

education programs. Costs for adding this component are relatively low (US $35 per

patient for the Hopkin program), and the additional patient time required is relatively

small (2.5 hours). However, the most difficult obstacle for establishing any coping

skills training program may be identifying a professional who is sufficiently

experienced in diabetes-specific coping skills training. It may be possible to identify a

mental health professional who is interested in developing expertise in working with

people with diabetes. Alternatively, diabetes health care providers who are not mental

health specialists may be interested in developing expertise in coping skills training.

This approach is teachable and professionals have successfully been trained to

implement the intervention. Rubin (2000b) has suggested further studies in which the

control group receives traditional diabetes education and the intervention group

receives traditional education supplemented by coping skills training.

A study was conducted on counselling women with breast cancer using principles

developed by Bandura’s theory (Lev & Owen, 2000). Eighteen women with breast

cancer were randomly assigned to efficacy-enhancing experimental (n=10) and

usual-care control (n=8) groups. The experimental group received five interventions

delivered monthly. The counselling technique given to women in this study included:

receiving a booklet describing self-care behaviours and receiving five counselling

interventions at monthly intervals and receiving a videotape. A trained

nurse-counsellor had contact with the women in the study. The results showed that

interventions to promote self-efficacy increase quality of life and decrease distress for

women diagnosed with breast cancer.

Barrera, Jr. Glasgow, McKay, Boles and Feil (2002) conducted a randomised trial of

160 adult type 2 diabetes patients and provided computers and internet access to


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novice internet users assigned to 1 of 4 conditions: diabetes information only; a

self-management coach; a social support intervention; or a self-management coach

and the social support intervention. After three months, participants in the two support

interventions showed significant increase in the support outcome and participants’ age

was found to be significantly related to change in social support. The social support

intervention provided activities on the internet that offered opportunities to exchange

diabetes-related information, coping strategies, and emotional support, for example,

through a peer-directed (but still professionally monitored) forum for participants to

interact with one another in a safe, supportive setting where they were encouraged to

express their concerns, successes, and frustrations. As can be seen, this support

strategy is effective for people with type 2 diabetes.

A randomised controlled trial was conducted by Howells et al. (2002), which aimed to

evaluate changes in self-efficacy for self-management in young people with type 1

diabetes participating in a “Negotiated Telephone Support” (NTS) intervention

developed using the principles of problem solving and social learning theory. The

result has shown that participants in group 2 (continued routine management with

NTS, n=25) and group 3 (annual clinic with NTS, n=26) received an average of 16

telephone calls per year (5-19), median duration 9 minutes (2-30), with a median

interval of 3 weeks (1-24) between calls. Significant correlations were found between

age and average length of calls (r = .44, P < .01) and frequency of contact (r = .36,

P<0.05). After one year, while the participants in the two intervention groups showed

significant improvements in self-efficacy (p = .035), there was no difference in

glycaemia control in the three groups. This study has shown that telephone support is

an effective medium to deliver a simple theory-based psychological intervention to

enhance self-efficacy for diabetes self-management.


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In summary, to develop self-efficacy beliefs for a specific task it is necessary to use

the four information sources of Bandura’s self-efficacy theory. The counselling skills

and self-efficacy enhancing strategies are guides to structuring the development of

self-efficacy. However, this requires application in a diabetes-related intervention.

4.6 Summary

There are some studies that showed that there are significant relationships between

self-efficacy theory and diabetes care (Rapley, 1990; Padgett, 1991; Hurley & Shea,

1992; Glasgow & Osteen, 1992; Johnson, 1996). Research conducted thus far has

shown that diabetic self-care behaviours can be improved by interventions based on

social learning theory (with the four information sources). However, most published

research on diabetes self-efficacy thus far has been conducted in the US or western

countries; it showed that self-efficacy is a predictor of self-care behaviour, and it

would seem useful to assess self-efficacy among other countries or linguistic groups,

such as Taiwan.

This chapter provides the overview of the self-efficacy model and the framework for

the study. A literature review of self-efficacy and outcome variables, such as

health-related quality of life, psychosocial well being and health care expenditure has

been explored. Moreover, three reasons for developing the intervention program

(SEEIP) and self-efficacy enhancing strategies have been described in this chapter, as

a guide to structuring the development of the SEEIP.

Glasgow and Osteen (1992) conclude that the past decade has seen a dramatic shift


139

from knowledge-attitude-belief models of diabetes education to a focus on

patient-centred perspectives, self-efficacy, self-management, and empowerment issues.

To address this change, we need to modify our assessment approaches to the

measurement of outcomes such as program reach and appeal to different patient

populations, health-related quality of life and cost effectiveness.

This study is therefore designed to assess the effectiveness of self-management for

persons with type 2 diabetes, following the implementation of a self-efficacy

enhancing intervention program (SEEIP). The SEEIP designed by the researcher was

used to enhance diabetic people’s self-confidence and ability in self-care for

themselves. This program uses interventions that add to the sources of development of

self-efficacy including: (1) viewing a 10-minute DVD (2) receiving the “Diabetes

Self-Care” booklet (3) participating in four efficacy- enhancing counselling

intervention sessions at weekly intervals (4) participating in telephone follow-up. It is

anticipated that the SEEIP component will affect diabetes self-efficacy directly, and

other outcomes such as self-care behaviours, glycaemic control, depression and social

support could be affected indirectly also. This program and the research methods will

be introduced in the next chapter.

Student number: n4513282 Shu-Fang Wu Chapter 5 Methods

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Chapter 5

Methods

5.1 Introduction

The study was divided into two research studies. Study I (Phase 1) translated two

diabetes-specific self-efficacy instruments (DMSES & PTES: the Diabetes

Management Self-Efficacy Scale and the Perceived Therapeutic Efficacy Scale) into

Chinese for use in a Taiwanese population, and tested their reliability and validity.

Study II covered two phases: Phase 2 consisted of development of an intervention

based on self-efficacy theory, and then Phase 3 was a randomised controlled trial to

evaluate the efficacy of the intervention in a Taiwanese population (see Figure 5.1).

This chapter outlines the research design, population and sample (including sample

size calculation), setting and procedure, instruments/measurement strategies, data

analysis, and ethical considerations in each phase of the study.


141

Figure 5.1 Two studies (or three phases) of the research

5.2 Study I: Translation, testing of validity and reliability of two

diabetes-specific self-efficacy instruments in a Taiwanese population

In Study I, two diabetes-specific self-efficacy instruments (DMSES and PTES) were

translated and tested for reliability and validity in a Taiwanese population.

5.2.1 Research design

A two-stage study design was used in order to test the validity and reliability of two

diabetes-specific self-efficacy instruments in a Taiwanese population. This study

was undertaken over two stages. Stage one involved forward translation, consensus

Study I Translation, testing of

validity and reliability of two

diabetes-specific self-efficacy

instruments in a Taiwanese

population

Translation

Content validity (CVI: a

panel of content experts,

n=8)

Criterion validity (n=230)

Convergent validity (n=230)

Construct validation: factor

analysis (n=230)

Internal consistency:

Cronbach’s alpha (n=230)

Stability: test-retest (after

2-4 weeks, n=30): ICC; a

Bland-Altman plot

Study II (Pilot study)

Development of an

intervention based on

self-efficacy theory &

Piloting of the intervention

Developing a suitable

intervention in Taiwanese:

included DVD, “Diabetes

Self-Care” booklet,

efficacy- enhancing

counselling intervention

sessions and telephone

follow-up

•Validation of the

intervention: provider

experts (n=4) and patients

(n=6)

•Pilot the intervention

Study II (Main study)

Randomised controlled trial

to evaluate the efficacy of

the intervention

Pre-test / post-test/

experimental study

(n=145)

Baseline- 3months- 6 months

Outcome measures:

C-DMSES

C-PTES

SDSCA

SF-12

MOS-SSS

CES-D

Health Service utilisation


142

meetings, focus groups, and backward translation of the instruments and examined

the content validity (CVI). Stage Two established the psychometric properties of the

Chinese version of the DMSES and PTES by examining the criterion, convergent

and construct validity, internal consistency and stability test (test-retest).

5.2.1.1 Stage one: translation and instruments development

The first stage involved the translation of the DMSES and PTES and examination of

the newly developed Chinese version of the DMSES and PTES for cultural

equivalency. Chinese versions of the DMSES and PTES were developed according

to the steps described in Brislin’s (1986) and Jones, Lee, Phillips, Zhang & Jaceldo

(2001) model of translation in order to assure equivalence. Several forward and

backward translations were undertaken by both monolingual and bilingual

personnel. The processes of Stage One (see Figure 5.2) involved:

(1) Forward translation

Two bilingual translators independently translated the DMSES and PTES scales

from English into Chinese.

(2) A consensus meeting

In a consensus meeting, a researcher, two translators, and a diabetes educator,

checked and agreed on a version of the DMSES and PTES that best reflected the

linguistic and conceptual matter of the original English DMSES and PTES scales.

(3) Focus group

A researcher, two diabetes educators, and three patients with diabetes were invited as

experts to give their opinions on the cultural equivalency of the DMSES and PTES

and the appropriateness of the language used in the items.

(4) Backward translation


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Two translators who had not seen the questionnaire in its original language

translated the new translation back into the original language. Ideally the

back-translators should be native speakers of the language in which the original

questionnaire is designed and fluent in the language of the translation (Bradley,

1994). In this study, two native English speaking translators with experience in

biomedical sciences and nursing but unaware of the original English DMSES &

PTES performed a back-translation of the Chinese DMSES and PTES formats into

the English language.

(5) A consensus meeting

The back-translations were then compared with the original to identify any linguistic

inaccuracies. Any poorly translated items identified were then translated and

subsequently back-translated by a back-translator (Bradley, 1994). In this study, a

team consensus meeting (two native English speaker researchers, and a bilingual

researcher) compared the back-translations with the English DMSES and PTES to

check for conceptual discrepancies. The team members of the consensus meeting

reviewed the English DMSES and PTES for conceptual equivalence with the

original source form. These discussions helped to streamline the translations

cross-culturally and contribute to the standarisation of the DMSES and PTES.

(6) Content validity (A panel of content experts)

The content validity of the instruments was examined using a method described by

Lynn (1986). The CVI (Content Validity Index) was the proportion of experts that

judged an item as content valid (a score of 3 or 4). The starting point was that a CVI

score of at least a score of 3 or higher should be maintained. The instrument was

sent to eight experts (two diabetologists, one teacher of nursing, two diabetes nurses

with expertise in patient education, two experts in self-efficacy theory and one

consultant) who judged the content validity of the Chinese version of the DMSES


144

and PTES. Content validity was assessed by asking the panel members to rate each

item as a valid measure of the construct using a five-point Likert scale (1 = ‘strongly

disagree’, 5 = ‘strongly agree’) based on two criteria: the applicability of content and

clarity of phrasing, which were described as follows:

(1) Applicability of content: this referred to the applicable level of expression and

content with local culture and research objective.

(2) Clarity of phrasing: this referred to the applicability of meaning in expression

and sentences to interviewees; description, clarity, understandability, and

comprehension.

A content validity index was calculated for each item as well as an overall score for

the Chinese version of the DMSES and PTES. An acceptable CVI score should be >

.78 (Grant & Davis, 1997). Thereafter, the panel was asked to make comments on

individual items in relation to the accuracy, clarity, style, and cultural relevance of

the translation. A panel-modified version was subsequently developed in this stage.


145

Figure 5.2.Stage one of the development processes of the C-DMSES & C-PTES

Translation 2

Chinese DMSES & PTES (First version)

English DMSES &

PTES

Translation 1 (A bilingual translator )

Translation 2 (A bilingual translator )

Consensus Meeting (A researcher, two

translators, and a diabetes

educator)

Translation 1

Chinese DMSES & PTES (First version)

Focus group (A researcher, two diabetes

educators, and three patients with diabetes)

Back-translation 1 (An native English speaker translator with

experience in biomedical sciences but

unaware of the original English DMSES &

PTES)

Back-translation 2 (An native English speaker translator

with experience in nursing but unaware

of the original English DMSES &

PTES)

Consensus Meeting (Two native English speaker researchers, and a bilingual

researcher)

Chinese DMSES & PTES

(Second version)


Content validity (CVI, n=8)

(Third version)

Items not O.K.


146

5.2.1.2 Stage two: validation and reliability of instruments

Following the translation and development stage, the second research stage tested

the validity and reliability of the Chinese version of the DMSES and PTES

(C-DMSES and C-PTES). The validity of questionnaires in the field has most often

been evaluated by criterion, convergent and construct validity. In addition,

estimation of scale scores, reliability used internal consistency and test-retest

methods.

(1) A pilot test of instruments

Before Stage Two (validation and reliability of instruments) was undertaken, the

panel-modified versions of the DMSES and PTES, together with an additional

section on demographic and clinical data, were pilot tested with ten type 2 diabetes

patients. We pilot tested these Chinese versions with ten diabetes patients to identify

difficulties in understanding. This was also done to check the data collection

procedures, completed time and the administration of the scale for clarity and

patients' willingness to complete it.

(2) Criterion validity

One of the assumptions underlying this study was that “self-efficacy is a useful

predictor for diabetic self-care behaviour and that self-care performances will be

improved among people with diabetes who have strong beliefs in self-efficacy”

(Williams and Bond, 2002). In this study, it was expected that the C-DMSES/

C-PTES would be a predictor for the Summary of Diabetes Self-Care Activities

(SDSCA) scale (Toobert, Hampson & Glasgow, 2000).

(3) Convergent validity


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According to Bandura (1986), self-efficacy was the most important predictor of

change in behaviour. Self-efficacy was categorised into three different dimensions

according to its generality: task specific self-efficacy (TSSE), generalized

self-efficacy (GSE), and middle ranged self-efficacy. GSE was good for predicting

outcomes of new and ambiguous situations. It also could be gained from a specific

mastery experience of one situation that may be generalized to other similar

situations (Bandura, 1986). The General Self-Efficacy Scale (GSE) (Schwarzer,

1992) appeared to be the most consistent for measuring the generalized self-efficacy

concept. In order to examine whether the C-DMSES/C-PTES was valid in the

self-efficacy domain, the Chinese version of the GSE (Chueng & Sun, 1999) and

C-DMSES/C-PTES were selected to provide convergent validity of this study.

(4) Construct validity (Factor analysis)

Factor analysis (exploratory factor analysis) could be undertaken to examine

construct validity of instruments. Items that were closely related were clustered into

a factor. The analysis might indicate the presence of several factors, which might

indicate that the instrument reflected several constructs rather than a single construct

(Burns & Grove, 1993). In this study, factor analysis was examined for construct

validity by undertaking Principal-Component Factor Analysis with a Varimax

rotation.

(5) Internal consistency

A Cronbach’s alpha-coefficient was calculated for each subscale and the overall

C-DMSES/C-PTES score to determine internal consistency.

(6) Stability test (test-retest)


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Two to four weeks after the initial survey, a random sample of 30 participants, using

a random number table, was asked to fill in the same questionnaire when they

visited a doctor again in the same outpatient setting. The respondents were used to

test the temporal stability of the instruments. The process of the validation and

reliability of instruments of the C-DMSES & C-PTES is illustrated in Figure 5.3.

Figure 5.3 Stage two of the validation and reliability of instruments of the

C-DMSES & C-PTES

A pilot test

(Pilot test with patients with

type 2 diabetes, n=10)

Criterion validity (Regression analysis, n=230)

Convergent validity (Pearson correlation, n=230)

Construct validity (Factor analysis, n=230)

Internal consistency

(A Cronbach’s alpha-coefficient, n=230)

Test-retest

(Pearson correlation coefficient and Bland-Altman plots

with 95% limits of agreement (LOA), n=30)


(Third version)

A random sampling (2-4 weeks after

the initial survey)


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5.2.2 Population and sample

A convenience sample for stage II of 230 people with type 2 diabetes from a diabetic

outpatient clinic in a medical center in Taipei, Taiwan, formed the sample of the

study. The sample size was determined by the number of participants required to

conduct a factor analysis using Tanaka (1987) recommended ratio of at least five

participants for each item. As the questionnaire was composed of two main scales:

20 items for C-DMSES and 10 items for C-PTES, at least 200 people with type 2

diabetes would be required as a minimum sample size.

Inclusion Criteria:

People were eligible for the study if they:

1) were aged 30 years or more;

2) satisfied clinical criteria for type 2 diabetes;

3) had an oral medication regime of diabetes;

4) spoke and understood Chinese or Taiwanese;

5) had a telephone in their residence and were able to use it effectively.

5.2.3 Setting and procedure

1) This study was conducted in an outpatient clinic in Tri-Service General Hospital

in Taipei, Taiwan.

2) Advertisements for the project were distributed in an outpatient clinic and

participants were invited to participate. Potential participants were contacted by the

project co-ordinator in the outpatient clinic or by telephone in response to an

advertisement. At that time each respondent was screened by the researcher to

determine whether the inclusion criteria were met. If so, once approval had been

received from QUT UHREC (University Human Research Ethics Committee),

potential participants were invited to join the study.


150

3) Each participant was given a questionnaire by a data collector and asked to

independently complete the questionnaire and provide feedback on the questions.

4) If participants were unable to complete the questionnaire alone, for example due

to vision impairment, they were provided assistance from the data collector. If

participants became weary, the interview was ceased and resumed at a later time.

5) The questionnaire was composed of two main scales: 20 items for C-DMSES, 10

items for C-PTES, 10 items for GSE, 12 items for SDSCA and demographic data.

6) Two to four weeks after the initial survey, a random sample of 30 participants

from this study were asked to fill in the same questionnaire when they visited a

doctor again in the same outpatient setting. The respondents were used to test the

temporal stability of the instruments.

5.2.4 Research Concept and Instruments/Measurement Strategies

In order to examine the criterion, convergent and construct validity, internal

consistency and stability are considered. The following instruments and

measurement strategies are summarised in Table 5.1. Moreover, the details of these

instruments used to examine validity and reliability are shown at the end of the

section.

Table 5.1 Instrument/ measurement strategies (Study I)

Used to examine Domains Instrument/ Measurement Strategies

Criterion, convergent,

construct validity, internal

consistency, and stability test

Self-efficacy towards

management of type 2

diabetes:

(Efficacy expectations)

The Diabetes Management Self-Efficacy

Scale (DMSES)

Criterion, convergent,

construct validity, internal

consistency, and stability test



diabetes:

The Perceived Therapeutic Efficacy Scale

(PTES)


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(Outcome expectations)

The criterion-related validity Self-care activities The Summary of Diabetes Self-Care

Activities (SDSCA)

The convergent validity General Self-Efficacy The General Self-Efficacy Scale (GSE)

Characteristics

of population

Demographics, and illness

history

A self-report questionnaire was designed to

collect: age; gender; education; marital

status; employment status; diagnosis

duration (years); diabetic complications; and

history of other diseases

-Instruments:

The Diabetes Management Self-Efficacy Scale

The Diabetes Management Self-Efficacy Scale (DMSES) (McDowell et al., 2005)

was a self-administered scale containing 20 items. It assessed the extent to which

respondents were confident they could manage their blood sugar, diet, and level of

exercise. Responses were rated on an 11 point scale ranging from “can’t do at all”

(0) to “certain can do” (10). Possible total scores ranged from 0 to 200 points.

DMSES was primarily directed on the strength dimension of self-efficacy (van der

Bijl, van Poelgeest-Eeltink & Shortridge-Baggett, 1999). Self-care tasks of type 2

diabetes were grouped under three main categories: 1) performing activities (use of

medication, such as insulin or tablets; keeping to a diet; and physical exercise); 2)

self-observation (reporting on glucose in urine and blood; body weight; skin

condition of the feet); 3) self-regulation activities: correct of hypo- and

hyperglycemia; preparation for a vacation; variation in nutrition (Pennings-van der

Eerden, 1992). As the DMSES tool has demonstrated acceptable reliability (alpha

.81-.91; test-retest .76- .79) and validity previously (McDowell et al., 2005; van der

Bijl, van Poelgeest-Eeltink & Shortridge-Baggett, 1999) it was chosen as the target

scale for validation in this study.


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The Perceived Therapeutic Efficacy Scale

People with diabetes perform self management activities which lead to the desired

outcome (outcome expectations). The PTES measured participants’ confidence

(outcome expectations) (Dunbar-Jacob, 2000). It focused on activities of people with

type 2 diabetes who were taking prescribed medication. This activity has been

incorporated into the PTES. The tool consisted of 10 items. Responses were rated on

an 11 point scale from “no confidence” (0) to “highest confidence” (10). The

responses were summed to become a total score for “confidence”. Possible scores

range from 0 to 100 points with higher scores indicating greater confidence. The tool

has had acceptable reliability and validity in the USA and UK. Internal consistency

was high (alpha .94-.96). Test-retest reliability was also high (.64-.80)

(Dunbar-Jacob, 2000; Shortridge-Baggett, 2001; Sturt & Hearnshaw, 2002). This

scale was chosen as the target scale for validation in this study.

The Summary of Diabetes Self-Care Activities (SDSCA) scale

The Summary of Diabetes Self-Care Activities (SDSCA) scale (Toobert, Hampson

& Glasgow, 2000) assessed the history of self-care activities of people with diabetes.

The relationship between SDSCA and C-DMSES/C-PTES was explored in this

study. The SDSCA questionnaire used the term “level of diabetes self-care” for the

absolute frequency or consistency of regimen behaviours. The Chinese version of

the SDSCA was a self-reporting measure of the frequency of performing diabetes

self-care tasks and consisted of 12 items that asked how often several activities such

as diet (items 1, 2, and 3), exercise (items 4 and 5), medication taking (item 6),

blood sugar testing (items 7 and 8), and foot care (items 9, 10, 11 and 12) were

carried out over a 7-day period. The possible total scores ranged from 0 to 84 points


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with higher scores indicating a higher frequency of performing diabetes self-care

activities (Chiou, 2002). As the Chinese version of the SDSCA (Chiou, 2002) has

demonstrated acceptable reliability and validity, it was chosen for testing criterion

validity. It was expected that the C-DMSES/ C-PTES would be a predictor for (or

would positively associate with) the Summary of Diabetes Self-Care Activities

(SDSCA) scale. The instrument has demonstrated internal consistency exceeding .50

and test-retest reliability ranged from .55 to .64 and validity reports were also high

(Glasgow et al., 1989; Glasgow et al., 1998; Toobert, Hampson & Glasgow, 2000).

The Cronbach alpha coefficient of the Chinese version of the SDSCA in this study

was .70.

The General Self-Efficacy Scale

The Chinese version of the General Self-Efficacy (GSE) Scale (Zhang & Schwarzer,

1995) was a 10-item scale that was designed to assess optimistic self-beliefs to cope

with a variety of difficult demands in life and measured the strength dimension of

self-efficacy. Bandura (1977b) stated that the concept of self-efficacy had three

dimensions, including magnitude, strength and generality. Also, Bandura (1997)

claimed that self-efficacy predicted behaviour-specific beliefs that would not

increase if the behaviour did not persist. The strength dimension of

behaviour-specific efficacy was of importance as a diagnostic strategy for diabetes

self-management aimed at the improvement of health outcomes (Maibach & Murphy,

1995).

Jerusalem and Schwarzer originally developed the GSE scale in 1981. It has been

used in many studies and it is now available in 29 languages (Schwarzer, 1992). The

Chinese version adapted from the English version was developed and tested among


154

a Chinese population. High internal consistency was noted (alpha= .91-.92) (Zhang

& Schwarzer, 1995; Chueng & Sun, 1999). There was a 4 point Likert scale

response format for each item with 0 = ‘not at all true’; 1 = ‘hardly true’; 2 =

‘moderately true’; and 3 = ‘exactly true’. Scores were added to give a total ranging

from 0 to 30; higher scores represented more self-efficacy. The Cronbach alpha

coefficient of the Chinese version of the GSE in this study was .93. It was expected

that participants who reported better C-DMSES/C-PTES scores would also report

having better GSE scores. Therefore, this tool was used to test for convergent

validity.

5.2.5 Data Analysis

(1) Descriptive statistics were used to establish the frequency, range, mean, and SD

of demographics and clinical characteristics of the sample.

(2) A regression analysis or Pearson correlation were performed to examine the

relationships between the C-DMSES /C-PTES, and SDSCA for criterion

validity.

(3) Pearson’s correlation coefficients between the C-DMSES/C-PTES, and GSE

were selected as a convergent validity of the scales.

(4) A Cronbach’s alpha-coefficient was calculated for each subscale and the overall

C-DMSES/ C-PTES score to determine internal consistency.

(5) Factor analysis was used to determine the construct validity of the scales.

(6) Pearson’s correlation coefficients and Bland-Altman plots (Bland & Altman,

1986) with 95% limits of agreement (LOA) were performed to evaluate stability

through a test-retest of the tool at a 2-4 weeks interval.


155

5.2.6 Ethical considerations

1) All participation in this study was voluntary.

2) All participants were provided with information both verbally and via an

information sheet, and asked to sign a consent form.

3) Personal information was keyed into a secure, computerised database, maintained

by the research team.

4) Potential participants were allowed to withdraw from the project during the

period of study without penalty to their further care.

5) Telephone numbers of the chief investigator and QUT Research Ethics

Committee were available to the participants if they required further information

about the project.


156

5.3 Study II (Pilot Study): Development of an intervention based on self-efficacy theory and piloting of the intervention

It is important to develop educational programs based on self-efficacy theory for the

self-management of diabetes (Johnson, 1996). The rationale for developing an

intervention program based on self-efficacy theory and development of self-efficacy

for people with diabetes was described in the previous chapter (see Section 4.5), for

example, the traditional model of diabetes education has been ineffective in bringing

about desired outcomes in Taiwan (see Section 2.5 and 4.5.1.3). We chose multiple

information resources and elements in the self-efficacy enhancing intervention

program (SEEIP) because combining different sources of self-efficacy is best for

enhancement of self-efficacy, and combining all four sources is most effective

(Maddux & Lewis, 1995; Bandura, 1997). The strengths of using the multiple

elements have been discussed in Section 4.5.2.2 also. Traditional patient education

emphasises disease-specific information and technical skills whereas the SEEIP

teaches self-efficacy enhancing skills in order to enhance people’s confidence and

change people’s behaviours. The comparison of traditional patient education and the

SEEIP in this research study is demonstrated in Table 5.2 below.

Table 5.2 Comparison of traditional patient education in Taiwan and the SEEIP

Topics Traditional education in Taiwan SEEIP

What is

taught?

Information and technical skills

about the disease

Information and technical skills about the

disease; skills on how to understand and act on

problems; skills of enhancing self-efficacy

What is the

goal?

Compliance with the behaviour

changes taught to the patient to

improve clinical outcomes

Increased self-efficacy to improve self-care

ability and clinical outcomes

How is

behaviour

changed?

External motivation Internal motivation. Patients gain understanding

and confidence to accomplish new behaviours


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Topics Traditional education in Taiwan SEEIP

Who is the

educator

(team

members)?

A health professional (may

include: doctor, nurse, or dietician)

A health professional (doctor, nurse, diabetes

educator, dietician, consultant, and podiatrist),

peer leader or other patients, often in group

settings

Materials? One page patient educational sheet Multiple information resources, such as:

videotape or DVD, “Diabetes Self-Care”

booklet, counselling sessions (group support),

telephone follow-up

Procedures? Depend on health providers, in

general the procedures is: (1) give

an educational sheet (2)

explanation the content of the

educational sheet

(1) View a 10-minute videotape

(2) Receive the “Diabetes Self-Care” booklet

(used in four efficacy - enhancing

counselling intervention sessions and give

them an explanation)

(3) Participate in four efficacy - enhancing

counselling intervention sessions

(40mins/session: a facilitator discusses with

particiapnts)

(4) Participate in telephone follow-up (2-3 times

during 6 months, 10-20 minutes per time)

Time? 10-20 minutes/ session 20-40 minutes per session (sequence of sessions)

What is the

theory

underling the

intervention?

Disease-specific knowledge creates

behaviour change, which in turn

produces better clinical outcomes

Related to a clear conceptualisations and

self-efficacy theory base (Shortridge-Baggett &

van der Bijl, 1996)

Greater patient confidence in his/her capacity to

make life-improving changes yields better

clinical outcomes

Theory based Information and technical skills

about the disease

. Information resources: -Performance accomplishments

-Vicarious Experience

-Verbal Persuasion

-Self appraisal (Bandura, 1977a)

Outcome

evaluation

Information and technical skills Self-efficacy in managing type 2 diabetes; self

management behaviour (such as, diabetes

self-care activities; health-related quality of life;

psychosocial well-being and health care

utilisation)


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The phase of Study II (Pilot Study) developed and pilot-tested a suitable intervention

(SEEIP) for Taiwanese people with diabetes. The intervention was perceived as a

supplement to a standard educational program that was provided by a researcher to a

group of people with type 2 diabetes. The SEEIP included viewing a DVD,

“Diabetes Self-Care” booklets, four weekly efficacy-enhancing counselling

intervention sessions, and follow -up telephone calls. It aimed to assist people to

maintain a healthy lifestyle, seek support, solve problems and make an action plan.

The methods and results of the pilot study of the intervention are provided in this

section.


A pilot test was used in order to test the validation of a self-efficacy enhancing intervention program (SEEIP).


A convenience sample of four people who were provider experts and six people with

type 2 diabetes from a diabetes outpatient setting formed the sample of the study.

Inclusion criteria

Provider experts:

People were eligible for the study if they were one of the following:

1) Nurse;

2) Doctor;

3) Nutritionist;

4) Clinical diabetes educator.

Patients:



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1. Permission has been sought and granted by the authors to translate and modify

each of the booklets into Chinese.

2. Four people (a nurse; a doctor; a nutritionist; and a clinical diabetes educator)

who were provider experts were contacted by telephone and invited to participate

in the study. Their roles involved expert input to assist with the development and

validation of the intervention of SEEIP.

3. Six potential participants were contacted by the project co-ordinator in the

outpatient clinic and asked if they would like to participate in the pilot study. They

were provided with information both verbally and via an information sheet, and

asked to sign a consent form.

4. Based on the comments from the sample of 10 people, the intervention of SEEIP

was modified and validated.

5.3.4 Ethical considerations

1) All participation in this study was voluntary.

2) All participants were provided with information both verbally and via an

information sheet, and asked to sign a consent form.

3) All participants were informed that they were free to withdraw from this study at

any time without comment or penalty.


160

4) Personal information was keyed into a secure, computerised database maintained

by the research team.

5) Full confidentiality was maintained.

5.3.5 Results: Study II (Pilot Study)

The intervention of SEEIP focused on five issues: diet control, physical activity,

blood glucose testing, adherence to medication regime, and foot care. This helped

people with type 2 diabetes to successfully manage their disease by providing four

ways to improve self-efficacy. Four information sources in the self-efficacy theory

are applied in the SEEIP intervention. Different interventions use different

information sources.

Four people (a nurse; a doctor; a nutritionist; and a clinical diabetes educator)

contributed expert suggestions for the intervention of SEEIP. For example, the panel

members were asked to make comments on four sessions of the “Diabetes Self-Care

booklet” in relation to the accuracy, clarity, and cultural relevance of the translation.

Experts added context and changed wording to make the booklet easier for people

with diabetes to understand the meanings of the contents. Also, the experts agreed to

show real stories of people with type 2 diabetes in the DVD and recommended the

material source of the 10 minute-story of Uncle Asparagus.

The panel-modified interventions of the SEEIP were pilot-tested with 6 patients

from a diabetes outpatient clinic in a medical center. All participants attended four

efficacy-enhancing counselling intervention sessions at weekly intervals

(participants had to participate in at least three of the four sessions). They stated they

had no difficulties in understanding the contents of a DVD, “Diabetes Self-Care”


161

booklet, and four weekly efficacy-enhancing counselling intervention sessions and

they all expressed willingness to receive follow -up telephone calls. The final

intervention suit of the SEEIP was summarised in Table 5.3.

Table 5.3 Intervention suite of the SEEIP

Timing Intervention Self-efficacy

theory

applications

Main content

Week 1 10 minute a

DVD

viewing

Information

source:

-Vicarious

experience

- The DVD showed people with type 2 diabetes who successfully

used self-care activities to prevent the occurrence rate of acute

and chronic complications.

- We discussed and cooperated with the Chung-Hua Christian

hospital in Taiwan to use the DVD materials of patient education

for diabetes. This DVD was released by the Bureau of Health

Promotion (see Appendix 20, p. A100).

- Real stories were provided in the DVD. One of diabetic patients

as a role model. That is Uncle Asparagus. 10 mins was shown

about one day in the daily life for Uncle asparagus. He could do

all the jobs of planting asparagus and do all his own self-care

activities, including checking blood sugar, taking medicine and

checking his feet when he finished his work.

Week 1 Receives the

“Diabetes

Self-Care”

booklet

Information

source:

-Vicarious

experience

-Performance

accomplishments

- The booklet includes author’s notes (coping with diabetes), unit

one, unit two, unit three, and unit four (see Appendix 20,

p.A68-99).

- The booklet presented stories of how Mei-mei, Wan-tsai, and

Ai-Jiau who have experienced their difficulties and met different

problems.

- The booklet showed real stories from people with type 2 diabetes

about how to perform their daily self-care activities, including

diet control, physical activity, blood glucose testing, adherence to

medication regime, and foot care.

- Questions in the booklet promote discussions.

- Goal-setting sheets for diabetes self-care were provided in the

booklet to encourage people to keep a record of their own

diabetic control.


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Week

1- 4

Four

efficacy-

enhancing

counselling

intervention

sessions

undertaken

Information

source:

-Performance

accomplishment

-Vicarious

experience

-Verbal

persuasion

- Self-evaluation

-Four efficacy-enhancing counselling intervention sessions at

weekly intervals were undertaken. Participants had to participate

in at least three of the four sessions.

- Each group was limited to between 15-20 participants according

to participants’ preferences.

-Each practice session lasted 40 minutes and contained

self-efficacy enhancing skills fostering, self-goal setting sharing

and peer support for diabetics, which were facilitated by the

researcher.

-A registered nurse and nurse educator, who was trained in

counselling techniques in Australia and Taiwan (see Appendix 18

& 19, p.A66-67).

-A booklet was used in the four sessions as well.

Week 8

and 16

after the

commenc

ement of

SEEIP

Telephone

follow-up

Information

source:

-Performance

accomplishment

-Verbal

persuasion

-The facilitator contacted participants by telephone 8 and 16

weeks after the commencement of the intervention.

-Telephone follow-up provided continuous self-efficacy enhancing

skills fostering, goal-setting sharing and mental support for

diabetics.

-The purpose of calling was to foster continued performance

accomplishment via verbal persuasion.

5.3.5.1 Viewing a 10-minute DVD

People’s beliefs that they can motivate themselves and regulate their own behaviour

play an important role whether they are even considering changing harmful health

habits or pursuing rehabilitative activities (Bandura, 1997). The media, particularly

television, plays a major role in informing the public about health risks. Efforts to

get people to adopt health practices that prevent disease, therefore, rely heavily on

persuasive communications in health education campaigns (McGuire, 1984). In

group education, group members can be encouraged to help each other in solving

their problems. They may offer innovative solutions that have not been thought of


163

by professionals (Gonzalez, Goeppinger & Lorig, 1990). Also, modelling can also

be used with other educational media like television, videos, movie, brochures and

textbooks. Some investigations have looked at movies or videos as a strategy for

various learning approaches because the desired behaviour was demonstrated using

comparable models whenever possible. Results found an increase in self-efficacy

(Gross, Fogg & Tucker, 1995; Johnson, 1996).

In this study, the DVD was designed to provide participants with vicarious

experience by showing people with type 2 diabetes (Uncle Asparagus) successfully

using self-care activities to prevent the occurrence rate of acute and chronic

complications. Uncle asparagus shared and described his number of years since the

initial diabetes diagnosis, what he did to help himself, the worst part of the

experience and how he dealt with his worst times, the best part of the experience and

what he would like to tell others going through treatment for illness and how the

experience of diabetes influenced his family or life. This intervention method,

utilizing the information resource of self-efficacy, is vicarious experience and verbal

persuasion.

5.3.5.2 Receiving the “Diabetes Self-Care” booklet

“Diabetes Self-Care” booklet was developed by the Australia IPSE team (“Get to

know your blood glucose level workbook”) (Courtney et al., 2006) and involved diet

control, physical activity, blood glucose testing, adherence to medication regime,

and foot care. These were translated, culturally adapted and modified to the

Taiwanese setting. The booklet was to give participants information through

vicarious experience and performance accomplishments by showing real stories

from people with type 2 diabetes about how they performed their daily self-care


164

activities. Observing how others deal with similar situations (vicarious experience)

was an effective method by which people would learn.

The content of the booklet involved author’s notes (coping with diabetes), unit one,

unit two, unit three, and unit four. The booklet showed stories of Mei-mei, Wan-tsai,

and Ai-Jiau. These real stories were provided by these patients from the Tri-Service

General Hospital in Taipei. Stories described that those patients have experienced

their difficulties and met different problems and these situations are presented with

questions in the booklet to provide discussions. Moreover, the goal-setting sheets of

diabetes self-care were also provided in the booklet to encourage people to keep a

record of their own diabetes control. The content was easy to read and understand

with illustrations and photographs related to self-management of diabetes. The

booklet was given out at the first efficacy- enhancing counselling intervention

session for discussion.

5.3.5.3 Participating in four efficacy- enhancing counselling intervention

sessions

Efficacy-enhancing counselling intervention sessions were made up of 4 (weekly)

sessions focused on increasing performance accomplishment, sharing experience

(vicarious experience), using verbal persuasion, and self-evaluation. Each practice

session lasted 40 minutes and contained fostering self-efficacy enhancing skills,

self-goal setting sharing and peer support for diabetics, and was facilitated by the

researcher, a registered nurse and a nurse educator, who was trained in counselling

techniques (a 10-week self-efficacy enhancing program which was conducted in

Australia and a 24-hour chronic diseases counselling skills program which was

conducted in Taiwan).


165

A major concept in the sessions was self-efficacy: the confidence that people could

carry out behaviour necessary to reach a desired goal. A facilitator applied

self-efficacy counselling skills for participants, including asking questions; focusing

on patient’s agenda; planning personal treatment schedules; defining problems;

setting goals (taking a step-by-step approach); regular follow-up and contact with

patients; scaling questions; brainstorming solutions; considering past

efforts-successes and failures; reassessing confidence; and finally checking

behaviour changes. For example, people were asked to assess their confidence on

the 0-10 scale that they could achieve their plan. Higher patient confidences in their

own capacity to make life-improving changes (self-efficacy) then yielded better

clinical outcomes.

The material in the “Diabetes Self-Care” booklets which included a number of

worksheets as mentioned previously was used in each session. Each session had the

same structure: participants worked with the facilitator, supported by the worksheet.

A final discussion which focused on self-efficacy fostering, self-goal setting sharing

and peer support for diabetics was conducted. Moreover, in the final session, group

participants were provided with a list of members’ phone numbers and encouraged

to call when in need of support.

5.3.5.4 Participating in telephone follow-up

The facilitator contacted the participants by telephone 8 and 16 weeks after the

commencement of the interventional program. The purpose of calling was to foster

continued performance accomplishment via verbal persuasion. Moreover,

maintaining contact not only helped patients feel cared for, which enhanced


166

motivation, it also provided the health care provider with an invaluable

early-warning system for problems that might get much worse before the patient

calls about them.

In summary, the self-efficacy enhancing intervention program (SEEIP) in this study

was different from the traditional education program in Taiwan. The SEEIP

emphasised confidence enhancing and goal-setting skills in order to increase

self-efficacy and change people’s behaviours. The SEEIP guided people to identify

their problems and provided techniques to help people make decisions, and take

proper actions as they encounter changes in circumstances or disease. The aim was

to improve their health outcomes. In this pilot study, based on the comments from

the sample of 10 people, the intervention of SEEIP was modified and validated. The

SEEIP was then used in the main study.


167

5.4 Study II (Main Study): Randomised controlled trial to evaluate

the efficacy of an intervention

The main study was a randomised controlled trial to evaluate the efficacy of the

intervention of SEEIP in a Taiwanese population.


A 2 × 3 randomised controlled trial (RCT) design was conducted in Study II (Main

Study) with pre (baseline) and post-testing (undertaken at 3 months and 6 months

following baseline collection).


A multistage sampling method was chosen in order to select at least 140 participants

(70 participants per group). Initially, potential participants in a diabetes outpatient

clinic were invited to participate through advertisements about the research, which

were posted on a bulletin board in a clinical setting. A sample of eligible people was

recruited and randomised to become the intervention group and the control group

using a random number table. It was expected there would be less than 30% dropout

rate and 5% potential attrition (see Figure 5.4).


168

Figure 5.4 Sampling strategy and procedures to collect the study sample in

Study II (Main Study)

5.4.3 Sample size

Statistical power analysis was used to calculate the required sample size. One of the

Population in diabetes

outpatient clinic

Ineligible or refuse

(Participants were invited to

contact the researcher by tel.

or at the outpatient clinic)

Advertisements on an

outpatient bulletin board in

clinic setting

Recruit sample

(An information sheet and consent form were

given and signed; and participants completed

a baseline questionnaire)

Randomly selected

Intervention group Control group

A dropout rate

and potential

attrition

A dropout rate

and potential

attrition

Final study sample Final study sample


169

major outcome variables in this project was health-related quality of life (as

measured by SF-12). The main hypothesis was that the mean quality of life scores of

diabetic subjects in the intervention group would be higher than those of control

group. We thereby measured the effect size (ES) of how “wrong” the null hypothesis

was, based on Cohen’s (1977) provided rule. A medium effect size should be

substantial, so it could be detected by the naked eye. Figure 5.5 displayed the results

of repeated measures ANOVA power analysis. A repeated measures design had two

groups of 69 subjects each for a total of 138 subjects. Each subject was measured

three times. The between-subject standard deviation was 18.78 (effect size= .27) and

the within-subject standard deviation was 16.26 (effect size= .15). This design

achieved 87% power when an F-test was used to test the group factor at a 5%

significance level.

Power vs n by Terms

0

0.2

0.4

0.6

0.8

1

0 20 40 60 80n

Powe

r GroupsTimesGxT

Term

s

Figure 5.5 The result of repeated measures ANOVA power analysis

In other words, sample size calculations were based on a significance level of p= .05

(two tailed) and power of 80%, z-alpha (v=1.96) and z-beta (u=.84). The sample size

was n=70 per group. However, a total of 110 were considered adequate to recruit for

a dropout rate (30%) and potential attrition (5%). Thus, 220 eligible people needed


170

to be approached in order to retain 140 participants (70 participants per group) at the

end of the study.

Inclusion Criteria:







Exclusion Criteria:

People were excluded from the study if they:

1) had major complications which would interfere with self-care (e.g. legally blind,

severe stroke, or undertaking kidney dialysis);

2) were cognitively impaired


1) This study was conducted in an outpatient clinic in a municipal hospital in Taipei.

2) A heterogeneous group of outpatients who were 30 or more years of age and had

type 2 diabetes were recruited. An advertisement was placed on the noticeboard

of the diabetes outpatient clinic and participants were invited to contact the

researcher by telephone or contact the researcher at the outpatient clinic.

3) An information sheet and consent form were given and signed. Participants were

advised that they would be given the opportunity to ask questions regarding this

study.


171

4) Participants completed a baseline assessment questionnaire and then were

randomly assigned to either the control group or intervention group by using a

random number table.

5) Both the control group and intervention group received a standard diabetic

educational program in the outpatient clinic. The standard diabetes educational

program, which was undertaken in Taiwan in 2001, consisted of a 15-20 minute

nutrition consultation with a nutritionist and an individual diabetic education

consultation with a diabetic nurse educator. The Bureau of National Health

Insurance (BNHI) reimbursed medical care providers if they provided nutrition

consulting and individual diabetic education. Therefore, this standard diabetes

educational program was provided for people with diabetes in the hospital where

this study was undertaken.

Control group participants received only the standard diabetes educational

program provided by nurse educators and nutritionists in the outpatient clinic as

outlined previously.

Intervention group participants received the standard diabetes educational

program provided by nurse educators and nutritionists as well as the following

additional interventions provided by the researcher: 1) viewed a 10 minute DVD;

2) received a “Diabetes Self-Care” booklet; 3) attended four, weekly focused

practice sessions (participants had to participate in at least three of the four

sessions); and 4) participated in a follow-up survey by telephone (see Figure

5.6).

6) Both groups underwent the same three measurements:

M1 (Measurement 1): baseline; prior to the intervention);

M2 (Measurement 2): 3 months from commencement of the intervention); and

M3 (Measurement 3): 6 months from commencement of the intervention).


140

Week1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Baseline Experimental Group Control Group Figure 5.6 Research design- experimental study

Measure 1 Demographics

C-DMSES,

C-PTES,

SDSCA, SF-12,

SSS, CES-D

Health Service

utilisation

The standard

diabetes

educational

program and

SEEIP

The standard diabetes

educational program


C-DMSES,

C-PTES,

SDSCA, SF-12,

SSS, CES-D

Health Service

utilisation


C-DMSES,

C-PTES,

SDSCA, SF-12,

SSS, CES-D

Health Service

utilisation

The

standard

diabetes

educational

program and

Tel F/U


C-DMSES,

C-PTES,

SDSCA, SF-12,

SSS, CES-D

Health Service

utilisation


C-DMSES,

C-PTES,

SDSCA, SF-12,

SSS, CES-D

Health Service

utilisation


C-DMSES,

C-PTES,

SDSCA, SF-12,

SSS, CES-D

Health Service

utilisation

The standard diabetes

educational program

Tel

F/U

172


140

5.4.5 Research concept and instruments/measurement strategies

In this study, the dependent variables (self-efficacy in managing type 2 diabetes, self

management behaviour, health-related quality of life, psychosocial well-being and

health care utilisation) were measured at three points in time: M1 (baseline: prior to

the intervention), M2 (3 months from commencement of the intervention) and M3 (6

months from commencement of the intervention).

Instruments used in data collection included:

1) Self-efficacy towards management of type 2 diabetes (as measured by C-DMSES

and C-PTES);

2) Self management behaviour (as measured by the SDSCA);

3) Health-related quality of life (as measured by Short Form-12);

4) Psychosocial well-being (as measured by the Medical Outcomes Study (MOS)

Social Support Survey tool and the Center for Epidemiology Studies Short

Depression Scale (CES-D)); and

5) Health care utilisation (as measured by health care utilisation self reporting

instrument). Measurement strategies of the study were summarised in Table 5.4.

Table 5.4 Instrument/ measurement strategies (Study II: Main Study)

Domains

Instrument/ Measurement Strategies



diabetes

The Chinese version of the Diabetes Management Self-Efficacy

Scale (C-DMSES)

The Chinese version of the Perceived Therapeutic Efficacy Scale

(C-PTES)

Self-management behaviours The Summary of Diabetes Self-Care Activities (SDSCA) was

designed to collect the diabetes self-care activities:

Adherence to medication regime;

Adherence to food regime;

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141

Adherence to exercise regime;

Adherence to blood glucose testing;

Adherence to feet check

Health-Related Quality of life Short Form- 12 (SF-12)

Psychosocial well-being The Medical Outcomes Study (MOS) Social Support Survey

(SSS) tool

The Center for Epidemiology Studies Short Depression Scale

(CES-D)

Health care utilisation

A tool was designed to collect:

Hospitalisations (yes or no)

Visit to OPD (yes or no)

Visit to ER (yes or no)

Demographics

Illness history

A self-report questionnaire was designed to collect:

Age; gender; ethnic status; religion; education; marital status;

employment; living arrangement

The length of time since diagnosed with diabetes; other chronic

conditions; diabetic complications; treatment regimen; patient

education

The Chinese version of the Diabetes Management Self-Efficacy Scale (C-DMSES)

The C-DMSES was developed and tested reliability and validity in Study I. This was

a self-administered scale containing 20 items. It assessed the extent to which

respondents were confident that they could manage their blood sugar, diet, and level

of exercise. The responses were summed to become a total score for “self-efficacy”.

Possible scores ranged from 0 to 200 points. The tool had acceptable reliability and

validity in a Taiwanese population. The analysis of the Cronbach’s alpha for

C-DMSES was .93 in Study I. According to the factor analysis results of Study I, four

subscales have been identified. The Cronbach’s alpha was .93 for nutrition (Items 4, 5,

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142

9,10, 13, 14, 15, 16, 17), .81 for physical exercise and weight (Items 6, 8, 11, 12), .79

for medical treatment (Items 18, 19, 20) and .77 for blood sugar and feet check (Items

1, 2, 3, 7). Test-retest reliability was also high (.86). The internal consistency (alpha)

of C-DMSES in this main study was .95.

The Chinese version of the Perceived Therapeutic Efficacy Scale (C-PTES)

The C-PTES measured participants’ confidence (outcome expectations)

(Dunbar-Jacob, 2000). It focused on activities of people with type 2 diabetes who

were taking prescribed medication. The C-PTES was developed and tested for

reliability and validity in Study I. The tool consisted of 10 items. Responses were

rated on an 11-point scale from “no confidence” (0 points) to “highest confidence”

(10 points). The responses were summed to become a total score for “confidence”.

Possible scores ranged from 0 to 100 points, with higher scores indicating greater

confidence. The tool had acceptable reliability and validity in Study I (alpha .95).

Test-retest reliability was also high (.79). The Cronbach alpha coefficient of the

C-PTES in this main study was .96.

The Summary of Diabetes Self-Care Activities (SDSCA) scale

The SDSCA scale (Toobert, Hampson & Glasgow, 2000) was the same as in Study I

(see Section 5.2.4). The internal consistency (alpha) of Chinese version of the SDSCA

in this main study was .74.

Health-Related Quality of Life (Short Form-12) scale

Health-related quality of life of people with diabetes was measured using the

well-known and well-validated Short Form-12 (SF-12v2). The SF-12 (Ware, Kosinski

& Keller, 1996) contained at least one item from each of the eight scales composing

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143

the SF-36 (physical function (PF)(items 2a and 2b); role-physical (RP)(items 3a and

3b); role-emotional (RE)(4a and 4b); social function (SF)(item 7); bodily pain

(BP)(item 5); vitality (VT)(item 6b); mental health (MH)(items 6a and 6c); and

general health (GH)(item 1). Item responses were weighted and combined to produce

a Physical Health Component Summary (PCS-12) and a Mental Health Component

Summary (MCS-12) score. The PCS-12 and MCS-12 referred to physical well-being

and emotional well-being, respectively. High scores for all dimensions reflected better

health-related quality of life. Possible total scores for PCS-12 and MCS-12 ranged

from 0 to 100 points.

Two-week test-retest reliabilities in a general United States population were .89

(n=232) and .86 from the United Kingdom population (n=187) for the PCS-12.

Coefficients of .76 and .77 were observed for the MCS-12. Moreover, PCS and MCS

scores for the general United States population, and in patients with different diseases,

congestive heart failure (CHF) and diabetes mellitus (DM), were available (Ware,

Kosinski & Keller, 1996; Ware, Kosinski & Keller, 1998; Nichols & Brown, 2004).

Higher scores indicated better health-related quality of life. The internal consistency

(alpha) of Chinese version of the SF-12 in this main study was .92.

The Medical Outcomes Study (MOS) Social Support Survey (SSS) scale

The MOS Social Support Survey tool (Sherbourne & Stewart, 1991) is a

self-administered tool containing 19 items, measuring a multidimensional of the

functional aspects of perceived social support developed for use with chronically-ill

patients. The tool consisted of 19 items and covered five dimensions: tangible support

(items 1, 4, 11, and 14), affection (items 5, 9, and 19), positive social interaction

(items 6, 10, and 17), emotional and information support (items 2, 3, 7, 8, 12, 15, 16,

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144

and 18) and additional item (item 13). Each item was responded by a 5-point

Liker-type scale to indicate how often the respondent received the support, with 0

representing “none of the time” and 5 representing “all of the time”.

The total range of raw data was from 1 to 95. However, these scores were rescaled to

a 0-100 range for each subscale by using the following algorithm: 100× (observed

score- minimum possible score)/ (maximum possible score- minimum possible score).

The index of social support or global social support was calculated from the mean of

the subscale scores and the structure support scores (RAND Health, 2006). The

higher scores indicated more support. Internal consistency of this scale was high

(alpha .97). Test-retest reliability was also high (.78) and item-scale corrections all

exceed .72. Correlations between the four subscales were .69-.82 (Sherbourne &

Stewart, 1991). Moreover, Yu, Lee and Woo (2004) showed that internal consistency

is .93-96 (alpha) and test-retest reliability was .84 in a Chinese version of the SSS.

The internal consistency (alpha) was .92 in a Chinese version of the SSS in this main

study.

The Center for Epidemiology Studies Short Depression Scale (CES-D)

The depression level of people with diabetes was measured using the CES-D scale

(Anderson, Carter, Malmgren & Patrick, 1994). The CES-D was a self-administered

tool which was a 10-item measure of depression. The CES-D 10-item survey was

used rather than a more comprehensive instrument such as the CES-D 20-item survey

in order to minimize respondent burden (Kibourne et al., 2002). Patients screened

positive for significant depressive symptoms if they obtained a standard cut point of

10 or more out of a possible 30 points. The cut point in the 10-item CES-D had a

sensitivity of 96% and specificity of 100% when compared to the CES-D 20-item

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145

survey in a sample of adults in primary care (Anderson et al., 1994; Kibourne et al.,

2002).

Responses to this tool were rated on a 4-point scale from “rarely or none of the time”

(0 points) to “all the time” (3 points). Scores were added to give a total ranging from 0

to 30; higher scores represented more severe depression. However, items five and

eight were reversed, so response of 3 were change to 0, 2 to 1, 1 to 2, and 0 to 3.

Kibourne et al. (2002) classified scores 0 to 9 as indicating a mild level of depression

symptoms, 10 to 14 as moderate depressive symptoms, and >15 representing severe

depressive symptoms. This scale’s internal consistency was alpha.84 (tested on 605

subjects with chronic disease). The internal consistency (alpha) of the Chinese version

of the CES-D in this main study was .68.

Health care utilisation self report scale

A tool was designed to collect data on hospitalisations, visit to OPD, and visit to ER.

Demographic and illness history data self-report questionnaire

A self-reporting questionnaire was designed to collect demographic data and illness

history, including: age, gender, marital status, ethnic status, education, employment,

living arrangements, the length of time since being diagnosed with diabetes and other

chronic conditions.

5.4.6 Data management and analysis

After the collection of data, all data or records of this study were stored in computer

files, protected by password and also coded to protect anonymity. In the study, data

management including the analytical plan, data coding, entry, and checking were

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146

carried out using a personal computer. After data management, data analysis was

performed using the SPSS for Windows statistical packages (SPSS Version 14). Data

management and analysis were discussed as follows.

5.4.6.1 Data management

1. The analytical plan

An analytical plan including table shells for analysis was developed before entering

the data in order to minimize potential data entry error.

2. Data coding and entry

A numerical coding scheme was implemented to transfer the information from the

questionnaires to the coding sheet. The same person entered the data. The coded data

were then entered into a computer data file using a database management package.

3. Data checking

Range and consistency checks were performed to find erroneous or inconsistent

values, which were then corrected according to the original questionnaire. The first

step was to examine the distribution of each of the variables to check for possible

errors. The next step was to conduct consistency checks, to search for cases where

two or more variables were inconsistent. Possible errors were checked against the

original questionnaire. In some cases, it was possible to correct the data. In other cases,

it was necessary to insert a “missing value” code if it was clear that the data were in

error.

4. Storing of Confidential Information

All confidential records of this study were kept in a locked cabinet for five years and

were only accessed by the researcher. Any information stored in the computer files

was protected by password and code to protect anonymity.

179 179


147

5.4.6.2 Data analysis

Computer analysis of frequencies of each value of every variable was performed as a

check of the accuracy of the data entry. Demographic and baseline variables for both

the control and intervention groups were analysed to ensure comparability of the

groups. Differences detected were controlled for during the subsequent analysis.

Based on the design and the purpose of the study, the following analysis was

performed. Statistical significance was reported at the conventional p-value of less

than .05 level (two-tailed).

1. Descriptive analysis

Descriptive analysis was used to examine demographic variables, health care

utilisation, self-efficacy towards management of type 2 diabetes, self-management

behaviour, health-related quality of life and psychosocial well-being. The mean and

standard deviation for continuous variables and the count and percentages for the

dichotomous or nominal data (categorical data) were calculated.

2. Inference analysis

Before evaluating the effects of the SEEIP, differences between the groups on a range

of variables were examined. T-tests were used to analyse differences on continuous

data between mean scores for the intervention and control groups. Categorical data

were analysed using Chi-square statistics to test the significance of different

proportions. The progressions of study variables between the two groups were

described separately for pre- and post-periods respectively. To assess the group

differences of dependent variable changes, we used repeated ANOVA/ ANCOVA, for

repeated measures.

3. Hypotheses testing

For each continuous outcome variable, a relevant scale score was developed.

Assuming that the outcome variables were normally distributed, Student’s t-tests were

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148

used to analyse differences between mean scores for the intervention and control

groups at the different time points for these variables. Where outcome variables were

not normally distributed, a non-parametric equivalent test was used. Therefore, the

following hypotheses were tested:

- People who received the intervention will have greater self-efficacy towards

managing their type 2 diabetes, undertake diabetes self-care activities more frequently,

have better HRQOL, have better social support and lower depression than people who

do not receive the intervention.

The self-efficacy towards management of type 2 diabetes, self-care activities,

HRQOL, social support and depression over the three time points and across the

groups (control and intervention) were tested by two-way repeated measures ANOVA.

Possible influences of the independent variables were controlled in this analysis. Thus,

two-way repeated measures ANCOVA might also be used. The changes between

Time1 and Time 2; Time 2 and Time 3; and Time 1 and Time 3 were examined.

- People who received the intervention will have a lower usage of health services

than people who do not receive the intervention.

Health care utilisation (as measured by self-reported questionnaires) measurement

items consisted of the dichotomous data (yes or no) related to hospitalisation, visit to

ER, and visit to the out-patient department (OPD). To compare the health care

utilisation of people with type 2 diabetes at Time 1, Time 2, and Time 3 between the

groups (control and intervention), data were analysed using the chi square statistic to

test the significance of different proportions.

5.4.7 Ethical Considerations

1) Participation in this study was voluntary.

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149

2) Potential participants were identified in conjunction with investigators and invited

to join the study.

3) Potential participants were not disadvantaged if they chose not to participate or

withdrew from the project during the period of study.

4) An information sheet and consent form was given and signed. The procedures

involved in this study were explained to participants and they were given the

opportunity to ask questions regarding this study.

5) If participants wished, they completed the questionnaire with the assistance of the

data collector through an interview. If they felt tired, the interview was ceased and

resumed at a later time.

6) All control group participants were provided with the opportunity to view the DVD

and were given the set of booklets at the end of the study.

7) Data collection tools did not included participant names. A separate database of

participant names and contact details were kept. Each participant was assigned a

number, and this number was used throughout the study.

8) Personal information of potential participants was keyed into a secure database,

maintained by the research team.

9) Telephone numbers of the chief investigator and QUT Research Ethics Committee

were available to the participants if they required further information about the

project.

5.5 Summary

The thesis has been divided into two studies (or three phases). Study I translated and

tested the reliability and validity of two diabetes-specific self-efficacy instruments.

Study II consisted of development of an intervention based on self-efficacy theory

(Pilot study) and was a randomised controlled trial to evaluate the efficacy of the

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150

intervention in a Taiwanese population (Main study). This chapter has discussed

methodology in each phase of the research study. The research design, population and

sample (including sample size calculation), setting and procedure,

instruments/measurement strategies, data analysis, ethics consideration were

described in each phase of the study.

183

Student number: n4513282 Shu-Fang Wu Chapter 6 Results

184

Chapter 6

Results

6.1 Introduction

This chapter firstly presents the results of Study I: the translation and development of

two instruments (the Diabetes Management Self-Efficacy Scale; DMSES (McDowell

et al., 2005) and the Perceived Therapeutic Efficacy Scale; PTES (Sturt & Hearnshaw,

2003) in a Taiwanese population. Secondly, results of Study II: ‘Provision of a

comprehensive diabetes education intervention: SEEIP (the self efficacy enhancing

intervention program) and demonstration of the effectiveness of a nursing intervention

will be presented.

Result of Study I

Research question 1: Are the two diabetes-specific self-efficacy instruments - the

DMSES and PTES - valid and reliable in a Taiwanese

population?

6.2 Description of sample Two hundred and forty-five patients with type 2 diabetes were asked to participate in

the study. Of these 245 patients, 15 did not complete the study for the following

reasons. Seven withdrew for non-specified reasons, three patients did not meet the

inclusion criteria (such as must be taking oral diabetic medications; aged above 30)

and five did not complete the questionnaire. Therefore, two hundred and thirty

respondents’ data was analysed. The mean age was 63.3 (SD=12.5) years with a


185

diagnosis of diabetes on average for 8.6 (SD=8.2) years. The youngest respondent

was 30, the oldest was 90. The average number of years they had suffered from

diabetes was 8.6 (SD=8.2) years. The respondents consisted of 55% females.

Thirty-one per cent had primary school education only, 54% were unemployed or

retired. When they visited their doctor for diabetes, either AC (before meals) or PC

(after meals) blood sugar examination was tested for each person. The average AC

sugar was 157mg% and PC sugar was 188mg%. The characteristics of participants are

presented in Table 6.1.

Table 6.1 Characteristics of participants (Study I) (n=230)

Characteristics Number % Mini-

mum

Maxi-

mum

Mean ( SD)

Age 230 100 30 90 63.3 (12.5)

Diagnosis duration (years) 230 100 .1 40 8.6 ( 8.2)

Blood sugar AC (mg %) 117 50.8 60 400 157.1 (50.6)

Blood sugar PC (mg %)

(Either AC or PC sugar examination for each

person when they visit the doctor)

113 49.1 64 499 188.3 (78.5)

Gender: Male

Female

103

127

44.8

55.2

Education: No education

Primary school

Junior high school

Senior high school

College or university

41

71

30

43

45

17.8

30.9

13.0

18.7

19.6

Marital status: Single

Married

Divorced/ Widowed

11

206

13

4.8

89.6

5.6

Employment status: None or retired

Presently employed

Home makers

124

45

61

53.9

19.6

26.5

Diabetic complications: No

Yes

97

133

42.2

57.3


186

History of other diseases: No

Yes

101

129

43.9

56.1

Management of diabetes:

Insulin injection: No

Yes

193

37

83.9

16.1

Diet control: No

Yes

71

159

30.9

69.1

Exercise control: No

Yes

102

127

44.3

55.2

Thirty people with type 2 diabetes were randomly selected (by using a random

number table) from the total sample of participants and were asked to complete the

C-DMSES and C-PTES scales for the second time after two to four weeks. Data for

the 30 subjects who completed questionnaires twice were used for examining

test-retest reliability. The mean age was 61.3 (SD=12.4) years and 50% of the

participants were men. The characteristics of the retest sample were similar to those of

the total sample (see Table 6.2).

Table 6.2 Characteristics of participants of the total and retest sample (Study I) (n=30)

Characteristics Total sample (n=230) Retest sample(n=30)

Number (%) Mean ( SD) Number (%) Mean ( SD)

Age 230 (100) 63.3 (12.5) 30(100) 61.3(12.4)

Diagnosis duration (years) 230(100) 8.6(8.2) 30(100) 6.7(8.5)

Blood sugar PC (mg %) 113(49.1) 188.3(78.5) 30(100) 155.93(74.4)

Gender: Male

Female

103(44.8)

127(55.2)

15(50)

15(50)

Education: No education

Primary school

Junior high school

Senior high school

College or university

41(17.8)

71(30.9)

30(13.0)

43(18.7)

45(19.6)

4(13.3)

6(20)

3(10)

9(30)

8(26.7)


187

Marital status: Single

Married

Divorced/widowed

11(4.8)

206(89.6)

13(5.6)

2(6.7)

28(93.3)

0(0)

Employment status:

None or retired

Presently employed

Home makers

124(53.9)

45(19.6)

61(26.5)

19(63.3)

6(20)

5(16.7)

Diabetic complications: No

yes

97(42.2)

133(57.3)

12(40)

18(60)

History of other diseases: No

Yes

101(43.9)

129(56.1)

13(43.3)

17(56.7)

Management of diabetes

Insulin injection: No

Yes

193(83.9)

37(16.1)

20(66.7)

10(33.3)

Diet control: No

Yes

71(30.9)

159(69.1)

10(33.3)

20(66.7)

Exercise control: No

Yes

102(44.3)

127(55.2)

15(50)

15(50)

6.3 Result of the Chinese version of the DMSES (C-DMSES) 6.3.1 Result of Stage one: translation and development of the C-DMSES

Based on the method and principles of translation proposed (see Chapter 5.2.1.1), the

translators were advised to maintain semantic equivalence and clarity, readability and

recognisability of the Chinese translation. Due to inherent differences in the linguistic

structure of English and Chinese, minor adaptations were made to the wording of

three items in the DMSES during the translation process. The translated Chinese

version of DMSES was finalized after four revisions during the process of forward

translation and backward translation. The modifications identified by group

discussion on the back-translation refer to the C-DMSES. To summarize the main

points of the translation and back-translation, challenges to be considered were found

concerning the semantic and content equivalence. Results of the modification of the


188

C-DMSES included: Item No. 6, “I am able to keep my weight under control” was

modified to “I am able to control my body weight and maintain it within the ideal

weight range”; Item No. 7, “ I am able to examine my feet (e.g. for cuts or blisters)”

was modified to “I am able to examine both of my feet (e.g. for cuts or blisters)”; and

Item No. 15, “I am able to follow a healthy eating plan when I am on holiday” was

modified to “I am able to follow a healthy eating plan during festive periods”.

Although three items were modified, no items were removed. Table 6.3 shows a few

items for which the back-translations were notably discrepant from the meaning of the

original wording in the process.

Table 6.3 Results of the translation and the back-translation of the C-DMSES

Original Items Back-Translation

Items

Comments of Experts and Patients Revised Items

6. I am able to

keep my weight

under control.

I am able to control

my body weight and

maintain it within the

ideal weight range.

Most patients don’t understand what “under

control” means, it would be more concrete

and easier for people to understand by

saying, “maintain the weight within the

ideal weight range”.

I am able to

control my body

weight and

maintain it within

the ideal weight

range.

7. I am able to

examine my feet

(e.g. for cuts or

blisters).

I can check my foot

by myself (such as

cuts or blisters).

The reason that ‘foot’ appears in single

form, instead of plural form, in the

back-translation is that the Chinese

language makes no difference between the

singular and plural forms of a noun.

I am able to

examine both of

my feet (e.g. for

cuts or blisters).

15. I am able to

follow a healthy

eating plan when

I am on holiday.

When I am in

festivities, I still can

follow my eating

plan.

Eating habits don’t change much on

weekends and holidays, but are influenced

by special festivities, for example, Chinese

New Year, the Dragon Boat festival and

Mid-Autumn Festival.

I am able to

follow a healthy

eating plan during

festive periods.

6.3.2 Result of Stage two: validation and reliability of the C-DMSES

Following the translation stage, the second research stage tested the validation and


189

reliability of the C-DMSES. The validity of questionnaires in the field has most often

been evaluated by examining content, criterion, convergent and construct validity. In

addition to these methods, the estimation of the reliability scale scores used in this

research will apply internal consistency and test-retest methods.

6.3.2.1 The content validity of the C-DMSES

A panel of content experts judged the content validity of the diabetes specific

instruments (see Table 6.4). Content validity was assessed by asking the panel

members to rate each item as a valid measure of the construction using a five-point

Likert scale (1 = ‘strongly disagree’, 5 = ‘strongly agree’) based on two criteria: the

applicability of content and clarity of phrasing. Moreover, the panel was asked to

make comments on individual items in relation to the accuracy, clarity, style, and

cultural relevance of the translated items.

Table 6.4 Expert panel for content validity

Experts Positions

Yu-Chan Lee Consultant

Su-Lan Lin Diabetes nurse with expertise in patient education

Jian-De Hong Diabetologist

Yung-Yi Chen Diabetes nurse with expertise in patient education

Liang-Gung Chen Diabetologist

Lian-Hua Hung Teacher of nursing

Shiou-Luan Cai Expert in self-efficacy theory

Li-Chi Jiang Expert in self-efficacy theory

The C-DMSES obtained an average score of .86 for CVI. Item No. 6, obtained a score

of .83, Item No. 15 obtained a score of .89, and it was agreed by the experts to change

the wording during the translation stages. Item No. 13 and Item No. 14 obtained a

score of.89 and .84. Two scholars thought that Items No. 13 and No. 14 were too


190

similar but were provisionally accepted. Finally, according to the regulations for the

Bureau of National Health Insurance, the clinicians suggested that Item No. 18, “I am

able to visit my doctor once a year to monitor my diabetes” which obtained a score

of .86 was changed to “I am able to visit my doctor four times a year to monitor my

diabetes”. Considering the cultural differences, the experts accepted the changes of

the above items. Table 6.5 shows the content validity score of each item for the

C-DMSES.

Table 6.5 Content validity score of C-DMSES

Items

Applicab

ility of

content

Clarity

of

phrasing

Average

scores of

CVI

1. I am able to check my blood sugar if necessary

當有需要時，我有能力自行檢測血糖

.83 .83 .83

2. I am able to correct my blood sugar when the sugar level is too high (e.g. eat

different foods)

當我的血糖太高時，我有能力調整我的血糖值(例如:食用不同種類的食

物)

.75 .80 .78

3. I am able to correct my blood sugar when the sugar level is too low (e.g. eat

different foods)

當我的血糖太低時，我有能力調整我的血糖(例如:食用不同種類的食物)

.75 .80 .78

4. I am able to choose the foods that are best for my health

我有能力選擇最有利於我健康的食物

.90 .90 .90

5. I am able to choose different foods and maintain a healthy eating plan

我有能力選擇不同種類的食物來維持健康的飲食計畫

.80 .80 .80

6. I am able to control my body weight and maintain it within the ideal weight

range

我有能力將我的體重控制在理想範圍內

.85 .80 .83

7. I am able to examine both of my feet (e.g. for cuts or blisters)

我有能力自行檢查我的雙腳(例如:傷口或起水泡)

.93 .90 .92

8. I am able to do enough physical activity (e.g. walking the dog, yoga, gardening,

stretching exercises)

我有能力做足夠的身體活動 (例如:溜狗、瑜珈、園藝、或伸展運動等)

.83 .88 .86

9. I am able to maintain my eating plan when I am ill

當我生病時，我仍然能維持我的飲食計畫

.88 .83 .86


191

10. I am able to follow a healthy eating plan most of the time

大部份的時間內，我都能確實遵守我的健康飲食計畫

.88 .88 .88

11. I am able to do more physical activity if the doctor advises me to do

當醫師建議我多做一些身體活動，我有能力確實做到

.88 .75 .82

12. When doing more physical activity, I am able to adjust my eating plan

當我身體活動量增加時，我有能力自行調整我的飲食計畫

.95 .90 .93

13. I am able to follow a healthy eating plan when I am away from home

當我外出時，我仍然能遵行健康的飲食計畫

.90 .88 .89

14. I am able to choose different foods and maintain my eating plan when I am

away from home

當我外出時，我有能力選擇不同的食物種類，來維持我的飲食計畫

.85 .83 .84

15. I am able to follow a healthy eating plan during festive periods

在特殊節日時，我仍然能遵守健康飲食計畫

.90 .88 .89


when I am eating out or at a party 當我在外用餐或參加聚會時，我有能力選

擇不同種類的食物來維持我的健康飲食計畫

.88 .88 .88

17. I am able to maintain my eating plan when I am feeling stressed or anxious

當我面對壓力或焦慮時，我仍然能維持我的飲食計畫

.93 .88 .91

18. I am able to visit my doctor four times a year to monitor my diabetes

我能每年至少去看醫生四次，以監測我的糖尿病狀況

.93 .78 .86

19. I am able to take my medication as prescribed

我能夠依醫師處方按時服藥

.93 .93 .93

20. I am able to maintain my medication when I am ill

當我生病時，我仍然能維持我的糖尿病藥物治療

.93 .90 .92

Total scores 17.48 17.03 17.31

Average scores .87 .85 .86

The panel-modified version of the C-DMSES was pilot tested with ten patients from a

diabetes outpatient clinic in a medical center. All participants stated they had no

difficulties in understanding the items and expressed willingness to complete all items,

taking about 15 to 20 minutes for completion.

6.3.2.2 The criterion validity of the C-DMSES

According to Bandura (1986), self-efficacy is the most important predictor of change


192

in behaviour. The assumption of this study was that self-efficacy is a useful predictor

for diabetic self-care behaviour. Therefore, the C-DMSES and the Summary of

Diabetes Self-Care Activities (SDSCA) were used to test the relationship at this stage.

A regression analysis was performed to explore how well the C-DMSES could

explain the SDSCA. Results indicated that the C-DMSES was significantly associated

with the SDSCA scores (see Figure 6.1). The C-DMSES was a significant predictor of

diabetes self-care activities using a regression analysis (R=.58; t=10.75, p<.01), and

accounted for 33.6% of the variance in the total SDSCA scores. Significant

statistically linear correlations were found between C-DMSES and SDSCA at each

subscale of self-care activities (from stronger to weaker): foot care (R=.45, p<.01);

diet (R=.39, p<.01); exercise (R=.33, p<.01); and blood sugar testing (R=.23, p<.01)

(see Table 6.6). This result suggests that the C-DMSES does measure self-efficacy

towards undertaking diabetes self-care activities.

0.00 50.00 100.00 150.00 200.00

todmses

0.00

20.00

40.00

60.00

80.00

100.00

tosd

sca

R Sq Linear = 0.336

Figure 6.1 Scatter plot between the Summary of Diabetes Self-Care Activities (SDSCA) scale

and the Chinese version of the Diabetes Management Self-Efficacy Scale (C-DMSES)

for individual observations


193

Table 6.6 A regression analysis summary for the C-DMSES predicting the SDSCA (n=230)

Variables R R square t Sig

Total score of SDSCA .58 .34 10.75 .00**

Foot care .45 .25 8.70 .00**

Diet .39 .15 6.40 .00**

Exercise .33 .11 5.29 .00**

Blood sugar testing .23 .05 3.55 .00**

Medication taking .07 .00 .99 .33

**p< .01

6.3.2.3 The convergent validity of the C-DMSES

The General Self-Efficacy Scale (GSE) (Schwarzer, 1992) appears to be the most

consistent for measuring the generalized self-efficacy concept. In order to examine

whether the C-DMSES is valid in the self-efficacy domain, the Chinese version of the

GSE and C-DMSES were selected to provide convergent validity of this study. A

Pearson’s correlation coefficient between scores on the C-DMSES and the Chinese

version of the GSE revealed a moderate association (r= .55; p< .01) which provides

evidence that the C-DMSES does measure self-efficacy.

6.3.2.4 The construct validity of the C-DMSES

Data were examined for construct validity by undertaking principal-component factor

analysis with a varimax rotation. The following criteria were used in order to obtain

the best fitting structure and the correct number of factors: (1) Eigenvalues greater

than 1.0, (2) Cattell’s scree test, (3) the percentage of total variance explained by each

factor, and (4) factor loading cutoff of .4.


194

Firstly, Bartlett’s chi-square test of sphericity was used to determine if the sample size

was appropriate for a factor analysis and to determine if the data came from a sample

of the population with a normal distribution. This test was significant (χ2=3261.22,

p<.00). In addition to Bartlett’s test, the Kaiser-Meyer-Olkin (KMO) measure of

sampling adequacy was examined and found to be acceptable at .90. Based on the

results of these two tests, it was determined that a factor analysis could be computed

on this dataset.

The principal-component factor analysis for C-DMSES revealed four factors with an

Eigenvalue > 1, explaining 68.32% of the total sample variance. All included

variables loaded highly on these factors (see Table 6.7). After inspecting the scree plot

(Figure 6.2), a four factor solution (Eigenvalue value: 9.33, 1.77, 1.49, and 1.08) was

considered. These four factors accounted for 46.65, 8.84, 7.43 and 5.40% of variance,

respectively.

Table 6.7 The result of the principal-component factor analysis for C-DMSES (n=230)

Factor number Eigenvaluea Percentiles of varianceb Cumulative percentilesb

1 9.33 46.65 46.65

2 1.77 8.84 55.49

3 1.49 7.43 62.92

4 1.08 5.40 68.32 a The latent dimension is usually taken to be equal to the number of Eigenvalues that are > 1.0 b Explained variation given inclusion of this factor.


195

Scree Plot

Component Number

2019

1817

1615

1413

1211

109

87

65

43

21

Eige

nval

ue10

8

6

4

2

0

Figure 6.2 Scree plot of the C-DMSES

Table 6.8 shows the results of the component factor analysis using Varimax rotation.

Factor one contained 9 items, factor two contained 4 items, factor three contained 4

items, and factor four contained 3 items that all loaded above .40. Four factors (four

subscales) specifically related to nutrition (Items 16, 14, 13, 15, 17, 10, 5, 4, 9), blood

sugar and feet check, (Items 3, 2, 1, 7), physical exercise and weight (Items 11, 8, 12,

6) and medical treatment (Items 19, 20, 18). Although the items of the subscales are

different from the Dutch version DMSES scale, overall, the factorial structure was

fairly consistent and the results reflect the four factors.

Table 6.8 Rotated factor matrix of the C- DMSES. Principal-component method with Varimax

rotation (n=230)

Items Factor 1 Factor 2 Factor 3 Factor 4

Factor 1 :

16. I am able to choose different foods and maintain a healthy eating plan when I am

eating out or at a party

.87

14. I am able to choose different foods and maintain my eating plan when I am away .86


196

from home

13. I am able to follow a healthy eating plan when I am away from home .81

15 I am able to follow a healthy eating plan during festive periods .77

17. I am able to maintain my eating plan when I am feeling stressed or anxious .68

10. I am able to follow a healthy eating plan most of the time .53

5. I am able to choose different foods and maintain a healthy eating plan .53

4. I am able to choose the foods that are best for my health .47

9. I am able to maintain my eating plan when I am ill .42

Factor 2 :

3. I am able to correct my blood sugar when the sugar level is too low (e.g. eat

different foods)

.85

2. I am able to correct my blood sugar when the sugar level is too high (e.g. eat

different foods)

.81

1. I am able to check my blood sugar if necessary .52

7. I am able to examine both of my feet (e.g. for cuts or blisters) .48

Factor 3 :

11. I am able to do more physical activity if the doctor advises me to do .78

8. I am able to do enough physical activity (e.g. walking the dog, yoga, gardening,

stretching exercises)

.37 .75

12. When doing more physical activity, I am able to adjust my eating plan .66

6. I am able to control my body weight and maintain it within the ideal weight range .46 .48

Factor 4 :

19. I am able to take my medication as prescribed .87

20. I am able to maintain my medication when I am ill .85

18. I am able to visit my doctor four times a year to monitor my diabetes .74

Variance explained (%) 68.32

6.3.2.5 Internal consistency of the C-DMSES

A Cronbach’s alpha coefficient was calculated by means of the reliability option. The

analysis of the Cronbach’s alpha for C-DMSES was .93. According to the results of

factor analysis, four subscales were formed. The Cronbach’s alpha was .93 for

nutrition (Items 4, 5, 9,10, 13, 14, 15, 16, 17), .81 for physical exercise and weight

(Items 6, 8, 11, 12), .79 for medical treatment (Items 18, 19, 20) and .77 for blood

sugar and feet check (Items 1, 2, 3, 7) (see Table 6.9).


197

Table 6.9 Cronbach’s α value of C-DMSES

Instruments (n=230)

Number of items Cronbach’s α

C-DMSES 20 .93

Nutrition (items 4, 5, 9,10, 13, 14, 15, 16, 17) 9 .93

Physical exercise and weight (items 6, 8, 11, 12) 4 .81

Medical treatment (items 18, 19, 20) 3 .79

Blood sugar and feet check, (items 1, 2, 3, 7) 4 .77

Analysis of the item level according to the “alpha if item deleted” procedure showed

that removal of one or more weakly correlated items would not have much

consequence for the height of the alpha value. The mean-item correlation was .42

(min. = .09, max= .86) for C-DMSES. This analysis indicated a non-unidimensional

scale. Furthermore, item-to-total correlations ranged from .37. to .76 for the

C-DMSES.

6.3.2.6 Stability of the C-DMSES

The test-retest was calculated using a Pearson’s correlation to determine the strength

of relationship between responses (n=30) to the C-DMSES over time, with three

weeks between administration. Pearson’s correlation coefficient of .86 for the total

scores indicated the instrument is stable over time. Similarly, coefficients for the

subscales (nutrition = .79; physical exercise and weight = .91; medical treatment = .69;

and blood sugar and feet check = .83) indicated they are reliable over time.

Calculation of intra-class correlations (ICC) using a 2-way random variable absolute

agreement approach resulted an average ICC of .82. Furthermore, in order to offer

information regarding agreement and detect systematic bias in response from one time


198

to another, test-retest reliability for the C-DMSES was determined by means of a

Bland-Altman plot (Bland & Altman, 1986) with 95% limits of agreement (LOA). In

the plot, the differences (d) between the two measurements were plotted against the

mean values of both measurements. Ninety-five per cent of those differences may be

expected to fall within ± 2 SDs of the mean difference between the test-retest scores.

The Bland-Altman plot illustrating the test-retest agreement is shown in Figure 6.3.

The mean difference of the total C-DMSES score was 10.13 and the 95% confidence

interval for the mean difference ranged from -24.09 to +44.35 (possible 0-200). Only

one subject was outside the limits of agreement and 97% (29/30) of the subjects were

within 2 standard deviations of the mean. The results showed a strong level of

agreement between individuals over time.

180.00150.00120.0090.0060.00

75.00

50.00

25.00

0.00

-25.00

-50.00

Diff

eren

ce in

DM

SES

scor

e

Bland-Altman plot for reproducibility

of DMSES

Average of two measurements

M=10.13; SD=17.46

Figure 6.3 Bland-Altman plot for reproducibility of C-DMSES scores

Mean+1.96SD= 44.35

Mean-1.96SD= -24.09


199

6.4 Result of the Chinese version of the PTES (C-PTES) 6.4.1 Result of stage one: translation and development of the C-PTES

The translated Chinese version of PTES was finalized after four revisions during the

process of forward translation and backward translation. There was little debate about

the Chinese version of PTES. The resulting overall high agreement of response

between the two versions and the feedback from the clinical experts suggested the

translated C-PTES has semantic equivalence with the source version.

6.4.2 Result of stage two: validation and reliability of the C-PTES

6.4.2.1 The content validity of the C-PTES

A panel of eight experts judged the content validity of the diabetes specific

instruments. Content validity was assessed based on two criteria: the applicability of

content and clarity of phrasing. Moreover, the panel was asked to make comments on

individual items in relation to the accuracy, clarity, style, and cultural relevance of the

translated items. The average CVI score obtained by C-PTES was .83. Based on the

expert panel’s comments, the wording of only four items were modified. These

included: Item No. 2, (CVI= .82); Item No. 5 (CVI= .84); Item No. 9 (CVI= .78) and

Item No. 10 (CVI= .78) (see Table 6.10). The expert panel believed the modifications

of the content and wording were necessary to ensure the wording reflected Taiwanese

culture, and that the wording would be easier for patients to understand. Table 6.11

shows the content validity score of each item for the C-PTES.


200

Table 6.10 The C-PTES after modification based on the experts’ comments

Expressions used in the

original Scale

Score Experts and patients’

opinions

Expressions adopted for the final

version

2.My level of confidence in

the ability of my diabetes

medication to prevent

episodes of high blood sugar

is:

.82 After revision, the meaning

was more complete and

easier for people, especially

the elderly, to understand.

My level of confidence in the

ability that my diabetes medication

can keep my blood sugar at a

stable level and prevent it from

becoming elevated is:

5.My level of confidence in

the ability to control my

diabetes by maintaining my

medication dose is:


was more complete and



My level of confidence in the

ability that the maintenance of the

dose of my medication can control

my diabetes effectively is:

9. My level of confidence in

my health professionals’

advice about my diabetes

treatment is:

.78 Giving some examples

could help patients to

answer the question.

My level of confidence in my

health professionals’ advice that

experts such as doctors or

nutritionists give me in my

diabetes treatment is:

10. My overall level of

confidence in my ability to

manage my diabetes is:


was more completed, and



My overall level of confidence in

my ability to cope with my

diabetes is:

Table 6.11 Content validity score for C-PTES

Items Applicab

ility of

content

Clarity

of

phrasing

Average

scores of

CVI

1.My level of confidence in the ability of my diabetes medication to control

my blood sugar is:

我的糖尿病藥物能夠控制我的血糖值,我對這件事的信心程度是:

.85 .83 .84

2.My level of confidence in the ability that my diabetes medication can keep

my blood sugar at a stable level and prevent it from becoming elevated is:

我的糖尿病藥物能夠穩定血糖，減少高血糖發作,我對這件事的信心

程度是:

.88 .75 .82


201

3.My level of confidence in the ability of my diabetes medication to limit the

severity of complications (e.g. eye or foot problems) is:

我的糖尿病藥物能夠減少併發症的嚴重程度(例如:眼睛或腳的併發症) ,

我對這件事的信心程度是:

.88 .83 .86

4.My level of confidence in the ability of my diabetes medication to prevent

me getting (more) complications is: 我的糖尿病藥物能夠預防我得到

(更多)併發症,我對這件事的信心程度是:

.88 .80 .84

5.My level of confidence in the ability that the maintenance of the dose of my

medication can control my diabetes effectively is: 維持我的藥物劑量可

以有效控制我的糖尿病,我對這件事的信心程度是:

.88 .80 .84

6.My level of confidence in the need to take my medication each day exactly

as prescribed to control my diabetes is: 每天需要依照處方正確服藥可

以控制我的糖尿病,我對這件事的信心程度是:

.90 .83 .87

7.My overall level of confidence in the value of the diabetes medication that I

am prescribed is: 醫師處方開給我的糖尿病藥物是有療效, 對於這件

事我的整體信心程度是:

.83 .77 .80

8.My level of confidence in the ability of medication in general to control my

diabetes is: 一般來講，藥物治療能夠有效控制我的糖尿病:

.83 .83 .83

9.My level of confidence in my health professionals’ advice that experts such

as doctors or nutritionists give me in my diabetes treatment is:

在我的糖尿病治療中，專家如醫師或營養師所給的專業建議,我對這件

事的信心程度是:

.80 .75 .78

10. My overall level of confidence in my ability to cope with my diabetes is:

我能應付自己的糖尿病，對於這件事我的整體信心程度是﹕

.80 .75 .78

Total scores 8.53 7.94 8.26

Average scores .85 .79 .83

The panel-modified version of the C-PTES was pilot tested with ten type 2 diabetes

patients to identify the linguistic and cultural equivalence. All of the participants also

stated that they had no difficulties in understanding items and expressed willingness

to complete all items and it takes about 10-12 minutes for completion.

6.4.2.2 The criterion validity of the C-PTES

The C-PTES (measuring outcome-expectations) was correlated as predicted with the


202

theoretically linked psychological variables of self-care behaviours and health

outcomes (Bandura, 1986; Kingery & Glasgow, 1989). The PTES measures

participants’ confidence (outcome expectations) and the extent to which the individual

believes their treatment will lead to personally desirable outcomes (Dunbar-Jacob,

2000; Sturt & Hearnshaw, 2003). The assumption of this study was that self-care

performance and blood sugar control will be better among people with diabetes who

hold strong beliefs in outcome-expectation. Therefore, the Summary of Diabetes

Self-Care Activities (SDSCA) and the C-PTES were used to test the relationship at

this stage.

Result revealed that the Pearson’s correlation coefficient between C-PTES and

SDSCA was r= .32; p< .01 demonstrating outcome expectations is moderately

correlated with self-care performances. Moreover, a regression analysis was

performed to explore how well the C-PTES could explain the SDSCA scores. Results

indicated that the C-PTES was significantly associated with the SDSCA scores (see

Figure 6.4 and a significant predictor of the SDSCA (Beta= .32; t= 5.14, p<. 00),

accounting for 10.4% of the variance. The results showed that the C-PTES total score

was a predictor of the diabetes self-care activities.

0.00 20.00 40.00 60.00 80.00 100.00

toptes

0.00

20.00

40.00

60.00

80.00

100.00

tosd

sca

R Sq Linear = 0.104

Figure 6.4 Scatter plot between the Summary of Diabetes Self-Care Activities (SDSCA) scale


203

and the Chinese version of the Perceived Therapeutic Efficacy Scale (C-PTES) for

individual observations

6.4.2.3 The convergent validity of the C-PTES

The C-PTES is a measure of efficacy expectation. In order to examine whether the

C-PTES is valid in the self-efficacy domain, the Chinese version of the GSE and the

C-PTES were selected to provide convergent validity of this study. Responses to the

C-PTES and the Chinese version of the GSE scale were correlated to assess the

strength of relationship. Pearson’s correlation coefficient between the C-PTES and the

Chinese version of the GSE total score revealed a moderately positive association

(r= .42; p< .01). The results provided evidence that the C-PTES does measure the

self-efficacy concept as well.

6.4.2.4 The construct validity of the C-PTES

Data were analysed by means of principal-component factor analysis and varimax

rotation. The following criteria were used in order to obtain the best fitting structure

and the correct number of factors: (1) Eigenvalues greater than 1.0, (2) Cattell’s scree

test, (3) the percentage of total variance explained by each factor, and (4) factor

loadings cut-off of .4.

Bartlett’s test of the C-PTES was significant ( χ 2=2183.13, p<.01) and the

Kaiser-Meyer-Olkin measure of sampling adequacy was found to be acceptable at .93.

The principal-component factor analysis for the C-PTES revealed only one factor

with an Eigenvalue > 1, explaining 71% of the total sample variance. All included

variables loaded highly on this factor. An examination of the scree plot (see Figure 6.5)

and the Eigenvalue suggested a one-factor solution accounting for 70.80% of the


204

variance was acceptable.

Scree Plot

Component Number

10987654321

Eige

nval

ue

8

6

4

2

0

Figure 6.5 Scree plot of the C-PTES

Table 6.12 shows the results of the component factor analysis using Varimax rotation.

Only one factor has been found and includes 10 items.

Table 6.12. Rotated factor matrix of the C-PTES. Principal-component method with Varimax

rotation (n=230)

Items Factor 1

8. My level of confidence in the ability of medication in general to control my diabetes is: .90

7.My overall level of confidence in the value of the diabetes medication that I am prescribed is: .89

2.My level of confidence in the ability that my diabetes medication can keep my blood sugar at a stable

level and prevent it from becoming elevated is:

.86

6.My level of confidence in the need to take my medication each day exactly as prescribed to control

my diabetes is

.85

5.My level of confidence in the ability that the maintenance of the dose of my medication can control

my diabetes effectively is:

.85

4.My level of confidence in the ability of my diabetes medication to prevent me getting (more)

complications is:

.83

1.My level of confidence in the ability of my diabetes medication to control my blood sugar is: .81

9.My level of confidence in my health professionals’ advice that experts such as doctors or nutritionists

give me in my diabetes treatment is:

.81

3.My level of confidence in the ability of my diabetes medication to limit the severity of complications .80


205

(e.g. eye or foot problems) is:

10. My overall level of confidence in my ability to cope with my diabetes is: .80

6.4.2.5 Internal consistency of the C-PTES

The C-PTES showed high internal consistency in this study (Chronbach's alpha .95).

The mean-item correlation was .67 (min.=.56, max=.88) and item-to-total correlations

ranged from .75 to .86. All of the 10 items had high item-total correlation values.

Table 6.13 shows under 'alpha if item deleted' that removal of these items only

reduced the over alpha by .001 to .005. Therefore, all 10 items were retained.

Table 6.13 Pearson item-total coefficient of correlation of the C-PTES (n= 230)

Alpha if item Deleted Correct Item- total Correlation

Item1 .949 .768

Item2 .946 .830

Item3 .949 .763

Item4 .948 .797

Item5 .947 .806

Item6 .947 .807

Item7 .946 .854

Item8 .945 .863

Item9 .949 .756

Item10 .950 .752

6.4.2.6 Stability of the C-PTES

The test-retest was calculated using a Pearson product moment correlation to

determine the strength of relationship between responses (n=30) to the C-PTES over

time, with three weeks between administrations. The test-retest reliability resulted in a

coefficient of .79 (p< .01) for the C-PTES. Furthermore, calculation of intra-class

correlations (ICC) using a 2-way random variable absolute agreement approach

resulted in an average ICC of .77.

Test-retest reliability for the C-PTES was also examined by means of a Bland-Altman


206

plot (Bland & Altman, 1986) with 95% limits of agreement (LOA) to offer

information regarding agreement and detection of systematic bias in response from

one time to another. In the plot, the differences (d) between the two measurements

were plotted against the mean values of both measurements. The Bland-Altman plot

illustrating the test-retest agreement is shown in Figure 6.6. The mean difference of

the total C-PTES score was 3.90 and the 95% confidence interval for the mean

difference ranged from -14.37 to +22.17 (possible 0-100). Only one subject was

outside the limits of agreement and 97% (29/30) of the subjects were within 2

standard deviations of the mean. Ninety-five per cent of those differences, as expected,

fall within ± 2 SDs of the mean difference between the test-retest scores. The

C-PTES was deemed to be a stable over the 2-week testing period.

100.0080.0060.00

40.00

20.00

0.00

-20.00Diffe

renc

e in

PTE

S sc

ore

Bland-Altman plot for reproducibility

of PTES

Average of two measurements

M=3.90;SD=9.31

Figure 6.6 Bland-Altman plot for reproducibility of C-PTES scores

Mean+1.96SD= 22.17

Mean-1.96SD= -14.37


207

6.5 Summary result of Study I A two-stage study design was used in order to test the validity and reliability of Study

I. During the translation process, three items were modified for the C-DMSES,

however, there was little debate about the C-PTES. Validity issues are at the heart of

findings in cross-cultural research (Jones & Kay, 1992). The content validity results of

this study showed that the C-DMSES and C-PTES were clear and understandable in

their Chinese versions after some items have been modified. There were adequate

results of criterion, convergent and construct validity of these two instruments. The

reliability of instruments was also examined and the results of the Cronbach’s alpha

showed that the C-DMSES and C-PTES were internally consistent. Finally, a Pearson

correlation-coefficient was calculated to determine the strength of relationship

between responses to the C-PTES and C-DMSES over time (within two to four weeks)

and the level of agreements between individual responses over time were strong. Thus,

one can conclude that the C-DMSES and C-PTES are reliable and stable instruments.


208

Result of Study II (Main Study)

6.6 Introduction

This chapter presents the results of Study II (the main study): Utilizing a randomised

controlled trial to evaluate the self-efficacy enhancing intervention program (SEEIP)

in a Taiwanese population. This chapter begins with a description of the sample,

examining differences between groups and key variables, and answers the following

research questions:

Research Question 2: Can an intervention (SEEIP) based on self-efficacy theory

improve self-management in people with type 2 diabetes in

Taiwan?

Within research question 2, the following research questions and hypotheses were

examined:

Question 2.1: Is there a difference in the self-efficacy of people with type 2 diabetes

following implementation of the SEEIP? (Hypothsis 1: People who

receive the intervention will have greater self-efficacy towards

managing their type 2 diabetes than people who do not receive the

intervention.)

Question 2.2: Is there a difference in the self-care activities of people with type 2

diabetes following implementation of the SEEIP? (Hypothsis 2: People

who receive the intervention will undertake diabetes self-care activities

more frequently than people who do not receive the intervention.)

Question 2.3: Is there a difference in health related quality of life of people with type

2 diabetes following implementation of the SEEIP? (Hypothsis 3:


209

People who receive the intervention will have better HRQOL than

people who do not receive the intervention.)

Question 2.4: Is there a difference in the psychosocial well-being of people with type

2 diabetes following implementation of the SEEIP? (Hypothsis 4:

People who receive the intervention will have better psychosocial

well-being than people who do not receive the intervention.)

Question 2.5: Is there a difference in health care utilisation of people with type 2

diabetes following implementation of the SEEIP? (Hypothsis 5: People

who receive the intervention will have a lower usage of health services

than people who do not receive the intervention.)

6.7 Description of Sample

One hundred and seventy-three people met study criteria. One hundred and fifty-eight

people agreed and signed the consent form and were randomly assigned to either the

control group or intervention group using a random number table (81 participants in

the intervention group and 77 participants in the control group).

Of these 81 participants in the intervention group, nine did not complete the study for

the following reasons: four did not complete the questionnaires and two withdrew for

non-specified reasons. After the intervention was undertaken, three only attended the

first session of efficacy-enhancing intervention sessions. They did not satisfy the

inclusion criteria of this study (at least three of the four efficacy-enhancing

intervention sessions). We excluded these participants in this study. Therefore, the

final sample of the intervention group at Time 1 , time 2 , and Time 3 was consisted of

72.


210

In the intervention group, all participants completed the questionnaires and

participated in the following activities: (1) viewing a 10-minute DVD; (2) receiving

the “Diabetes Self-Care” booklet; (3) participating in at least three of the four

efficacy-enhancing counselling intervention sessions at weekly intervals (There were

four groups of efficacy-enhancing counselling intervention sessions which were

conducted at different times and in different settings. Each group was limited to

between 15-20 participants according to participants’ preferences); and (4)

participating in telephone follow-up. This high retention rate of the intervention group

was attributed to the implementation of a retention strategy which allowed

participants to make up a missed lesson at an alternate time and setting and being able

to easily contact the researcher.

On the other hand, of these 77 participants in the control group, four did not complete

the study for the following reasons: three refused to participate as they were not

allocated to a group they preferred, and one did not complete the questionnaires.

These participants were excluded in this study. Therefore, the final sample of the

control group was consisted of 73. In the control group, participants were asked to

complete questionnaires at Time 1, Time 2, and Time 3 and received the routine care

in the outpatient clinic. The high retention rate of control group was attributed to

patients being required to routinely return to the outpatient clinic every two or four

weeks to obtain oral medication. (see Figure 6.7 sample of the main study).

The characteristics of participants who dropped out were similar to those who stayed

in the study.


211

Figure 6.7 Sample of the main study

The baseline data (Time 1) of 145 respondents from the total sample were analysed in

this section. Age ranged from 30-81 years, with a mean of 64.4(SD=9.9) years. The

average number of years they had suffered from diabetes was 5.8 (SD =6.7) years.

The respondents consisted of 64.1% females. Most participants were married (83.4%),

Agreed and participated in the study (n=158)

Intervention group (n=81) Control group (n=77)

Time 1 (n=72)

Time 2 (n=72)

Three months following baseline collection

Randomly assigned

Time 2 (n=73)

Three months following baseline collection

Time 3 (n=72)

Six months following baseline collection

Time 1 (n=73)

Met study criteria (n=173)

Time 3 (n=73)

Six months following baseline collection

-Not complete

questionnaires (n=4)

-Withdrew

non-specified reasons

(n=2)

-Did not complete the

intervention (n=3)

-Refused as not preferred group (n=3) -Did not complete the questionnaires (n=1)

Refuse to participate (n=15)

Allocation

Follow-Up

Analysis


212

Buddhist (48.3%) and came from the southern part of Fukien Province (78.6%). The

majority of participants had below primary schooling (59.3%), were living with

family (91.7%) and 84.1% had never been employed. Half of the participants (51.0%)

had a chronic disease other than diabetes. Sixty per cent of participants did not

experience complications related to diabetes and 66.2% experienced monotherapy.

Nearly half of the participants had been receiving diabetes patient education (49.7 %).

6.8 Checking differences between groups

6.8.1 Sociodemographics and illness history

Before evaluating the effects of the SEEIP, differences between the groups on a range

of variables were examined.

No significant differences were found between the intervention and the control groups

on sociodemographics, and illness history. (see Table 6.14). This means that both

groups had similarities in relation to the characteristics of participants.

Table 6.14 Comparisons of sociodemographics and illness history between intervention and

control groups (n=145)

Variables Intervention (n=72) Control (n=73) Significance

Sociodemographics: Mean SD Mean SD

Age 64.83 9.77 64.05 10.07 t=.47; p=.64

Duration of disease (years) 6.05 6.91 5.59 6.49 t=.41; p=.68

Gender Count % Count %

Male 25 34.7 27 37.0 χ2=.08;

Female 47 65.3 46 63.0 p= .86

Ethnic status

Fukien province 56 77.8 58 79.5 χ2=.09;

Mainland 9 12.5 8 11.0 p= .99

Hakka 5 6.9 5 6.8

Others 2 2.8 2 2.7


213

Religion

Buddhist 36 50.0 34 46.6 χ2=1.21;

Taoist 27 37.5 26 35.6 p= .88

Christian 5 6.9 9 12.3

Catholicism 3 4.2 3 4.1

Others 1 1.4 1 1.4

Education

Illiteracy 22 30.6 27 37.0 χ2= .92;

Primary school 20 27.8 17 23.3 p= .92

Junior high school 16 22.2 14 19.2

Senior high school 13 18.1 14 19.2

college 1 1.4 1 1.4

Marital status

Unmarried 1 1.4 1 1.4 χ2= .32;

Married 59 81.9 62 84.9 p= .96

Divorced 3 4.2 3 4.1

Widower/Widow 9 12.5 7 9.6

Employment

None 60 83.3 62 84.9 χ2= .07;

Yes 12 16.7 11 15.1 p= .82

Living arrangement

Living alone 5 6.9 4 5.5 χ2= .45;

Living with family 66 91.7 67 91.8 p= .80

Others 1 1.4 2 2.7

Illness history

Other chronic conditions

None 36 50.0 38 52.1 χ2= .06;

Yes 36 50.0 35 47.9 p= .81

Complications

None 44 61.1 43 58.9 χ2= .07;

Yes 28 38.9 30 41.1 p= .87

Treatment regimen

Monotherapy (oral

medication)

49 68.1 47 64.4 χ2= .22;

Complexity (combine others) 23 31.9 26 35.6 p= .73

Patient education

None 36 50.0 37 50.7 χ2= .01;

Yes 36 50.0 36 49.3 p= 1.00


214

6.8.2 Key variables of participants

The instruments used for the collection of data on key variables included:

self-efficacy towards management of type 2 diabetes (as measured by the Chinese

version of the Diabetes Management Self-Efficacy Scale (C-DMSES) and the Chinese

version of the Perceived Therapeutic Efficacy Scale (C-PTES)); self management

behaviour (as measured by the Summary of Diabetes Self-Care Activities (SDSCA));

health-related quality of life (as measured by Short Form-12 (SF-12)); and

psychosocial well-being (as measured by the Medical Outcomes Study (MOS) Social

Support Survey tool and the Centre for Epidemiology Studies Short Depression Scale

(CES-D).

The mean score of the C-DMSES was 131.80 (SD= 44.52) for the intervention group;

and 129.61 (SD= 42.10) for the control group. The mean score of the C-PTES was

M= 70.64 (SD=23.47) for the intervention group; and 68.95 (SD=23.21) for the

control group. The mean score of the SDSCA was 46.15 (SD= 15.24) for the

intervention group; and 46.99 (SD= 14.46) for the control group. The SF-12 outcomes

used for analysis in this study were physical and mental component summary scores

(PCS-12 and MCS-12). The PCS-12 and MCS-12 refer to physical well-being and

emotional well-being, respectively. High scores for all dimensions reflect better

health-related quality of life (HRQOL). The mean score of the PCS-12 was 43.26

(SD=10.20) for the intervention group; and 43.13 (SD=9.20) for the control group.

The mean score of the MCS-12 was 45.99 (SD=11.32) for the intervention group; and

44.56 (SD=11.19) for the control group.

The mean score of the MOS-SSS was 63.43 (SD= 17.53) for the intervention group;


215

and 65.68 (SD= 17.01) for the control group. Finally, the mean score of the CES-D

was 9.64 (SD= 4.75) for intervention group; and 9.29 (SD=3.88) for control group.

Kibourne et al. (2002) classified scores 0 to 9 as indicating a mild level of depression

symptoms, 10 to 14 as representing moderate depressive symptoms, and >15

representing severe depressive symptoms. The mean score (9.29-9.64) showed that

the participants in the intervention and control group indicated a mild level of

depression symptoms at baseline.

No significant differences were found between the intervention and the control groups

for the key outcome variables. This means that there were similar mean scores of key

variables for the intervention and control groups at the baseline data (see Table 6.15).

Table 6.15 Differences between groups on the key variables of baseline (n=145)

Variables

Intervention group

(n=72)

Control group

(n=73)

M SD M SD t p

Self-efficacy towards management of

type 2 diabetes:

Efficacy expectation (C-DMSES) 131.80 44.52 129.61 42.10 .30 .76

Outcome expectation (C-PTES) 70.64 23.47 68.95 23.21 .44 .66

Self-management behaviours :

(SDSCA)

46.15

15.24

46.99

14.46

-.34

.74

Health-Related Quality of life :

(SF-12)

Physical health 43.26 10.20 43.13 9.20 .08 .94

Mental health 45.99 11.32 44.56 11.19 .77 .44

Psychosocial well-being:

The Medical Outcomes Study (SSS) 63.43 17.53 65.68 17.01 -.78 .43

Depression Scale (CES-D) 9.64 4.75 9.29 3.88 .49 .63

The key variable of health care utilisation (as measured by self-reported

questionnaires) measurement consisted of hospitalisation, visit to ER, and visit to the


216

out-patient department (OPD). Most participants reported that they had not been

hospitalised and had not received emergency treatment in the last three months.

However, they did regularly visit the outpatient clinic in the last three months. No

significant differences were found between the intervention and the control groups for

the variables of health care utilisation (see Table 6.16).

Table 6.16 Differences between groups on health care utilisation of baseline (n=145)

Variables Intervention (n=72) Control (n=73) Significance

Hospitalisations

None 66 91.7 67 91.8 χ2= .00;

Yes 6 8.3 6 8.2 P= 1.00

Visit to ER

None 65 90.3 67 91.8 χ2= .10;

Yes 7 9.7 6 8.2 P= .78

Visit to OPD

None 17 23.6 22 30.1 χ2= .79;

Yes 55 76.4 51 69.9 P= .46

6.9 Question 2: Can an intervention (SEEIP) based on self-efficacy

theory improve self-management in people with type 2 diabetes

in Taiwan?

Participants for both groups were similar in relation to their sociodemographics,

illness history, the key variables, and health care utilisation. Thus, Question 2 of the

main study “Can an intervention (SEEIP) based on self-efficacy theory improve

self-management in people with type 2 diabetes in Taiwan?” is explored in this

section. Within Question 2, five research hypotheses were examined.

Two-way repeated measures ANOVA was conducted with 2×3 design (group× time).

The between-subjects factor was the intervention and control group. Repeated


217

measures included time with three levels (Time 1, Time 2, and Time 3). Two-way

repeated measures ANOVA was used to examine the differences in each variable

between groups and across three time points. The assumptions for the ANOVA were

examined as follows: the dependent variables were continuous; the data were

approximately normally distributed; and the variances were equal (by Mauchly’s

Sphericity Test, p> .05). If Mauchly’s Sphericity Test, p> .05 (the variances were

equal), it could report the standard univariate F results. If Mauchly’s test < .05, it

could either report the multivariate results (Wilks’ Lambda) for the time factor and for

the interaction between group and time, or it could report the univariate results with

an epsilon correction (eg.Greenhouse-Geisser, Huynh-Feldt) (Munro, 2000).

However, Green and Salkind (2005) recommended Wilks’ Lambda (it appears

frequently in the social science literature).

If the interaction is significant, it would normally be necessary to conduct follow-up

simple main effect tests, and interaction comparisons (independent t test at Time 1,

Time 2 and Time 3). Moreover, as the time main effect was significant, it would be

necessary to conduct follow-up tests (paired t test, Time 1-2, Time 1-3, and Time 2-3)

to this main effect. Familywise error rate across these tests was controlled by using

Holm’s sequential Bonferroni approach (Bonferroni correction involved revising the

significance level such that the desired alpha is divided by the number of pairs being

compared) (Polit, 1996).

6.9.1 Question 2.1: Is there a difference in the self-efficacy in people with

type 2 diabetes following implementation of the SEEIP?


218

The means and standard deviations for the efficacy expectations and outcome

expectations scores for the three time points and two groups are presented in Table

6.17.

Table 6.17 The mean (SD) for the efficacy-expectation and outcome-expectation scores

Variables Intervention group

M(SD)

Control group

M(SD)

Time 1 Time2 Time3 Time 1 Time2 Time3

Efficacy-expectations

(C-DMSES)

131.79

(44.52)

146.64

(37.01)

157.89

(34.68)

129.62

(42.10)

130.45

(42.31)

130.32

(41.95)

Outcome-expectations

(C-PTES)

70.64

(23.47)

83.04

(15.30)

83.64

(15.44)

68.95

(23.21)

68.26

(22.86)

68.57

(23.01)

Efficacy expectations

A two-way repeated measures ANOVA was conducted to test the effects of efficacy

expectations of the SEEIP. Main and group× time interaction effects were tested using

the multivariate criterion of Wilks’ Lambda (Λ).

The main effect of time of measurement of efficacy expectations was significant

(Wilks’ Λ=.81, F (2,141) = 16.58, p =.00). The group main effect was also significant

between groups, F (1,142) =5.44, p =.02. The interaction effect of group by time was

also significant, Wilks’ Λ=.80, F (2,141) =17.42, p =.00. The associated Partial Eta

square was .20, indicating a moderate effect size (see Table 6.21).

To interpret the significant main effect of time, planned post-hoc comparisons using

paired t-test were conducted with Bonferroni’s adjustment, where the p level was set

at .017 (to test for differences between the three pairs at the .05 significance level,

the alpha would be .05/ 3, or .017) (Polit, 1996). The follow-up paired t-test

comparisons showed Time 1-2 (t= - 3.63, p= .00), Time 1-3 (t= - 5.18, p= .00), and


219

Time 2-3 (t= - 3.09, p= .00) (see Table 6.22). The mean score of efficacy expectations

was statistically different at Time 1-2, Time 1-3, and Time 2-3.

To interpret the significant interaction of group by time (see Figure 6.8), independent

pairwise comparisons were conducted. These tests showed that the intervention group

had significantly better efficacy-expectations than the control group at Time 2 (t=2.45,

p= .02), and Time 3 (t=4.3, p= .00) but not at Time 1 baseline data (t=.30, p=.76 (see

Table 6.23). These results supported Hypothesis 1 that people who receive the

intervention will have greater self-efficacy (efficacy expectations) towards managing

their type 2 diabetes than people who do not receive the intervention.

321

200

150

100

50

0

Estim

ated

Mar

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l Mea

ns

controlintervention

intervention or control

Estimated Marginal Means of efficacy-expectation

Time

Figure 6.8 Graph of the interaction between time and group for the efficacy expectations

Outcome expectations

The main effect of time of measurement of outcome expectations of diabetes was


220

significant (Wilks’ Λ=.89, F (2,141) = 8.36, p =.00). The group main effect was also

significant between groups, F (1,142) =11.11, p =.00. The interaction effect of group

by time was significant, Wilks’ Λ=.87, F (2,141) =10.27, p =.00. The associated

Partial Eta square was .127, indicating a small to moderate effect size.

To interpret the significance of main effect over time, planned post-hoc comparisons

using paired t-test were conducted, with Bonferroni’s adjustment, where the p level

was set at .017. The follow-up paired t-test comparisons showed the significance at

Time 1-2 (t= -3.75, p= .00), Time 1-3 (t= -3.67, p= .00), and Time2-3 (t= - .42, p= .68)

(see Table 6.22). The mean score of outcome expectations was statistically different at

Time 1-2, and Time 1-3. However, there was no significant difference at Time 2-3.


pairwise comparisons were conducted, with Bonferroni’s adjustment, where the p

level was set at .017. These tests showed that the intervention group had significantly

better outcome expectations than the control group at Time 2 (t=4.58, p= .00), and

Time 3 (t=4.62, p= .00) but not at Time 1 baseline data (t=.44, p=.66) (see Table 6.23).

These results supported the Hypothesis 1 that people who receive the intervention will

have greater self-efficacy towards (outcome expectations) managing their type 2

diabetes than people who do not receive the intervention.


221

321

100

80

60

40

20

0

Estim

ated

Mar

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l Mea

ns

controlintervention


Estimated Marginal Means of outcome-expectation

Time

Figure 6.9 Graph of the interaction between time and group for the outcome expectations

6.9.2 Question 2.2: Is there a difference in the self-care activities of

people with type 2 diabetes following implementation of the

SEEIP?

Two-way repeated measures ANOVA was used to examine the differences in the

self-care activities (as measured by the SDSCA) between groups and three time points.

The means and standard deviations for the self-care activities scores for the three time

points and two groups are presented in Table 6.18.

Table 6.18 The mean (SD) for the self-care activities scores


M(SD)

Control group

M(SD)


Self-care activities

( SDSCA)

46.15

(15.24)

52.86

(14.10)

55.06

(16.01)

46.99

(14.46)

46.78

(14.14)

46.71

(14.28)


222

The main effect of time of measurement of the self-care activities for diabetes patients

was significant (Wilks’ Λ=.89, F (2,141) = 9.05, p =.00). The group main effect was

also significant between groups, F (1,142) =4.16, p =.04. The interaction effect of

group by time was significant, Wilks’ Λ=.87, F (2,141) =10.32, p =.00. The associated

Partial Eta square was .13, indicating a moderate effect size.

To interpret the significant of main effect of time, planned post-hoc comparisons

using paired t-test were conducted, with Bonferroni’s adjustment, where the p level


Time 1-2 (t= -3.13, p= .00), Time 1-3 (t= -4.00, p= .00), and Time 2-3 (t= - 1.44,

p= .15) (see Table 6.22). The mean score of the self-care activities was statistically

different at Time 1-2, and Time 1-3. However, there was no significant difference at

Time 2-3.



level was set at .017. These tests showed that the intervention group had significantly

better self-care activities than the control group at Time 2 (t= 2.59, p= .01), and Time

3 (t=3.30, p= .00) but not at Time 1 baseline data (t= .34, p=.74) (see Table 6.23).

These results supported the Hypothesis 2 that people who receive the intervention will

undertake diabetes self-care activities more frequently than people who do not receive

the intervention.


223

321

80

60

40

20

0

Estim

ated

Mar

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ns

controlintervention


Estimated Marginal Means of self-care activities

Time

Figure 6.10 Graph of the interaction between time and group for the self-care activities

6.9.3 Question 2.3: Is there a difference in health-related quality of life of


SEEIP?

Two-way repeated measures ANOVA was used to examine the differences in

health-related quality of life of people with type 2 diabetes. The SF-12 outcomes

used for analysis of health related quality of life in this study were physical and

mental component summary scores (PCS-12 and MCS-12). The PCS-12 and MCS-12

refer to physical well-being and emotional well-being, respectively. The means and

standard deviations for the PCS and MCS scores for the three time points and two

groups are presented in Table 6.19.


224

Table 6.19 The mean (SD) for the physical health and mental health scores


M(SD)

Control group

M(SD)


Physical health

(PCS)

43.26

(10.20)

46.28

(8.01)

46.24

(8.89)

43.13

(9.20)

43.18

(8.97)

43.17

(9.19)

Mental health

(MCS)

46.00

(11.32)

48.18

(9.19)

47.16

(9.12)

44.56

(11.19)

44.72

(11.20)

44.76

(11.11)

Physical health related quality of life

The main effect of time of the physical health-related quality of life was not

significant (Wilks’ Λ=.96, F (2,141) = 2.70, p =.07). The group main effect was also

not significant between groups, F (1,142) =2.08, p =.15. The interaction effect of

group by time was not significant (Wilks’ Λ=.96, F (2,141) = 3.04, p =.05) (see Figure

6.11).

321

100

90

80

70

60

50

40

30

20

10

0

Estim

ated

Mar

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ns

controlintervention


Estimated Marginal Means of physical health-related quality of life

Time

Figure 6.11 Graph of the interaction between time and group for the physical health-related

quality of life


225

Mental health related quality of life

The main effect of time of the mental health-related quality of life was not significant

(Wilks’ Λ=.99, F (2,141) = 1.08, p =.34). The group main effect was also not

significant between groups (F (1,142) =2.45, p =.12). The interaction effect of group

by time was not significant (Wilks’ Λ= .99, F (2,141) = .89, p = .41) (see Figure 6.12).

These results can not support the Hypothesis 3 that people who receive the

intervention will have better HRQOL (mental health) than people who do not receive

the intervention.

321

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70

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30

20

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Estimated Marginal Means of mental health-related quality of life

Time

Figure 6.12 Graph of the interaction between time and group for the mental health-related

quality of life


226

6.9.4 Question 2.4: Is there a difference in the psychosocial well-being of


SEEIP?

Two-way repeated measures ANOVA was used to examine the differences in the

social support (as measured by the MOS-SSS), and depression (as measured by

CES-D) between groups and three time points. The means and standard deviations for

the MOS-SSS and CES-D scores for the three time points and two groups are

presented in Table 6.20.

Table 6.20 The mean (SD) for the social support and depression scores


M(SD)

Control group

M(SD)


Social support

(MOS-SSS)

63.43

(17.53)

68.29

(18.60)

70.43

(16.64)

65.68

(17.01)

65.66

(17.01)

64.77

(16.75)

Depression

(CES-D)

9.64

(4.75)

9.33

(4.97)

9.34

(4.65)

9.29

(3.88)

9.45

(3.95)

9.50

(3.88)

Social support

The main effect of time of the social support for type 2 diabetes was significant

(Wilks’ Λ=.94, F (2,141) = 4.74, p = .01). The group main effect was not significant

between groups, F (1,142) =.62, p = .43. The interaction effect of group by time for

the social support was significant (Wilks’ Λ= .90, F (2,141) =8.01, p =.00). The

associated Partial Eta square was .10, indicating a small to moderate effect size.

To interpret the significance of main effect of time, planned post-hoc comparisons

using paired t-tests were conducted, with Bonferroni’s adjustment, where the p level



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Time 1-2 (t= -2.08, p= .04), Time 1-3 (t= -2.94, p= .00), and Time 2-3 (t= - .80, p= .43)

(see Table 6.22). The mean score of the social support was statistically different at

Time 1-3. However, there was no significant difference at Time 1-2 and Time 2-3

after they were examined by Bonferroni’s correction, where the p level was set

at .017.



level was set at .017. These tests showed that the intervention group did not have

significantly better social support than the control group at Time 1 (t=-.78, p= .43),

Time 2 (t= .89, p= .38), and Time 3 (t=2.04, p= .04) (see Table 6.23). Even though the

group main effect was not significant between groups, the main effect of time and the

interaction effect of group by time for the social support were significant. These

results supported the Hypothesis 4 that people who receive the intervention will have

better psychosocial well-being (social support) than people who do not receive the

intervention.


228

321

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Time

Figure 6.13 Graph of the interaction between time and group for the social support

Depression

The main effect of time of the depression was not significant (Wilks’ Λ= .1.00, F

(2,141) = .04, p =.97). The group main effect was also not significant between groups

(F (1,142) = .00, p =1.00). The interaction effect of group by time was not significant

(Wilks’ Λ= .99, F (2,141) = .44, p = .64) (Figure 6.14). These results can not support

the Hypothesis 4 that people who receive the intervention will have better

psychosocial well-being (less depression) than people who do not receive the

intervention.


229

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Time

Figure 6.14 Graph of the interaction between time and group for the depression


230

Table 6.21 Repeated measure analysis of variance for the outcome variables (n=145)

Effect df Wilks’ Λ Effect sizes

(Eta square)

F p


Group 1,142 .04 5.44 .02*

Time 2,141 .81 .19 16.58a .00**

Group× Time 2,141 .80 .20 17.42a .00**


Group 1,142 .07 11.11 .00**

Time 2,141 .89 .11 8.36 a .00**

Group× Time 2,141 .87 .13 10.27a .00**


Group 1,142 .03 4.16 .04*

Time 2,141 .89 .11 9.05 a .00**

Group× Time 2,141 .87 .13 10.32 a .00**

Physical health-related QOL

Group 1,142 .01 2.08 .15

Time 2,141 .96 .04 2.70 a .07

Group× Time 2,141 .96 .04 3.04 a .05

Mental health-related QOL

Group 1,142 .02 2.45 .12

Time 2,141 .99 .02 1.08a .34

Group× Time 2,141 .99 .01 .89 a .41

Social support

Group 1,142 .00 .619 .43

Time 2,141 .94 .06 4.74 a .01**

Group× Time 2,141 .90 .10 8.01 a .00**

Depression

Group 1,142 .00 .00 1.00

Time 2,141 1.0 .00 .04 a .97

Group× Time 2,141 .99 .01 .44 a .64 *p< .05, **p< .01 a Exact statistic

Note: To interpret effect sizes: .02= small magnitude, .15= medium magnitude, .35= large magnitude

(Cohen, 1988: 477-478)


231

Table 6.22 Comparisons of outcome variables by time of groups (Paired-t Test) (n=145)

Variables Mean

difference

SD t pa


Pair T1- T2 -7.79 25.85 -3.63 < .017 *

Pair T1- T3 -13.01 30.12 -5.18 < .017 *

Pair T2- T3 -5.16 20.01 -3.09 < .017 *


Pair T1- T2 -5.81 18.68 -3.75 < .017 *

Pair T1- T3 -6.22 20.32 -3.67 < .017 *

Pair T2- T3 -.36 10.36 -.42 ns


Pair T1- T2 -3.23 12.40 -3.13 < .017 *

Pair T1- T3 -4.31 12.92 -4.00 < .017 *

Pair T2- T3 -1.06 8.80 -1.44 ns

Physical health-related QOL

Pair T1- T2 -1.52 8.07 -2.27 ns

Pair T1- T3 -1.39 8.06 -2.07 ns

Pair T2- T3 .14 4.99 .33 ns

Mental health-related QOL

Pair T1- T2 -1.17 9.60 -1.46 ns

Pair T1- T3 - .72 8.25 -1.04 ns

Pair T2- T3 .46 6.33 .88 ns

Social support

Pair T1- T2 -2.41 13.94 -2.08 ns

Pair T1- T3 -3.09 12.59 -2.94 < .017 *

Pair T2- T3 -.67 10.07 -.80 ns

Depression

Pair T1- T2 .07 3.21 .26 ns

Pair T1- T3 .06 3.63 .21 ns

Pair T2- T3 -.01 3.04 -.03 ns

a Bonferroni correction applied *p< .017


232

Table 6.23 Comparisons of outcome variables by time of groups (Independent-t Test) (n=145)

Variables t pa


Time 1 .30 ns

Time 2 2.45 < .017 *

Time 3 4.30 < .017 *


Time 1 .44 ns

Time 2 4.58 < .017 *

Time 3 4.62 < .017 *


Time 1 -.34 ns

Time 2 2.59 < .017 *

Time 3 3.30 < .017 *

Physical health-related quality of life

Time 1 .08 ns

Time 2 2.19 ns

Time 3 2.04 ns

Mental health-related quality of life

Time 1 .77 ns

Time 2 2.03 ns

Time 3 1.41 ns

Social Support

Time 1 -.78 ns

Time 2 .89 ns

Time 3 2.04 ns

Depression

Time 1 .49 ns

Time 2 -.16 ns

Time 3 -.23 ns

a Bonferroni correction applied *p< .017


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6.9.5 Question 2.5: Is there a difference in health care utilisation of


SEEIP?

Health care utilisation (as measured by self-reported questionnaires) measurement

items consisted of the dichotomous data (yes or no) related to hospitalisation, visit to

ER, and visit to the out-patient department (OPD). To compare the health care

utilisation of people with type 2 diabetes at Time 1, Time 2, and Time 3 between the

groups (control and intervention), data were analysed using the chi square statistic to

test the significance of different proportions.

Hospitalisation

Table 6.24 showed that no significant differences were found after comparison of the

proportion of the hospitalisation between the intervention and the control groups at

Time 1 and Time 2. However, there was a significant difference at Time 3 (χ2= 9.10,

P= .00). The results showed that a greater proportion of the participants in the control

group had been hospitalised (15.1%) than the participants who were in the

intervention group (1.4 %) at the point of Time 3 (see Figure 6.15).


234

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

Time 1 Time 2 Time 3

Intervention

Control

Figure 6.15 The percentage of the hospitalisation between the intervention and

control groups at Time 1, Time 2 and Time 3

Visit to emergency room

No significant differences were found after comparison of the proportion of visits to

the emergency room between the intervention and the control groups at Time 1 and

Time 2. However, there was a significant difference at Time 3 (χ2= 4.10, P= .04) (see

Table 6.24). The results showed that a greater proportion of the participants in the

control group had visited the emergency room (17.8%) than the participants who were

in the intervention group (6.9%) at the point of Time 3 (see Figure 6.16).


235

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

20.00%


InterventionControl

Figure 6.16 The percentage of visits to emergency room between the intervention and control

groups at Time 1, Time 2 and Time 3

Visit to OPD

No significant differences were found after comparison of the proportion of visits to

the OPD between the intervention and the control groups at Time 1, Time 2, and Time

3 (see Table 6.24). Therefore, there was no significant change in the proportion of

visits to OPD between groups at any points of time (see Figure 6.17).

56.00%

58.00%

60.00%

62.00%

64.00%

66.00%

68.00%

70.00%

72.00%

74.00%

76.00%

78.00%


Intervention

Control

Figure 6.17 The percentage of visits to OPD between the intervention and control groups

at Time 1, Time 2 and Time 3


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These results supported Hypothesis 5 that people who receive the intervention will

have a lower usage of health services (hospitalisation and visit to emergency room)

than people who do not receive the intervention. However, the lower usages of

hospitalisation and visit to emergency room were not found until Time 3 (six months

following baseline collection).

Table 6.24 Comparison of visits to emergency room between intervention and control groups

(n=145)

Intervention

(n=72)

Control

(n=73)

Significance Variables

Count % Count %

Hospitalisation

Time 1 Yes 6 8.3 6 8.2 χ2= .00;

No 66 91.7 67 91.8 p=1.00

Time 2 Yes 7 9.7 6 8.2 χ2= .10;

No 65 90.3 67 91.8 P= .78

Time 3 Yes 1 1.4 11 15.1 χ2= 9.10;

No 71 98.6 61 83.6 p= .00**

Visit to emergency room

Time 1 Yes 7 9.7 6 8.2 χ2= .10 ;

No 65 90.3 67 91.8 p= .78

Time 2 Yes 9 12.5 8 11.0 χ2= .08 ;

No 63 87.5 65 89.0 p= .80

Time 3 Yes 5 6.9 13 17.8 χ2= 4.10 ;

No 67 93.1 59 80.8 p= .04*

Visit to OPD

Time 1 Yes 55 76.4 51 69.9 χ2= .79 ;

No 17 23.6 22 30.1 p= .46

Time 2 Yes 53 73.6 47 64.4 χ2= 1.44 ;

No 19 26.4 26 35.6 p= .28

Time 3 Yes 46 63.9 50 68.5 χ2= .50;

No 26 36.1 22 30.1 p=.60

*p< .05, **p< .01


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6.10 Summary result of Study II

The participants for both groups were similar in relation to the sociodemographics,

illness history, the key variables and health care utilisation. Five hypotheses were

examined and answered:

1). People who receive the intervention will have greater self-efficacy towards

managing their type 2 diabetes than people who do not receive the intervention.

The finding showed that the scores of efficacy expectation and outcome

expectation were significantly increased in the intervention group at Time 2 and

Time 3 compared to the control groups (p<.01). Efficacy expectations and

outcome expectations were increased between Time 1 and Time 2 and Time 2 and

Time 3.

2). People who receive the intervention will undertake diabetes self-care activities

more frequently than people who do not receive the intervention.

The score of self-care activities was significantly increased in the intervention

group at Time 2 to and Time 3 compared to the control groups (p<.01). Self-care

activities increased between Time 1 and Time 2 and Time 1 and Time 3.

3). People who receive the intervention will have better HRQOL than people who do

not receive the intervention.

The scores of the health (physically and mentally) related quality of life were not

significantly increased in the intervention group at Time 2 or Time 3 compared to

the control groups. The results indicated that the change over time was not

different in the two groups.

4). People who receive the intervention will have better psychosocial well-being than

people who do not receive the intervention.


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The interaction effect of group by time for the social support was significant and

the score of social support was increased between Time 1 and Time 3 (p<.01).

However, the results of the depression scores indicated that the change over time

was not different in the two groups.

5). People who receive the intervention will have a lower usage of health services


A smaller proportion of the participants significantly in the intervention group,

have been hospitalised (p<.01) and visited the emergency room (p<.05) than the

participants who were in the control group at Time 3.

Student number: n4513282 Shu-Fang Wu Chapter 7 Discussion

239

Chapter 7

Discussion

7.1 Introduction

This chapter will discuss the evidence found in this study in response to the research

questions and hypotheses. Firstly, Study I : ‘Demonstration of the validity and

reliability of two diabetes-specific self-efficacy questionnaires in the Taiwanese

population’ will be discussed. The original version of the Diabetes Management

Self-Efficacy Scale (DMSES) and the Perceived Therapeutic Efficacy Scale (PTES)

were translated and psychometrically tested as instruments in the diabetes population

in Taiwan. Although the scales have been tested before (McDowell et al., 2005; van

der Bijl, van Poelgeest-Eeltink & Shortridge-Baggett, 1999; Sturt & Hearnshaw,

2003), it is of great importance to continue to test them in different countries with

different languages. Very few self-efficacy towards management of diabetes studies

and instrument development have been found in Taiwan. In this research, the DMSES

and PTES are used for the first time in the Chinese population. To test a self-efficacy

and diabetes specific instrument in Taiwan is a new challenge and a significant issue.

Secondly, Study II: ‘Provision of a comprehensive diabetes education intervention:

SEEIP (the self efficacy enhancing intervention program) and demonstration of the

effectiveness of a nursing intervention will be discussed. Diabetes is a prevalent,

costly condition associated with substantial morbidity and mortality in Taiwan. Even

though the health care system has persistently emphasised patients’ health education,

the increased knowledge of individual cases may not represent the well-controlled


240

levels of blood glucose. Taiwan also has increasing trends of diabetes mortality and

healthcare cost. It is important to prevent the complications and to prolong the life of

the patients. The concept of self-efficacy provides a scientific evidence base for health

promotion strategies (Bandura, 1986; Poradzisz, 2001). Thus, developing and

evaluating the self-efficacy enhancing intervention program (SEEIP) for diabetes

mellitus based on the self-efficacy theory is the next topic which will be discussed.

Discussion of Study I

Research question 1: Are the two diabetes-specific self-efficacy instruments, the

DMSES and PTES valid and reliable in a Taiwanese

population?

7.2 Discussion of the Chinese version of the DMSES (C-DMSES) 7.2.1 Discussion of Stage one: translation and development of the

C-DMSES

The use of Western instruments translated from English into other languages has been

a frequent feature and trend around the world. Language is one of the most obvious

barriers to assessment; simple, direct translation of standardised or new instruments

will not solve this problem (Brislin, 1986; Marin & vanOss, 1991). In translating an

instrument for cross-cultural use, it is significant that the meaning of test items be

approximately the same across the different language versions. However, measures of

health related concepts must be sensitive to these subtle language differences, as well

as to cultural differences that influence understanding of the constructs (Varricchio,

2004). The recommended procedure for translating research instruments is known as a


241

back-translation (Brislin, 1986). Jones et al. (2001) claimed an adaptation and

extension of the Brislin’s model which includes simultaneous translations and

back-translations followed by group consultation by the bilingual experts is

recommended. We applied a revised approach to increase efficiency, strengthen the

integrity of the translation process, and to achieve the goals of cultural and functional

equivalence. In this present study, a rigorous multi-stepped translation and

back-translation process was undertaken in developing the C-DMSES. These

processes aim to ensure the equivalent meaning of items in both languages.

The translator attended to inherent differences in the overall linguistic structure of

English and Chinese that may require item modification beyond literal translation.

Three modifications identified by group discussion on the back-translation refer to the

C-DMSES. To summarize the main points of the translation and back-translation,

challenges for consideration were found concerning the semantic and content

equivalence. After discussions between the researchers and the translators it was

found that the questionable concepts were actually identical in meaning. For example,

‘my feet’ was translated into ‘my foot’. When the difference was slight, but the

meaning was considered the same, changes were not made in the translation. In two

cases, wording of items was modified through adding context or using synonyms

when literal translations seemed unclear or awkward. For example, the item “I am

able to keep my weight under control” was modified to “I am able to control my body

weight and maintain it within the ideal weight range”. Moreover, one term in the item

was changed due to the culture differences. Generally speaking, eating habits do not

change much on weekends and holidays, but are influenced by special festivals, for

example, people eat rice cakes (niangao) at Chinese New Year, glutinous rice

dumplings (zongzi) during the Dragon Boat festival and moon cakes at Mid-Autumn


242

Festival. Diet control is the basis of the whole therapy for diabetics and through diet

control a satisfactory level of the blood sugar can be maintained for one-third of

diabetic patients (Funnell et al., 1992). The eating habits and other lifestyle factors

influence diabetes control effectively. Thus, we replace ‘holiday’ with ‘festivals’.

Although Brislin (1986) stated that adding context can narrow the possibilities of

meanings and make the test item more specific, the C-DMSES is specifically a

self-efficacy and diabetes instrument, so adding context or wording was considered a

solution to address the difficulty in translating English words. These changes would

be more concrete and make it easier for people to understand the meanings of the

items.

7.2.2 Discussion of Stage two: validation and reliability of the C-DMSES

7.2.2.1 The content validity of the C-DMSES

Content validity is established by using a team of experts who agree that the items on

the instrument provide adequate coverage of the concepts (Kim & Han, 2004) and this

is essential for all instruments and should not be seen as less important than other

forms of validity evidence (Berk, 1990). The suggested number of experts is five to

ten experts who meet detailed criteria for expertise in order to respond to specific

questions about the content relevance of each item and the total scale, suggest

revisions, and identify omissions (Grant & Davis, 1997). In this study, a panel of eight

experts judged the content validity of the Chinese version DMSES and content

relevance was determined as based on two criteria: including the applicability of

content and clarity of phrasing. The C-DMSES obtained a score of the applicability of

content .87 and the clarity of phrasing .85. Thus, the C-DMSES obtained a total


243

average score of .86 for CVI. Grant and Davis (1997) proposed that the minimum

acceptable agreement score should range from .7 to .8. An acceptable CVI was greater

than .85 for this instrument. That means that there was at least 85% agreement among

eight experts that each one of the items fitted its own concept clearly. The results of

the content validity indicate that the C-DMSES was content valid.

The experts’ comments

In addition to their quantitative ranking of the items, the experts identified several

specific concerns with item content. In the C-DMSES, two of the eight experts

thought that Item No. 13, “I am able to follow a healthy eating plan when I am away

from home” (CVI= .89), and Item No. 14 “I am able to choose different foods and

maintain my eating plan when I am away from home” (CVI= .84) were too similar.

However, the average total score of CVI still remains high and greater than .80. Thus,

both two items were provisionally accepted. A number of items were culturally or

contextually irrelevant to Taiwanese society, for example, Item No. 15, “I am able to

follow a healthy eating plan during festive periods” (CVI= .89), People generally

over-eat or have a different eating habit during special festivities. Considering the

cultural differences, experts accepted that the term “holiday” has been replaced with

“festival” during the translation process. The other example is that Item No. 18, “I am

able to visit my doctor four times a year to monitor my diabetes” (CVI= .86), because

according to the regulations of the Bureau of National Health Insurance, prescriptions

for patients with chronic diseases are only valid for three months, therefore, doctors

and experts suggested that patients should visit their doctor at least four times a year.

Although some items were modified, no items were removed and be further tested

their psychometric.


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7.2.2.2 The criterion validity of the C-DMSES

Establishing criterion-related validity involves determining the relationship between

an instrument and an external criterion. The instrument is said to be valid if its score

correlates highly with the score on the criterion (Polit & Beck, 2004). Studies

demonstrate that self-efficacy is a useful predictor for diabetic self-care behaviour and

self-care performance will be improved in people with diabetes who have strong

beliefs in self-efficacy. (Williams & Bond, 2002; Sigurardóttir & Árún, 2005).

Therefore, the Summary of Diabetes Self-Care Activities (SDSCA) and the

C-DMSES were used to test the relationship using regression analysis for the

criterion-related validity. Regression analysis is to use to make predictions about

phenomena (Green & Salkind, 2005). In bivaricate regression, one predictor

(C-DMSES) is used to predict a dependent variable (SDSCA).

Results (R=.58; R2= .34, t=10.75, p=.00) show the C-DMSES is a significant

predictor of diabetes self-care activities. This means that higher self-efficacy has a

correlation with self-care performances. These findings were similar to Hurley and

Shea’s study (1992), which showed self-efficacy accounted for an average 33.0 % of

the variance in self-care and Williams and Bond’s study (2002), which demonstrated

self-efficacy was a significant predictor of self-care activities, contributing between

14% and 35 % (average 24%) of the variance of self-care activities. Therefore, the

C-DMSES instrument performed as predicted for criterion validity testing.

7.2.2.3 The convergent validity of the C-DMSES

Convergent validity refers to substantial correlations between an instrument and other

measures to which it should theoretically relate (Kim & Han, 2004). Convergent

validity is generated from the correlations between two different methods measuring


245

the same trait (Polit & Beck, 2004). In the General Self-Efficacy Scale (GSE) higher

scores equate with higher personal expectations of ability to initiate and persist with a

task and reflect the strength of self-efficacy as a willingness to perform and persist

with behaviour in difficult situations (Schwarzer, 1992). The General Self-Efficacy

Scale (GSE) (Schwarzer, 1992) appears to be the most consistent for measuring the

self-efficacy concept and this scale been used to test whether the C-DMSES is valid in

this trait. The results showed that C-DMSES and GSE score had moderate

associations (r= .55; p< .01). This result confirms the convergent validity, which the

DMSES was tested in an Australia population (r= .52; p< .00) (McDowell et al.,

2005). The Chinese version DMSES is a domain-specific measure of efficacy

expectations (or self-efficacy) in a diabetic population. This result indicated that

C-DMSES has the ability to measure underlying the strength dimension of

self-efficacy.

7.2.2.4 The construct validity of the C-DMSES

The evidence of construct validity would further support the clinical meaningfulness

of an instrument (Nunnally & Bernstein, 1994). Construct validity of the C-DMSES

was assessed through factor analysis. According to Green and Salkind (2005) the

criteria of eigenvalues higher than 1.0 and factor loadings higher than .4 could attain

the best fitting structure and the correct number of factors. The results of C-DMSES

gave four factors, rotated in the initial solution which had eigenvalues >1.0; consistent

with the previous analysis with the Dutch DMSES (van der Bijl, van

Poelgeest-Eeltink & Shortridge-Baggett, 1999) a four-factor solution was generated.

These four factors explained 68.32% of the total sample variance and the loading

factor of each item greater than .4. Factor one accounts for the largest percentage of

variance (46.65%) and is a comprehensive factor with high internal consistency.


246

Because the Australian/English version of the DMSES has not tested the construct

validity (factor analysis), the results of factor analysis thus compared with the Dutch

version DMSES.

Although the scale can be classified into four functional factors, the four clusters of

diabetes self-care activities of C-DMSES, namely nutrition, blood sugar and feet

check, physical exercise and weight, and medical treatment, are different from the

Dutch version instrument outlined by van der Bijl, van Poelgeest-Eeltink and

Shortridge (1999). In fact, in the development of the Dutch version DMSES, the

authors stated it is tricky to conclude the four factors represent four subscales: (a)

nutrition specific and weight; (b) nutrition general and medical treatment; (c) physical

exercise; and (d) blood sugar (van der Bijl, van Poelgeest-Eeltink &

Shortridge-Baggett, 1999). They hope more research with this scale would confirm or

modify their findings. Interestingly, this present study revealed better and more

suitable four categories: (a) nutrition (Items 4, 5, 9, 10, 13, 14, 15, 16, 17); (b) blood

sugar and feet check (Items 1, 2, 3, 7); (c) physical exercise and weight (Items 6, 8, 11,

12); and (d) medical treatment (Items 18, 19, 20).

Differences in the subscales found between the Chinese and Dutch versions may be

attributed to the changes to wording and cultural difference which were better

reflection of the Taiwanese environment and society as mentioned previously. In the

C-DMSES, the first factor all related to food or nutrition (Items 16, 14, 13, 15, 17, 10,

5, 4, and 9). Factor two is related to the checking issue (Items 3, 2, 1, 7). Generally

speaking, blood sugar and feet checking takes time and equipment, such as a blood

sugar testing machine or mirrors so that the two issues cluster in the same factor.

Factor three (Items 11, 8, 12, and 6) related to physical exercise and weight. This is


247

different from the Dutch version DMSES where nutrition and weight were

categorized in the same factor. This may be due to local perception in Taiwan where

controlling body weight is more likely to be associated with exercise rather than

nutrition. Factor four (Items 18, 19, and 20) related to medical treatment. In Taiwan

people believe accessing health providers and taking medication is sufficient

treatment to control their diabetes. Table 7.1 shows the differences between the Dutch

version DMSES and the Chinese version DMSES.

Table 7.1 Comparison of subscales in the Dutch and Chinese versions of DMSES

The Dutch version DMSES Chinese version DMSES

Nutrition specific and weight (5 items) Nutrition (9 items)

6. I think I’m able to keep my weight under

control

4. I am able to choose the foods that are best for

my health

13. I think I’m able to follow a healthy eating plan

when I am away

5. I am able to choose different foods and

maintain a healthy eating plan

14. I think I’m able to adjust my diet when I am

away from home from home

9. I am able to maintain my eating plan when I am

ill

15. I think I’m able to follow my diet when I am

on vacation

10. I am able to follow a healthy eating plan most

of the time

16. I think I’m able to follow my diet when I am

at a reception/party

13 I am able to follow a healthy eating plan when

I am away from home

Nutrition general and medical treatment (9

items)


maintain my eating plan when I am away from

home

4. I think I’m able to select the right foods 15 I am able to follow a healthy eating plan

during festive periods

5. I think I’m able to select different foods but

stay within my diabetic diet


maintain a healthy eating plan when I am

eating out or at a party

7. I think I’m able to examine my feet for skin

problems

17 I am able to maintain my eating plan when I

am feeling stressed or anxious

9. I think I’m able to adjust my diet when I am ill Medical treatment (3 items)

10. I think I’m able to follow my diet most of the

time

18 I am able to visit my doctor four times a year

to monitor my diabetes


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17. I think I’m able to adjust my diet when I am

under stress or tension

19 I am able to take my medication as prescribed

18. I think I’m able to visit the doctor once a year

to monitor my diabetes

20. I am able to maintain my medication when I

am ill

19. I think I’m able to take my medication as

prescribed

Physical exercise and weight (4 items)

20. I think I’m able to adjust my medication when

I am ill

6 I am able to control my body weight and

maintain it within the idea weight range

Physical exercise (3 items)

8 I am able to do enough physical activity (e.g.

walking the dog; yoga; gardening; stretching

exercises)

8. I think I’m able to get sufficient physical

activities, for example, talking a walk or biking

11 I am able to do more physical activity if the

doctor advises me to do

11. I think I’m able to take extra physical

activities, when the doctor advises me to do so

12 When doing more physical activity I am able

to adjust my eating plan

12.When taking extra physical activities, I think

I’m able to adjust my diet

Blood sugar and feet check (4 items)

Blood sugar (3 items) 1 I am able to check my blood sugar if necessary

1. I think I’m able to check my blood sugar if

necessary

2 I am able to correct my blood sugar when the

sugar level is too high (e.g. eat different foods)

2. I think I’m able to correct my blood sugar when

the sugar value is too high

3 I am able to correct my blood sugar when the

sugar level is too low (e.g. eat different foods)

3. I think I’m able to correct my blood sugar when

the sugar value is too low

7. I am able to examine both of my feet (e.g. for

cuts or blisters)

7.2.2.5 Internal consistency of the C-DMSES

Internal consistency reliability evaluates the degree to which items designed to

measure the same content domain are inter-correlated (Polit & Beck, 2004).

Cronbach’s alpha for the total scale of a new instrument was expected to be greater

than .7 (Nunnally & Bernstein, 1994; Jacobson, 2004). The target language version is

treated as a new instrument, with an alpha of .70 (Nunnally & Bernstein, 1994).

Reliability of C-DMSES was high with a value of .93 for the total scale and ranged

from .77 to .93 for the subscales for C-DMSES, which is sufficient for assessment at


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an individual level (Jacobson, 2004). It is a little higher than that found for the Dutch

version (Cronbach’s alpha .81) of the DMSES (van der Bijl, van Poelgeest-Eeltink &

Shortridge-Baggett, 1999) but similar to results reported for the Australia/ English

version (Cronbach’s alpha .91) (McDowell et al., 2005).

Item analysis is an additional means of finding weaknesses in the measure and

assessing how well each item contributes to the overall measure (Kim & Han, 2004).

The items were homogenous to the scale, as there was no significant increase in the

Cronbach’s alpha when any item was left out. The correlated item-to–total

correlations ranged from .37 to .76. The recommend Pearson correlation coefficient

item-total correlation coefficients should be greater than .3 and inter-item correlations

should be less than .7 to indicate a lack of multicollinearity (Nunnally & Bernstein,

1994). The mean-item correlation= .42 (min. = .09, max= .86) for the C-DMSES in

this study. This analysis indicated a non-unidimensional scale for the C-DMSES.

7.2.2.6 Stability of the C-DMSES

The stability of an instrument is the extent to which similar findings are gained on two

separate administrations (Polit & Beck, 2004). The test-retest reliability of the

C-DMSES was tested with a sample of 30 participants assessed twice over an interval

of three weeks. The results of the Pearson r were high with a value of .86 for the total

scale and ranged from .77 to .93 for the subscales for C-DMSES, indicating good

consistency of the test results over time. The results were a little higher than that

found for the Australia / English version DMSES (r= .76, p< .00) (McDowell et al.,

2005) and the Dutch version DMSES (r= .79, p< .00) (van der Bijl, van

Poelgeest-Eeltink & Shortridge-Baggett, 1999). These outcomes confirm previously

undertaken analysis of temporal stability in other versions of the instrument.


250

Traditionally, within the nursing literature the test-retest reliability or stability of

psychometric questionnaires was examined by the Pearson correlation (Polit &

Hungler, 1999). Bland and Altman (1986) argued that correlations are an indication of

relationship and do not offer information regarding agreement, so are unable to detect

systematic bias in response from one time to another. Therefore, a Bland-Altman plot

was used to graphically display the variability involved in this study as well. The

result of the mean difference was greater than zero indicated that there may be bias in

the data. It is a similar result that found for an Australian population (M= 4.13,

SD=15.5) (McDowell, Courtney & Edwards, 2005). This may be attributed to

participant’s previous knowledge of the C-DMSES scale. The level of agreement (2

SD of the difference between the test-retest measurements) between individual

responses over time is strong. Thus, one can conclude that the C-DMSES is a reliable

and stable instrument. A limitation to the proportion of agreement approach

(Bland-Altman plot) employed in other studies of testing reliability for DMSES

instrument are still absent, it would seem that there is a need for future research to

extend this method to their studies.

7.3 Discussion of the Chinese version of the PTES (C-PTES) 7.3.1 Discussion of stage one: translation and development of the

C-PTES

There is little debate regarding the translation of the C-PTES. The items may not have

a translation problem because, based on translation theory, the accurate and

appropriate processes of translation and back-translation had been undertaken for the

study (see Chapter 5.2.1.1).


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7.3.2 Discussion of stage two: validation and reliability of the C-PTES

7.3.2.1 The content validity of the C-PTES

The score for the applicability of content was .85 and the clarity of phrasing was .79

for the C-PTES. The total average score was .83 of CVI for the C-PTES. An

acceptable CVI for this instrument is greater than .79, which was in the acceptable

range from .7 to .8 suggested by Grant and Davis (1997). However, some items have

been changed due to selections of culturally appropriate wording. The results of the

content validity indicate the C-PTES was content valid.

The experts’ comments

Regardless of the different grammatical forms or languages, three items of the

C-PTES have been changed. Item No. 2, “My level of confidence in the ability of my

diabetes medication to prevent episodes of high blood sugar is” (CVI=.81) was

changed to “My diabetes medication can keep my blood sugar at a stable level and

prevent it from becoming elevated”; Item No. 5, “My level of confidence in the ability

to control my diabetes by my maintaining my medication dose is” (CVI=.84) was

changed to “The maintenance of the dose of my medication can control my diabetes

effectively”; and No. 10 “My overall level of confidence in the ability to manage my

diabetes is” (CVI=.78) was changed to “My overall level of confidence in my ability

to cope with my diabetes is”. Moreover, the experts suggested adding specific

examples to the item No. 9 to further explain the intended meaning. Item No. 9 “My

level of confidence in my health professionals’ advice about my diabetes treatment is”

(CVI=.78) was changed to “The professional advice that experts such as doctors or

nutritionists give me in my diabetes treatment”. Experts thought that the modifications

of the above content and wordings would fit better with Taiwanese culture, and were


252

easier for patients to understand.

According to Bijnen, van der Net and Poortinga (1986), each item must be considered

as a separate measurement and be checked for adequacy of translation, systemic item

response bias, and fairness within each cultural group. The experts’ comments and the

positive results from the CVI enhanced the usefulness and practicability of the

instruments and may serve as an indicator of the efficacy of that cross-cultural

translation. The measures are ready to be evaluated for their psychometric properties

when the research team is satisfied that the language versions are conceptually and

linguistically equivalent (Kim & Han, 2004). Testing psychometric properties will

thus be discussed next regarding the process in cross-cultural instrumentation.

7.3.2.2 The criterion validity of the C-PTES

People with diabetes perform self management activities which lead to the desired

outcome (outcome expectations). The PTES measures participants’ confidence

(outcome expectations) and the extent to which the individual believes their treatment

will lead to personally desirable outcomes (Dunbar-Jacob, 2000; Sturt & Hearnshaw,

2003). It focuses on activities of people with type 2 diabetes who are taking

prescribed medication. We chose the Summary of Diabetes Self-Care Activities

(SDSCA) to examine the criterion validity, because the C-PTES (measuring outcome-

expectation) was correlated as predicted with the theoretically linked psychological

variables of self-care behaviours and health outcomes (Bandura, 1986; Kingery &

Glasgow, 1989). The assumption of this study was that self-care performance will be

better among people with diabetes with strong beliefs in outcome expectations.

Therefore, the SDSCA and C-PTES were used to test the relationship for the

criterion-related validity.


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The result of Pearson’s correlation coefficients (r= .32; p< .01) showed the C-PTES

correlated with self-care activities. Moreover, the C-PTES was a significant predictor

of the Summary of Diabetes Self-Care Activities (SDSCA) (Beta= .32; t= 5.14, p<.

01), accounting for 10.4 % of the variance. This means that higher

outcome-expectation has a correlation with self-care performances. These results were

similar to Williams and Bond’s study (Williams & Bond, 2002) which showed that

outcome expectancies accounted for an average 10% of the variance in self-care. The

average variance in self-care accounted for by outcome expectancies was about 10%,

considerably less than that found in Skelly et al. (1995). However, results of the

criterion validity indicate that the C-PTES was valid.

7.3.2.3 The convergent validity of the C-PTES

Efficacy expectations and outcome expectations combine to determine an individual’s

self-efficacy perceptions, which itself is an important determinant of empowerment

(Sturt & Hearnshaw, 2003). Convergent validity is the most direct evidence, which

comes from the correlations between two different methods measuring the same trait

(Polit & Beck, 2004). The PTES measures participants’ confidence which the

individual believes their medication will lead to personally desirable outcomes

(Dunbar-Jacob, 2000; Sturt & Hearnshaw, 2003). Responses to the C-PTES and the

Chinese version of the GSE scale were correlated to assess the strength of relationship

between both instruments. The C-PTES and the Chinese version of the GSE total

score revealed positive associations (r= .42; p< .01). The C-PTES is a measure of

outcome expectations; we tested the relationship between the C-PTES and the

Chinese version of the GSE to provide evidence of the instrument’s ability to measure

underlying self-efficacy. This is the first time to test the convergent validity of the


254

C-PTES and the results expertly provided evidence that the C-PTES does measure the

self-efficacy concept as well. However, continuing research with this scale will have

to confirm these findings.

7.3.2.4 The construct validity of the C-PTES

According to Green and Salkind (1995) the criteria of eigenvalues higher than 1.0 and

factor loadings higher than .4 could attain the best fitting structure and the correct

number of factors. The results of C-PTES revealed one factor, rotated in the initial

solution which had an eigenvalue >1.0; this result was consistent with previous

analysis of the English version of the PTES in UK which also generated only one

single factor related to medication (Sturt & Hearnshaw, 2003).

7.3.2.5 Internal consistency of the C-PTES

The internal consistency of the analysis resulted in an alpha of .95 for the C-PTES. A

similar result was found in a study in a UK population where the Cronbach’s alpha for

the English version of the PTES was reported as .94 (n=121) (Sturt & Hearnshaw,

2003). Although the alpha is high and could suggest items overlap, we believe that in

some situations, a higher coefficient may be required as the higher the coefficient, the

more stable the measure (Polit & Beck, 2004). The item-to-total correlations ranged

from .75 to .86 and were assessed to contribute to the internal consistency. Nunnally

and Bernstein (1994) noted that items with high item-total correlation values have

more variance and add more to the reliability of a test than items with low correlation

values. Therefore, items with low item-total correlation should be considered for

deletion from the scale. In order to reach the desired reliability, items were deleted

one-at-a-time from the C-PTES. However, item deletion did not effectively change

the reliability of the C-PTES (only reduced the over alpha by .001 to .005). Moreover,


255

the content validity for the overall CVI was appropriate. Thus, in the end no items

were deleted in terms of item analysis. However, as this is a newly developed

instrument, the C-PTES needs further replication studies that will contribute to

evidence of its reliability and validity.

7.3.2.6 Stability of the C-PTES

A Pearson correlation-coefficient (r= .79, p< .01) was found to determine the strength

of relationship between responses (n=30) to the C-PTES over time, with two to four

weeks between administrations. These results indicated good consistency of the test

results over time. It is a similar result that found for a UK population (Spearman’s

p= .64 to .80, p< .00) (Sturt & Hearnshaw, 2003) and this result was a little higher

than that found for the Australia / English version PTES (r= .68, p< .00) (McDowell,

Courtney & Edwards, 2005). These outcomes confirm previously undertaken analysis

of temporal stability in other versions of the instrument.

Moreover, in order to offer information regarding agreement and detection of

systematic bias in response from one time to another, a Bland-Altman plot (1986) was

used to graphically display the variability involved in this study. The result of the

mean difference was greater than zero indicated that there may be bias in the data. It is

a similar result that found for an Australian population (M=.54, SD=12.05)

(McDowell, Courtney & Edwards, 2005). This may be attributed to participant’s

previous knowledge of the C-PTES scale. The level of agreement (2 SD of the

difference between the test-retest measurements) between individual responses over

time, however, is strong. Thus, one can conclude that the C-PTES is a stable

instrument.


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7.4 Summary discussion of Study I

Results of this study support both the validity and reliability of the C-DMSES and

C-PTES in providing a measure for self-efficacy specific to persons with diabetes

type 2. Adapting an existing instrument for cross-cultural use not only requires

language translation; cultural and environmental characteristics need to be taken into

account also. Kim and Han (2004) suggest a number of essential steps in developing

instruments for cross-cultural research, including building a bicultural research team,

identifying the research goal translation method, testing psychometric properties and

revaluation. They believe that validity and reliability can be greatly enhanced by the

well designed process in cross-cultural instrumentation. As discussed previously a

strong bicultural research team and a two-stage design was used for this study.

Therefore, we can answer in regard to the research question of study 1 that both the

C-DMSES and C-PTES are valid and reliable in a Taiwanese population due to the

following conclusions: the convergent validity of the C-DMSES and C-PTES were

supported, as they correlated well with the validated measure of the Chinese version

GSE in measuring the same domain of self-efficacy; the significant correlation

between the C-DMSES and C-PTES and SDSCA scores also demonstrated modest

evidence for criterion-related validity. Further, factor analysis supported the

C-DMSES being composed of four subscales equivalent to the Dutch version DMSES

although it clustered different items in the four subscales. However, the C-PTES

demonstrate consistency in just one factor with the original version PTES. According

to the criteria set for reliability testing, the internal consistency and the stability of the

C-DMSES and C-PTES were acceptable. Item analysis showed the homogeneity of

the items in measuring the construct. In addition, the 20-item C-DMSES and 10-item

C-PTES is relatively short and is easy to administer to Taiwanese persons with


257

diabetes. It generally requires only 15-20 minutes for completion of the C-DMSES

and 10-12 minutes for completion of the C-PTES. In conclusion, together with the

good psychometric properties of the C-DMSES and C-PTES, their value for use in

persons with diabetes in Taiwan is heightened.

For developing professional knowledge in self-efficacy in diabetes care in Taiwan, the

establishment of psychometrically sound assessment tools for clinical use is very

important. The above evidence of reliability and validity strengthens confidence in

using the C-DMSES and C-PTES. Validation and reliability of a measurement tool is

an ongoing process. Both of the C-DMSES and C-PTES thus need future studies to

strengthen psychometrically property.

The next section will discuss the evidence of this present study related to the

self-efficacy enhancing intervention program and the stated hypotheses.


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Discussion of Study II (Main Study)

7.5 Description of sample, sociodemographics, and illness history of

participants

The mean age of the total sample was 64.44 years and the average number of years

for which they had suffered from diabetes was 5.82 years. The respondents consisted

of 64.10% females. Most participants were married (83.40%). The majority of

participants had below primary schooling (59.30%), were living with family (91.75%)

and 84.10% had never been employed. The demographic characteristics of

participants were similar to those of a large Taiwanese survey report of diabetes (n=

5698) which was conducted by Tasi et al. (2002).

Half of the participants (51%) had been suffering chronic diseases other than diabetes.

This figure was similar to the finding of Chen, Chang and Lin (1998) that 68.20% of

diabetic patients had been suffering chronic diseases and the percentage of suffering

from chronic disease was higher than the general elderly population in Taiwan. Sixty

per cent of participants did not experience complications related to diabetes and

66.20% experienced monotherapy (oral hypoglycemics). These figures were similar

to the finding of Via and Salyer (1999) that the medication regimen for the majority of

the participants (65%) was oral hypoglycemics and 30% required insulin therapy.

Generally speaking, Taiwanese diabetic patients regard oral hypoglycemics as the first

choice for their disease treatment. Participants must visit the outpatient clinic

regularly to obtain their diabetic oral medicines.

Moreover, since 2001, the Bureau of National Health Insurance commenced a


259

quality-based payment program for improving diabetes care (Bureau of NHI, 2002).

This extra payment reimburses medical care providers if they provide nutrition

consulting and individual diabetic education. That is why nearly half of the

participants (49.70%) of this study readily accessed the patient education from

hospitals when they visited the OPD (73.10% of participants at baseline did regularly

visit the OPD).

Most of the limitations (attrition, experimenter’s expectations) were minimised

through a range of retention strategies employed in this study, such as, allowing

participants to make up a missed lesson at an alternate time/ setting and the researcher

being easily contactable. Thus, the retention rate was high in the intervention group.

Also, the high retention rate of control group participants was due to the requirement

for patients to routinely return to the outpatient clinic every two or four weeks for oral

medication. In addition, participants received a certificate of participation which

helped to maintain interest in the study and minimize attrition. Moreover, the role of

research assistants in recruiting participants and collecting data could minimize the

impact of the experimenter’s expectations regarding the results.

7.6 Research Question 2: Can an intervention (SEEIP) based on

self-efficacy theory improve self-management in people with type

2 diabetes in Taiwan?

7.6.1 Hypothesis 1: People who receive the intervention will have greater

self-efficacy towards managing their type 2 diabetes than people

who do not receive the intervention


260

Changes in self-efficacy over time

The present findings indicated that the self-efficacy (efficacy-expectations) could be

enhanced through the self-efficacy enhancing intervention program (SEEIP) at

three-month and six-month follow-up. These results support those of researchers who

have examined the effect of diabetes education programs on self-efficacy (Rubin,

Peyrot & Saudek, 1993; Anderson et al., 1995; Corbett, 1999; Guo, Tsay & Yen,

2002).

Rubin, Peyrot and Saudek (1993) found an improvement in self-efficacy scores at 6

and 12 months following their diabetes education program which focused on coping

skills training on emotional well-being and diabetic self-efficacy. The results of their

study reported that this program increased self-efficacy and decreased anxiety and

these effects remained 12 months after the program finished. Anderson et al. (1995)

observed gains in self-efficacy in their patient empowerment diabetes education

program for their intervention group, and overall sustained improvements in all

self-efficacy areas at the 12-week follow-up. Corbett et al. (1999), who based her

study on Bandura’s four sources of self-efficacy, measured self-efficacy before and

after a home visit by a nurse. Interventions were teaching and other

efficacy-enhancing activities. Diabetes-related self-efficacy improved significantly

after home care. People with lower self-efficacy received more general interventions

from the home care nurses but people with high self-efficacy received two advanced

self-care activities, prevention of hypo and hyperglycaemias and adjustment of insulin.

In Taiwan, Guo, Tsay and Yen (2002) conducted an empowerment-training program

for persons with diabetes in hospitals and then evaluated improvements in HbA1c,

self-efficacy and depression levels. Patients in the experiment group showed more


261

significant improvement in the levels of empowerment, self-efficacy and self-care

than the patients in the control group. The finding of this present study met the

hypotheses and was consistent with the modified self-efficacy model for evaluation of

the SEEIP for people with type 2 diabetes

Changes in outcome expectations over time

The present findings indicated that outcome expectations also could be enhanced

through the self-efficacy enhancing intervention program (SEEIP) at three-month and

six-month follow-up. Very few studies have examined outcome expectations (as the

dependent variable) following the implementation of a diabetic intervention related to

self-efficacy theory. The present results support those of Miller, Edwards, Kissling &

Sanville (2002). Their intervention study evaluated a social cognitive-based nutrition

intervention and examined outcome expectations (Miller et al., 2002). Older adults

with diabetes were involved in the study with 48 in the experimental and 50 in the

control group. Participants in the experimental group attended a 10 weekly nutrition

intervention. Study findings found the experimental group had significant

improvement in outcome expectations compared to the control group.

Although the result of the present study was consistent with Miller’s study, there were

differences in the sample and the design of diabetic intervention between these two

studies. No previous studies could be found to compare the effects of outcome

expectations following the delivery of a diabetic intervention related to self-efficacy

theory. Some studies, however, have shown a relationship between outcome

expectations and self-efficacy or self-care behaviour. For example, Kingery and

Glasgow (1989) found self-efficacy and outcome expectations were moderately

strongly associated with self-care behaviour (dietary and glucose testing) and the


262

authors argued greater attention should be directed toward examination of the

outcome-variable in future diabetic interventions.

Self-efficacy offers a basis for improving the effectiveness of diabetes education

because it focuses on behavioural change (van der Bijl & Shortridge-Baggett 2001).

There are two cognitive components in the theory, efficacy expectations and outcome

expectations (Bandura 1977a) and Bandura (1982) proposed that behaviour is best

predicted by considering both self-efficacy and outcome expectations. Self-efficacy

provides the confidence to overcome barriers to undertake a certain behaviour

whereas outcome expectations provide the motivation for the behviour (Bandura,

1995). In hypothesis 1 of the present study, self-efficacy towards managing type 2

diabetes (including both self-efficacy and outcome expectations scores) can be

increased with a moderate effect size (.13 to .20). This approach contributes to the

strategies and instruction of the SEEIP. A major concept in the efficacy- enhancing

counselling intervention sessions of the SEEIP was self-efficacy (confidence)

whereby people were encouraged to believe they could carry out behaviour necessary

to reach a desired goal. During the intervention, participants were asked to assess their

confidence to achieve their plans on a 0-10 scale where ‘0’ refers to ‘no confidence at

all’ and ‘10’ refers to ‘very confident’. For example, the facilitator asked participants

“If you decide to change the regularly of your blood sugar level check, how confident

are you that it will work?”. Participants were asked to choose a number and said “why

do you give yourself this score instead of a higher score?” Facilitator would proceed

with the following question: “you gave yourself a score of 4”. How do you think you

could increase your confidence to pursue a higher score? How could you make

yourself more confident? ” The practice sessions were designed to foster self-efficacy

enhancing skills and focused on increasing performance accomplishment, sharing


263

experience (vicarious experience), using verbal persuasion, and self-evaluation in

order to assist participants in managing their diabetes.

In addition, in this present study, examination of the reliability and validity of the

C-DMSES (used to measure self-efficacy) and C-PTES (used to measure outcome

expectations), adds to current tools available to evaluate diabetes-related self-efficacy

in self-management of diabetes. The findings support the importance of incorporating

self-efficacy and four information sources into the diabetes education interventions.

Van de Laar and Van der Bijl (2001) reported that helping people set achievable goals

and focusing on the success of attaining the goals enhances self-efficacy. Bandura

(1977b) remarked that efficacy expectations (confidence in ability) and outcome

expectations (belief that the behaviour will have the desired effect), and their

influence on behaviour change is synergistic. The findings of the present study

demonstrated enhanced levels of self-efficacy and outcome expectations and

confirmed the effects on diabetic patients as those who received the SEEIP had

greater self-efficacy towards management of their type 2 diabetes.

7.6.2 Hypothesis 2: People who receive the intervention will undertake

diabetes self-care activities more frequently than people who do

not receive the intervention

This study evaluated an intervention based on self-efficacy theory to improve diabetes

self-care for people with type 2 diabetes. Results showed that people who received the

intervention undertook diabetes self-care activities more frequently than people who

did not receive the intervention at both three-month and six-month follow-up. This

finding was consistent with findings reported by Glasgow et al. (1992), Anderson et al.

(1995) and Fu et al. (2003).


264

In the USA, Glasgow et al. (1992) conducted a 10-session self-management training

program designed for people over 60 years of age with type 2 diabetes which targeted

problem-solving skills and self-efficacy. 102 adults were randomized to immediate or

delayed intervention conditions. At post-test, subjects in the immediate group showed

significantly greater reductions in calorie intake (29% versus 10%, p< .05) and

percent of calories from fat (45% versus 29%, p< .05) than control subjects.

Additionally, the intervention group increased the frequency of glucose testing

(r=- .21, p< .05) compared to the control group.

Anderson et al. (1995) conducted a randomized controlled evaluation of their

empowerment program, focusing on self-efficacy and its component skills in the US.

Participants (n=86) were asked to complete experiential worksheets, attend six

sessions and participate in group discussions. At 12 weeks from baseline, the

intervention group demonstrated a significantly greater improvement in glycosylated

haemoglobin than the control group (intervention 11.75 ± 3.01% to 11.02 ± 2.89 %;

control 10.82 ± 2.94 % to 10.87 ± 2.59 %, p=.05). Self-efficacy was significantly

increased among the intervention group in terms of setting goals, managing stress,

obtaining social support and making self-care treatment decisions.

In Shanghai, mainland China, Fu et al. (2003) conducted a study to evaluate the

effectiveness of a chronic disease self-management program (CDSMP). A randomised

controlled trial was undertaken with six month follow-up comparing patients who

received treatment with those who did not receive treatment. Participants in the

treatment group received education from a lay-led CDSMP leader and one copy of a


265

help book. Results showed that patients who received treatment (n=526) had

significant improvements in their weekly minutes of aerobic exercise (> 25 minutes,

p= .01), and scores in their practice of cognitive symptom management increased

by .37 (p= .01).

Findings presented by participants of the present study demonstrated it was also

participants (especially older people) need to repeat a single task until they have

mastered it and this eventually leads to success. Performance accomplishment, the

repeated execution of the task, is the most powerful source of improving self-efficacy

as it is based on direct information. Sometimes people interpret their successes

negatively. They do not see their successes or they underestimate their importance. In

these cases, it is important to establish goal setting in order to enhance self-efficacy

(van der Laar & van der Bijl, 2001). The combination of setting goals in a contract

and giving feedback is important in the present study. Before every education session,

feedback should be given on the goals of the preceding period, and clients should

report their achievements (van der Laar & van der Bijl, 2001). Moreover, a diabetes

diary is another good source of feedback for persons with diabetes. For example,

blood glucose values, the self-care actions and the surrounding circumstances can be

noted in the diary, and therefore the client can gain insight into self-regulation (van


The contents and strategies built into the design of the intervention improve self-care

behaviour. Hurley and Shea (1992) claimed diabetes education can be focused on

promoting independence and confidence, therefore, patients will carry out their

self-care activities. When patients believe they can perform self-care activities (with

higher self-efficacy), they make the most of their skills and easily succeed.


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7.6.3 Hypothesis 3: People who receive the intervention will have better

HRQOL than people who do not receive the intervention

In the present study, health-related quality of life (HRQOL) was not significantly

increased in the intervention group at either the three-month or six-month follow-up

compared to the control group. Results indicate change over time was not different in

the two groups. However, several researchers have found significant improvement in

quality of life in previous studies (Grey et al., 2000; Rose et al., 2002; Fu, et al.,

2003).

Grey et al. (2000) conducted a behavioural intervention combined with intensive

diabetes management (IDM) sustained over 1 year in a youthful population.

Participants (n=77) electing to initiate IDM were randomly assigned to one of two

groups: with or without coping skills training (CST), which consisted of 6 small

group sessions and monthly follow-up to help the youth cope with their lives; skills

included social problem solving, cognitive behaviour modification, and conflict

resolution. The results showed the CST subjects had lower HbA1C (p= .00) and better

diabetes (p= .00) and medical (p= .04) self-efficacy, and less impact from diabetes on

their quality of life (p= .01) than youth receiving IDM alone after 1 year.

Rose et al. (2002) used structural equation modelling and confirmed when a patient

reports strong beliefs in self-efficacy, he or she is more likely to report a higher

quality of life. Furthermore, Fu, et al. (2003) conducted a chronic disease

self-management program (CDSMP) and found that, after six months follow-up,

patients who received treatment (n=430) had significant improvements in HRQOL

(eight measures of health status) (p< .05).


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Even though some previous studies have shown self-efficacy could enhance HRQOL,

Maddigan et al. (2004) argued few patient-reported outcomes such as HRQOL were

captured and it was important for its effect to be examined in further diabetic

intervention studies. The finding of this present study failed to find congruence

between the significant effects of the self-efficacy enhancing intervention program

and HRQOL. This may well be explained by the fact that participants in the present

study had quite high HRQOL scores at baseline. For example, in this present study,

the mean score of PCS for the intervention at baseline (43.26) was higher than those

of the diabetic study (39.50 for the intervention) which was reported by Nichols and

Brown (2004). These higher mean scores may have precluded the ability to detect

further significant increases in the present study.

The other explanation for these findings may be may be that other factors influenced

the concept of quality of life. The lack of detecting other concepts which affect

HRQOL may potentially influence the results of the SEEIP. Wexler et al. (2006)

examined the relationship of clinical variables to HRQOL in primary care patients

with type 2 diabetes and found depression is a well-recognised determinant of quality

of life in diabetes and people with type 2 diabetes have a substantially decreased

quality of life in association with symptomatic complications. Authors suggested that

treatment of depression and prevention of complications have the greatest potential to

improve HRQOL in type 2 diabetes. The other example is that coping with a chronic

disease and improving quality of life requires substantial effort and a great capacity to

adjust to new and changing situations on the part of the ill person (Kuijer & deRidder,

2003). Several tasks, such as maintaining an emotional balance, maintaining

self-esteem and attaining personal goals are common to a chronic disease and may be


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difficult to meet for some patients. Kuijer and deRidder (2003) found greater

discrepancy in goal attainability was generally associated with lower levels of quality

of life. In this present study, the lack of detecting other concepts that affect HRQOL

may influence the effects of the SEEIP.

Moreover, to improve HRQOL for people with diabetes requires time to adjust to

circumstances and to refine goals. The result of this present study may be a reflection

of the follow-up intervention. The outcome measure of HRQOL may have been

different if the intervention could have been extended over a longer period of time. As

a further limitation, the 6-month follow-up period for evaluating changes in

humanistic outcomes, particularly HRQOL, was relatively short. Evaluation over a

longer period of time for this study needs to be considered.

7.6.4 Hypothesis 4: People who receive the intervention will have better

psychosocial well-being than people who do not receive the

intervention

Changes in social support over time

Diabetes creates a need for increased support, as the demands of the regimen are

extensive (Guthrie & Guthrie, 2002). White, Richter and Fry (1992) stated the greater

the perceived social support, the better the psychosocial adjustment to illness.

Williams and Bond (2002) found that social support was associated with exercise

self-care and the relationship between the two variables was mediated by self-efficacy.

Moreover, Gallant (2003) stated there might be an indirect influence of social support

on diabetes self-management through self-efficacy. In this present study, people who

received the SEEIP had better social support than people who did not receive the

intervention, and social support for the intervention group was increased between


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Time 1 and Time 3. These results were consistent with those of researchers who have

examined the effect of diabetes education programs previously (Maxwell, Hunt &

Bush, 1992; Lai & Liu, 2003).

In a randomised clinical trial conducted by Maxwell, Hunt and Bush (1992), 204

patients with diabetes were randomly divided into two groups. The control group

received a training program only, whereas the experimental group was offered the

same program in addition to eight support group meetings, where they had the

opportunity to receive informational and emotional support. After 7 months of

follow-up, patients in both groups showed improved metabolic control (HbA1C),

diabetes knowledge, frequency of practicing recommended diabetes management

behaviours, and emotional adjustment. No further improvement was seen in those

people in the experimental group. However, more than 80% of the participants in the

experimental group reported that members of the group supported each other and

helped them to cope with problems related to diabetes more easily.

Lai and Liu (2003) undertook a social support and empowerment education module

(SSEM) and evaluated the effect of social support on people with type 2 diabetes in a

community in Taiwan (n=49). The experimental group took part in a series of SSEM

courses based on social cognitive theory during a 4-week period of time. The SSEM

course significantly increased social support and empowerment in the experimental

group and empowered patients with self-efficacy and self-care behaviour.

The efficacy-enhancing counselling intervention sessions involving small group

practice sessions for fostering self-efficacy enhancing skills, self goal-setting, sharing

and peer support, aimed at changing norms in the intervention group and were


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particularly effective for the variable of social support. For example, viewing a

10-minute DVD provided participants with a vicarious experience opportunity,

showing a person with type 2 diabetes who successfully used self-care activities to

control the occurrence rate of acute and chronic complications.

Also, a booklet presented four stories of how Mei-mei, Wan-tsai, and Ai-Jiau

experienced difficulties and encountered different problems. Questions in the booklet

promoted discussions. Participants in the intervention group realised they were not the

only person who had difficulty in controlling their disease. Comparison of their own

situation with others in a small group setting promoted medical referral, increased

confidence, and encouraged goal setting. Increasing confidence and goal setting were

important in maintaining self-management activities (Barlow, Wright, Turner &

Bancroft, 2005). In this study, social support from peer members was one resource for

building diabetes self-efficacy. The social environment in which individuals operate

might facilitate people’s self-efficacy.

Changes in depression over time

Depression is a major outcome experienced by people with diabetes and contributes to

high economic burden and health care costs (deGoot et al., 2001). Therefore, it is

necessary to explore the impact of depression on people with diabetes. In the results

of the present study, depression scores did not change over time in the two groups.

However, Rubin, Peyrot and Saudek (1993) and Wright and colleagues (Wright et al.,

2003; Barlow et al., 2005) found significant improvement in depression when

undertaking their study.


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Rubin, Peyrot and Saudek (1993) reported an improvement in self-efficacy scores at 6

and 12 months following their diabetes education program which focused on coping

skills training related to emotional well-being and diabetic self-efficacy. They

reported increased self-efficacy and decreased anxiety. The research thus

recommended the incorporation of diabetes self-efficacy and behavioural efforts into

diabetes education designed to improve emotional status.

An RCT study of self-management training for people with chronic disease was

conducted by Wright et al. (2003). They determined the effectiveness of a

community-based chronic disease self-management course (CDC) for UK participants

(n=232) with a range of chronic diseases. The CDC comprised six weekly sessions

and aimed to enhance self-efficacy through weekly action planning sessions which

involved problem solving, decision-making, role modelling, and persuasion. In the

results, significant reductions were found for female participants in respect of

depressive and anxious moods. Also, the research team undertook a 12-month

follow-up study of self-management training for people with a chronic disease, and no

significant changes between 4 and 12 month assessments were found in any study

variable (Barlow et al., 2005). They concluded attendance at the self-management

training program may lead to longer-term changes in self-efficacy, self-management

behaviours and depressed mood.

On the other hand, results of the present study were consistent with a previous study

reported in Taiwan. Guo, Tsay and Yen (2002) undertook an empowerment-training

program for people with diabetes in hospitals and then evaluated improvements in

HbA1C, and depression levels. There were no significant findings in blood sugar

control and depressive mood between groups.


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In this present study, failure to find change in relation to depression may be attributed

to the type of questionnaire, the length of this study and nature of the chronic disease

in the sample. The CES-D (Center for Epidemiology Studies Short Depression) Scale

is a self-administered tool which is a 10-item measure of depression. Even though

Kibourne et al. (2002) explain that the CES-D 10-item survey is used instead of a

more comprehensive instrument such as the CES-D 20-item survey, in order to

minimise respondent burden, it seems difficult to collect enough participant data

regarding depression through the 10-item tool. Moreover, the length of the study was

not sufficient to examine the effects of depression. The findings of this study reflected

the outcome only during a short period of time (6 months). Longer (1-2 years)

follow-up studies are needed to determine whether benefits are found over the

life-course of the disease.

Kibourne et al. (2002) classified CES-D scores 0 to 9 as indicating a mild level of

depression symptoms, 10 to 14 as moderate depressive symptoms, and >15

representing severe depressive symptoms. In this present study, the mean score of

depression at the baseline for the intervention (9.64) and control group (9.29)

indicated a mild level of depression symptoms. Comparing with the score of CES-D

scale in those of study of van der Ven et al. (2005), the proportion of diabetic patients

who were likely to be clinically depressed (CES-D > 16) accounts for 44% of the

intervention group at the baseline. The high baseline score of this present study may

preclude the ability to detect further significant decreases. Moreover, Grigg,

Thommasen, Tildesley and Michalos (2006) undertook an investigation for people

with type 2 diabetes and found patients with diabetes understand they have poorer

health than others, but no more likely to be unhappy or dissatisfied with their lives.


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The authors claimed even though a person may recognize that his or her current health

is not well, he or she may not feel motivated to maintain or improve it if they are

already satisfied with it. This also may explain why failure to find change in relation

to depression over time in the two groups in the present study.

The impact of psychosocial factors is a stronger predictor of mortality in diabetic

patients than many other physiological variables (Delamater et al., 2001). In this

present study, the variable of psychosocial well-being includes the factors of social

support and depression; however, only social support was significantly improved in

this study.

7.6.5 Hypothesis 5: People who receive the intervention will have a lower

usage of health services than people who do not receive the

intervention

According to 2003 Taiwanese Bureau of National Health Insurance data, healthcare

cost for diabetic patients amounts to 11.50% of the total healthcare expenditure in

Taiwan (Tseng, 2003) and consumes more than 320 million US dollars (Taiwan

Health and Vital Statistics, 2003; Tseng et al., 2006). The costs of diabetic patients

have increased rapidly under the Taiwanese National Health Insurance (NHI)

program. How to improve the quality of diabetes care cost-effectively is an urgent

issue (Tseng et al., 2006).

In this present study, 8.30-9.70% of participants in the intervention group and

8.20-15.10% of participants in the control group had been admitted to hospital

previously. Furthermore, 6.90-12.50% of participants in the intervention group and

8.20-17.80% of participants in the control group had visited an emergency room.


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Tseng (2003) reported the rate of previous admission to hospital in 2001 was 19.90%,

and visits to an emergency service, 20.80%. The admission to hospitals and visits to

emergency room rates of our study were found to be less than figures identified in

Tseng et al.’s work.

The results of health service usage in this study showed a greater proportion of

participants in the control group have been hospitalised and have visited an

emergency room than for the participants who were in the intervention group at Time

3 (six-month follow-up). These results support those of previous researchers who

examined the effect of a chronic disease self-management program (CDSMP) in

Shanghai (Fu et al., 2003). Their study results showed patients who received

treatment (n=430) had significant improvements and fewer hospitalisations (p= .00)

compared with those in the control group.

The health service usage of participants in this present study did not change during the

first three months (Time 2), but decreased at sixth months (Time 3). This gradual

improvement in hospitalisations and emergency room visits in the intervention group

may be attributed to the longer term effect of behaviour change. According to

Bandura (1986), self-efficacy plays an important role in predicting behaviour and its

outcomes. Obviously, participants’ self-efficacy towards self-management increased

following the implementation of the SEEIP, which in turn increased respondents’

sense of confidence in attending to their self-care activities. Prochaska and

DiClemente (1983) stated maintaining long-term motivation and cooperation are the

main problems for patients with diabetes; it requires the changing of lifelong

behaviours of diet and physical activities, and this is a very difficult and complex

process. It is clear that behaviour change needs time to take effect as demonstrated in


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the reduction in hospitalisations and emergency visits after 6 months rather than 3

months.

Interestingly, there was no significant change (reduction) in the rate of OPD visits

between the intervention group compared to the control group at all three points of

time. In Taiwan, people with diabetes believe regular OPD visits are a superior and

effective way to control diabetes. In this present study, there were no significant

differences between intervention and control group participants who visited the OPD

regularly. According to Tseng et al. (2006), who conducted a large diabetic

investigation in Taiwan (n=2259), the observations of multiple care unit visits (mean

21.70± 18.10) of diabetic patients revealed the convenience of seeking medical care in

Taiwan. Due to the lack of an orthodox system of family physicians in Taiwan,

patients can visit a hospital directly without referral from general practitioners. People

have free access to medical care as the NHI provides convenient transportation and

applies no strict regulation in the referral process (Tai et al., 2006). Although visiting

the OPD is an effective solution for participants in Taiwan, there was no significant

change in the proportion of OPD visits in the intervention or the control groups at any

points of time.

7.7 Summary discussion of Study II (Main Study) The participants for both groups were similar in relation to socio-demographics,

illness history, and health care utilisation. Overall, the findings were consistent with

the modified self-efficacy model for people with type 2 diabetes (Section 4.5.1.1),

except for the variables of HRQOL and depression. Failure to find change in

depression may be attributed to the high scores at baseline, the nature of the chronic

disease in our sample and the length of this study.


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Findings of the present study indicate the SEEIP can advance both levels of

self-efficacy and outcome expectations, self-care activities, and social support with a

small or moderate effect size (Eta equare ranged from .10 to .20). These findings may

contribute to developing the content and design of SEEIP, for example, the booklet

and the efficacy-enhancing counselling intervention sessions for fostering

self-efficacy enhancing skills, self-goal setting, sharing and peer support for diabetics

which aimed at changing norms in the intervention group were particularly effective.

Moreover, the SEEIP reduced health care utilisation in Taiwan. This gradual

improvement (decreasing at the sixth month) in hospitalisations and emergency room

visits in the intervention group was attributed to the behaviour change. In conclusion,

SEEIP focused on promoting independence and confidence in patients to carry out

their self-care activities and produce better health outcomes. The information about

the SEEIP effects of self-management for people with type 2 diabetes can be useful in

Taiwan.

Student number: n4513282 Shu-Fang Wu Chapter 8 Conclusions and Recommendations

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Chapter 8

Conclusions and Recommendations

8.1 Introduction

Diabetes mellitus is a prevalent, costly condition associated with substantial morbidity

and mortality in Taiwan. Taiwanese health care system has persistently emphasised

patients’ health education, however, there remains a lingering doubt about how

effective it is in achieving the desired effect of improvement in self-care of people

with diabetes. It is important to prevent diabetic complications through patients’

self-management and to prolong the lives of the patients. The self-efficacy model

provides a useful framework and scientific evidence base for diabetes interventions. A

pilot study of the main study revealed that the effectiveness of the SEEIP for type 2

diabetes based on the self-efficacy theory was culturally acceptable to Taiwanese

people with diabetes and the main study showed that the SEEIP is effective in the

self-management for people with type 2 diabetes.

The purpose of this study was to develop, trial and evaluate a theory-based nursing

intervention program suitable for people with type 2 diabetes in Taiwan. The

evaluation focussed on the effects of enhancing self-management, health-related

quality of life, and psychosocial well-being for people, to determine if there was any

reduction in health service usage. To achieve the purposes, several objectives and

questions were developed.

Objectives:

• Translate and test the validity and reliability of two diabetes-specific


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self-efficacy instruments (DMSES scale & PTES scale) in a Taiwanese

population.

• Develop an intervention based on self-efficacy theory that is appropriate for

the Taiwanese population; and

• Use a randomised controlled trial to evaluate the efficacy of the intervention in

a Taiwanese population in improving:

1. Self-efficacy towards management of type 2 diabetes;

2. Diabetes self-care activities, i.e., adherence to medication regime;

blood glucose testing; foot care;

3. HRQOL (health-related quality of life);

4. Psychosocial well-being; and

5. Health service utilisation.

Research Questions:

Study I

Research Question 1: Are the two diabetes-specific self-efficacy instruments, the

DMSES and PTES, valid and reliable for a Taiwanese population?

Study II

Research Question 2: Can an intervention based on self-efficacy theory improve

self-management in people with type 2 diabetes in Taiwan?

Within Research Question 2, the following further questions were examined.

For people with type 2 diabetes, following implementation of the SEEIP, is there a

difference in their: self-efficacy, self-care activities, health-related quality of life,

psychosocial well-being and health care utilisation?


279

This chapter will provide an overview of the key findings of the study and present

recommendations for clinical practice, nursing education and research in the future.

8.2 Conclusion and significance of Study I

Results of this study supported the validity and reliability of the Chinese version of

the DMSES (C-DMSES) in providing a measure for self-efficacy specific to people

with type 2 diabetes. Three items were modified to better reflect Chinese practice

during the translation process. The C-DMSES obtained a total average CVI score

of .86. The convergent validity of the C-DMSES correlated well with the validated

measure of the General Self-Efficacy Scale in measuring self-efficacy (r=.55; p<.01).

Criterion-related validity showed the C-DMSES was a significant predictor of the

Summary of Diabetes Self-Care Activities scores (Beta= .58; t=10.75, p< .01). Factor

analysis supported the C-DMSES being composed of four subscales. Good internal

consistency (Cronbach’s alpha= .93) and test-retest reliability (Pearson’s correlation

coefficient r= .86, p< .01 and a Bland-Altman plot showed that 97% of the subjects

were within 2 standard deviations of the mean) were found.

Similarly, results of this study supported the validity and reliability of the Chinese

version of the PTES (C-PTES) in providing a measure for self-efficacy specific to

persons with type 2 diabetes. Four items on the C-PTES scale were changed during

the development process. Significant criterion-related validity was demonstrated

between the C-PTES and the Summary of Diabetes Self-Care Activities scores

(Beta= .32; t= 5.14, p<. 00). Convergent validity was confirmed as the C-PTES

converged well with the General Self-Efficacy Scale in measuring self-efficacy


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(r= .42; p< .01); Construct validity using factor analysis composed of single subscale.

Internal consistency showed Cronbach’s alpha was .95 and the test-retest reliability

resulted in a coefficient of .79 (p< .01) and a Bland-Altman plot showed that 97% of

the subjects were within 2 standard deviations of the mean.

The 20-item C-DMSES and 10-item C-PTES were relatively short and were easy to

administer to Taiwanese persons with diabetes. It generally required only 15-20

minutes for completion of the C-DMSES and 10-12 minutes for completion of the

C-PTES. Together with the good psychometric properties of the C-DMSES and

C-PTES, their value for use in people with type 2 diabetes in Taiwan was heightened.

The findings provide nurses and other health providers or researchers using the

instruments to examine the development of interventions for diabetes.

8.3 Conclusion and significance of Study II

Pilot study

A self-efficacy enhancing intervention program (SEEIP) emphasised confidence

enhancing and goal-setting skills in order to increase self-efficacy and change

people’s behaviours. Four sources of information adopted from Shortridge-Baggett

and van der Bijl (1996) and Bandura (1977a) are applied in the intervention of the

SEEIP. The SEEIP guided people to identify their problems and provides techniques

to help people make decisions, and take proper actions as they encounter changes in

circumstances and improve their health outcomes.

Four provider experts (a nurse; a doctor; a nutritionist; and a clinical diabetes educator)

contributed expert input to assist with the development and validation of this

intervention. The panel-modified version of the SEEIP was pilot tested with 6 patients


281

from a diabetes outpatient clinic in a medical center. All participants stated they had

no difficulties in understanding the contents of a DVD, “Diabetes Self-Care” booklet,

and four weekly efficacy-enhancing counselling intervention sessions, and they all

expressed willingness to receive follow -up telephone calls. In this pilot study, based

on the comments from the sample of 10 people, the intervention of SEEIP was shown

valid and was then used in the main study. The intervention suite of the SEEIP is

summarised in Chapter 5, Table 5.3.

Main study

The participants for both groups were similar in relation to the sociodemographics,

illness history, the key variables and health care utilisation. Five hypotheses were

examined and answered:

Hypothesis 1: People who receive the intervention will have greater

self-efficacy towards managing their type 2 diabetes than people who do not

receive the intervention.

The scores of the efficacy expectations and outcome expectations were significantly

increased in the intervention group at Time 2 and Time 3 compared to those of the

control groups (p<.01). Efficacy expectations and outcome expectations were

increased between Time 1 and Time 2 and Time 2 and Time 3.

Hypothesis 2: People who receive the intervention will undertake diabetes

self-care activities more frequently than people who do not receive the

intervention.

The score of self-care activities was significantly increased in the intervention group

at Time 2 to and Time 3 compared to those of the control groups (p<.01). Self-care

activities increased between Time 1 and Time 2 and Time 1 and Time 3.


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Hypothesis 3: People who receive the intervention will have better HRQOL


The results of this study could not support the Hypothesis 3 as the scores of the health

(physically and mentally) related quality of life were not significantly increased in the

intervention group at Time 2 or Time 3 compared to those of the control groups. The

results indicated that the change over time was not different in the two groups.

Hypothesis 4: People who receive the intervention will have better

psychosocial well-being than people who do not receive the intervention.

The interaction effect of group by time for the social support was significant and the

score of social support was increased between Time 1 and Time 3 (p<.01). However,

the results of the depression scores indicated that the change over time was not

different in the two groups.

Hypothesis 5: People who receive the intervention will have a lower usage of

health services than people who do not receive the intervention.

A smaller proportion of the participants in the intervention group, have been

hospitalized (p<.01) and visited the emergency room (p<.05) than the participants

who were in the control group at Time 3.

Overall, the findings met the hypotheses and were consistent with the modified

self-efficacy model for evaluation of the SEEIP for people with type 2 diabetes

(Section 4.5.1.1), except for the variables of HRQOL and depression. Failure to find a

change on depression may be attributed to the high scores at baseline, nature of the

chronic disease in our sample and the length of this study. The information about the

SEEIP effects of self-management for people with type 2 diabetes can be helpful in

Taiwan.


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8.4 Implications

The study has implications for various areas, including further clinical practice,

nursing education and nursing research.

1. Both the C-DMSES and C-PTES are relatively short and easily administered and

provide a measure of self-efficacy and outcome expectations in people with type 2

diabetes in a Taiwanese population. Facilitating personal self-efficacy of an

individuals’ ability to manage self-care regimens, is viewed as an effective solution

for diabetes management in Taiwan. However, there are few instruments measuring

self-efficacy towards management of diabetes, in particular, focusing on measuring

outcome expectations, which have been found useful to measure the effectiveness of

self-management. For developing professional knowledge, in self-efficacy in diabetes

care in Taiwan, the establishment of psychometrically sound assessment tools for

clinical use is very important. The above evidence of reliability and validity

strengthens confidence in using the C-DMSES and C-PTES in further diabetic

research undertaken in Taiwan.

2. It is important that interventions for Taiwanese patients with type 2 diabetes

incorporate the concept of self-efficacy in their design and implementation. Four

information sources of the self-efficacy model applied into the strategies of the

intervention were found to be effective. The SEEIP is based on self-efficacy theory,

which effectively assists people with diabetes to self-manage their disease, for

example, the SEEIP can advance both levels of self-efficacy and outcome

expectations, self-care activities, and social support with a small or moderate effect

size (Eta equare ranged from .10 to .20). The SEEIP aims to assist people to maintain

a healthy lifestyle, seek support, solve problems and make an action plan and may be

an improvement on the traditional health education of diabetes.


284

This study, through transforming the theory into actual clinical health plans,

demonstrates how it is possible to carry out and apply the self-efficacy-enhancing

training program in individual cases with diabetes, and to strengthen confidence of

self-care ability and change health behaviours. Diabetes educators and researchers

could understand these factors related to self-efficacy and self-care behaviour applied

in diabetic patients and their use in diabetes education or interventions. We suggested

that the SEEIP program should be included in the clinical care for people with type 2

diabetes.

3. This study was conducted in a medical center in Taipei. In general, the SEEIP has

had great effects on the self-management in people with type 2 diabetes. Replication

of this study in various setting (such as regional hospitals or communities) or other

population (such as type 1 diabetes) would also be beneficial. Moreover, the

applicability of the intervention program design may be modified and extended to

other chronic diseases, for example, hypertension or heart diseases.

4. This study provides evidence and increases nursing staff’s confidence to apply the

SEEIP in practice because nursing staff can be trained to effectively implement the

SEEIP. Patient education faces the challenge of generating new and innovative ideas

for practice. Peyrot et al. (2005) mentioned that to improve psychosocial health

outcomes of diabetic patients, it also requires increased training for providers to

enhance their confidence and skills in managing patients’ problems. Health providers

can introduce self-efficacy enhancing strategies into their nursing interventions and

can be trained to provide relevant diabetic interventions based on self-efficacy theory.


285

5. It is important to provide care for patients both physically and mentally. Thus this

study has taken a cross-discipline approach across the fields of nursing care and

counselling. In this study, four efficacy-enhancing counselling intervention sessions

were undertaken. Subjects participated in small counselling group which contained

self-efficacy enhancing skills fostering self-goal setting, sharing and peer support for

diabetes. There were numerous opportunities for patients to share with and learn from

others who experienced the same problems as themselves. Also, nurses or other health

providers involved played a vital role in affecting changes in self-care for diabetes

management. We suggest providing support-based interventions to groups rather than

individuals. It is worth promoting this kind of application for diabetes patients and

encouraging related research to integrate physical and mental health care for chronic

patients which will lead to greater self-efficacy and peer support.

6. The knowledge obtained from this study enhance future nursing education.

Publication of the present research study (see List of Publications, p. iv) introduce a

comprehensive theory and a rich growing body of international knowledge about

self-efficacy and self-management of a chronic disease in Taiwan and provide nurses

with knowledge and enable them to practise safe and competent evidence-based care

for people with chronic diseases such as diabetes. Results apply to chronic diseases

where patients are required to make changes to their self-management practices.

Teaching the relevance of the concept of self-efficacy to nurses can lead to

improvement in patient education and subsequently improvement in self-management

and patients’ health outcomes. Education for practising nurses could include seminars

or training course on the usefulness of self-efficacy in patient education.


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8.5 Limitations

Research limitations were primarily related to the research design. Although most of

the limitations were minimised through strategies incorporated as part of the research

process (for example, the randomised controlled trail is considered to be the strongest

design when testing hypotheses), the non- double blind design may appear to be

biased in that participants may exaggerate the data they provide. Moreover, the

potential for response bias may be attributed to the self-reporting nature of the data.

It has not been possible with this study design to completely exclude the possibility of

a Hawthorn effect. The effects of the SEEIP of this present study may be influenced

by a Hawthorn effect due to the increase of the researcher’s attention on participants

in the intervention group. We provided a standard research procedure to undertaken

the intervention of SEEIP in order to minimise the limitation.

The findings of this study reflected the outcomes only during a short period of time (6

months). The length of the study was not sufficient to examine the effects of the

SEEIP; for example, the change of health-related quality of life and depression over

time had no significant differences in the intervention and control group. Longer

follow-up studies are needed to determine whether benefits are found over the

life-course of disease. A 1-2 year follow-up study is required to be undertaken in the

future.

A tool designed to collect the health care utilisation at the beginning of this study

considered “the continuous variables”: number of hospitalisations; number of visit to

emergency room and OPD; and the cost amount of hospitalisations and emergency

room visits. Unfortunately, participants disclosed they found it difficult to recall the


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data of the exactly number and were only able to answer “yes” or “no”. Therefore, the

“continuous variables” were changed to “categorical variables”. This change may

influence those results of this study.

Finally, this study did not measure HbA1c as a physiological indicator. Many

international studies of outcome measures used glycosolated hemoglobin levels

(HbA1c), a test indicating a three-month average blood glucose level. A systemic

review of evidence-based interventions study conducted by DeCoster and Cummings

(2005) found that of those 73 intervention articles more than one-third (40%) used

HbA1c as an outcome measure. This present study fails to measure HbA1c as a

physiological indicator which may will be explained by the fact that diabetes patients

in the Taiwanese medical system lack routine HbA1c testing. HbAc1 data was

difficult to measure in the present study. However, the majority of patients with

diabetes in Taiwan still do not control their disease appropriately recently, for

example, only 9.4 % of patients < 65 years and 14.0% of patients >65 years had

HbA1c values within the optimal range (HbA1c < 6.5 %) (Tai et al., 2006). Further

studies need to consider the HbA1c indicator to measure long-term physiological

health outcomes in the intervention studies of diabetes.

8.6 Recommendations

1. The above evidence of reliability and validity strengthens confidence in using the

C-DMSES and C-PTES, however, validation of a measurement tool is an ongoing

process. Both the C-DMSES and C-PTES thus need future studies to confirm their

psychometric properties.

2. Some participants found it difficult to disclose their personal circumstances or


288

difficulties. A qualitative research study is required to clarify their individual needs.

Replication of this study in various settings or with other populations and adding

other outcome measures (such as HbA1c) would also be suggested in further studies.

3. We suggest interventions or patient education for Taiwanese people with type 2

diabetes incorporate the concept of self-efficacy in their design and implementation

and that they provide support-based interventions to groups rather than individuals.

Actually, health providers can be trained to provide relevant diabetic interventions

based on self-efficacy theory and can introduce self-efficacy enhancing strategies into

their nursing interventions. Overcoming cost barriers could be undertaken through

reimbursement of attendance at the SEEIP from the National Health Insurance. For

example, “diabetes quality-based payment programs” could be granted to medical

providers, reimbursing them for providing the SEEIP intervention. Health providers

have traditionally cared for diabetes clients on an individual basis and thus their use of

interventions has been considered costly and time prohibitive. However, the findings

of the present study provide evidence of effectiveness of the use of group activity

through the SEEIP and may influence the national policy makers to consider adding

or modifying the reimbursement criteria.

4. Health providers can be trained to recognise psychosocial problems and incorporate

the concept of self-efficacy in the design of diabetic interventions. According to

Peyrot et al. (2005), the majority of patients with type 2 diabetes suffer from

diabetes-related psychological problems and many have poor psychological

well-being (41%). However, many providers can not manage patients’ problems. So,

only a few patients receive diabetes-related psychosocial services (10%). Peyrot et al.

(2005) advocated the need for increased training for providers to enhance their


289

confidence and skills in managing patients’ problems. Integrating mental health

professionals into the diabetes care team or training health providers to recognise and

provide psychosocial services could help patients with diabetes to manage their

disease.

5. Educational programs should be regularly held and evaluated in nursing schools

and clinical practices. The usefulness of self-efficacy in patient education should be

incorporated into nursing curricula for nursing students and into continuing education

for practicing nurses.

6. This is a cross-discipline approach in the fields of nursing care and counselling, and

it conforms the trend of caring for patients physically and mentally. It is worth

promoting this application on clinical cases and encouraging related research to

integrate physical and mental health care for chronic patients through a series of

group intervention strategy.

8.7 Summary

In conclusion, this chapter has overviewed the main results and information related to

the thesis. The implications for nursing practice, education and research have been

highlighted. Study limitations and recommendations have been considered.

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Appendix 5. Study information sheet (Study I)

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STUDY INFORMATION SHEET (STUDY I)

This study is the basis of a dissertation in a Doctor of Philosophy qualification at Queensland University of Technology (QUT) and will be performed by Shu-Fang Wu under the guidance of a team of experienced researchers from QUT and NTCN (National Taipei College of Nursing). The names and contact details of the research team are listed below. Please call Shu-Fang Wu for all initial inquires. Contact details

Chief investigator: Shu-Fang Wu NTCN Ph: 886-2-28227101~3164 Co- investigator: Prof. Mary Courtney QUT Ph: 61-7-38643887

Prof. Helen Edwards QUT Ph: 61-7-38643884 Dr. Jan McDowell QUT Ph: 61-7-38643882

Associate Prof. Pei-Jen Chang

NTCN Ph: 886-2-28227101~3192

Purpose of the study The aim of this study is to translate and test the validation and reliability of two diabetes-specific self-efficacy: DMSES: the Diabetes Management Self-Efficacy Scale; and PTES: the Perceived Therapeutic Efficacy Scale in a Taiwanese population. Rational of the study Diabetes Mellitus (DM) in adults is a global health problem and is associated with long-term complications and poor health-related quality of life. A self-efficacy enhancing intervention program offers a basis for improving the effectiveness of diabetes education because it focuses on behavioral change. It is different from the

Title: Effectiveness of self-management for persons with type 2 diabetes following the implementation of a self-efficacy (confidence) enhancing

intervention program in Taiwan


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traditional diabetes education which focuses only on the transformation of information or skills. The DMSES and PTES scales are important tools to evaluate the effectiveness of the intervention. The tools have been translated into several languages and psychometrically tested with diabetes populations in several countries, such as The Netherlands, Switzerland, Belgium, UK, the USA and Australia. This is first time these questionnaires have been used in Taiwan and therefore it is necessary to test the validity and reliability of the Chinese versions in a Taiwanese population. Procedures Prior to commencement, I will verbally inform you about the research study, explain the study and then ask you to provide written consent to participate. If you agree to participate in this study, it will take you for about 20 minutes. However, you are free to withdraw from this study at any time, if it is not convenient for you, without comment or penalty.

At the beginning, you will complete the questionnaire and provide feedback on the questions. The questionnaire is composed of two scales: 20 items for DMSES and 10 items for PTES

1 month after the initial survey, a random sample of at least 35 participants from this study will be asked to fill in the same questionnaire to check the accuracy of the questionnaires.

Expected outcomes Develop two Chinese diabetes-specific self-efficacy questionnaires, the DMSES and PTES, in order to enable other researchers to use these in the Taiwanese population.

Risks and discomforts No major risks to you have been identified due to your participation in this project. You may become tired when completing the questionnaire. If you are unable to complete the questionnaire yourself then you may complete the questionnaire with the assistance of the data collector through an interview. If you feel tired, the interview will be ceased and resumed at a later time. Confidentiality All information you provide for the project will be treated in confidence and securely stored during the study period. Your results will only be revealed to the investigators and yourself. When the results of the study are published we will ensure that you will remain anonymous.


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Inquiries Questions related to this study are welcome at any time. Please direct them to Shu-Fang Wu (phone: 28227101~3164). If at any time you are not satisfied with my response, you may direct your inquires to Professor Mary Courtney (Director of Research Center for Health Research (Nursing), Queensland University of Technology, Australia; on 61-7-38643887). Acknowledgment Thank you for your agreement to participate in this study. Your help is greatly appreciated in the completion of my Doctor of Philosophy degree. Please ensure that you have read and understood the previous information. When you have come to a final decision as to whether or not you will participate in this study, I would greatly appreciate it if you could inform me of your decision on 28227101~3164 or I will contact you to ask your final decision after one week. Thank you very much Shu-Fang Wu No.365, Ming Te Road, 112 , Taipei, Taiwan, R.O.C. Phone: 28227101~3164

Appendix 6. Study information sheet (Study II) (Intervention group)

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STUDY INFORMATION SHEET (STUDY II) (Intervention group)





NTCN Ph: 886-2-28227101~3192

Purpose of the study The aim of this study is to examine the effects of a self-efficacy enhancing intervention program, which is designed to improve self-efficacy in managing type 2 diabetes; diabetes self-care activities, quality of life, psychosocial well-being and reduce health service utilization. Rational of the study Diabetes Mellitus (DM) in adults is a global health problem and is associated with long-term complications and poor health-related quality of life. A self-efficacy enhancing intervention program offers a basis for improving the effectiveness of




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diabetes education because it focuses on behavioural change. It is different from the traditional diabetes education which focuses only on the transformation of information or skills. So, it is important to develop educational programs based on self-efficacy theory for the self-management of diabetes. In addition, up to now there is a lack of literature on self-efficacy enhancing programs used in diabetes education in Taiwan. Further studies on nursing interventions for diabetes are particularly crucial in the future. Procedures Prior to commencement, I will verbally inform you about the research study, explain the study and then ask you to provide written consent to participate. If you agree to participate in this study, your involvement will be for a six month period. However, you are free to withdraw from this study at any time, if it is not convenient for you, without comment or penalty.

At the beginning, you will complete a baseline assessment questionnaire. And then you will receive the standard diabetes educational program provided by nurse educators, including: 1) view a videotape; 2) attend 4 weekly focused practice sessions, lastly approximately 1 hour; 3) receive information booklet; and 4) participate in follow-up survey by telephone twice: 8weeks and 16 weeks after

commencement At 3 month and 6 month after commencement you will be asked to complete

follow-up questionnaires. Expected outcomes If the study is found to be effective, then the expected outcomes of the research include: Enhancing your efficacy (confidence) in your ability to manage the disease, and The potential to reduce the risk of complications and improve quality of life and psychosocial well-being, and

Reducing the risk of complications and health care usage, and improving quality of life for you and will indirectly lower health care costs.

Risks and discomforts No major risks to you have been identified due to your participation in this project. You may become tired when completing the questionnaire. If you are unable to complete the questionnaire yourself then you may complete the questionnaire with the


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assistance of the data collector through an interview. If you feel tired, the interview will be ceased and resumed at a later time. Confidentiality All information you provide for the project will be treated in confidence and securely stored during the study period. Your results will only be revealed to the investigators and yourself. When the results of the study are published we will ensure that you will remain anonymous. Inquiries Questions related to this study are welcome at any time. Please direct them to Shu-Fang Wu (phone: 28227101~3164). If at any time you are not satisfied with my response, you may direct your inquires to Professor Mary Courtney (Director of Research Center for Health Research (Nursing), Queensland University of Technology, Australia; on 61-7-38643887). Acknowledgment Thank you for your agreement to participate in this study. Your help is greatly appreciated in the completion of my Doctor of Philosophy degree. Please ensure that you have read and understood the previous information. When you have come to a final decision as to whether or not you will participate in this study, I would greatly appreciate it if you could inform me of your decision on 28227101~3164 or I will contact you to ask your final decision after one week. Thank you very much Shu-Fang Wu No.365, Ming Te Road, 112 , Taipei, Taiwan, R.O.C. Phone: 28227101~3164

Appendix 7. Study information sheet (Study II) (Control group)

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STUDY INFORMATION SHEET (Study II) (Control group)





NTCN Ph: 886-2-28227101~3192

Purpose of the study The aim of this study is to examine the effects of a self-efficacy enhancing intervention program, which is designed to improve self-efficacy in managing type 2 diabetes; diabetes self-care activities, quality of life, psychosocial well-being and reduce health service utilization. Rational of the study Diabetes Mellitus (DM) in adults is a global health problem and it’s associated with long-term complications and poor health-related quality of life. A self-efficacy enhancing intervention program offers a basis for improving the effectiveness of




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diabetes education because it focuses on behavioral change. It is different from the traditional diabetes education which focuses only on the transformation of information or skills. So, it is important to develop educational programs based on self-efficacy theory for the self-management of diabetes. In addition, up to now there is a lack of literature on self-efficacy enhancing programs used in diabetes education in Taiwan. Further studies on nursing interventions for diabetes are particularly crucial in the future. Procedures Prior to commencement, I will verbally inform you about the research study, explain the study and then ask you to provide written consent to participate. If you agree to participate in this study, your involvement will be for a six month period. However, you are free to withdraw from this study at any time, if it is not convenient for you, without comment or penalty.

At the beginning, you will complete a baseline assessment questionnaire. At 3 month and 6 month after commencement you will be asked to complete

follow-up questionnaires. Expected outcomes If the study is found to be effective, then the expected outcomes of the research include: The potential to reduce the risk of complications and improve quality of life and psychosocial well-being, and

Reducing the risk of complications and health care usage, and improving quality of life for you and will indirectly lower health care costs.

Risks and discomforts No major risks to you have been identified due to your participation in this project. You may become tired when completing the questionnaire. If you are unable to complete the questionnaire yourself then you may complete the questionnaire with the assistance of the data collector through an interview. If you feel tired, the interview will be ceased and resumed at a later time. Confidentiality All information you provide for the project will be treated in confidence and securely stored during the study period. Your results will only be revealed to the investigators and yourself. When the results of the study are published we will ensure that you will remain anonymous.


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Inquiries Questions related to this study are welcome at any time. Please direct them to Shu-Fang Wu (phone: 28227101~3164). If at any time you are not satisfied with my response, you may direct your inquires to Professor Mary Courtney (Director of Research Center for Health Research (Nursing), Queensland University of Technology, Australia; on 61-7-38643887). Acknowledgment Thank you for your agreement to participate in this study. Your help is greatly appreciated in the completion of my Doctor of Philosophy degree. Please ensure that you have read and understood the previous information. When you have come to a final decision as to whether or not you will participate in this study, I would greatly appreciate it if you could inform me of your decision on 28227101~3164 or I will contact you to ask your final decision after one week. Thank you very much Shu-Fang Wu No.365, Ming Te Road, 112, Taipei, Taiwan, R.O.C. Phone: 28227101~3164

Appendix 8. Study consent form (Study I & II)

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STUDY CONSENT FORM (STUDY I & II)

Chief investigator: Shu-Fang Wu Phone number: 28227101~3164 The investigator will conduct this study using the principles governing the ethical conduct of research, and at all times, will protect the interests, comfort and safety of all participants. My signature below will indicate that: 1. The procedures involved in this study have been explained to me and I have been

given the opportunity to ask questions regarding this study. 2. I acknowledge that:

a) The possible effects of procedures have been explained to me. b) The study is only for purpose of research. c) I have been informed that I am free to withdraw from this study at any time

and without comment or penalty. d) I have been informed that the confidentiality of the information I provide will

be safeguarded. 3. I consent to participate in this research study. Participant: Signature: Date: I have explained the purpose of this study to the above participant and have given the opportunity to ask questions and answer their questions regarding this study. Investigator: Date:



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Appendix 9. The questionnaire in English Effectiveness of self-management for persons with type 2 diabetes following

the implementation of a self-efficacy (confidence) enhancing intervention program in Taiwan

- INSTRUCTION -

This questionnaire asks for your views about managing issues associated with living

with type 2 diabetes.

Answer every question by responding as indicated. Your individual answers will remain confidential and not be shared with anyone else.

Certain questions may look alike but each one is different. Some questions ask

about problems you may not have. That’s great, but it’s important for us to know. Please answer each question.

There are no right or wrong answers. If you are unsure how to answer a question

please give the best answer you can.

Check the completed questionnaire. Occasionally a question can be accidentally missed when completing the questionnaire so it would be really helpful if you could take an extra couple of minutes to check that every question has been answered as indicated.

Hand in the completed questionnaire. When you are satisfied that all questions have

been answered, please hand in to the data collector or later the data collector will contact you to collect it.

Nursing School Centre for Health Research (Nursing) Queensland University of Technology

Victoria Park Road KELVIN GROVE QLD 4059

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Sample No.

Hospital Code Serial Number (This page will be filled by the interviewer)

Effectiveness of self-management for persons with type 2 diabetes following the implementation of a self-efficacy (confidence) enhancing intervention program

in Taiwan

(The followings are reserved to the interviewer)

Completeness of this questionnaire: □All questions are completed □Other situation (Please

describe)

Had you called to make interview appointment? □Yes □No □Other situation(Please describe)

Who fill up this form:□Interviewee □Interviewer filled up for interviewee(Please describe the

reason) □ Others filled up for the

interviewee(Please describe the reason) Interview duration: mins Name of interviewer: Interview date:

Name:

Sex: □M □F

Date of Birth: / / (dd/mm/yy) Current Address:_______________________________________________

Street City Zip code TEL:(Day) (Night) Mobile: Name of core cohabit person: Relationship: Tel:

Permanent Address:□ Same as current address

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Demographics 1. Sex: □(1)Male □(2)Female 2. Age: ____ Date of birth:____/____/____(dd/mm/yy) 3. Height is_______ cm 4. Family register province:□(1)Southern part of Fukien Province □(2)Mainland □(3)Hakka □(4)

Others (Please describe) 5. Religion: □(1)Buddhist □(2)Taoist or social religious □(3)Christian

□(4)Catholicism □(5) Others (Please describe) 6. Education:□(1)Illiteracy □(2)Primary school □(3)Junior high school

□(4)Senior high school □(5)College above 7. Marital status:□(1)Single □(2)Married □(3) Divorced □(4)Widower/Widow 8. Career:□(1)None □(2)yes 9. Living arrangement: □(1)Living alone □(2)Living with family

□(3) Others (Please describe 10. / (mm/yy) were you diagnosed with diabetes, therefore, you have been with

diabetes for years.

11. Co-morbidity:□(1)No □(2)Yes; Disease:

12. Since you are with diabetes, have you received any health education of diabetes

provided by health care worker (Each time at least 10 minutes above) □(1)None

□ (2)Yes, □ (1)Group health education _____times

(Names of the hospitals:________________________) and/or □ (2)Individual health education _____times

(Names of the hospitals:________________________) 13. Your weight is_______ kg.

14. Do you regularly go to outpatient clinic:

□(1)No □ (2)Yes, Name of the hospital: ___________________(How often:_____weeks

or ____months per time) 15. In the past 3 months, have you ever received emergency treatment:

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□(1)No □(2)Yes, totally _____times , you have totally spent NTD$ (After deducted the expense paid by health insurance) 16. Have you ever been hospitalized in the latest 3 months: □ (1)No □ (2)Yes, _____ times, total hospitalized days (Please continue the following questions) -From the past hospitalizations, you have totally spent NTD$

(After deducted the expense paid by health insurance) -Due to the hospitalization, you can’t go to work for days, the average

pay per day is NTD$ (If applicable) -Your family or friend who accompanied you in the hospital can’t go to work for - days, his/her average pay per day is NTD$ (□For accompanier who doesn’t have job □or who doesn’t have accompanier

can skip this question) 17. The current treatment is (Can be multiple chose): □(1)Oral hypoglycemic drugs: Medication:_________________ □(2)Insulin injection: Medication:_________________ □ (3)Controlled by diet □(4)Controlled by physical exercise □(5)Others (Please describe)

18. Do you have any complications of diabetes: □(1)None □ (2)Yes, □(1)Retinopathy (Eye) problem □(2)Kidney disease □(3)Nerve problem (4)Diabetic foot problem □(5)Hypertension □(6)Heart disease □(7)Hyperlipidaemia □(8)Others (Can be multiple chose)

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Diabetes Management Self-Efficacy Scale (DMSES)

Circle one number on each line I am confident that: Cannot do

at all Maybe Yes

Maybe No

Certainly can do

1. I am able to check my blood sugar if necessary

0 1 2 3 4 5 6 7 8 9 10

2. I am able to correct my blood sugar when the sugar level is too high (e.g. eat different food)

0 1 2 3 4 5 6 7 8 9 10

3. I am able to correct my blood sugar when the sugar level is too low (e.g. eat different food)

0 1 2 3 4 5 6 7 8 9 10

4. I am able to choose foods that are best for my health

0 1 2 3 4 5 6 7 8 9 10


0 1 2 3 4 5 6 7 8 9 10

6. I am able to control my body weight and maintain it within the ideal weight range

0 1 2 3 4 5 6 7 8 9 10

7. I am able to examine both of my feet (e.g. for cuts or blisters)

0 1 2 3 4 5 6 7 8 9 10

8. I am able to do enough physical activity (e.g. walking the dog; yoga; gardening; stretching exercise)

0 1 2 3 4 5 6 7 8 9 10

9. I am able to maintain my eating plan when I am ill

0 1 2 3 4 5 6 7 8 9 10

10. I am able to follow a healthy eating plan most of the time

0 1 2 3 4 5 6 7 8 9 10

Below is a list of activities your may have to perform to manage your diabetes. Please read each one and then circle the number that best describes how confident you usually are that you could carry out that activity. For example, if you are completely confident that you are able to check your blood sugar levels when necessary, circle 10. If you feel that most of the time you could not do it, circle 1 or 2. If you feel that all of the time you could not do it, circle 0

A39

Circle one number on each line

I am confident that: Cannot do at all

Maybe Yes Maybe No

Certainly can do

11. I am able to do more physical activity if the doctor advises me to

0 1 2 3 4 5 6 7 8 9 10

12. When doing more physical activity I am able to adjust my eating plan

0 1 2 3 4 5 6 7 8 9 10

13. I am able to follow a healthy eating plan when I am away from home

0 1 2 3 4 5 6 7 8 9 10

14. I am able to choose different foods and maintain my eating plan when I am away form home

0 1 2 3 4 5 6 7 8 9 10

15. I am able to follow a healthy eating plan during festive periods

0 1 2 3 4 5 6 7 8 9 10

16. I am able to choose different foods and maintain a healthy eating plan when I am eating out or at a party

0 1 2 3 4 5 6 7 8 9 10

17. I am able to maintain my eating plan when I am feeling stressed or anxious

0 1 2 3 4 5 6 7 8 9 10

18. I am able to visit my doctor four times a year to monitor my diabetes

0 1 2 3 4 5 6 7 8 9 10

19. I am able to take my medication as prescribed

0 1 2 3 4 5 6 7 8 9 10

20. I am able to maintain my medication when I am ill

0 1 2 3 4 5 6 7 8 9 10

DMSES (cont): Below is a list of activities your may have to perform to manage your diabetes. Please read each one and then circle the number that best describes how confident you usually are that you could carry out that activity. For example, if you are completely confident that you are able to check your blood sugar levels when necessary, circle 10. If you feel that most of the time you could not do it, circle 1 or 2. If you feel that all of the time you could not do it, circle 0

A40

Perceived Therapeutic Efficacy Scale (PTES)

Circle one number on each line

No

Confidence

Highest confidence

1. My level of confidence in the ability of my diabetes medication to control my blood sugar is:

0 1 2 3 4 5 6 7 8 9 10

2. My level of confidence in the ability that my diabetes medication can keep my blood sugar at a stable level and prevent it from becoming elevated is:

0 1 2 3 4 5 6 7 8 9 10

3.My level of confidence in the ability of my diabetes medication to limit the severity of complications (e.g. eye or foot problems) is:

0 1 2 3 4 5 6 7 8 9 10

4.My level of confidence in the ability of my diabetes medication to prevent me getting (more) complications is:

0 1 2 3 4 5 6 7 8 9 10

5.My level of confidence in the ability that the maintenance of the dose of my medication can control my diabetes effectively is:

0 1 2 3 4 5 6 7 8 9 10

6.My level of confidence in the need to take my medication each day exactly as prescribed to control my diabetes is:

0 1 2 3 4 5 6 7 8 9 10

7.My overall level of confidence in the value of the diabetes medication that I am prescribed is:

0 1 2 3 4 5 6 7 8 9 10

8.My level of confidence in the ability of medication in general to control my diabetes is:

0 1 2 3 4 5 6 7 8 9 10

9.My level of confidence in my health professionals’ advice that experts such as doctors or nutritionists give me in my diabetes treatment is:

0 1 2 3 4 5 6 7 8 9 10

10. My overall level of confidence in my ability to cope with my diabetes is:

0 1 2 3 4 5 6 7 8 9 10

For each statement listed below you are asked to circle the number that best describes your level of confidence. For example: 0 = no confidence and 10 = highest confidence.

A41

SDSCA (the Summary of Diabetes Self-Care Activities)

1. How many of the last SEVEN DAYS have you followed a healthy eating plan

0 1 2 3 4 5 6 7

2. On how many of the last SEVEN DAYS did you eat more than 5 plates of vegetables and fruits a day (such as: you have taken 3 plates of vegetables, 2 plates of fruits.) (a plant of fruits is about one tangerine, 1/3 of papaya… and so on, a plate of vegetables is about 100g. Interviewer will illustrate more examples according to food exchange list).

0 1 2 3 4 5 6 7

3. On how many of the last SEVEN DAYS did you eat high fat foods such as red meat or full-fat dairy produce (such as: fried foods, high-fat meat, chick skin)?

0 1 2 3 4 5 6 7

4. On how many of the last SEVEN DAYS did you participate in at least 30 minutes of physical activity? (Total minutes of continuous activity, including walking, and housework)

0 1 2 3 4 5 6 7

5. On how many oft he last SEVEN DAYS did you participate in a specific exercise session (such as: jogging, mountain climbing, Taijiquan, dancing, etc.) other than what you do around the house or as part of your work?

0 1 2 3 4 5 6 7

6. On how many of the last SEVEN DAYS did you take hypoglycemic drugs prescribed by your physicians?

0 1 2 3 4 5 6 7

7. On how many of the last SEVEN DAYS did you test your blood sugar?

0 1 2 3 4 5 6 7

8. On how many of the last SEVEN DAYS did you test your blood sugar the number of times recommended by your health care provider?

0 1 2 3 4 5 6 7

9. On how many of the last SEVEN DAYS did you check your feet?

0 1 2 3 4 5 6 7

10. On how many of the last SEVEN DAYS did you inspect the inside of your shoes (such as: if there are any stones inside shoes? If they are flat, no any tears, sharp edges or wet)?

0 1 2 3 4 5 6 7

11. On how many of the last SEVEN DAYS did you dry your foots carefully after washing, especially between toes?

0 1 2 3 4 5 6 7

12. On how many of the last SEVEN DAYS did you put on your appropriate shoes when you go out?

0 1 2 3 4 5 6 7

The questions below ask you about your diabetes self-care activities during the past 7 days. If you were sick during the past 7 days, please think back to the last 7 days that you were not sick.

SF-12v2™ Health Survey © 1994, 2003 Health Assessment Lab, Medical Outcomes Trust and QualityMetric Incorporated. All rights reserved. SF-12® is a registered trademark of Medical Outcomes Trust. (IQOLA SF-12v2 Standard, Australia (English))

HRQOL Short Form-12

This questionnaire asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. Thank you for completing this survey! For each of the following questions, please mark an in the one box that best describes your answer.

1. In general, would you say your health is:

2. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

Yes, limited

a lot

Yes, limited a little

No, not limited at all

a Moderate activities, such as moving a table, pushing

a vacuum cleaner, bowling, or playing golf .......................... 1............. 2............. 3

b Climbing several flights of stairs........................................... 1............. 2............. 3

Excellent Very good Good Fair Poor

1 2 3 4 5


3. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

4. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

Not at all A little bit Moderately Quite a bit Extremely

1 2 3 4 5

All of the time

Most of the time

Some of the time

A little of the time

None of the time

a Accomplished less than you would like...................................... 1 ............. 2............. 3 ............. 4............. 5

b Were limited in the kind of work or other activities ................. 1 ............. 2............. 3 ............. 4............. 5

All of the time

Most of the time

Some of the time


None of the time

a Accomplished less than you would like...................................... 1 ............. 2............. 3 ............. 4............. 5

b Did work or other activities less carefully than usual ................ 1 ............. 2............. 3 ............. 4............. 5


6. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks…

7. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

All of the time Most of the time

Some of the time


None of the time

1 2 3 4 5

All of the time

Most of the time

Some of the time


None of the time

a Have you felt calm and

peaceful? ....................................... 1 ............. 2............. 3 ............. 4............. 5

b Did you have a lot of energy? ....... 1 ............. 2 ............. 3 ............. 4 ............. 5

c Have you felt downhearted and depressed? .............................. 1 ............. 2............. 3 ............. 4............. 5


MOS-SSS (the Medical Outcomes Study - Social Support Survey tool)

None of the time


Some of the time

Most of the time

All of the

time

1. Someone to help you if you were confined to bed

1 2 3 4 5

2. Someone you can count on to listen to you when you need to talk

1 2 3 4 5

3. Someone to give you good advice about a crisis

1 2 3 4 5

4. Someone to take you to the doctor if you needed it

1 2 3 4 5

5. Someone who shows you love and affection 1 2 3 4 5

6. Someone to have a good time with 1 2 3 4 5

7. Someone to give you information to help you understand a situation

1 2 3 4 5

8. Someone to confide in or talk to about yourself or your problems

1 2 3 4 5

9. Someone who hugs you 1 2 3 4 5

10. Someone to get together with for relaxation 1 2 3 4 5

11. Someone to prepare your meals if you were unable to do it yourself

1 2 3 4 5

12. Someone whose advice you really want 1 2 3 4 5

13. Someone to do things with to help you get your mind off things

1 2 3 4 5

14. Someone to help with daily chores if you were sick

1 2 3 4 5

15. Someone to share your most private worries and fears with

1 2 3 4 5

16. Someone to turn to for suggestions about how to deal with a personal problem

1 2 3 4 5

17. Someone to do something enjoyable with 1 2 3 4 5

18. Someone who understands your problems 1 2 3 4 5

19. Someone to love you and make you feel wanted

1 2 3 4 5

People sometimes look to others for companionship, assistance, or other types of support. How often is each of the following kinds of support available to you if you need it? Circle one number on each line


Center for Epidemiologic Studies Depression (CES-D) Scale

Questions

Rarely or none of the time (less than 1 day)

Some or a little of the time (1-2 days)

Occasionally or a moderate amount of time (3-4 days)

All of the time (5-7 days)

1. I was bothered by things that usually don't bother me.

0 1 2 3

2. I had trouble keeping my mind on what I was doing.

0 1 2 3

3. I felt depressed.

0 1 2 3

4. I felt that everything I did was an effort.

0 1 2 3

5. I felt hopeful about the future.

3 2 1 0

6. I felt fearful.

0 1 2 3

7. My sleep was restless.

0 1 2 3

8. I was happy.

3 2 1 0

9. I felt lonely.

0 1 2 3

10. I could not get "going."

0 1 2 3

Below is a list of some of the ways you may have felt or behaved. Please indicate how often you have felt this way during the past week by checking the appropriate box for each question.

A47

Appendix 10. The questionnaire in Chinese

樣本編號(研究員填寫)

醫院代碼序號

台灣第二型糖尿病個案實行自我效能增進措施方案後之自我管理改善成效

戶籍地址：□同現在地址

□ 縣市鄉鎮市區村里

路街段巷

弄號樓

(研究員填寫)

本問卷填寫結果：□全部完成 □其他狀況(請說明)

有無事先電話通知？□有 □無 □其他狀況(請說明)

姓名：性別： □男 □女

出生日期：年月日

現在地址：縣市鄉鎮市區村里

路街段巷

弄號樓

電話：(日) (夜)

行動電話：

重要同住者姓名：關係：電話：

A48

填寫狀況：□自填 □訪員代填(原因請說明) □其他人代填(請說明)

完成時間：分鐘

訪員姓名：完訪日期:

複閱者：複閱日期:

資料輸入：輸入日期:

- 問卷說明 –親愛的先生女士您好：

我們是昆士蘭科技大學及台北護理學院，為了糖尿病個案的健康，提供一連串的健康促進系列活動，以期增進大家對疾病的預防和管理能力，希望您能全程參與，因為您的全程參加將是我們最大的動力。這是一份請教您個人對糖尿病看法的一份問卷，回答問題時您不用和其他人做比較，也沒有所謂的「對」和「錯」，請您放心回答。

請您耐心填完這份問卷，以下內容分為幾個部分：糖尿病管理自我效能表、自覺治療效能表、日常生活自我照顧活動、生活品質、社會支持及憂鬱狀態。您個人的回答或基本資料絕對安全及保密，除了工作人員知道之外，資料不會外洩。

您參加的這個健康促進方案的目的是：希望藉由提供您對疾病管理的自信心（自我效能）進而增加自我照顧能力，減少潛在性合併症之發生，最後可以間接改善生活品質、心理社會安適狀態及降低醫療成本。若是您因為個人的因素想要中途停止參與，您有權力提出並告訴我們。

您在回答這份問卷時，有些問題看起來會很像，但事實上每一題都不一樣且都很重要。或許有些題目中，您可能沒有這些症狀或困擾，還是請您一題一題作答，選擇最合您個人情況的答案，因為您真實的答案對我們而言非常非常寶貴的，也是我們很想知道的研究資料。若是您對於讀或寫有困難，我們工作同仁將逐一唸給您聽，並提供書寫問卷之協助。

回答後請檢查是否填妥了每一題答案及確保整份問卷是完整的。因為有時某些題目在填寫過程中會不小心被遺漏，請您多花幾分鐘檢查一下，確定每一題都填妥了答案。

檢查完問卷後請您交給研究人員或稍後工作人員會來向您收取。最後要感謝您的合作及用心地填寫這份問卷，您的資料提供有助於糖尿病領域相關研究的發展，期待研究結果能提供及落實更好、更完整的糖尿病照護。

昆士蘭科技大學及台北護理學院研究小組敬上

A49

基本資料

1.性別：□（1）男 □（2）女 2.年齡：____歲出生：____年____月____日 3.身高：公分 4.籍貫：□（1）閩南 □（2）外省 □（3）客家 □（4）原住民 □（5）其他（請說明） 5.宗教信仰：□（1）佛教 □（2）道教或燒香、拜拜民間傳統信仰 □（3）基督教

□（4）天主教□（5）一貫道 □（6）其他（請說明）

6.教育程度：□（1）不識字 □（2）小學 □（3）國中 □（4）高中職

□（5）專科 □（6）大學 □（7）研究所以上 7.婚姻狀況：□（1）未婚 □（2）已婚 □（3）分居 □（4）離婚 □（5）喪偶

□（6）同居 □（7）其他（請說明） 8.職業狀況：□（1）無 □（2）有，（請說明） 9.居住狀況: □（1）獨居 □（2）與家人同住 □（3）其他（請說明） 10.民國年月醫生診斷我罹患糖尿病，所以患病時間到現在為止已經年了

11.除了糖尿病外，有無其他疾病史：□(1)無 □(2)有，病因：（請說明）

12.自從患病後，有無曾經接受過醫護人員提供的糖尿病衛生教育（至少每次接受 10 分鐘以上的衛

生教育） □(1)無 □(2)有，團體衛教_____次（那些醫療院所名稱：）個人衛教_____次（那些醫療院所名稱：） 13.體重是_______公斤

14.有無固定到醫療院所門診看醫生： □(1)無 □(2)有，醫療院所名稱： ___________________；

平均多久看一次醫生：_____週/月一次 15.最近三個月內有無到醫院掛急診：□無 □有；總共_____次, 結帳時，醫藥費用總共花了我

元新台幣 (扣除健保金額後)

A50

16.最近三個月內有無到醫院住院過： □(1)沒有 □(2)有，總共_____次，全部住院總天數共_____天(續答)； ‧□這幾次住院結帳時，醫藥費用總共花了我元新台幣 (扣除健保金額後) ‧□自己因住院而無法上班的天數_____天，一天平均工資約_____元新台幣（無工作者免填） ‧□主要照顧我的親友因照顧我而無法上班的天數_____天，他一天平均工資約元新

台幣（□主要照顧者無工作或 □無主要照顧者則免填） 17.目前治療方法(可複選)：

□（1）口服降血糖藥；用藥名稱： □（2）注射胰島素；用藥名稱： □（3）飲食控制 □（4）運動控制 □（5）其他（請說明）

18.有無糖尿病合併症

□（1）無 □（2）有：（□(1)視網膜(眼睛)病變 □(2)腎臟病變 □(3)神經病變 □(4)糖尿病足□(5)高血壓 □(6)心臟病 □(7)高血脂 □(8)其他）(可複選)

A51

中文版糖尿病管理自我效能量表 (Chinese version Diabetes Management Self-Efficacy Scale; C-DMSES)

第一部分: 以下為你在糖尿病自我管理中可能要做的事項。請仔細閱讀每一個項目，然後選出最能代表你自己執行這件事的信心程度。例如:如果你認為自己在「有需要時我有能力自行檢測血糖」非常有自信的話，請圈選 10; 如果你覺得大部份時間你無法做到的話(很少自信的話)，請圈選 1 或 2;完全無法做到(完全沒自信的話)請圈選 0。

請在每一列中圈選出一個數字

我有自信: 完全無

法做到

也許可以

也許不可以

完全可

以做到

1. 有需要時，我有能力自行檢測血糖

0 1 2 3 4 5 6 7 8 9 10

2. 當我的血糖太高時，我有能力自己調整我的血糖值(例如:食用不同種類的食物)

0 1 2 3 4 5 6 7 8 9 10

3. 當我的血糖太低時，我有能力自己調整我的血糖值(例如:食用不同種類的食物)

0 1 2 3 4 5 6 7 8 9 10

4. 我有能力選擇最有利於我的健康的食物

0 1 2 3 4 5 6 7 8 9 10

5. 我有能力選擇不同種類的食物來維持健康的飲食計畫

0 1 2 3 4 5 6 7 8 9 10

6. 我有能力將我的體重控制在理想範圍內

0 1 2 3 4 5 6 7 8 9 10

7. 我有能力自行檢查我的腳(例如:傷口或起水泡)

0 1 2 3 4 5 6 7 8 9 10

8. 我有能力做足夠的身體活動(例如:溜狗、瑜珈、園藝、或伸展運動等)

0 1 2 3 4 5 6 7 8 9 10

9. 當我生病時，我仍然能維持我的飲食計畫

0 1 2 3 4 5 6 7 8 9 10

10. 大部份的時間內，我都能確實遵從我的健康飲食計畫

0 1 2 3 4 5 6 7 8 9 10

A52

請在每一列中圈選出一個數字

我有信心: 完全無

法做到

也許可以

也許不可以

當然可以

11. 當醫師建議我多做一些身體活動，我有能力確實做到

0 1 2 3 4 5 6 7 8 9 10

12. 當我身體活動量增加時，我有能力自行調整我的飲食計畫

0 1 2 3 4 5 6 7 8 9 10

13. 當我外出時，我仍然能遵行健康的飲食計畫

0 1 2 3 4 5 6 7 8 9 10

14. 當我外出時，我有能力選擇不同的食物種類，並維持我的飲食計畫

0 1 2 3 4 5 6 7 8 9 10

15. 在特殊節日時，我仍然能遵守健康飲食計畫

0 1 2 3 4 5 6 7 8 9 10

16. 當我在外用餐或參加聚會時，我有能力選擇不同種類的食物並維持我的健康飲食計畫

0 1 2 3 4 5 6 7 8 9 10

17. 當我面對壓力或焦慮時，我仍然能維持我的飲食計畫

0 1 2 3 4 5 6 7 8 9 10

18. 我能每年至少去看醫生四次，以監測我的糖尿病狀況

0 1 2 3 4 5 6 7 8 9 10

19. 我能夠依醫師處方按時服藥 0 1 2 3 4 5 6 7 8 9 10

20. 當我生病時，我仍然能維持我的糖尿病藥物治療

0 1 2 3 4 5 6 7 8 9 10

A56

日常生活自我照顧活動

此部分題目試想瞭解您對自我的日常生活照顧活動，請依據過去七天（包含今天）的實際情況

回答以下問題，若是過去七天您洽好在生病當中, 請您依據這次生病之前的實際情況回答

1.在過去 7 天中，您有多少天，按照健康的飲食計畫來進食

1 2 3 4 5 6 7 天

2.在過去 7 天中，您有多少天，一天所吃的蔬菜水果加起來超過 5 份〈如：吃蔬菜 3 碟、水果 2 個。(水果一份約橘子一個，木瓜 1/3 個‧‧‧等；蔬菜一份 100 公克，約 1 碟，研究者會依照食物代換表逐一舉例〉？

1 2 3 4 5 6 7 天

3.在過去 7 天中，您有多少天吃油脂多的食物〈如：油炸食物、肥肉、雞皮等〉？

1 2 3 4 5 6 7 天

4.在過去 7 天中，您有多少天，有做 30 分鐘以上的活動〈指身體持續活動超過 30 分鐘，包括：走路、做家事〉？

1 2 3 4 5 6 7 天

5.在過去 7 天中，除了工作及做家事以外，您有多天，有另外撥時間的去做運動〈如：慢跑、爬山、太極拳、土風舞等〉？

1 2 3 4 5 6 7 天

6.在過去 7 天中，您有多少天，有照醫師指示定時定量服用降血糖的藥？〈醫囑不需服降血糖藥者，不用回答此題〉

1 2 3 4 5 6 7 天

7.在過去 7 天中，您有多少天，在家自己(或家人幫忙)量血糖？

1 2 3 4 5 6 7 天

8. 在過去 7 天中，您有多少天，依照醫師指示的血糖測量標準次數(例如ㄧ天量血糖兩次)在家按時自己(或家人幫忙)量血糖？

1 2 3 4 5 6 7 天

9.在過去 7 天中，您有多少天，檢查您的雙腳〈包括腳趾、腳板與腳底〉？

1 2 3 4 5 6 7 天

10.在過去 7 天中，您有多少天，在穿鞋之前有先檢查鞋內的情形〈如：鞋內有無小石頭，是否平整、有無破損或潮濕等〉？

1 2 3 4 5 6 7 天

11.在過去 7 天中，您有多少天在洗完腳後將腳擦乾，並保持腳趾間乾燥？

1 2 3 4 5 6 7 天

12. 在過去 7 天中，您有多少天在出門時，都有穿合適的鞋子(例如沒有穿露腳趾得拖鞋或涼鞋而穿包鞋)？

1 2 3 4 5 6 7 天

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中文版自覺治療效能量表 (Chinese version the Perceived Therapeutic Efficacy Scale; C-PTES)

第二部份: 請在以下每個題目右方數字中，圈選出最能代表你的信心程度。例如:0 代表完全沒有信心，10 代表非常有信心。

請再每一列中圈選出一個數字

沒有信心

非常有信

心

1. 我的糖尿病藥物能夠控制我的血糖值,我對這件事的信心程度是

0 1 2 3 4 5 6 7 8 9 10

2. 我的糖尿病藥物能夠穩定血糖，減少高血糖發作,我對這件事的信心程度是:

0 1 2 3 4 5 6 7 8 9 10

3. 我的糖尿病藥物能夠減少併發症的嚴重程度(例如:眼睛或腳的併發症) ,我對這件事的信心程度是:

0 1 2 3 4 5 6 7 8 9 10

4. 我的糖尿病藥物能夠預防我得到(更多)併發症,我對這件事的信心程度是:

0 1 2 3 4 5 6 7 8 9 10

5. 維持我的藥物劑量可以有效控制我的糖尿病,我對這件事的信心程度是:

0 1 2 3 4 5 6 7 8 9 10

6. 每天需要依照處方正確服藥可以控制我的糖尿病,我對這件事的信心程度是:

0 1 2 3 4 5 6 7 8 9 10

7. 醫師處方開給我的糖尿病藥物是有療效, 對於這件事我的整體信心程度是:

0 1 2 3 4 5 6 7 8 9 10

8. 一般來講，藥物治療能夠有效控制我的糖尿病

0 1 2 3 4 5 6 7 8 9 10

9. 在我的糖尿病治療中，專家如醫師或營養師所給的專業建議,我對這件事的信心程度是:

0 1 2 3 4 5 6 7 8 9 10

10. 我能應付自己的糖尿病，對於這件事我的整體信心程度是

0 1 2 3 4 5 6 7 8 9 10

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生活品質量表

本調查目的在探討您對自己健康的看法。這些資訊將能幫助您記錄您的感受，以及您在執行日

常生活的能力。敬請回答下列各問題並圈選一適當答案。如您對某一問題的回答不能確定，還

是請您盡可能選一個最適合的答案。在本部份所指過去一個月內﹐係指從今天往前算三十天內。

1. 一般來說，您認為目前的健康狀況是:

極好的很好好普通不好

1 2 3 4 5

2. 下面是一些您日常可能從事的活動，請問您目前健康狀況會不會限制您從事這些活動？如果會，到底限制有多少？

活動會受到很多限制

會受到一些限制

不會完全不受限制

a. 中等程度活動，例如搬桌子、拖地板、打保齡球或打太極拳

1 2 3

b. 爬數層樓樓梯 1 2 3

3.在過去一個月內，您是否曾因為身體健康問題，而在工作上或日常活動方面有下列任何的問題？

一直

都是

大部

分時間

有時很少從不

a. 完成的工作量比您想要完成的較少 1 2 3 4 5

b. 可以做的工作或其他活動種類受到限制 1 2 3 4 5

4.在過去一個月內，你是否曾因為情緒問題 (例如，感覺沮喪或焦慮)，而在工作上或日常活動方面有下列任何問題？

一直大部有時很少從不

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都是分時間

a. 做工作或其他活動的時間減少 1 2 3 4 5

b. 做工作或其他活動時不如以往小心 1 2 3 4 5

5. 在過去一個月內，身體疼痛對您日常工作 (包括上班及家務) 妨礙程度如何？

完全沒有妨礙有一點妨礙中度妨礙相當多妨礙妨礙多到極點

1 2 3 4 5

6. 下列各項問題是關於過去一個月內，您的感覺及對您周遭生活的感受，請針對每一問題選一最接您感覺的答案。

一直都

是

大部分

時間

有時很少從不

a. 您覺得心情平靜？ 1 2 3 4 5

b. 您精力充沛？ 1 2 3 4 5

c. 你覺得悶悶不樂憂鬱？ 1 2 3 4 5

7. 在過去一個月內，您的身體健康或情緒問題有多少時候會妨礙到您的社交活動(如拜訪親友等)？

一直都是大部分時間有時很少從不

1 2 3 4 5

社會支持量表

本部分想要瞭解您的友誼、幫助或其他形式的支持情況。請您依據個人實際情形及想法，在適當的答案打勾或圏選，請勿遺漏，非常謝謝您！ ◎以下題目所提的「人」是指親人、朋友、鄰居、醫護人員或其他「1=從來沒有」表示不曾如此；「2=很少」表示大部分時候不是如此；「3=有時」表示約一半的時候是如

此；「4=經常」表示大部分時候是如此；「5=總是」表示幾乎每次都是如此

項目從來沒有

很少有時經常總是

1. 假如你臥病在床時，有會幫助你的人。 1 2 3 4 5

2. 當你需要與人談話時，有能傾聽你講話的人。 1 2 3 4 5

3. 當你面臨難關時，有給你良好意見的人。 1 2 3 4 5

4. 假如你需要有人帶你去看病時，有可以帶你去的人。

1 2 3 4 5

5. 有會向你表達喜愛及好感的人。 1 2 3 4 5

6. 有讓你覺得和他相處時很愉快的人。 1 2 3 4 5

7. 有提供資訊來幫助你了解所處情況的人。 1 2 3 4 5

8. 有值得信任或談論關於你本身或你難題的人。 1 2 3 4 5

9. 有與你很親近的人。 1 2 3 4 5

10. 有能陪伴你而讓你覺得身心很放鬆的人。 1 2 3 4 5

11. 假如你無法準備三餐時，有可以為你準備的人。 1 2 3 4 5

12. 有會供你真正想要之意見的人。 1 2 3 4 5

13. 有會做一些事情，讓你除去心中煩念的人

14. 假如你生病了，有可以協助你例行工作的人。 1 2 3 4 5

15. 有可以與你分享你個人苦惱和害怕的人。 1 2 3 4 5

16. 如果你需要一些建議以處理個人問題，有可以求助的人。

1 2 3 4 5

17. 有會做一些事令你愉快的人。 1 2 3 4 5

18. 有了解你煩惱的人。 1 2 3 4 5

19. 有疼愛且讓你感到被需要的人。 1 2 3 4 5

憂鬱量表這部分是有關想了解您有無憂鬱狀況之調查，請您仔細閱讀每一題中的敘述，然後圏選一項最能描述您最近七天〈包括今天〉的感受，在適當的答案打勾或圏選。

項目一點也不 (少於一

天)

有時是 (1-2 天)

大部份是 (3-4 天)

總是 (5-7 天)

1. 原本不介意的事，最近竟然會困擾我。 0 1 2 3

2. 我做事無法專心。 0 1 2 3

3. 我覺得悶悶不樂。 0 1 2 3

4. 我做任何事都覺得費力。 0 1 2 3

5. 我對未來充滿希望。 0 1 2 3

6. 我覺得恐懼。 0 1 2 3

7. 我睡得不安寧。 0 1 2 3

8. 我是快樂的。 0 1 2 3

9. 我覺得寂寞。 0 1 2 3

10. 我缺乏幹勁。 0 1 2 3

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