Psychological adjustment to Type 2 diabetes and relationship quality

'We are in control of this thing, and we know what to do now': Pilot and process evaluation of 'Diabetes Together', a couples-focused intervention to support self-management of Type 2 Diabetes in South Africa

We piloted the delivery of a prototype couples-focused intervention, 'Diabetes Together' with 14 people living with diabetes (PLWD) and their partners, in Cape Town, South Africa in 2022. We aimed to: assess feasibility of recruiting couples in this setting; explore acceptability of intervention materials and changes needed; and investigate whether our prespecified logic model captured how the intervention may work. We used questionnaires, interviews and focus groups after each workshop and after couples completed counselling. We conducted a process evaluation to identify intervention modifications and used inductive thematic analysis to explore whether the data supported our logic model. Twelve of the 14 couples completed the second workshop and 2 couples completed two counselling sessions post-workshop. Feedback showed participants appreciated the intervention and limited improvements were made. Thematic analysis identified four main themes: (1) involving partners matters; (2) group work supports solidarity with other couples; (3) improving communication between partners is crucial; and (4) taking part helped couples to take control of diabetes. Data suggested the logic model should explicitly acknowledge the importance of group education and of equalising partners' knowledge. This pilot suggests that 'Diabetes Together' increased knowledge and skills within couples and could facilitate improved, collaborative self-management of diabetes.

Intervention development of 'Diabetes Together' using the person-based approach: a couples-focused intervention to support self-management of type 2 diabetes in South Africa

OBJECTIVES

Type 2 diabetes (T2D) is a growing concern in South Africa, where many find self-management challenging. Behaviour-change health interventions are enhanced by involving partners of patients. We aimed to develop a couples-focused intervention to improve self-management of T2D among adults in South Africa.

DESIGN

We used the person-based approach (PBA): synthesising evidence from existing interventions; background research; theory; and primary qualitative interviews with 10 couples to ascertain barriers and facilitators to self-management. This evidence was used to formulate guiding principles that directed the intervention design. We then prototyped the intervention workshop material, shared it with our public and patient involvement group and ran iterative co-discovery think-aloud sessions with nine couples. Feedback was rapidly analysed and changes formulated to improve the intervention, optimising its acceptability and maximising its potential efficacy.

SETTING

We recruited couples using public-sector health services in the area of Cape Town, South Africa, during 2020-2021.

PARTICIPANTS

The 38 participants were couples where one person had T2D.

INTERVENTION

We developed the 'Diabetes Together' intervention to support self-management of T2D among couples in South Africa, focussing on: improved communication and shared appraisal of T2D; identifying opportunities for better self-management; and support from partners. Diabetes Together combined eight informational and two skills-building sections over two workshops.

RESULTS

Our guiding principles included: providing equal information on T2D to partners; improving couples' communication; shared goal-setting; discussion of diabetes fears; discussing couples' roles in diabetes self-management; and supporting couples' autonomy to identify and prioritise diabetes self-management strategies.Participants viewing Diabetes Together valued the couples-focus of the intervention, especially communication. Feedback resulted in several improvements throughout the intervention, for example, addressing health concerns and tailoring to the setting.

CONCLUSIONS

Using the PBA, our intervention was developed and tailored to our target audience. Our next step is to pilot the workshops' feasibility and acceptability.

Psychometric evaluation of Persian version of Diabetes Acceptance Scale (DAS)

BACKGROUND

Acceptance of diabetes is a psychological adaptation to the potential limitations of the disease. Poor acceptance of diabetes impairs effective self-management of diabetes, leading to worsening metabolic control. This study aimed at determining the psychometric properties of the Persian version of the Diabetes Acceptance Scale.

METHODS

This cross-sectional methodological study was performed on diabetic patients in Iran in 2021. The questionnaire consisted of two parts: demographic characteristics and Diabetes Acceptance Scale. The questionnaire was translated into Persian through the forward-backward translation method. The face validity and content validity were performed qualitatively and quantitatively. Exploratory (n = 200) and confirmatory (n = 200) factor analysis were performed to evaluate the validity of the structure. Internal consistency and temporal stability were estimated to determine reliability.

RESULTS

Exploratory factor analysis on the polychoric correlation matrix obtained three factors: Rational dealing, Resentment and Avoidance, which explained 68.8% of the total DAS variance. Confirmatory factor analysis showed that the 3-fractor model had a good fit to a second independent data set. Finally, Ordinal Cronbach's alpha coefficient was 0.96, 0.94 and 0.93, respectively for the Rational dealing, Resentment, and Avoidance factor. Also, using intraclass correlation coefficient, the stability of the instrument was 0.97.

CONCLUSION

Based on the findings of this study, the Persian version of DAS has sufficient validity and reliability to measure the admission of Iranian diabetic patients.

Exploring the perceptions of emotional distress among couples living with Type 2 diabetes and among diabetes healthcare providers, and consideration of support needs

AIMS

To compare the emotional distress experienced by people with Type 2 diabetes with the perceptions of their partners, and to explore the perceptions of healthcare providers and how these differ from the perceptions and experiences of couples living with Type 2 diabetes regarding their support needs.

METHODS

A purposive sample of people with Type 2 diabetes and their partners was recruited through Diabetes UK media outlets and support groups, while healthcare providers were recruited through hospital and diabetes education teams. Inductive thematic analysis was conducted.

RESULTS

Seven people with Type 2 diabetes and six partners took part in separate semi-structured interviews and seven healthcare providers took part in focus groups. Themes emerged regarding unique psychological struggles for people with Type 2 diabetes: 'sense of restriction'; 'disempowerment'; and 'acceptance of diabetes'. For partners the themes of 'feeling responsible' and 'need for greater involvement' emerged. Common themes arising from people with Type 2 diabetes, partners and healthcare providers highlighted diabetes-related stresses: 'self-care struggles' and 'perceived need for appropriate psychological support'. A key theme drawn from healthcare providers was 'perceived professional barriers to psychological support', which captures concerns related to providing emotional support in clinical practice.

CONCLUSIONS

People with Type 2 diabetes, partners, and healthcare providers share a common understanding of the emotional stresses of living with Type 2 diabetes, but also experience diabetes differently depending on their role and responsibilities. All face barriers that need to be considered to ensure that emotional support in diabetes is meaningful and feasible in routine practice.

Family and Couple Variables Regarding Adherence in Type 2 Diabetes Patients in the Initial Stages of the Disease

This study analyzed which family and couple variables predicted adherence to standard care treatment, in patients recently diagnosed with type 2 diabetes. The sample comprised 224 dyads assessed during the first year of diagnosis (T1) and 4 months later (T2). The results showed that family stress, dyadic adjustment, family coping, and positive support assessed by patients at T1 predicted medication adherence and glucose monitoring at T2. Positive support and dyadic adjustment, assessed by partners at T1, predicted patients' adherence to glucose monitoring and diet at T2. This study highlights the important role of the partner in patient`s adherence. Therefore, standard care in type 2 diabetes should be offered in the context of the dyad.

Health-promoting Lifestyle, Illness Control Beliefs and Well-being of the Obese Diabetic Women

The study examines the role of health-promoting lifestyle and illness control beliefs in well-being of obese diabetic women. Measures of illness control belief, health-promoting lifestyle and obesity-related well-being were given to 100 obese diabetic women selected from outdoors of hospitals in Varanasi. Analysis revealed patients’ stronger belief in ‘doctor-control’ and ‘supernatural-control’ than ‘self-control’ of the disease. Nutrition, interpersonal relations, physical activity and stress management were given more importance in health promotion than spiritual growth-related practices. Belief in ‘self-control’ and ‘doctor-control’ of disease was negatively correlated with ‘psychosocial discomfort’, ‘physical discomfort’ and ‘psychosocial impact’ aspects of obesity, whereas ‘supernatural-control’ showed positive relationship with all aspects. All components of ‘health-promoting lifestyle’ were negatively correlated with ‘physical discomfort’, ‘psychosocial discomfort’ and ‘psychosocial impact’ aspects of obesity. Multiple regression analysis brought out ‘self-control’, ‘supernatural-control’, ‘health responsibility’, ‘physical activity’ and ‘stress management’ as significant predictors of ‘well-being’ of the obese diabetic women.

Managing Type 2 diabetes as a couple: The influence of partners' beliefs on diabetes distress over time

AIMS

Partners and spouses have an important role in supporting healthy self-care in adults with Type 2 diabetes. While evidence has shown that the beliefs held by people with diabetes influence emotional wellbeing, little is known about the long-term impact of partners' illness beliefs on diabetes distress.

METHODS

Persons with Type 2 diabetes (pwt2d) and their partners completed a questionnaire at baseline (N = 75 couples) and 12 months later (N = 45 couples). Measures included demographic/clinical parameters, the Revised Illness Perception questionnaire, and the Diabetes Distress Scale. A repeated measures ANOVA was used to examine change in measures over time. Multiple regression and moderation analysis were used to explore the indirect influence of partners beliefs on diabetes distress at baseline and follow-up.

RESULTS

Illness perceptions and diabetes distress in pwt2d and partners did not change overtime. Partners' beliefs about the controllability, chronicity, and predictability of symptoms of diabetes moderated the relationship between the corresponding pwt2d beliefs and diabetes distress. These indirect effects were observed across both time points.

CONCLUSIONS

Conflicting illness perceptions about the controllability and chronicity of diabetes, and congruous negative perceptions about diabetes symptoms among couples sustain distress overtime. Targeting the beliefs of couples to improve communication and understanding may reduce diabetes distress.

Measurement of psychological adjustment to diabetes with the diabetes acceptance scale

AIMS

To develop a psychometric measure of diabetes acceptance.

METHODS

An item pool was developed and pilot-tested using a sample of 220 people with diabetes; item selection resulted in the 20-item 'Diabetes Acceptance Scale (DAS)'. 606 people with diabetes were then cross-sectionally assessed with the DAS to evaluate its reliability, validity and clinical utility; concurrent measurements included diabetes-related coping (FQCI), diabetes distress (PAID-5), depressive symptoms (PHQ-9), quality of life (EQ-5D), self-management (DSMQ), glycaemic control (HbA_1c) and complications.

RESULTS

Internal reliability was high (Cronbach's α = 0.96). Factorial and criterion-related results supported validity. Higher diabetes acceptance scores correlated with more functional coping styles, lower distress and depression levels, higher treatment adherence, better glycaemic control and better quality of life (all P < .001). Persons with low diabetes acceptance (22% of the sample) were four times more likely to have HbA_1c values over 9.0% (75 mmol/mol), two times more likely to be diagnosed with long-term complications and each over two times more likely to have had episodes of severe hypoglycaemia and ketoacidosis in the past year; the prevalence of major depression in this group was fivefold increased (all P < .05).

CONCLUSIONS

The DAS is a reliable and valid tool to measure diabetes acceptance. It may help identify patients with significant problems of accepting diabetes, a putative high-risk group in need of tailored care and support.

Exploring the effectiveness of couples interventions for adults living with a chronic physical illness: A systematic review

OBJECTIVE

Partners have a significant role in a person's ability to adjust to a chronic physical illness, which warrants their inclusion in couples interventions. However to deliver more specific, tailored support it is necessary to explore which types of couples interventions are most effective across certain chronic illness populations and outcomes.

METHODS

Five databases were searched using selected terms. Thirty-five articles met the eligibility criteria for inclusion.

RESULTS

The majority of studies were from the US, and most interventions targeted cancer populations. Couples interventions fell into two categories according to therapeutic approach; Cognitive Behavioural Skills Training (CBST) and Relationship Counselling (RC). When compared with a patient-only intervention or controls, CBST interventions effectively targeted behavioural, physical/somatic and cognitive outcomes, while RC more effectively targeted interpersonal outcomes.

CONCLUSION

Couples interventions can be more effective than patient-only interventions or controls across various patient and partner outcomes. Couples interventions tend to favour a skills-based or a relationship-based approach, which strongly influences the types outcomes effectively targeted.

PRACTICE IMPLICATIONS

Our findings suggest it could be therapeutically useful to integrate these two approaches to more holistically support couples living with chronic illness. We also identify the need to target understudied illness groups and ethnicities.

Illness perception clusters and relationship quality are associated with diabetes distress in adults with Type 2 diabetes

This report aims to augment what is already known about emotional distress in Type 2 diabetes, by assessing the predictive value of illness perception clusters and relationship quality on four subcategories of Diabetes Distress.162 individuals with Type 2 diabetes responded to a postal questionnaire assessing demographics, depression, diabetes distress, illness perceptions and relationship quality. Long-term blood glucose was retrieved from participants' General Practitioner. Three illness perception clusters emerged from the data, capturing three subgroups of participants sharing similar illness perception schemas. Regression analyses were performed across each diabetes distress subscale, with demographics, illness perception clusters, and relationship variables entered into three blocks. Covariates explained 51.1% of the variance in emotional burden, 41% of the variance in regimen-related distress, 20% of the variance in interpersonal distress, and 8.6% of the variance in physician-related distress. Cluster membership was strongly associated with emotional burden, regimen-related distress, and to a lesser degree interpersonal distress, but was not associated with physician-related distress. Relationship quality most strongly predicted regimen-related distress. Illness perception schemas and interpersonal issues influence emotional adjustment in diabetes. This study provides direction for the content of a novel approach to identifying and reducing diabetes distress in people with Type 2 diabetes.

Evaluating the effectiveness of an empowerment program for self-care in type 2 diabetes: a cluster randomized trial

BACKGROUND

The prevalence of type 2 diabetes mellitus is increasing substantially worldwide, leading to serious economic effects, complications and deaths. This study evaluated the effectiveness of an empowerment program providing support for psychosocial, behavioral, and clinical aspects of diabetes to help Brazilian users of public health services obtain metabolic control of this condition.

METHODS

In this cluster randomized trial, participants aged 30-80 diagnosed with type 2 diabetes were recruited from ten Brazilian public health units in 2014 and 2015. Five units were randomly assigned to receive the empowerment program based on a behavior change protocol, and five continued to receive only conventional treatment. The primary outcome was the biochemical and anthropometric parameters, and the secondary outcomes were self-care, attitude, knowledge and empowerment related to diabetes. The effect of the experiment was defined as the percentage variation between the values at the initial and final periods. To evaluate this effect and to compare it in the two groups, tests were used for paired and independent samples, respectively.

RESULTS

There were 238 participants: 127 and 111 in the intervention and control group, respectively. For glycated hemoglobin, the mean effect in the control and intervention groups was 3.93 and -5.13, respectively (p < 0.001). Levels of glycated hemoglobin and other metabolic indicators, as well as the most part of the secondary outcomes showed a significant difference in the experimental group compared to the control group.

CONCLUSIONS

The empowerment program improved metabolic control of type 2 diabetes in Brazilian users.

TRIAL REGISTRATION

NCT02132338 - April 22, 2014.

Patients' and Spouses' Contribution Toward Adherence to Self-Care Behaviors in Type 2 Diabetes

This article focuses on patients' and partners' variables regarding adherence to self-care, in recently diagnosed patients with Type 2 diabetes. One hundred four patients and partners were included. Instruments answered were Family Inventory of Life Events and Changes (family stress), Family Crisis Oriented Personal Evaluation Scales (family coping), Revised Dyadic Adjustment Scale (dyadic adjustment), Multidimensional Diabetes Questionnaire (partner support) and Hospital Anxiety and Depression Scale (psychological morbidity). Results showed adherence to diet to be positively predicted by patient dyadic adjustment and patient positive support and negatively by partner depression and partner negative support. Adherence to exercise was predicted by patient's family stress and negatively by partner anxiety. Adherence to glucose monitoring was predicted by partner positive support. Psychological variables were not associated with adherence to foot care. Finally, positive partner support moderated the relationship between family stress and dyadic adjustment in patients. The results emphasize the need to treat the patient in the context of the dyad. Future research should focus on partners' specific instrumental behaviors that promote patients' self-care behaviors.

Modelling of diabetes knowledge, attitudes, self-management, and quality of life: a cross-sectional study with an Australian sample

BACKGROUND

Quality of life (QoL) is an important aspect of wellbeing for people with chronic conditions like type 2 diabetes, making it a noteworthy outcome. Knowledge about diabetes, attitudes, and self-management of diabetes are key factors that might directly or indirectly impact QoL. However, little is known about the inter-relationships between diabetes knowledge, attitudes, self-management and QoL among people with type 2 diabetes mellitus (T2DM). The aim of this study was to examine a model describing the relationship between diabetes knowledge, attitudes, self-management, and QoL of people with T2DM that is based on previous research linking pairs of these variables.

METHODS

A cross-sectional study design was employed in this research. A total of 291 participants, 192 males and 99 females, with T2DM, whose mean age was 55.8 (standard deviation = 11.09) completed questionnaires measuring diabetes knowledge (Diabetes Knowledge Scale), attitudes (Diabetes Integration Scale -19), self-management (Summary of Diabetes Self-care Activities Scale), including the aspects of diet, exercise, blood glucose testing, and foot care, and QoL (Diabetes Quality of Life Scale), comprising the aspects of satisfaction and impact on QoL respectively. To examine the model we proposed relating these variables, data were analysed using the path analysis.

RESULTS

In the final model, diabetes knowledge was a significant predictor for attitudes and self-management in terms of blood glucose testing. Attitudes was a significant predictor for self-management in terms of diet. In addition, self-management in terms of blood glucose testing was a significant predictor of impact of QoL, and self-management in terms of diet was a significant predictor of satisfaction and impact of QoL. Self-management in terms of exercise was a significant predictor of satisfaction in QoL. The final model reflected a good fit (χ(2) (14) = 22.52, p = 0.069; CFI = 0.983; GFI = 0.983; RMSEA = 0.046).

CONCLUSIONS

Diabetes knowledge, attitudes, and self-management are important factors that can impact the QoL among people with type 2 diabetes.

A study exploring the association of attitude and treatment satisfaction with glycaemic level among gestational diabetes mellitus patients

AIMS

The aim of this study was to evaluate attitude and treatment satisfaction of women suffering from GDM and their association with glycaemic level.

METHODS

A cross sectional study was conducted in antenatal clinic of Hospital Pulau Pinang, Malaysia from June to December 2013 on the sample of 175 patients. Data was collected through modified version of Diabetes Integration Scale (ATT-19) and Diabetes Treatment Satisfaction Questionnaires (DSTQs). Glycaemic level was evaluated in terms of Fasting Plasma Glucose (FPG). Three most recent values of FPG (mmol/l) were taken from patients medical profiles and their mean was calculated. Descriptive and inferential statistics were used for data analysis.

RESULTS

A total of 166 patients were included in final analysis. Only 35 (21.1%) patients had positive attitude and 122 (73.5%) of patients had adequate treatment satisfaction. There was no significant association of total mean ATT-19 score with age, ethnicity, educational level, occupational status, family history and type of therapy. For treatment satisfaction statistically significant association was present only between total mean treatment satisfaction score and educational level. Patients with negative attitude and inadequate treatment satisfaction had higher mean glycaemic level.

CONCLUSIONS

It is concluded that more than two folds of patients were satisfied with their ongoing treatment but majority of the patients were feeling difficulty in active coping measures for the management of GDM.

Mental health and relational self-management experiences of patients with type 2 diabetes and stage 3 chronic kidney disease

Self-management (SM) behaviors reduce disease burden from advancing diabetic kidney disease. From a parent study about patients' transition experience to SM, this study report presents coping resources that support SM and barriers from two focus group interviews (n = 6). Ethnographic analysis identified two patterns: (a) mental health self-management characterized by coping, and (b) relational self-management characterized by social support. Practice implications include focused assessment of perceived social support and social network, dating advisement, and workplace management. Future study considerations include inquiry about diabetes and dating relationships and workplace resources for SM support.