Self-efficacy, self-management, and glycemic control in adults with type 2 diabetes mellitus☆,☆☆,★
Introduction
Diabetes mellitus (DM) is a major health problem worldwide with its prevalence increasing, thus becoming a pandemic (Hjlem, Mufunda, Nambozi, & Kemp, 2003). According to the World Health Organization (WHO, 2008), more than 180 million people worldwide have DM. Moreover, a recent global estimation by the WHO indicated that there would be 366 million people with DM by the year 2030 (Wild, Roglic, Green, Sicree, & King, 2004). In Jordan, the prevalence of diabetes in adults ≥25 years of age is 13.4%, while an additional 9.8% of Jordanians have impaired glucose tolerance (Ajlouni, Jaddou, & Batiha, 1998). However, a recent study in Jordan reported that the age standardized prevalence rate of diabetes and impaired fasting blood glucose was 17.1% and 7.8%, respectively, with no significant differences between women and men (Ajlouni, Khader, Batieha, Ajlouni, & El-Khateeb, 2008). These results confirmed that the prevalence of diabetes in Jordan is increasing. Diabetes has a significant impact on the lives of individuals, their families, and the health care system. The chronicity of DM and the potential for serious complications often result in a significant financial burden and decreased quality of life (Coffey et al., 2002), and major lifestyle changes are needed for patients and their families. Poorly controlled diabetes too often results in complications such as heart disease, stroke, high blood pressure, blindness, kidney disease, nervous system disease, amputations of legs, and premature death (Sratton et al., 2000).
The burden of diabetes in Jordan is very high. Diabetes as a chronic disease is one of the leading causes of morbidity and mortality in Jordan (Zindah, Belbeisi, Walke, & Mokdad, 2004). Diabetes mellitus was identified as a major risk factor for cardiovascular disease (Jaffe, Nag, Landsman, & Alexander, 2006). Cardiovascular diseases are the leading causes of death in many countries in the world and in Jordan (Brown et al., 2009, International Diabetes Federation, 2006). However, estimating the mortality burden has been challenging because more than a third of countries of the world do not have any data on diabetes-related mortality and also because existing routine health statistics have been shown to underestimate mortality from diabetes (Roglic et al., 2005). The increasing prevalence, the emergence of complications as a cause of early morbidity and mortality, and the enormous burden on health care systems make diabetes a priority health concern.
The American Diabetes Association (ADA, 2007) describes type 2 DM as the most common form of DM, and its frequency increases with advancing age. Self-management approaches have become a key strategy of health care providers (Norris, Engelgau, & Narayan, 2001). The majority of researchers and clinicians advocate that DM is a disease that requires essential diabetes self-management (DSM) care abilities, and that patients need to be taught the diabetes self-management skills to become reliable, capable, and sufficiently responsible to take care of themselves (Sousa, Zauszniewski, Musil, McDonald, & Milligan, 2004). Self-management of type 2 DM is challenging and often requires adherence to complex treatment regimen that requires skilful integration of healthy diet, regular exercise, optimum weight control, self-monitoring of blood glucose, and medication adjustment into the daily routine over long periods (Montague, Nichols, & Dutta, 2005). Diabetes self-management is of great importance because the adoption of healthy lifestyles behaviors will produce optimum glycemic control for DM, which in turn will help minimize or prevent subsequent acute and long-term complications of the disease (Norris et al., 2001, Sousa et al., 2005).
Diabetes is a lifelong disease that needs behavioral changes, most often through education, counseling, skill building, and support through behavioral interventions offered by health care providers, to enable diabetic patients to perform self-care activities. Behavioral changes are complex processes that are influenced by such factors as knowledge, beliefs, attitudes, skills, motivation, and social support. One of the key factors in attaining behavioral goals is self-efficacy, the belief in one's capability to perform specific behaviors necessary to achieve his or her goals (Bandura, 1997). The theory of self-efficacy by Bandura in 1986, and advanced in 1997, was derived from social learning theory and guides this study.
The theory of self-efficacy proposes that individual beliefs about personal capabilities predict behavioral performance. In the case of DSM, self-efficacy is the patient's confidence in his/her ability to perform a variety of DSM behaviors. Improving DSM, prevention of DM complications, and reducing health service utilization for patients with DM are ongoing challenges for nurses and other health care providers globally and in Jordan. Therefore, addressing the task-related issues of DSM behaviors required by people with DM and gaining a better understanding of factors that influence glycemic control are of vital importance. Information about the current DSM behaviors and their relationships with glycemic control can help to identify groups at high risk for poor glycemic control. Identifying DSM behaviors and diabetes management self-efficacy and examining their effects on glycemic control can assist nurses in planning and developing interventions and educational programs that enhance self-care management and improve glycemic control. In addition, results may enable nurses to evaluate those areas of diabetes management self-efficacy and DSM behaviors in which patients with DM may need additional support.
This study proposes to answer the following research questions:
- 1.
What are the levels of diabetes management self-efficacy?
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What are the levels of DSM behaviors?
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Does diabetes management self-efficacy predict DSM behaviors?
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Do sociodemographic and clinical characteristics, self-efficacy beliefs for diabetes management, and DSM behaviors predict glycemic control in patients with type 2 diabetes?
Section snippets
Design, setting, and sample
A cross-sectional research was conducted using face-to-face interviews. The study setting was an outpatient clinic in a National Diabetes Center in Amman, Jordan. A consecutive–convenience sampling technique was used to recruit the subjects. The sample was Jordanian adults with type 2 DM who sought care for periodic follow-up between July 15, 2008, and September 16, 2008. Subjects were invited to participate if they (a) had type 2 DM for at least 1 year prior to data collection, (b) were aged
Sociodemographic and clinical characteristics of the sample
The sample consisted of 223 subjects; 56.1% were men, 89.7% were married, 39% reported being employed, and 45.4% had a monthly income of less than 500 Jordanian dinars. Their average age was 56.9 (S.D.=±8.4) years, with a range of 33 to 77 years. The average years of education were 13.43 (S.D.=±4. 6) years. The clinical characteristics of the sample are displayed in Table 1. The average duration since diagnosis with DM was 9.4 (S.D.=±6.9) years. Only 7.2% had ideal body mass indexes (BMIs);
Discussion
The main purpose of this study was to examine the significance of diabetes management self-efficacy and DSM behaviors in predicting glycemic control in adult subjects with type 2 DM. The sample was composed of Jordanian adult patients with type 2 DM who were visiting the outpatient clinics of the National Diabetes Center for regular follow-up. The study findings indicated that more than half of the participants had uncontrolled HbA1c levels, suggesting poor control of their DM. These study
Conclusions
This study provides an understanding of the factors contributing to glycemic control in adult Jordanian subjects with type 2 DM. The suboptimal self-management behaviors reported and the low levels of subjects' participation in diabetes education programs are alarming. Education, counseling, and behavioral skill-building programs that focus on self-efficacy enhancing interventions are required to achieve better glycemic control and better health outcome. This study was carried out in Arabs with
Acknowledgment
We would like to extend our deep appreciation to Professor Kamel Al-Ajlouni, president of the National Center for Diabetes, Endocrinology, and Genetics, and all the staff for providing access, support, and facilitating data collection from the center. Lastly, the authors are indebted to the patients who generously volunteered their time and participated in the study.
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The dissertation study received some funding from the Deanship of Scientific Research, University of Jordan.
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Contributors: Dr. Omar Al-Khawaldeh conceived the study questions; designed the study; and did all data collection and analysis under the supervision, direct guidance, and input from Dr. Al-Hassan and Dr. Froelicher. Dr. Al-Hassan read numerous drafts of this manuscript and offered Arabic specific input for translation and interpretation of this study. Dr. Froelicher provided conceptual and methodological input into the study design and methods, provided expertise for theoretical approach to the study of chronic disease management, guided all data analysis and reporting, and cowrote the manuscript.
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Conflict of interest: None.