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ORIGINAL ARTICLES |
From Denver Veterans Affairs Medical Center (C.H.J-B.), Denver, CO; University of North Carolina at Chapel Hill (M.A.L.), Chapel Hill, NC; and University of Colorado Health Sciences Center (S.G.), Denver, CO.
Address reprint requests to: Catharine H. Johnston-Brooks, PhD, Routing #116 B, Denver VAMC, 1055 Clermont St., Denver, CO 80220. Email: catharine.johnston-brooks{at}med.va.gov
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSelf-Efficacy, Self-Care, and...Self-Esteem, Self-Care, and...Present StudyMETHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: One hundred ten participants were recruited from a regional diabetes outpatient clinic. Inclusion criteria were age (18–35 years) and duration of diabetes (>1 year before recruitment). Participants were 61% female and 88% white. In addition, the sample had an average annual income between $24,999 and $34,999, and 85% had completed some or all of college. The average duration of diabetes was 15 years.
RESULTS: Using multiple regression analyses we found that, compared with self-esteem, self-efficacy was a better predictor of all aspects of self-care and HbA1c in cross-sectional analyses, in addition to diet and exercise self-care, and a better predictor of HbA1c in longitudinal analyses. The data also supported the cross-sectional and longitudinal mediational model in which better self-care helped account for the association between greater self-efficacy and better HbA1c.
CONCLUSIONS: Self-efficacy is an important factor for management of self-care practices and physiological outcomes among young adults with Type I diabetes, and self-care may be an important mechanism by which self-efficacy influences HbA1c levels.
Key Words: diabetes, • self-efficacy, • self-esteem, • HbA1c, • self-care, • mediation.
Abbreviations: DCCT = Diabetes Control and Complications Trial;; HbA1c = glucose control/glycosylated hemoglobin;; IDDM = insulin-dependent diabetes mellitus;; NIDDM = non–insulin-dependent diabetes mellitus.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSelf-Efficacy, Self-Care, and...Self-Esteem, Self-Care, and...Present StudyMETHODSRESULTSDISCUSSIONREFERENCES |
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Researchers have investigated a variety of psychosocial factors with regard to self-care and HbA1c; little research, however, has focused on understanding the role of the self in predicting these outcomes. Research and theory on the self have a long tradition in psychology, originating in the19th century when William James wrote his observations and theories of self-psychology. Psychologists and sociologists have long believed the self to be important because of its potentially strong organizing force on behavior. In support of this contention, research has found aspects of the self to be associated with a wide variety of behavioral outcomes (6–9), including health outcomes (eg, Refs. 10–12). Given the associations found between the self and such a wide range of outcomes, it is curious that the self has not been investigated more extensively with respect to long-term health outcomes. The study reported here addressed this gap in the literature by examining how aspects of the self are related to chronic disease management.
Epstein’s Cognitive-Experiential Self-Theory provides a conceptual basis for this study. Epstein proposed that information from emotional and cognitive aspects of the self is essential in understanding and predicting behavior (13, 14). Therefore, in the present study, self-efficacy (a cognitive perception of the self’s abilities) and self-esteem (an emotional perception of the self) were selected as important aspects of self-functioning that may be related to better disease management, including self-care practices such as glucose testing, adherence to dietary and exercise regimens, and HbA1c among young adults with IDDM.
Self-variables, such as self-efficacy and self-esteem, could affect self-care and HbA1c among individuals with IDDM in a variety of ways. The literature has assumed that self-care is the mediational mechanism through which the psychosocial factors affect HbA1c (15). Furthermore, given that self-care is associated with better HbA1c (16) and that psychological factors have been found to influence both self-care (17) and HbA1c (18), most researchers have assumed a mediational model, as shown in Figure 1. Although the individual paths of this model have been established, the full mediational model has rarely been tested. The study reported here sought to formally test the mediational impact of self-care practices on HbA1c using self-efficacy and self-esteem as the self-related predictor variables of interest.
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Self-Efficacy, Self-Care, and HbA1c |
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TOPABSTRACTINTRODUCTIONSelf-Efficacy, Self-Care, and...Self-Esteem, Self-Care, and...Present StudyMETHODSRESULTSDISCUSSIONREFERENCES |
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Among individuals with diabetes, self-efficacy has been associated with self-reported adherence to their self-care regimen both cross-sectionally and longitudinally (17, 18, 24–26). However, in only one study (24) did researchers examine a sample solely composed of participants with IDDM. Furthermore, compared with the literature examining the association between self-efficacy and self-care practices, few studies have examined the association between self-efficacy and HbA1c among individuals with IDDM. One study of individuals with non–insulin-dependent diabetes mellitus (NIDDM) found that self-efficacy was related cross-sectionally to HbA1c (18). In another study of individuals with NIDDM (62% of sample) and IDDM (38% of sample), self-efficacy at baseline predicted HbA1c for the combined sample at a 2-month follow-up evaluation (17).
Despite the strong theoretical contention for self-efficacy as an important predictor of self-care and HbA1c among individuals with IDDM, little empirical evidence has been reported. The study reported here examined self-efficacy as it predicts self-care and HbA1c, going one step further by testing the mediational model shown in Figure 1.
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Self-Esteem, Self-Care, and HbA1c |
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A few studies have examined the role self-esteem plays in the self-care among individuals with IDDM. For example, Kovacs et al. (32) found that lower self-esteem marginally predicted less adherence as defined by the DSM-III (33) among 95 children and adolescents longitudinally over a 9-year period. However, the use of the DSM-III criteria for noncompliance has not been considered standard, is not diabetes-specific, and has not been replicated in any other published studies.
Several studies have examined the role of self-esteem in predicting HbA1c. In one study, Swift et al. (34) compared 50 children and adolescents with IDDM with 50 individually matched control subjects, examining "self-percept," defined as how the children felt about themselves, and diabetic control, as indexed by blood glucose levels and number of hospitalizations for diabetic complications. Results indicated that participants with "adequate" self-percept demonstrated better diabetic control. In another study of children with IDDM, investigators split their sample into those who were in better control (HbA1c values of <10) and those who were in worse control (HbA1c values of 10–14) and found that children in better control had significantly higher self-esteem (35). It is important to note that these studies focused on children and used nonstandard measures of either self-esteem or HbA1c. Given these limitations, our study used current and standard measures to examine the role of self-esteem in self-care practices and HbA1c among young adults with IDDM.
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Present Study |
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METHODS |
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Sample
Participants were recruited from the Barbara Davis Center, a regional treatment center for adults and children with IDDM in Denver, Colorado. All those who came to the Barbara Davis Center between June and July 1996 and met study criteria were approached and invited to take part in the study. Criteria for inclusion were as follows: age, 18 to 35 years; diagnosis, IDDM only; and duration of diagnosis, at least 1 year. Of the original 156 eligible individuals contacted, 110 agreed to participate (70% response rate); of these, 88 completed all three waves of data collection (80% completion rate). A majority of the final sample was female (61%), white (88%), had completed some or all of college (84%), and had an annual income between $24,999 and $34,999. The average age of the participants was 25 years, and the average duration of diabetes was 15 years.
Those who declined participation in the study at baseline were asked to complete a short questionnaire that inquired about health and demographic factors. Fourteen of the 46 who declined participation returned this short questionnaire. In addition, this questionnaire was sent to those who did not show up for their appointments. Of the 32 individuals who did not come to the clinic for their scheduled appointments, 20 returned their short questionnaires. No significant differences were found between either of these groups and the study participants on any of the predictors, outcomes, or demographic variables described in the study.
Measures
Predictor variables.
Self-efficacy was assessed with the measure developed by Kavanaugh et al. (17), who found it to have adequate reliability and validity. Self-efficacy for exercise was assessed with the following question: "Over the next 3 months, how certain are you that for 25% of the time, that is 3 of the next 12 weeks, you can follow your exercise program?" This question was repeated three more times using 50%, 75%, and 100% in place of 25%. The same set of four questions was asked in reference to diet (ie, "Over the next 3 months, how certain are you that for 25% of the time, that is 3 of the next 12 weeks, you can follow your recommended diet?"). Participants responded to these questions by giving a number between 0 and 10, where 0 = none of the time and 10 = 100% of the time; higher scores indicated greater self-efficacy. Three averaged self-efficacy indices were created: overall self-efficacy, diet self-efficacy, and exercise self-efficacy. All measures had adequate internal consistency for the overall measure (
= 0.92), for the exercise-specific questions ( = 0.95), as well as for the diet-specific questions ( = 0.94). Correlations indicated that diet and exercise self-efficacy were similarly related to self-care and HbA1c; therefore, the overall self-efficacy measure was used in all analyses. The overall measure of self-efficacy demonstrated adequate test-retest reliability in this study (r = 0.78 for overall self-efficacy over 3 months).
Self-esteem was measured with Rosenberg’s (27) 10-item unidimensional measure of global self-esteem. Items are scored from 1 (never) to 4 (most of the time) and were reverse coded as needed so that higher scores indicated greater self-esteem. We averaged items to create an overall self-esteem score. In the present study this scale had adequate internal consistency ( = 0.90) and test-retest reliability (r = 0.73 over 3 months). Previous research has established the reliability and validity of this particular self-esteem scale among a variety of populations (eg, see Refs. 12, 26, and 36).
Outcome variables.
Self-care practices were measured with the Summary of Diabetes Self-Care Activities (37). This 13-item measure assessed self-care over the preceding 7 days in four distinct areas. Specifically, five items measured diet, three items measured exercise, three items measured glucose testing, and two items measured medication. However, because none of our participants were taking oral diabetes medication, the medication subscale was reduced to one item pertaining to injections. This item was not reliably related to the other self-care subscales or HbA1c and was therefore not included in our analyses. Questions are answered using scales that assessed the frequency of adherence to each self-care practice; responses ranged from 1 (always) to 5 (never) or from 0% to 100%. Items were reversed scored as needed so that higher scores reflected better self-care and standardized so that an overall self-care index could be constructed as the average of all 11 items. Individual subscales for diet, exercise, and glucose testing were also constructed from the averages of the relevant items. Previous research has established the construct validity, internal consistency, and test-retest reliability of this measure (37). Internal consistency of the self-care measure in the present study varied between good and adequate: overall = 0.75, diet = 0.65, testing = 0.84, and exercise = 0.84. Test-retest data over 3 months in the present study indicated adequate temporal stability for the overall measure of self-care (r = 0.70) as well as the diet (r = 0.53), glucose testing (r = 0.73), and exercise (r = 0.49) subscales.
HbA1c was assessed by review of the participant’s medical records. HbA1c, the percentage of total hemoglobin bound to glucose, is a measure of the average glucose concentration over the preceding 3 months and is argued to be an accurate measure of glucose control (38, 39). Test-retest reliability in the present study indicated temporal stability (r = 0.73) over 9 months.
Health status was assessed by information in the interview and survey. Self-reported health information included age of onset, duration of diabetes, and diabetic complications (retinopathy, neuropathy, and/or nephropathy). In addition, participants reported on their height, weight, and alcohol and tobacco use.
Demographic characteristics assessed included age, gender, education, income, employment status, and ethnicity.
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RESULTS |
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For the cross-sectional analyses, T1 predictors (self-efficacy and self-esteem) were regressed on T1 outcomes (self-care and HbA1c). For the longitudinal analyses, T1 predictors were regressed on T3 self-care outcomes and T4 HbA1c. These outcome measures were selected because they were furthest from baseline; outcome points furthest from baseline may reflect stronger predictive associations between variables.
Mediation.
For the cross-sectional analyses, T1 measures were used for all variables. For the longitudinal analyses, the outcome variable was T4 HbA1c, the mediator was T3 self-care, and the predictor was the T1 self variables.
Statistical controls.
Potential statistical controls were chosen on the basis of previous research. These included gender, education level, current age, age at diagnosis, smoking status, years diabetic, ethnicity, income, employment status, and complications. These controls were first correlated with HbA1c and the self-care variables, and the variables that reached significance of p < .10 on any of the outcomes were retained in the analyses. Stepwise multiple regressions predicting HbA1c and self-care were then used on the remaining variables, using a criterion of .05 significance for inclusion. Using this method, smoking and gender were the only demographic and health controls that predicted self-care and HbA1c such that smokers had worse self-care and HbA1c than nonsmokers and women had worse self-care than men. These two variables were used as statistical controls in all analyses. Baseline levels of metabolic control and self-care were used as controls in all longitudinal analyses with these respective outcomes.
Descriptive Analyses
As shown in Table 1, on average this sample had fairly high self-esteem and self-efficacy, and these values were comparable to those found in other studies (17, 42). The mean HbA1c and self-care values were also comparable to those reported in other studies (5, 21, 37).
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Cross-Sectional Analyses
The results of the cross-sectional analyses are presented below in two sections. The first section examines the associations between the self variables and self-care and HbA1c using full and partial models to determine the best predictors of these outcomes. The second section of analyses tests whether a mediational relationship exists among these variables.
Full versus partial model.
Greater self-efficacy was a significant predictor of better self-care and HbA1c above and beyond the effects of self-esteem. Specifically, as shown in Table 2, when examining overall self-care, the model with self-efficacy alone (R2 = 0.35) accounts for nearly as much variance as the model combining both self variables (R2 = 0.36). This general pattern held true when predicting diet, testing, and exercise self-care as well as HbA1c. Furthermore, it can be seen that greater self-esteem, when examined by itself, reliably predicted better overall (R2 = 0.08) and diet self-care (R2 = 0.13) and that these associations became insignificant when controlling for self-efficacy. Therefore, the best predictor of all aspects of self-care and HbA1c were models that accounted for self-efficacy alone rather than models that accounted for self-esteem alone or the combination of self-efficacy and self-esteem.
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Tables 2 and 3 depict data supporting the cross-sectional hypothesis that self-care meditates the association between self-efficacy and HbA1c. Specifically, Table 2 depicts support for path A of the mediational model: self-efficacy was significantly associated with all self-care outcomes. Furthermore, Table 3 shows support for path B of the mediational model, as demonstrated by significant associations between self-efficacy and HbA1c. Finally, paths C and D were confirmed for overall and testing self-care. Specifically, the significant association between self-efficacy and HbA1c became insignificant and the ß values for self-efficacy decreased when controlling for overall and testing self-care.
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Full versus partial model.
In these analyses, the self variables at T1 were used to predict T3 self-care and T4 HbA1c. Comparing the full model that used both self variables to the models that used each self variable separately revealed a pattern similar to that found in the cross-sectional analyses. Specifically, greater self-efficacy was a significant longitudinal predictor of better self-care and HbA1c above and beyond the effects of self-esteem. Specifically, as can be seen in Table 4, when examining diet self-care, the model with self-efficacy alone (R2 = 0.07) accounts for nearly as much variance as the model combining both self variables (R2 = 0.08). In contrast to the cross-sectional analyses, greater self-esteem, when examined by itself, did not predict better diet self-care (R2 = 0.00). This general pattern held true when predicting exercise self-care as well as HbA1c. Neither self-efficacy nor self-esteem, nor the combination of the two, reliably predicted overall or testing self-care. The best longitudinal predictor of diet and exercise self-care and HbA1c were models that included self-efficacy alone rather than models that accounted for self-esteem alone or the combination of self-efficacy and self-esteem.
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DISCUSSION |
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Self-Efficacy, Self-Care, and HbA1c
The finding that self-efficacy is important in the prediction of self-care and HbA1c among young adults with IDDM joins "growing evidence that indicates that perceived self-efficacy to cope with the consequences of chronic disease is an essential contributor to developing self-management capabilities" (44). Specifically, these data suggest that the more individuals with IDDM believe they can follow their self-care regimen, the better their self-care and glucose control will be. Although the amount of variance associated with self-efficacy in the longitudinal analyses was small, these findings have important clinical significance. Even in young adults who have been diagnosed with diabetes for some time, self-efficacy continues to play an important role in their self-care practices and physiological functioning.
In addition, the findings of the present study build on previous research by using a sample composed solely of young adults with IDDM. Previous research has tended to focus either on individuals with NIDDM or on mixed samples of individuals with NIDDM and IDDM (eg, Refs. 17, 25, and 26). Because the severity and duration of Type 1 and Type 2 diabetes can vary, the psychosocial correlates of these conditions may vary as well. Furthermore, no study to date has reported that self-efficacy is longitudinally related to better HbA1c in an adult sample. These findings extend previous work done with adolescents (eg, Ref. 45) and highlight the continued importance that self-efficacy plays as individuals cope with chronic health conditions into adulthood (44).
The goal of building the best model to predict self-care and HbA1c was to determine which of the self-variables was the more important indicator of these outcomes. The results generally indicated that a model including only self-efficacy was the best predictor of self-care and HbA1c. The results suggest that when measuring psychosocial variables related to the self, measuring self-efficacy may be the most expedient and efficient means to predict self-care and HbA1c, both cross-sectionally and longitudinally, among young adults with IDDM.
Self-Esteem, Self-Care, and HbA1c
The present study also lent partial support to the hypothesis that self-esteem is important in the prediction of self-care among individuals with IDDM, although these findings were not as strong as those for self-efficacy. For example, a model with self-esteem alone was related concurrently to overall, diet, and exercise self-care, supporting previous research that suggests greater self-esteem is important in predicting healthier behavior (11, 28, 46). However, cross-sectional and longitudinal analyses indicated that self-esteem alone was not significantly related to any aspects of self-care over and above the effects of self-efficacy. It may be that the relationship between self-esteem and self-care has a small effect size and can be detected only with a great deal of statistical power.
It is also possible that because self-esteem represents an emotional aspect of the self, it would be a better predictor of more affective outcomes, such as anxiety, depression, or quality of life, rather than the behavioral and physiological outcomes that were examined in this study. This explanation is consistent with previous research that shows lower self-esteem is associated with depressed mood (47, 48), which in turn is associated with poorer health (49). In addition, lower self-esteem is associated with increased anxiety (47), a correlate of poorer health (50). Finally, poorer self-esteem is associated with greater stress (51), a correlate of worse health and HbA1c (52, 53). These affective states may represent factors that mediate any association between self-esteem and HbA1c. Future research should examine these potential pathways.
Mediational Role of Self-Care
There was evidence suggesting that the association between greater self-efficacy and better HbA1c was mediated, or partially explained, by better self-care. Specifically, cross-sectional analyses demonstrated that greater self-efficacy predicted better overall and testing self-care, which in turn predicted better HbA1c. This model is often assumed, but to date it has not been established empirically. Understanding the explanatory mechanism (eg, better self-care) in the association between greater self-efficacy and better HbA1c helps researchers, theorists, and clinicians by providing insight into the mechanism by which self-efficacy influences health outcomes. Not only does this finding contribute to our theoretical understanding, but it also has implications for the development of interventions and clinical practice as well. For example, interventions aimed at improving young adults’ HbA1c should seek to improve self-efficacy while concomitantly teaching techniques that support better self-care (eg, 45, 54). In other words, these data suggest that teaching self-care behaviors will have a greater positive impact on HbA1c when combined with interventions aimed at improving self-efficacy.
It is noteworthy that mediation was evident only for certain aspects of self-care. Specifically, overall and testing self-care were significant mediators in cross-sectional analyses, and diet self-care was the only significant mediator that emerged from longitudinal analyses. Previous research examining psychosocial influences on self-care, using the same measure used in the present study, also finds a differential relationship between health-related beliefs and the various aspects of self-care we examined (55). Several reasons for this pattern of results may exist. Recent evidence from the Diabetes Control and Complications Trial (DCCT) suggests that very tight control is especially important in controlling and delaying diabetes complications such as peripheral neuropathy and related vascular disorders. One means of achieving such tight control is frequent glucose testing (56). The results of the present study are consistent with these findings from the DCCT. Previous research also points to the importance of proper nutrition, diet, and exercise in maintaining health for people with diabetes (57). Although findings from the DCCT corroborate the current findings for each type of self-care we found to be significant in the cross-sectional and longitudinal analyses, we know of no research suggesting that the temporal patterning of interrelationships between psychosocial factors, such as self-efficacy, and self-care should be different over time for HbA1c. It is possible that some types of self-care are more proximal in predicting HbA1c and that other practices, like diet self-care, are more distal in predicting HbA1c. Until other research tests models similar to those tested here, however, such conclusions must remain tentative.
Future research that tests models similar to those tested in the present study and replicates these findings would be useful. Furthermore, given that insulin compliance has been established as an important aspect of glucose control (58, 59), future studies should include a more comprehensive assessment of insulin compliance. In addition, future work that can help explain why the mediational hypotheses were supported only for overall and testing self-care in cross-sectional analyses and diet self-care in longitudinal analyses would be fruitful. Further investigation may help explain why the evidence for mediation was stronger for the cross-sectional data as compared with the longitudinal data. It may be that cross-sectional analyses more appropriately reveal the importance of psychosocial factors for young adults who have had diabetes for an average of 15 years. Such a population is more likely to be stable with respect to psychosocial and behavioral dimensions, and the change and variability necessary for longitudinal analyses to be meaningful may be reduced for such a stable population. On the other hand, the analyses conducted would provide the most conservative test of the idea that self-care mediates the association between self-efficacy and HbA1c over time.
In sum, the present study’s findings provide further evidence that among a sample of young adults with IDDM, self-efficacy beliefs are strong predictors of behavior and HbA1c. An individual’s self-esteem may also be important to his or her health. For researchers and theorists, these findings suggest that certain aspects of the self are important for understanding individuals’ health behaviors and health outcomes. In the clinical field of diabetes treatment, these findings suggest that strengthening an individual’s self-efficacy beliefs may have long-term benefits in both the area of self-care as well as HbA1c. The finding that overall and testing self-care cross-sectionally mediates the association between self-efficacy and HbA1c is particularly intriguing because this study is the first to test and find empirical evidence of this mediational association. Understanding the explanatory mechanisms that link psychosocial factors, like self-efficacy, with important physiological outcomes, like HbA1c, is of great importance to researchers and clinicians alike.
Received for publication August 14, 2000.
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