Evaluation of Health Psychology theory and research to explain type 2 diabetic patients’ experience of self-management
by Dipl.-Psych. Sebastian A. Wagner, B.Sc. (F.C. Hon.) in Psych. University of Bamberg, Germany
Diabetes mellitus (D) is a disease that is characterised by high levels of sugar in the blood (hyperglycaemia) and a failure to transfer it to organs that need it (Morrison & Bennett, 2006). This originates from the body not producing enough of the hormone insulin that re- duces hyperglycaemia (H), classed as type 1 diabetes (D1). People who suffer from type 2 diabetes (D2) have a resistance to insulin, which means their body cannot use it properly (National Health Service; NHS, 2007). The long-term consequences of H are severe: it can lead to a dysfunction or breakdown of the eyes, nerves, kidneys, heart and blood vessels, which results in an increased morbidity (Lloyd, Sawyer & Hopkinson, 2001). A higher rate of mortality is also observed, as life expectancy is reduced dramatically. D is also the main con- tributor to the chief cause of death in the UK - cardiovascular heart disease (Gillibrand & Stevenson, 2006). Among patients with D2 for example, 75-80% die from coronary heart dis- ease, cerebrovascular disease and / or peripheral vascular disease (Clark & Hampson, 2001). D is not a rare condition - it is very common and on the increase. In the year 2000 for in- stance, its prevalence in the UK was 1,765,000 registered cases, which amounts about 2% of the population, whereas 2,668,000 cases are expected in 2030 (World Health Organization; WHO, 2007).
It is widely acknowledged that lifestyle and behavioural factors play an important role in the cause, progression and consequences of modern disease of civilisation (Cark & Hamp- son, 2001). This applies directly to D and in particular to D2, as the risk factors for develop- ing a resistance to insulin are highly associated with obesity and sedentary lifestyle, whereas genetics are comparatively less influential here (NHS, 2007). From this follows that espe- cially patients who already suffer from D2 should not only take their medication but also change their lifestyle in order to prevent the aforementioned complications by controlling H (Clark & Hampson, 2001; Norris, Lau, Smith, Schmid & Engelgau, 2002). However, lifestyle changes require a high degree of SM in daily life. This involves behaviour such as eating regular healthy meals, taking medicine, self-testing blood glucose levels and taking physical exercise (Whittemore, Melkus & Grey, 2005; Searle, Norman, Thompson & Vedhara, 2007).
SM means in this context not only carrying out aforementioned activities, but also considering interrelationships between them and implementing appropriate changes in the daily plan when necessary. However, Searle et al. (2007) refer that 30-70% of patients suffer- ing from D2 do not integrate described health behaviour in their lives! This poses the question on what score these people are more or less able to manage their health condition. It is obvi- ous that psychological factors play a decisive role in this respect, since aforementioned indi- viduals’ behaviours take up a key role in modern civilisation diseases (Clark & Hampson, 2001). This literature review is therefore going to critically evaluate health psychology theo- ries and research in order to explain D2 patients ’ experiences with SM (D2ESM); and will argue that these are influenced by a complex interaction of multiple psychological factors. The following broad themes were identified from reviewing the literature: Patients’ needs, characteristics and interventions. Before discussing these in detail, it will be outlined how models of illness cognitions and health beliefs are applied in the bespoken topic.
Health Psychology Models
One of these is the Health Belief Model (HBM; Rosenstock 1966, cited in Ogden, 2004). It states, the likelihood that health behaviour will occur is predicted by beliefs: per- ceived severity and vulnerability, costs and benefits, cues to action, health motivation and perceived control. D2ESM can be explained with these complex interacting elements, whereas the behaviour here is lifestyle, e.g. taking exercise. However, evidence shows that the HBM only predicts small amounts of the variance in adherence to diabetes self-care regime: 12-52% (Gillibrand & Stevenson, 2006). Nevertheless, four elements appear to be particularly helpful in understanding D2ESM.
Perceived severity and vulnerability were used in the reviewed literature (Clark, Hampson, Avery & Simpson, 2004). Severity of illness in D2 patients can be cognitions such as “D2 is a serious disease”. An example for the belief of vulnerability is “My risk of getting a heart attack later is high”. D2ESM is influenced by such beliefs, because people who are aware of the dangerousness and personal relevance of their condition are more likely to control H in order to prevent consequences.
Other elements considered within the literature, are the costs and benefits in carrying out health behaviour (Gillibrand & Stevenson, 2006). A belief of costs in D2 patients could be “Insulin injections in front of my friends are embarrassing”, a benefit “taking exercise will make me feel well-balanced”. If the costs are outweighed by the benefits, it is more likely that SM behaviours are carried out with subsequent lifestyle changes. Thus, these are interacting factors that influence D2ESM. However, the model suggests that intentions for a behavioural change are moderated by behavioural cues (Ogden, 2004). The problem with applying this model to D2ESM is that internal cues are hardly existent, as many symptoms develop not until complications (e.g. heart attack) have emerged. Mainly external cues may be relevant in D2ESM, e.g. health education. However, those are not analysed with reference to the HBM, illustrating a gap in the literature.