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ORIGINAL ARTICLE
Year : 2021 | Volume
: 24
| Issue : 3 | Page : 393-399
The relationship between self-efficacy of diabetes management and well-being in patients with type 2 diabetes
D Calli1, A Kartal2
1 Department of Nurse, Cardiovascular Surgery Pamukkale University Hospital, Denizli, Turkey
2 Public Health Nursing Department, Faculty of Health Sciences, Pamukkale University, Denizli, Turkey
Correspondence Address:
Prof. A Kartal
Faculty of Health Sciences, Pamukkale University, Kınıklı Campus, 20160, Denizli
Turkey
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/njcp.njcp_280_18
Abstract
Background: Self-efficacy is defined as the ability of an individual to perform an action successfully or her/his perception of being able to control events. The self-efficacy perception of diabetes management may affect well-being of the patient. Aims: This study aimed to examine the relationships between self-efficacy of diabetes management and well-being in patients with type 2 diabetes. Subjects and Methods: The study used a descriptive correlational design. Sample of the study included 200 patients with type 2 diabetes. Sociodemographic and disease-related questionnaire form “Self-Efficacy Scale for Diabetes Management” and “Well-Being Questionnaire” have been used as data collection tools. Multiple linear regression analysis was performed to explore the predictors of well-being in patients with type 2 diabetes. Results: Self-efficacy level, age, level of compliance with treatment, and state of doing exercise were found to be statistically significant predictors of well-being in type 2 diabetic patients. Self-efficacy level for diabetes management was found to be the strongest predictor of well-being in patients with type 2 diabetes. Conclusion: Self-efficacy level of diabetes management is a factor that affects well-being in type 2 diabetes patients and it should be considered during interventions for improving the well-being of patients.
Keywords: Diabetes mellitus, self-efficacy, type 2, well-being
Introduction 
One of the greatest global health threats of the 21st century is diabetes mellitus (DM). Diabetes and its complications are the leading causes of death in many countries.[1] While the number of diabetic individuals is 425 million as of 2017 all over the world, it is estimated that this number will reach 629 million in 2045.[1] The prevalence of diabetes in our country is 12.1%.[2]
Increasing prevalence of chronic diseases all over the world today reveals the importance of effective management of chronic diseases.[3] Management of chronic diseases can be optimized to decrease admissions to emergency services and hospitalizations, to limit physiological and psychological effects of the disease, to prevent addiction, and to increase the quality of life with effective and sustainable disease management.[4] Due to its nature of being a long-term disease, there is a need for lifelong care and management in diabetes.[5]
Psychological well-being is itself an important goal of medical care and well-being of the individual has a significant role in the success of diabetes management. Type 2 DM is a chronic disease that affects persons' general health and well-being in various ways.[6] Complications caused by DM lead to a decrease in life quality as well as impairment in overall well-being.[7] People with type 2 diabetes have significantly lower well-being compared to the general population,[8] whereas positive well-being of type 2 diabetic patient is an important factor affecting health behaviors and clinical outcomes of the patient.[9] In patients with type 2 diabetes, positive well-being has been associated with superior medical outcomes, including better glucose control and lower mortality rates. Although psychological well-being is one of the significant goals in diabetes management, there has been less focus on the promotion of positive psychological well-being in type 2 diabetic patients.[10] Information about patients' well-being and the factors that affect it is needed in order to develop strategies for managing diabetes.
The self-efficacy perception of diabetes management may affect the well-being of the patient. Self-efficacy is defined as the ability of individual to perform an action successfully or her/his perception of being able to control events.[11] Self-efficacy impacts compliance with treatment and, therefore, plays a role in the clinical outcome.[11],[12] Increase in the self-efficacy of the individual increases the compliance with the recommended treatment in chronic disease.[13] It also reflects one's ability to adopt behavioral changes for better self-care abilities.[11] Therefore, evaluation of self-efficacy of the diabetic individuals helps in the selection of suitable self-care interventions for the patient.[14] In the literature, there are several studies investigating the relationship between self-efficacy levels of diabetic individuals and sociodemographic factors, medical characteristics, HbA1c, depression and quality of life, and self-care.[15],[16],[17],[18] Furthermore, prior works have found that positive psychological well-being has been linked to superior health outcomes including healthier diet, increased physical activity, and lower rates of mortality across various medical conditions.[19],[20] However, there are no studies evaluating the relationship between self-efficacy and psychological well-being in Turkey to the best of our knowledge. Identification of this relationship may help health care professionals in promoting well-being and improving clinical outcomes in type 2 diabetes patients. Therefore, this study aimed to examine the relationship between self-efficacy of diabetes management and well- being in patients with type 2 diabetes in Turkey.
Subjects and Methods The study design was a descriptive correlational. The research population was made up of diabetic patients registered in the Endocrinology Outpatient Clinic of a university hospital in Denizli. Denizli is located in the relatively developed southwest part of Turkey with a population of 1005687.[21] A population-based study reported a 13.7% prevalence of diabetes.[2] In the present study, the sample size was calculated to detect a proportion of at least 13.7% type 2 diabetes people in the sample, with an error margin of 5% and a confidence level of 95%. The calculated sample size was 182 diabetes patients. Sample of the study included 200 type 2 diabetic patients who agreed to participate in the study and who were eligible for the criteria in the study. A convenient sample composed of 200 patients with type 2 diabetes. The interview lasted approximately 25 min. The sample selection criterion was being a patient having type 2 diabetes. Lack of the development of chronic complications such as seeing, hearing, and stroke was inclusion criterion for the study.
Instruments
As data collection instruments, a questionnaire form including sociodemographic and disease-related characteristics of diabetic patients and self-efficacy and well-being scale for diabetes management were used in the study.
It consisted of 15 questions related to sociodemographic and disease-related characteristics of diabetic patients.
Self-efficacy scale for diabetes management
Self-efficacy scale for diabetes management in type 2 diabetic patients was adapted to Western culture by Van Der Bijl et al. (1999) in order to detect the perceptions of diabetic patients for their own power in undertaking their own care activities.[22] The scale was composed of 20 items five-point Likert type scale with responses that range from one (absolutely never) to five (absolutely yes). The lowest score that would be taken from the scale was 20, and the highest score was 100. The scale was composed of a total of four subscales including nutrition and weight, physical exercise, blood glucose and overall nutrition, and medical treatment control. At general assessment of the scale, the patients who were below mean score were considered as having low self-efficacy and the ones who were above the mean score were considered as having high self-efficacy based on the mean scores obtained from all subscales.[22] Validity and reliability study of the scale was performed by Kara et al. in 2006. At the end of validity and reliability study, Cronbach's alpha level for the whole scale was found to be 0.89.[23]
WHO well-being questionnaire
WHO Well-Being Scale was developed by Clare Bradley in 1982 in order to investigate positive or negative effects of the changes done during the treatment of the patients on psychological well-being.[24] Its adaptation to Turkish and its validity and reliability studies were carried out by Sengul in 1998. Cronbach's alpha value of the scale was 0.81.[25] The scale was composed of 22 items and included four subscales as depression, anxiety, positive well-being, and energy. Each item in the scale was scored between “0” (never) and “3” (always). Scores given for each item were added after making an inverse scoring for necessary items. High scores that were obtained from subscales indicated a high well-being for that subscale. Overall well-being was obtained by the addition of four subscales after making an inverse scoring for depression and anxiety subscales. The high score obtained for the overall well-being showed that overall well-being was high.[24]
Ethical considerations
Before starting the study, an approval was obtained from the Ethics Committee of the university. Besides, a written approval was obtained from the university hospital in which the study was conducted. All of the patients with type 2 diabetes who participated in the research were informed about the study and were told that they could withdraw from the study at any time (approval no. B.30.2.PAÜ.Ü.20.05.09/12).
Statistical analysis
Statistical analysis of the study was performed by SPSS 18.0 package program. Number and percentage distributions were used to assess sociodemographic and disease-related characteristics of the patients; mean and standard deviation were used to evaluate self-efficacy level for diabetes management and well-being. Pearson correlation test was used to determine the relationships between self-efficacy for diabetes management and well-being. Multiple linear regression analysis was used to detect the effect of self-efficacy for diabetes management on well-being in type 2 diabetic patients. In addition to the self-efficacy for diabetes management variable, independent variables (age, sex, marital status, education, health insurance, smoking, alcohol use, duration of diabetes, type of diabetes treatment, level of compliance with treatment, state of doing exercise, and blood glucose measurement) that were significant in the univariate analysis were included in the multiple linear regression.
Results 51.5% of the patients were women, 35% were between 40 and 49 years old, 70% were married, 34.5% were graduates of high school, most of them had social insurance, 55% were smoking, and 25.5% were using alcohol. When disease-related characteristics of the patients were examined, it was observed that 50% had a diabetes duration of 1–4 years, 47.5% were using Oral Anti Diabetic (OAD) treatment, 78% had a level of compliance with treatment at a moderate level, 58.5% were doing exercises, and 58.5% were undertaking blood glucose measurements [Table 1].
When mean scores of the patients from self-efficacy scale for diabetes management were examined, it was found that mean score of “special nutrition and weight” subscale was 13.83 ± 3.25, of “physical exercise” was 8.70 ± 2.28, of “blood glucose” was 9.93 ± 3.18, and of “overall nutrition and medical treatment control” was 28.14 ± 5.70. Mean score from overall self-efficacy was found to be 60.61 ± 11.29 [Table 2].
Table 2: Mean scores of self-efficacy scale and well-being scale among the patientsWhen mean score from well-being scale of the patients was investigated, mean score from “depression” subscale was 15.83 ± 12.49, from “anxiety” subscale was 15.19 ± 17.81, from “energy” subscale was 12.08 ± 19.85, and “positive well-being” was 39.27 ± 11.18 [Table 2]. Mean score from overall well-being was found to be 69.22.
A statistically significant correlation was found between patients' self-efficacy for diabetes management and their well-being. As their self-efficacy for diabetes management increased, their well-being increased [Table 3].
Multiple linear regression analysis was performed to detect the effect of self-efficacy on the well-being in patients with type 2 diabetes. The multiple linear regression analysis results for overall self-efficacy and overall well-being [Beta (β):= 0.28, P < 0.001] indicate positive and significant standardized partial regression coefficient effects. This means that as the patients overall self-efficacy improved, their overall well-being also improved. The results of this analysis revealed that the self-efficacy total score (β = 0.28), age (β = −0.24), treatment compliance (β = −0.17), and exercises status (β = −0.13) were significant predictors of the well-being. Self-efficacy of diabetes management was the strongest predictor of the well-being. Explanatory power R2 was 0.46 [Table 4].
Table 4: Predictors affecting the well-being of patients according to multiple linear regression analysis Discussion The result of our study showed that self-efficacy levels of the patients for diabetes management were at a moderate level when evaluated based on the highest score that could be obtained from the scale. In the study by Gedik and Kocoglu, self-efficacy levels of the patients were found to be at a moderate level.[26] Another study by Akpunar that was performed regarding the effect of diabetes training on the management of diabetes, self-efficacy levels of study group (67.98 ± 12.74) as well as control group (69.37 ± 9.64) were found to be at a moderate level before the training.[27] In the study by Taha et al., self-efficacy levels of the patients for diabetes management were at a low level before the intervention.[28] Another study has found that Korean patients who received specialist care reported higher self-efficacy than those who received generalist care.[16] Despite the differences in sampling, the similarities in these scores are striking. Moreover, our result showed that self-efficacy for diabetes management was at a moderate level and should be improved. In fact, it is important that patients should have high self-efficacy levels in order to undertake and control behaviors that are recommended for the treatment of diabetes. Patients who have a low self-efficacy are less prone to new health behaviors or to changing usual behaviors.[29] In the study by Morrison and Weston (2013) on diabetic patients, it was reported that patients who had a high self-efficacy level had a more positive blood glycemic level, overall health, and psychological health; and patients who had a low self-efficacy experienced a high level of stress.[30] Thus, the participation of self-efficacy levels for diabetes management should be maintained above a moderate level.
In our study, the mean score from overall well-being scale was found to be 69.22 ± 11.28. Our findings showed that moderate levels of well-being were present in patients. In the study by Saatci et al.,[31] mean score from overall well-being was reported to be 44.40 ± 13.23, whereas this score was reported to be 57.04 ± 10.3 in the study by Sargin et al.[32] In another study performed by Altun et al. (2014), overall well-being scores of the diabetics were determined to be low. Based on these results, we can state that overall well-being of diabetic patients is not very good.[33] In order to cope with diabetes and manage disease, it is required that the patient should have a positive well-being and have self-care skills. Well-being may also have a protective role in the maintenance of health.[34] Prior works have found that positive psychological well-being has been linked to superior health outcomes including healthier diet, increased physical activity, better glucose control, and lower rates of mortality across various medical conditions.[19],[20],[35] Thus, well-being of the diabetic patients should be maintained above a moderate level. For that reason, nurses should primarily evaluate well-being and affecting factors in providing a successful disease management.
Also in this study, the relationship between self-efficacy for diabetes management and well-being was investigated. Self-efficacy for diabetes management was found to be the strongest predictor of well-being in patients. This meant that the overall well-being of the patients improved as their overall self-efficacy increased. The results of the present study highlighted the importance of well-planned interventions in order to increase self-efficacy in diabetic patients and to help them further improve their well-being. In the literature, Sympa et al. (2017) have determined that there was a negative correlation between depression and self-efficacy among diabetic patients and depression levels of the patients decreased as their self-efficacy levels increased.[36] Wang et al. (2017) have reported that there was a strong correlation between self-efficacy and life quality of the patients who had a good HbA1c level, and their self-efficacy levels and life quality were at a high level.[18] The results of other studies including ours showed that a strong perception of self-efficacy was correlated with being more healthier. Therefore, nurses can evaluate these two parameters together in providing a successful management of diabetes. Nursing care should be planned and performed for increasing and supporting self-efficacy levels of the patients who had a low level of self-efficacy. Therefore, improving self-efficacy can help to increase well-being among the patients with Type 2 diabetes.
In our study, second significant factor affecting well-being of the patient was age (β = −0.16). This meant that there was a negative correlation between the age and well-being, and well-being of the patient decreased as age increased. Psychological well-being and health are closely linked at older ages. Older people suffering from illnesses such as DM, coronary heart disease, arthritis and chronic lung disease present with elevated levels of depressive mood and impaired well-being.[34] In “The Incidence of Chronic Diseases and Risk Factors Study” in Turkey, it was found that well-being states were worse among the population older than 65 years old compared to younger population.[37]
At the end of regression analysis, another significant variable affecting well-being was compliance level of the patient with the recommended treatment (β = −0.17). This meant that well-being was also poor among the patients whose treatment compliance levels were poor. In the literature, positive well-being states of the patients were found to be associated with the increase in behaviors such as level of compliance with nutrition and exercise, and these behaviors were indicated as the beneficial effects of positive well-being.[10] The result of our study supports data in the literature.
At the end of regression analysis, fourth significant variable affecting patient's well-being was found to be her/his state of doing exercise (β = 0.15). The result of our study showed that patients who were doing exercises had a higher overall well-being. Based on the literature, another factor affecting health and life quality of the individual is lifestyle behaviors of the individual such as exercise.[38] In a study with over 5000 participants, those who exercise increased their well-being, depression decreases.[39] In a 1-year cohort study including type 2 diabetic individuals, a significant difference was detected between the state of weekly physical activity at a moderate level and physical functionality, overall health, vitality, and health-associated life quality. It was determined that physical functionality states and the scores of the participants, who were doing weekly physical activity at a moderate level, for health-associated life quality were higher.[40] The result of our study supports the data in the literature and previous study findings.
The limitations of the study
Limitation of this study is related to its design in that it used a convenience sample and cross-sectional research design; hence, it may be difficult to generalize the results. Furthermore, this study was a descriptive-correlational study. Therefore, no causal relationships could be confirmed. A longitudinal study is needed to ascertain the causal association between self-efficacy and well-being.
Conclusion Self-efficacy level of diabetes management was the strongest predictor of well-being in patients with type 2 diabetes. The result shows that self-efficacy level of diabetes management is a factor that affects well-being in type 2 diabetes patients and it should be considered during interventions for improving the well-being of patients. Recommended behavioral changes such as nutrition, exercise, and compliance with treatment are facilitated by increasing self-efficacy levels of the patients because high self-efficacy increases patient's motivation. Therefore, nurses should evaluate self-efficacy levels primarily in order to gain positive health behaviors in promoting the health of the patients. They should plan and implement nursing interventions for the patients, who have a self-efficacy at a low level, by using their roles including health education and consulting.
Acknowledgments
The authors would like to thank the type 2 diabetes patients who participated in our study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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