Elsevier

General Hospital Psychiatry

Volume 34, Issue 6, November–December 2012, Pages 598-603
General Hospital Psychiatry

Psychiatric–Medical Comorbidity
Effect of diabetes fatalism on medication adherence and self-care behaviors in adults with diabetes

https://doi.org/10.1016/j.genhosppsych.2012.07.005Get rights and content

Abstract

Objective

Diabetes fatalism is defined as “a complex psychological cycle characterized by perceptions of despair, hopelessness, and powerlessness” and associated with poor glycemic control. This study examined the association between diabetes fatalism and medication adherence and self-care behaviors in adults with diabetes.

Methods

Data on 378 subjects with type 2 diabetes recruited from two primary care clinics in the Southeastern United States were examined. Previously validated scales were used to measure diabetes fatalism, medication adherence, diabetes knowledge and diabetes self-care behaviors (diet, physical activity, blood sugar testing and foot care). Multiple linear regression was used to assess the independent effect of diabetes fatalism on medication adherence and self-care behaviors controlling for relevant covariates.

Results

Fatalism correlated significantly with medication adherence (r= 0.24, P< .001), diet (r=−0.26, P< .001), exercise (r=−0.20, P< .001) and blood sugar testing (r=−0.19, P< .001). In the linear regression model, diabetes fatalism was significantly associated with medication adherence [β= 0.029, 95% confidence interval (CI) 0.016, 0.043], diabetes knowledge (β=−0.042, 95% CI − 0.001, − 0.084), diet (β=−0.063, 95% CI − 0.039, − 0.087), exercise (β=−0.055, 95% CI − 0.028, − 0.083) and blood sugar testing (β=−0.055, 95% CI − 0.023, − 0.087). There was no significant association between diabetes fatalism and foot care (β=−0.018, 95% CI − 0.047, 0.011). The association between diabetes fatalism and medication adherence, diabetes knowledge and diabetes self-care behaviors did not change significantly when depression was added to the models, suggesting that the associations are independent of depression.

Conclusion

Diabetes fatalism is associated with poor medication adherence and self-care and may be an important target for education and skills interventions in diabetes care. In addition, the effect of diabetes fatalism is independent of depression, suggesting that interventions that target depression may not be sufficient to deal with diabetes fatalism.

Introduction

Self-care behaviors are a significant component of glycemic control in adults with type 2 diabetes (T2DM). Poor adherence to self-care guidelines and medication adherence leads to increased complications and mortality [1]. While diabetes knowledge has been associated with glycemic control in some studies [2], knowledge alone has been an insufficient predictor of self-care behaviors, suggesting that other factors are influencing the decision to follow self-care regimen [3]. Recently, psychosocial variables have been recognized as a strong predictor of diabetes management, including diabetes fatalism, depression, social support, coping and self-efficacy [3], [4], [5], [6], [7]. Gonzalez and colleagues conducted a meta-analysis that evaluated the association between depression and diabetes self-care (i.e., including missed appointments, blood glucose self-monitoring, diet and medication adherence) and found that depression had a medium effect size [8]. Like depression, fatalistic attitudes have been found to influence interaction with others, the meanings attached to those interactions and the decision to adopt effective self-care behaviors [7]. While diabetes fatalism is related to constructs such as depression and locus of control, it differs conceptually.

In an effort to better address diabetes fatalism, a scale to measure diabetes fatalism has been developed and validated in adults with type 2 diabetes [9]. Diabetes fatalism is defined as “a complex psychological cycle characterized by perceptions of despair, hopelessness, and powerlessness” [9], [10], [11]. The perspective of fatalism may be more applicable to African Americans than the locus of control construct due to its conceptualization in the context of the African American experience in the United States [7]. Development of the scale found three dimensions of diabetes fatalism including emotional distress (despair), religious and spiritual coping (hopelessness) and perceived self-efficacy (powerlessness). Emotional distress represents frustration with the disruption in lifestyle caused by diabetes, religious and spiritual coping represents acceptance and coping through attributing the outcome of diabetes to a higher power, and perceived self-efficacy represents self-confidence in one's ability to control diabetes and prevent complications [9]. While diabetes-specific distress is an important construct in itself, it is one aspect of the fatalism scale as a whole. The 12-item Diabetes Fatalism Scale (DFS-12) can be investigated as an overall score rather than the individual constructs as they were found to be internally consistent (Cronbach's alpha of 0.804) and independently associated with increased HbA1c (standardized beta=0.21, P= .005) after adjusting for demographics, comorbidity and insulin use [9].

Research has shown fatalistic beliefs to be a barrier to effective diabetes self-management, glycemic control and health outcomes [7], [9], but the association between these measures has not been conclusive. Lange and Piette did not find fatalism to be associated with HbA1c, but did find higher fatalism to be associated with patients with lower education levels, lower income, more recent symptoms and higher number of comorbidities [12]. Egede and Ellis found fatalism to be associated with self-care problems, poor glycemic control and decreased quality of life [9]. Rather than being directly associated with health outcomes, Osborne and Egede found an indirect association of diabetes fatalism with glycemic control through four diabetes self-care measures: general diet, specific diet, foot care and blood sugar testing [13]. Other self-care measures, such as exercise, did not show a significant association [13], and no studies have investigated the relationship between fatalism and medication adherence.

The purpose of this study was to examine the association between diabetes fatalism and medication adherence and self-care behaviors in adults with type 2 diabetes. However, because depression is strongly associated with poor diabetes outcomes and self-care behaviors [8], [14], [15], [16], we wanted to determine if the association between diabetes fatalism and self-care behaviors was independent of depression. We hypothesized that individuals with more diabetes fatalism would have poorer self-care behaviors and lower medication adherence in a primary care sample with type 2 diabetes and that these effects would be independent of depression.

Section snippets

Sample

We recruited patients with consecutively scheduled appointments with a diagnosis of T2DM at two different adult primary care clinics in the Southeastern United States. The institutional review board at our institution approved all procedures prior to study enrollment. Eligible patients were clinic patients 18 years or older with a diagnosis of T2DM in the medical record and a clinic appointment between June 2010 and August 2010. Patients were ineligible if they did not speak English or if the

Results

We assessed the psychometric properties of the DFS in our study population. The principal component analysis yielded a 12-item scale with three factors having eigenvalues of 4.09, 3.15 and 1.30 that accounted for 71% of the variance. The eigenvalues provide the variance explained by each factor. Factor loadings ranged from 0.57 to 0.77. An item analysis for the 12-item scale revealed a Cronbach's α of 0.82. The item–test correlation of the 12-item scale ranged from 0.81 to 0.82, and the item

Discussion

Consistent with our hypothesis, diabetes fatalism was significantly associated with poor medication adherence and self-care behaviors. After adjustment for pertinent covariates, the relationship remained statistically significant for the association between increased diabetes fatalism, decreased medication adherence and decreased levels of three self-care behaviors (diet, exercise and blood sugar testing). In addition, the effects of diabetes fatalism on medication adherence, diabetes knowledge

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    Supported by Grant #T35DK007431 from the National Institute for Diabetes, Digestive and Kidney Disease.

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