Does Patient Empowerment Predict Self-Care Behavior and Glycosylated Hemoglobin in Chinese Patients with Type 2 Diabetes?

Abstract

Background:

Patient empowerment is playing an increasingly important role in diabetes and related disorders. This study evaluated the correlations among patient empowerment, self-care behavior, and glycemic control among patients with type 2 diabetes in mainland China.

Subjects and Methods:

We conducted a multicenter cross-sectional study. Eight hundred eighty-five patients who sought care at hospitals in Nanjing, Changsha, Yunnan, and Chongqing, China, were enrolled. Structured questionnaires and medical records provided the data. The instruments included a demographic and clinical questionnaire, the Diabetes Empowerment Scale–Short Form, and the Chinese version of the Summary of Diabetes Self-Care Activities Scale. Glycosylated hemoglobin (HbA1c) was used as a measure of glycemic control. The data analyses are presented as proportions, means (±SD), β, and 95% confidence intervals (CIs). Multilinear regressions were used to examine the correlations among the scores of patient empowerment, self-care behavior, and HbA1c values.

Results:

Linear regression revealed that patient empowerment was a statistically significant predictor of patients' self-care behavior even after controlling for age, gender, marital status, educational level, and diabetes duration. Diet (β=0.449; 95% CI, 0.370, 0.528), exercise (β=0.222; 95% CI, 0.164, 0.279), blood glucose testing (β=0.152; 95% CI, 0.106, 0.199), medication taking (β=0.062; 95% CI, 0.030, 0.095), and foot care (β=0.279; 95% CI, 0.217, 0.342). Additionally, patient empowerment was a statistically significant predictor of HbA1c (β=−0.094; 95% CI, −0.123, −0.065).

Conclusions:

Our study indicated that perceived diabetes empowerment is a predictor of self-care behavior and HbA1c in Chinese patients with type 2 diabetes. Therefore, interventions to enhance and promote patient empowerment should be essential components of diabetes education programs to improve self-care behavior and glycemic control.

Introduction

Diabetes is a worldwide noncommunicable chronic disease, which requires lifelong treatment. A recent national survey in 2010 reported that the prevalence of diabetes in mainland China was 11.6%, representing up to 113.9 million Chinese adults with diabetes, and only 39.7% of those patients had achieved good glycemic control (glycosylated hemoglobin [HbA1c] <7%).¹ Poor metabolic control can lead to a series of complications, including cardiovascular disease, stroke, and chronic kidney disease, which dramatically diminish the quality of patients' lives. The costs of diabetes and its complications are heavy burdens on both patients' families and society.² It is well known that good glycemic control can prevent or postpone long-term complications.³ Among the factors affecting metabolic control, diabetes self-management education has been recognized as one of the most important components. It was suggested that diabetes education played an important role in patients' self-care behavior change, which was deemed to be an intermediate goal, and metabolic control.^4,5 However, in China, it was not until the late 1990s that the attention was paid to diabetes self-management education.⁶ Furthermore, most Chinese diabetes educators used a didactic (i.e., lecture-based) approach to deliver diabetes self-management education.⁷

In the traditional approach to patient education, most educators viewed increased adherence as the primary goal for diabetes education. This approach stressed the role and expertise of professionals in modifying patient behavior.⁸ The professionals thought they were responsible for patients' self-care decisions. They tried to get patients to do what they considered “the right thing.”⁹ However, this approach created conflict between educators and patients and was generally ineffective in helping patients live successfully with diabetes.⁸

In 1991, Funnell et al.¹⁰ introduced the concept of “patient empowerment” into diabetes patient education. Empowerment-based diabetes education is a process in which the purpose of an educational intervention is to increase the inherent capacity of patients to think critically and make autonomous, informed decisions about the self-management of their diabetes.¹¹ When using the empowerment approach, the mission of educators is to provide patients with the information and skills they need to help them enhance their own innate ability to gain mastery over their diabetes.¹⁰ Empowerment is viewed as an outcome when patients acquire an enhanced sense of their diabetes-related psychosocial self-efficacy as a result of an intervention.¹¹ In 2000, Anderson et al.¹² developed the Diabetes Empowerment Scale (DES) to measure the patients' perceived ability to deal effectively with the psychological and social aspects of living with diabetes. In 2003, Anderson et al.¹³ simplified the original DES, which contained 37 items, into an eight-item short form of the scale (DES-SF). This version was translated into Chinese and has shown good validity and reliability (i.e., the Cronbach's α coefficient of the DES-SF is 0.848).¹⁴

However, few studies in China have focused on the relationship between patient empowerment and HbA1c. The primary focus of these studies^15,16 was assessing the correlations between patient empowerment and self-care behavior. What's more, their samples were relatively small. This multicenter cross-sectional study was designed to evaluate the perceived empowerment of Chinese patients with type 2 diabetes and to assess if the degree of perceived patient empowerment can predicted diabetes self-care behavior and glycemic control in patients with type 2 diabetes mellitus.

Research Design and Methods

Sample

A multicenter cross-sectional study was conducted using questionnaires and laboratory data. The patients studied were Chinese adults with type 2 diabetes who sought care at those tertiary hospitals that have more than 40 beds in their endocrinology department. We invited six hospitals to participate, and four of them (hospitals in Nanjing, Changsha, Yunnan and Chongqing, China) agreed. Subjects were included if they (a) had been diagnosed with type 2 diabetes mellitus, according to the 1999 World Health Organization diagnostic criteria,¹⁷ more than 3 months prior to data collection, (b) were ≥18 years of age, (c) were mentally healthy, and (d) were able to provide informed consent. Pregnant women with gestational diabetes and patients with severe complications of diabetes mellitus that might affect performance of diabetes self-care behavior, such as end-stage renal disease, and heart failure were excluded. According to these criteria, we recruited patients from September 2012 to November 2012 at the four hospitals.

During the 2-month period, 1,050 subjects were approached in the hospitals and invited to participate in the study. Most (n=950; 90.5%) of these patients agreed to take part. Their medical records were also obtained from the hospitals. This study was given permission to proceed by the Ethics Committee of the Hospital of Integrated Traditional Chinese and Western Medicine of Jiangsu Province. All patients enrolled in the study gave written informed consent before participation.

Data and procedure

Eight nurse researchers from four hospitals collected data for this study. All of the nurse researchers were trained by a primary investigator to adhere to the study protocol, in order to assure the quality of the data collection. The medical records of patients were reviewed while they were in the hospital. At the beginning of the survey, eligible patients were provided a brief description of the objectives and methods of the study by a trained nurse. Eligible patients were asked to sign an informed consent form and complete a demographics questionnaire as well as the validated patient empowerment and diabetes self-care behavior questionnaires.

Demographic, clinical, and laboratory data were abstracted from the patients' medical records.

Demographic and clinical characteristics

The demographic and clinical characteristics questionnaire contained questions about age, gender, weight, height, body mass index, education levels, marital status, duration of diabetes, and the status of diabetes complications. These data were extracted from the subjects' medical records. Marital status was categorized as married, not married, divorced, or widowed. Education was categorized as below primary school, primary school, junior high school, senior high school, or bachelor degree and above. Health insurance was categorized as insured or uninsured.

Glycemic control

The main outcome variable in this study was glycemic control as measured by HbA1c. The HbA1c levels were analyzed using the high-performance liquid chromatography method. The data for HbA1c were obtained by reviewing the participants' medical records.

Empowerment scale

The DES-SF¹³ was used to measure diabetes-related perceived psychosocial self-efficacy. The Chinese version is a summated rating scale containing eight items with a good reliability and validity.¹⁴ The Cronbach's α coefficient of internal consistency reliability of DES-SF was 0.85 for the total scale, and the test–retest reliability was 0.82. Responses were rated on 5-point Likert scale, where 1=not agree, 2=not usually agree, 3=agree half the time, 4=usually agree, and 5=always agree. A higher score indicated that the patient had a higher level of perceived empowerment.

Diabetes self-care behavior

Self-care behavior was measured with the Chinese version of the Summary of Diabetes Self-care Activities (SDSCA) Scale,¹⁸ which was from a revised version by Toobert et al.¹⁹ The Scale is used to assess the frequency of performing 11 diabetes self-care activities in the last 7 days and consisted of five dimensions: diet, exercise, blood glucose testing, medication taking, and foot care. Scores ranged from 0 to 7, according to the number of the days the behavior was performed by the patient. Item 4 is a negative one, so the negative score was reversed. Higher scores indicated better self-care behavior. The Cronbach's α coefficient of the SDSCA was 0.62 for the total scale, and the test–retest reliability was 0.83.

Data analysis

SPSS version 16.0 software (SPSS, Inc., Chicago, IL) was used to establish the database and perform the analysis. First, descriptive statistics were used to describe demographic and clinical characteristics of the sample with mean, SD, frequency, and composition ratio. The mean was calculated for the DES-SF. For the SDSCA Scale, the mean number of days for each dimension and the total score were calculated. Second, we used Spearman's correlation to test the association among patient empowerment, HbA1c, and self-care behavior. Third, we ran regression analysis to assess the independent relationships among patient empowerment, diabetes self-care behavior (diet, exercise, blood glucose testing, medication taking, and foot care), and HbA1c while controlling for covariates. For regression models, self-care behavior (diet, exercise, blood glucose testing, and foot care) and HbA1c were the dependent variables, and patient empowerment was the primary independent variable, whereas age, gender, marital status, educational level, and duration of diabetes diagnosis were included in the model as covariates. A two-tailed α of 0.05 was used to assess for significance.

Results

Demographic and clinical characteristics

A copy of the questionnaire was distributed to 950 patients who had agreed to participate. Of these patients, 885 (93.2%) completed the questionnaires properly. Of the 885 participants, 53.1% were men, and 94.6% were married. Their average age was 57.7 (SD±12.0) years, with a range of 23–84 years. The average duration of diabetes was 7.9 (SD±6.1) years. Of the patients, 41.5% had ideal body mass indexes, 39% were overweight, and 13.7% were obese. Among all the participants, 35.5% had complications, including retinopathy, nephropathy, etc.; the most common complication was retinopathy. About 61.2% of patients had hypertension or dyslipidemia. The mean value for glycemic control as measured by HbA1c was 9.1% (SD±2.4%); using a cutoff point of 7% according to the American Diabetes Association standard, only 21.7% had well-controlled diabetes (Table 1).

Table 1.

Sample Demographic Characteristics (n=885)

Variable	Value
Age (years) [mean (SD)]	57.7 (12.0)
Gender male [n (%)]	470 (53.1%)
Marital status [n (%)]
Not married	16 (1.8%)
Married	843 (95.3%)
Divorced	24 (2.7%)
Widowed	2 (0.2%)
BMI [n (%)]
Normal (18.5–23.9 kg/m²)	367 (41.5%)
Overweight (24–27.9 kg/m²)	345 (39.0%)
Obese (≥28 kg/m²)	121 (13.7%)
Height (cm) [mean (SD)]	164.6 (8.1)
Weight (kg) [mean (SD)]	66.1 (11.4)
Waist (cm) [mean (SD)]	86.7 (11.2)
Blood pressure (mm Hg) [mean (SD)]
Systolic	132.0 (17.7)
Diastolic	79.7 (9.7)
Duration of diabetes (years) [mean (SD)]	7.9 (6.1)
HbA1c [n (%)]
<7%	192 (21.7%)
≥7%	664 (75.0%)
Missing value	29 (3.3%)
Comorbidities [n (%)]
Hypertension	413 (76.2%)
Dyslipidemia	129 (23.8%)
Diabetes complications [n (%)]
Coronary heart disease	86 (27.4%)
Cerebral infarction	59 (18.8%)
Retinopathy	104 (33.1%)
Nephropathy	45 (14.3%)
Diabetic foot	20 (6.4%)
Education level [n (%)]
Below primary school	75 (8.5%)
Primary school	149 (16.8%)
Junior high school	283 (32%)
Senior high school	237 (26.8%)
Bachelor's degree and above	141 (15.9%)
Health insurance [n (%)]
Insured	743 (84%)
Uninsured	142 (16%)

BMI, body mass index; HbA1c, glycosylated hemoglobin.

Patients' self-care behavior and patient empowerment

The mean score for the total self-care behavior scale was 38.3. Table 2 shows the item means and±SD for each dimension. The most frequently reported self-care behavior was taking medications (mean=5.5, SD±2.5) followed by diet self-care behavior (mean=4.1, SD±1.7). The least frequently reported self-care behavior was blood glucose testing (mean=1.4, SD±1.9). The mean score on the DES-SF was 31.3. Each item average score is shown in Table 3.

Table 2.

Item Means of Self-Management Behavior for Each Dimension (n=885)

Item	Mean (±SD)
Diet	4.1 (1.7)
Exercise	4.0 (2.4)
Blood glucose testing	1.4 (1.9)
Foot care	3.1 (2.7)
Medication taking	5.5 (2.5)

Table 3.

Item Means of the Diabetes Empowerment Scale–Short Form (n=885)

Item	Mean (±SD)
Know what part(s) of taking care of my diabetes than I am dissatisfied with	4.0 (1.0)
Be able to turn my diabetes goal into a workplace plan	3.6 (1.0)
Can try out different ways of overcoming barriers to my diabetes goals	3.7 (1.0)
Can find ways to feel better about having diabetes	4.1 (0.9)
Know the positive ways I cope with diabetes-related stress	3.8 (0.9)
Can ask for support for having and caring for my diabetes when I need it	4.1 (0.9)
Know what helps me stay motivated to care for my diabetes	4.1 (1.0)
Know enough about myself as a person to make diabetes care choices that are right for me	4.0 (0.9)

Does patient empowerment predict self-care behavior?

The linear regression analysis indicated that patient empowerment was a statistically significant predictor of patients' self-care behavior even after controlling for age, gender, marital status, educational level, and diabetes durations (Table 4): diet (β=0.449; 95% confidence interval [CI], 0.370, 0.528), exercise (β=0.222; 95% CI, 0.164, 0.279), blood glucose testing (β=0.152; 95% CI, 0.106, 0.199), medication taking (β=0.062; 95% CI, 0.030, 0.095), and foot care (β=0.279; 95% CI, 0.217, 0.342)

Table 4.

Adjusted Model for the Relationships Among Empowerment Self-Management Behaviors and Glycosylated Hemoglobin

	β	95% CI	P
Diet	0.449	0.370, 0.528	<0.001
Exercise	0.222	0.164, 0.279	<0.001
Blood glucose testing	0.152	0.106, 0.199	<0.001
Medication taking	0.062	0.030, 0.095	<0.001
Foot care	0.279	0.217, 0.342	<0.001
HbA1c	−0.094	−0.123, −0.065	<0.001

The linear regression model was adjusted for age, gender, marital status, educational level, and diabetes duration.

CI, confidence interval; HbA1c, glycosylated hemoglobin.

Does patient empowerment in diabetes predict glycemic control in patients with type 2 diabetes?

The linear regression analysis indicated that after controlling for age, gender, marital status, educational level, and diabetes duration, patient empowerment was a statistically significant predictor of HbA1c (β=–0.094; 95% CI, −0.123, −0.065) (Table 4).

Discussion

This study was conducted to examine the ability of perceived patient empowerment to predict self-care behavior and glycemic control in adult subjects with type 2 diabetes in China. This found that the mean score of patient empowerment in diabetes was 3.91±0.69, similar to the figures reported by Anderson et al.²⁰ and in another article from China.¹⁴ The patients exhibited uneven performances in the five dimensions of self-care behavior. The highest self-care score was found in the administration of medication (mean=5.5). This is understandable given that medication is considered as the most effective way to control diabetes, and it was easy to comply with instructions for taking medicine. The lowest self-care score was observed in blood glucose testing (mean=1.4), which could be related to cost of blood glucose testing or being afraid of pain. Another possible explanation was a lack of education in blood glucose testing. These findings are consistent with previous research studies^21,22 and illustrated the differences that occurred in the performance of different aspects of self-care behavior among patients with type 2 diabetes. This finding indicates that diabetes educators should address specific deficits in the patient's self-management behavior after an initial assessment,²³ instead of placing equal stress on all the aspects of diabetes self-care education. Additionally, the study revealed that only about 21.7% of the patients achieved the recommended level of HbA1c (<7%).

In the regression analysis, empowerment was found to be a significant predictor of self-care behavior and HbA1c, which is consistent with the finding from a previous study.²⁴ Higher scores in patient empowerment were related to better self-care behavior and better glycemic control. This is understandable given that higher empowerment scores indicate that patients have an enhanced capacity to accept responsibility for their daily self-management,¹² leading to improved self-care and health outcomes.

Traditional diabetes education has focused on adherence rather than patient empowerment. Many patients feel obligated to manage their diabetes in a way that pleases healthcare professionals. This approach can be contrasted with empowerment-based education, which is intended to enhance the patient's capacity for autonomous and effective diabetes self-management.¹¹

Although there is no consensus on the design and content of one “best” diabetes empowerment education program, there are some strategies and technologies that are intended to enhance the perceived empowerment of patients with diabetes. For example, Problem-Based Learning, the five-step approach to setting a patient's selected goals, patient-directed group education, self-directed behavior change, and personal reflection on values and beliefs are used frequently in empowerment-based education.²⁵ The sharing of personal experiences, family and peer support, and role-playing are also promising strategies to use in empowerment-based education. The shift from the “acute care model” to a patient-centered collaborative approach to care²⁶ is designed to enable patients with diabetes to make informed decisions while accepting personal responsibility for managing their own diabetes.

The patient empowerment approach has been found in randomized controlled trials to produce superior metabolic, behavioral, and psychosocial outcomes compared with usual care.^20,27 In agreement with the study of Anderson et al.,²⁷ positive results have also been found in Chinese studies.^28,29 Patients gained diabetes-specific knowledge and skills through the nondidactic and culturally specific curriculum set by health professionals. It included the significance of self-management and behavior change, healthy diet, regular exercise habit, sharing self-monitoring experience, insulin injection, problem-solving skills, stress and emotional coping management, and communicating effectively with health professionals.³⁰

Although most patients benefit from empowerment-based education, there are barriers and difficulties when it is applied in clinical settings. Some health professionals lack the skills needed to use the empowerment approach, and there are also widespread misunderstandings of the patient empowerment approach.²⁴ As an educator, concentrating on patient empowerment has been very rewarding because participants paid close attention and were motivated to set the goals and make the changes they chose.³¹

Limitations

This study has several limitations that are should be noted. First, there are additional confounding factors that could influence the relationship among diabetes empowerment, diabetes self-care behavior, and HbA1c, such as severity of illness and economic status. Future studies need to consider these variables to better understand the relationships. Second, psychological factors such as depression, anxiety, and stress may inhibit patients' empowerment, but we did not measure these variables in this study. Third, data on diabetes self-care behavior and diabetes empowerment were measured with self-report scales and may be flawed by recall bias, making findings from this study limited.

Nevertheless, our multicenter study identified a significant relationship between patient empowerment and HbA1c.

In conclusion, the results of our study suggested that diabetes empowerment was a significant predictor of self-care behavior and HbA1c in Chinese patients with type 2 diabetes, which provided valuable information to guide educators to emphasize patient empowerment in diabetes education, in order to promote better health outcomes in the management of diabetes.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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