Type 2 Diabetes: A Couples Study 1 Running Head: TYPE 2 DIABETES: A COUPLES STUDY Type 2 Diabetes: A Couples Study on Spousal Relationship and Health Behaviors

This study is designed to examine how the spousal relationship is related to the health behavior of people with type 2 diabetes. Participants consisted of 21 persons with type 2 diabetes and their spouses. Both patients and spouses completed a brief questionnaire that consisted of questions related to health behavior, partner communication, and marital quality. We hypothesized that when spouses engage in more positive diabetes behaviors, patients will engage in better self-care behavior, have higher self-efficacy, and have higher well-being. We also hypothesized that patient and spouse active engagement will be associated with better patient outcomes, whereas patient and spouse protective buffering will be associated with worse patient outcomes. We hypothesized that relationship quality and communal coping would be associated with better patient outcomes. Results showed that spouse positive behaviors were related to better patient self-care behaviors, and spouse negative behaviors were related to lower levels of patient self-efficacy. Neither positive nor negative behaviors were associated with patient well-being. Active engagement was related to better patient self-care behaviors but not patient well-being. There was some suggestion that protective buffering was related to a couple of poor patient outcomes. Marital satisfaction was related to some indicators of patient wellbeing, but communal coping was associated to better self-care behaviors. These results suggest that spouses may have an impact on how patients take care of their diabetes. Type 2 Diabetes: A Couples Study 3 Type 2 Diabetes: A Couples Study on Spousal Relationship and Health Behaviors Diabetes mellitus affects more than 23 million Americans and is the fifth deadliest disease in the United States. Diabetes mellitus is a chronic illness in which the body does not properly produce or use insulin. Insulin is a hormone that is necessary for converting sugar and other food into energy for daily use. There are two types of diabetes. The first type of diabetes is type 1 diabetes, and is relatively rare. Type 1 diabetes occurs when the body’s immune system destroys pancreatic beta cells. Pancreatic beta cells are the cells in the body that produce insulin. People with type 1 diabetes must have insulin delivered into their bodies by injection or pump. The second type of diabetes, type 2 diabetes, is much more common. Type 2 diabetes usually occurs because the body develops insulin resistance. This means the cells in the body do not use insulin properly or the body does not produce sufficient amounts of insulin. Type 2 diabetes is associated with older age, family history of diabetes, obesity, physical inactivity and race (American Diabetes Association, 2008). Although type 1 diabetes is not limited to children and type 2 diabetes is not limited to adults, type 1 diabetes usually affects children and type 2 diabetes usually develops in adulthood. The focus of this research is on type 2 diabetes. The management of type 2 diabetes involves making drastic lifestyle changes. People with type 2 diabetes have to change their diets and the amount of physical activity they perform. In addition, people with type 2 diabetes have to test their blood glucose levels and closely monitor these levels on a regular basis. In order to maintain an optimal level of blood glucose, people have to take oral medication or administer insulin. Without either, blood glucose levels increase. Research has shown that long term high blood glucose levels are associated with devastating complications (American Diabetes Association, 2008). People with diabetes who have poor blood glucose control are more prone to having nerve damage, eye problems, kidney Type 2 Diabetes: A Couples Study 4 disease and amputations. Thus, it is important to find ways to help people with diabetes take better care of themselves to maintain optimal blood glucose control. Adherence to proper self-care is a significant problem for two reasons. First, diabetes is mostly an invisible problem, meaning that people with diabetes, may not know they have this incurable disease. Second, people who have diabetes might not understand that there are harmful effects of having high blood sugar levels because the consequences are not immediate. Thus, people with diabetes may not be motivated to adhere to proper self-care behaviors. Factors that are associated with good self-management of type 2 diabetes belong to one of four broad categories: characteristics of patients, nondisease-related stress, characteristics of the doctor, and characteristics of social networks (Fisher et al., 1998). Past studies have identified several characteristics of patients, including the way patients’ understand diabetes and their concern about controlling symptoms, that are predictive of self-management behaviors (Hemera et al., 1988; Toobert & Glasgow, 1994). People with diabetes who have to manage other stressors may not have the time or energy to adhere to and follow the recommendations for proper self-management behavior (Peyrot, McMurry, & Hedges, 1988). Research has shown that physician attitudes about diabetes and diabetes management are associated with patient selfcare behaviors. For instance, patient self-care behaviors are positively associated with physicians’ beliefs about how serious diabetes is and how important glucose control is, physicians’ expertise in diabetes, and the way physicians communicate with patients (Anderson & Zimmerman, 1993; Ho, Marger, Beart, Yip, & Shekelle, 1997; Johnson, 1992). However, much less attention has been devoted to the issue of social support among adults with type 2 diabetes (Trief, Grant, Elbert, & Weinstock, 1998). Thus, this is the focus of the present investigation. Below, we briefly review the literature on social support and diabetes. Type 2 Diabetes: A Couples Study 5 Family Support and Chronic Illnesses Emotional, instrumental, and informational support are the three main types of social support that are usually provided to patients with chronic diseases. Emotional support includes providing empathy, care, love and trust. Instrumental support includes aid in money, time, or labor. Informational support includes advice, suggestions, directives and information. Studies have shown that patients with chronic illnesses receive different kinds of social support from different people. One study suggests that people with type 1 diabetes receive emotional and instrumental support from their family and informational support primarily from health care staff (Aalto, Uutela, & Aro, 1997). It is not clear which kind of support is most strongly related to adherence. A study that examined the relation of emotional and instrumental support to adherence among 86 patients with rheumatoid arthritis, showed that emotional support provided more motivation to improve adherence than instrumental support (Taal, Rasker, Seydel, & Wiegman, 1993). Each of these kinds of support can be further divided into general support or diseasespecific support. General support is support that is provided overall and does not pertain to a particular disease. Disease-specific support is support that is provided in the context of the specific disease. For example, general support includes listening or assisting in everyday problems, whereas diabetes-specific support includes helping with insulin injections, reminding to take medication, helping to monitor blood glucose, eating meals and exercising with the person with diabetes. Studies have shown that both general support and disease-specific support from family members and friends are related to better self-care behaviors among people with diabetes. For instance, one study of 80 people with diabetes showed that patient satisfaction with general Type 2 Diabetes: A Couples Study 6 support from family members and friends was associated with better self-care behaviors but only during times of stress (Griffith, Field, & Lustman, 1990). During nonstressful times, patient satisfaction with general social support was not associated with self-care behaviors. Two studies of people with diabetes showed that diabetes-specific social support was associated with better self-care behavior (Garay-Sevilla et al., 1995; Toljamo & Hentinen, 2001). Thus, assistance with everyday diabetes-related tasks, as well as, general support may be helpful to those with diabetes. Some social support research has focused specifically on the spouse relationship and how it is related to self-care behaviors of people with diabetes. Studies have shown that higher marital quality and greater marital intimacy is associated with better self-care behavior (Trief, Ploutz-Snyder, Britton, & Weinstock, 2004; Trief, Wade, Britton, & Weinstock, 2002) and less diabetes-related stress and better diabetes adaptation (Trief et al., 2002; Trief et al., 2004). Marital quality is a vague and diffuse construct. To more fully understand how marital quality affects self-care behavior, we need to understand more about the specific patient-spouse interactions surrounding self care. Some studies have tried to determine what behaviors are perceived as supportive by patients with diabetes. In a qualitative study of couples, partners were asked to describe what they did to help manage diabetes (Trief et al., 2003). Both patients and spouses provided a number of answers relating to dietary control. For example, spouses assisted in grocery shopping or food preparation, and shared a diet plan. Patients generally perceived these behaviors as helpful. Adjusting to the timing and location of meals, assisting with shots or medication, and checking blood sugar levels also were perceived as beneficial by patients. Reminding in general was considered to be a helpful behavior, whether it was a quick reminder to take medication or to pack extra snacks. Type 2 Diabetes: A Couples Study 7 However, the same study showed that some spouse behaviors were considered not supportive. Nagging, criticizing, overprotecting, and preparing inappropriate foods or modeling bad eating habits were viewed as unhelpful behaviors. These kinds of behaviors could reduce the person’s sense of independence or exacerbate the person’s stress which might then contribute to poorer self-care behaviors. It is also possible that some spousal behaviors are considered helpful in some circumstances but unhelpful in other contexts. An interview study of people with diabetes showed that there are two main factors that determine if a behavior is considered helpful or not (Bailey & Kahn, 1993). One is “perceived need”, which is how people evaluate their need for help in a situation. For instance, when people with diabetes received help during hypoglycemic episodes, the help was perceived as needed. On the other hand, when wakened by spouses who were reminding them to take their morning shot, the help was perceived as unnecessary, unneeded, and unhelpful. A second factor is “perceived spousal motivation”, which is the way that people with diabetes evaluate their spouses’ reasons for offering help to them. If people with diabetes believe that their spouse is displaying genuine concern for their well-being, the spouse motivation is considered acceptable. On the other hand, if people with diabetes perceive their spouses’ behavior as indicating a lack of trust or confidence in their abilities, the motivation was considered to be negative. When people with diabetes viewed spouse help as unnecessary and the spousal motivation as not acceptable, they were more likely to refuse their spouses’ offers of help. Help was then viewed as intrusive. In some instances, the help backfired and patients did just the opposite of what was requested. For example, if a husband reminded his wife to eat something, she might respond by delaying her eating. This study showed that people Type 2 Diabetes: A Couples Study 8 with diabetes are more likely to view behaviors as helpful when they need help and when they view their spouses’ motives as acceptable (Bailey & Kahn, 1993). Relationship Coping and Chronic Illnesses The spouse relationship can affect diabetes outcomes not only by supportive or unsupportive interactions but also by how the couples independently or jointly cope with diabetes. How the spouses react to the disease and how the efforts of both members of the couple fit are important in determining what patients will do while they are coping with a chronic disease (Coyne & Smith, 1994). Some couples decide together what needs to be done and how to proceed with the chronic disease. Some spouses take more of a passive role, and other spouses actively try to make changes in the patient’s life. Two main types of relationship-focused coping have been identified (Coyne & Smith, 1991). The first is active engagement. This strategy involves both partners discussing problems, inquiring how the other partner feels about the problem, and utilizing beneficial problem solving methods. A study of 56 couples, in which the husbands suffered myocardial infarctions, examined how relationship-focused coping was associated with patient self-efficacy (Coyne & Smith, 1994). Patient active engagement was related to higher patient self-efficacy. Another study of men who had suffered myocardial infarctions showed that husbands’ use of active engagement was associated with a decrease in wives’ distress (Coyne & Smith, 1991). Interestingly, these strong associations only occurred among couples with lower marital quality and did not occur in couples with high marital quality. The second type of relationship-focused coping is protective buffering. Protective buffering is a method that involves denying worries, hiding concerns, and yielding to the partner in order to avoid disagreements and arguments. Studies of men who had suffered myocardial Type 2 Diabetes: A Couples Study 9 infarctions showed that husbands’ use of protective buffering was related to lower patient efficacy, whereas wife protective buffering was positively associated with patient self-efficacy. Patients’ use of protective buffering was associated with an increase in wives’ distress. These findings support the idea that the coping styles of both patients and spouses may play an important role in patient self-efficacy and, ultimately, patient adherence. Another type of relationship-focused coping that has been investigated among those with a chronic illness is communal coping. Communal coping occurs when partners solve problems collectively instead of individually. For example, in the case of diabetes, communal coping implies that both members of the couple consider diabetes to be their joint problem. Communal coping among patients with chronic illnesses may be related to better self-care behaviors because partners and patients might solve problems better together and might be more cooperative with one another. Although research has not examined the link of communal coping to adherence, communal coping has been related to patient outcomes. In a study of men and women with congestive heart failure, communal coping predicted a reduction in heart failure symptoms over a 6-month period (Rohrbaugh, Mehl, Shoham, Reilly, & Ewy, 2008). In this study, communal coping was operationalized as the use of first-person plural pronouns during a discussion about coping with the patient’s heart conditions. Goals and Hypotheses There were 5 goals of this study. First, we wanted to determine how spouses help their partners take care of their diabetes. To do this, we administered a questionnaire that asked patients to rate how often their partners engaged in a set of behaviors and how helpful or unhelpful those behaviors were. We also asked an open-ended question to elicit other helpful behaviors. We asked spouses the same questions. Type 2 Diabetes: A Couples Study 10 Second, we examined the association of positive and negative behaviors to patient selfcare behavior, patient self-efficacy and three indicators of patient well-being (depression, perceived stress, and life satisfaction). We hypothesized that when spouses engage in more positive behaviors, patients will take better care of their diabetes than when spouses engage in less positive behaviors. We also hypothesized that positive behaviors would be associated with higher patient self-efficacy and higher patient well-being (i.e. be less depressed, less stressed and more satisfied with their lives). By asking both patients and spouses to evaluate spouse behavior, we can examine the relation between patient perception of spouse behavior and spouse reports of their own behavior. We also will be able to link both patient and spouse perception of spouse behavior to patient outcomes. Third, we determined how two different relationship coping styles were associated with patient self-care behavior and patient health outcomes. Specifically, we examined both patient and spouse active engagement and protective buffering. We hypothesized that patients who have spouses who engage in more active engagement will have better self-care than patients who have spouses who engage in less active engagement. Spouses who engage in more active engagement will discuss concerns and problems with the patient. For instance, if spouses are engaging in active engagement, they might feel that the patient should eat healthier. The spouse would most probably suggest that the patient eat more fruits and vegetables, which could lead the patient to have a better diet. We also hypothesized that patients who engage in more active engagement will have higher self-efficacy then patients who engage in less active engagement. By contrast, patients who have spouses who engage in more protective buffering will have worse self-care. If spouses are not openly discussing how they feel about the patients’ diabetes, then patients would not know how spouses truly feel. If spouses are not Type 2 Diabetes: A Couples Study 11 communicating their concerns about health behavior, then patients are less likely to execute good health behavior. We also hypothesized that patients who have partners who engage in more protective buffering will have lower self-efficacy then patients who have partners who engage in less protective buffering. We hypothesized that patients who engage in more protective buffering will have worse self-care than patients who engage in less protective buffering. Patients who are worried about how their spouses are coping and engage in protective buffering might not ask their spouse for assistance or needed help. For example, a spouse may cook an unhealthy meal and the patient may eat the meal because he or she is afraid of hurting the spouse’s feelings. The patient may continue to eat unhealthy meals in order to avoid disagreements which may ultimately lead to worse self-care. For the same reasons, we also hypothesized that patients who engage in more protective buffering will have lower self-efficacy then patients who engage in less protective buffering. Fourth, we examined whether aspects of the spouse relationship were associated with patient self-care behavior and patient health outcomes. We did this in two ways. First, we examined whether marital satisfaction was associated with better patient self-care behavior, higher self-efficacy, and higher well-being. Happily married couples may receive encouragement and support from their partners to perform new behaviors that may be overwhelming or challenging without support. Secondly, we examined if relationship satisfaction moderated the association of spouse behaviors to patient outcomes. We hypothesized that marital quality will influence the perception of spouse behaviors. In high quality relationships, patients would view behaviors as helpful. For instance, spouses might remind patients to go exercise. Patients in high quality relationships might view this behavior as helpful because they might feel that their spouses truly care about them and want them to take Type 2 Diabetes: A Couples Study 12 care of themselves. On the other hand, patients in low quality relationships might view this reminder as not helpful because they might feel that their spouses are trying to control them. Thus, the association of spouse behaviors (positive and negative) to patient outcomes might be stronger among couples who have high than low marital satisfaction. Fifth, we measured communal coping. We hypothesized that if the patient and partner view diabetes as a joint problem, then the patient will have higher life satisfaction, lower perceived stress and depression, and better self-care. Couples who view diabetes as a joint problem may be highly interdependent. Patients and partners would be motivated to act for the needs of each other. Thus, patients who cope with diabetes in a communal way should receive the necessary support to help them manage their distress, make changes in their life-style and cope with the burdens that diabetes has forced on their lives. Method