Relationship Between Self-Efficacy And Adherence To Health-Promoting Behaviors In Patients With Diabetes And Co-Morbid Depression: A Literature Review

Search strategy

The present review investigates the topic of adherence to health-promoting behaviors in patients who have diabetes and co-morbid depression. In the wake of promotion of adherence to mandates of diet, medication, and lifestyle, the self-efficacy theory has been deemed as relevant. Therefore, the application of self-efficacy theory in promoting the patients who have diabetes has been discussed, as literature indicates the worsening of symptoms due to co-morbid depression. Co-morbid depression makes adherence to regimes of self-care in diabetic patients highly ineffective (Kav, Yilmaz, Bulut, & Dogan, 2017). The present review, therefore, highlights the relationship between the three constructs and aims to justify the relevance of self-efficacy theory about the improved health status of those suffering from chronic illness and diabetes. With a focus on demographic variable and social support, the essential evidence has been synthesized from the published literature. The accumulated knowledge through investigation of the effect of inclusion of self-efficacy regimes in the care plan of diabetic individuals who have diabetes aims to provide a direction for the design of better interventions. The review, therefore, presents the literature which illustrates the self-efficacy theory concept, the relevance in patient behavior, and culminates with the evidentiary material which will through light on the role of demographic variable of gender and complete social support in promoting adherence.

The database used for the search strategy included PubMed, Cochrane Library, and SciVerse. The keyword used for search include:

Single keywords: Self-efficacy, diabetes, co-morbid depression

Combination keywords: Self-efficacy theory, Diabetes Self-efficacy co-morbid depression, health behavior theories

The theoretical frameworks have always been utilized by the researchers to find relevant areas of application which could bring about better health behaviors among the patients. A range of constructs effect behavior including intentions, perceived control, the expectancy of outcomes, stimuli, and self-efficacy. The theoretical construct of self-efficacy finds implications in improved health behaviors and have been discussed regarding diabetes and co-morbid depression.

The self-efficacy theory found its origin through Bandura (1977) seminal article, wherein the concept has been described as driven by people’s need to make contributions to their psychosocial functioning through mechanisms of personal efficacy. A belief that desired effects can be brought about their actions serves as the incentives to act. The beliefs of self-efficacy have been stipulated as the core of human function, which drives a person to perform a function despite having the required skills. Self-efficacy has therefore been defined as “People’s judgments of their capabilities to organize and execute courses of action required to attain designated types of performances”(Bandura, 1986, p. 391). The concept has been said to influenced by factors of mastery experience, verbal persuasion, somatic and emotional state, and vicarious experience. The theory has undergone multiple empirical testing over time, with the earliest empirical test undertaken by Weinberg, Gould, & Jackson (1979).

The participants were tested in a motor-performance situation wherein the results supported the self-efficacy predictions, as those having higher self-efficacy performed better than other subjects on the second trial of extending legs as well. The constructs of learned helplessness and patterns of sex-role socialization made the basis for discussion. Lee, Arthur, & Avis (2008) in a discussion paper explored the advantage of incorporating self-efficacy in the care plans to promote the elderly to undertake the minimum required level of physical activity to ensure the health benefits. The reviewed information from published trial results showed the incorporation to be beneficial, with the dimensions of performance accomplishment, verbal encouragement, physiological and affective states, and vicarious learning proving to be helpful. A meta-analysis by Ashford, Edmunds, & French (2010) showed the interventions involving feedback on past and other’s performance brought about the highest levels of self-efficacy. Graded mastery, barrier identification, and persuasion although significant found association with lower self-efficacy levels.

Literature review

As shown by the research, integration of self-efficacy proves to be successful in bringing changes in patient behavior, exhibiting progress towards a state of health. Depression is encountered as a frequent co-morbidity with diabetes mellitus, which often finds an association with non-adherence to diabetes self-care. Self0care for diabetes includes paying attention to diet, medication, and blood glucose levels. Due to co-morbidity, the effective disease component becomes difficult to care for, and often treated inadequately in primary healthcare settings. An increased incidence of diabetes finds co-relation with high depressive symptoms (Katon, 2008). Therefore, self-efficacy could drive better adherence to aspects of self-care among the patients suffering from diabetes mellitus, which could help in improved health state and avoidance of recurring or occurrence of depressive symptoms. Self-efficacy along with social support was highlighted as a mediator between depressive symptoms and adherence. The negative impact of depression on adherence was therefore concluded to be reduced with the use of self-efficacy. To make the theoretical concept successful regarding improved adherence to the collaborative efforts of friends, family, and healthcare team proves to be beneficial. Also, impart self-management training was also emphasized to be highly effective in patients with a severe degree of depressive symptoms (Tovar, Raynes, Gokun, & Clark, 2013).

Cherrington, Wallston, & Rothman (2010) directed their research towards the exploration of the relationship between diabetes, depressive symptoms, and glycemic control. The cross-sectional study conducted among groups of men and women tested the mediating relationship between depression and glycemic control. The results showed the self-efficacy to be effective among men in mediating the relationship between depression and glycemic control. Therefore, the findings were suggestive of the possible application of designed interventions in men only. The gender-specific results were also indicated by Messina, Rucci, Sturt, Mancini, & Fantini (2018) wherein men were reported to have poorest self-efficacy, with focus on constructs of disease management and lifestyle management. The gender-specific results need to be explored further as the clear reasons behind gender specific adherence and efficacy were not explored using scientific measures. A probable explanation for these behaviors has been the difference in coping strategies, lifestyle, or any other unmeasured variables. Therefore, it could be concluded that while the statistical results indicate the higher need for self-efficacy interventions among men, however, the evidence-based research needs to explore the basis of such differentiation. It could greatly help in diabetes and depression control among different genders.

The mediating role of work support and family support with self-efficacy for a higher degree of satisfaction has been implicated by Gayathri & Karthikeyan (2016). A positive relationship between self-efficacy, life satisfaction, and social support was found to exist, wherein work to family enrichment shared a mediating relationship between the antecedents and outcomes. Devarajooh & Chinna (2017) emphasized the need to deal with depression and diabetes distress, as self-care was found to be indirectly affected by depression. Therefore, those exhibiting reduced levels of self-efficacy need to be provided with required support. Aflaksei & Malekpour (2014) in their study on Iranian participants also found a significant association between low levels of self-efficacy, social support, and depression. The participants who received a high level of social support received psychological support and protection from the stressful experiences. Therefore, social support proved to be an essential determinant for the positive psychological health of patients, which further enabled self-efficacy behaviors. These studies highlight the role of positive psychological states in helping diabetic patients exhibit better self-care behaviors, which further accentuates self-efficacy. Therefore, it could be concluded that positive support not solely from family, but from all the social spheres including work and healthcare staff act as reinforcement towards higher adherence. Higher the degree of support more will be self-efficacy behavior, and better health states could be achieved.

Theory perspective

Conclusion:

In the view of the literature search and review the evidence-based research and trials have indicated the self-efficacy theory to be a plausible avenue for promoting health behaviors. The patients are promoted to alter behavior in the wake of improved outcomes, which further stimulate the cycle of adhering behaviors. The issue of diabetes and co-morbid depression continues to deteriorate patient life. As due to depression self-care becomes impaired, which is highly required in case of diabetes, the clinical state and the psychological both continue to downgrade. Therefore, the use of self-efficacy theory in designing healthcare plans and interventions could prove to be useful. The self-efficacy literature was investigated about gender, and men were found to have lower self-efficacy and therefore required intervention plans designed around self-efficacy behaviors. On the other, those patients who received complete social support exhibited positive psychological states and better self-efficacy. Both the findings paint a positive picture. However, they need to be supported with better empirical evidence. Such as the gender-based bias needs to investigated using well-designed trials to unravel the possible reasons and future implications for designing interventions.

References:

Aflaksei, A., & Malekpour, F. (2014). The role of self-efficacy and social support in predicting depression symptoms in diabetic patients. Iranian Journal of Diabetes and Obesity, 6(3), 126–130.

Ashford, S., Edmunds, J., & French, D. P. (2010). What is the best way to change self?efficacy to promote the lifestyle and recreational physical activity? A systematic review with meta?analysis. British Journal of Health Psychology, 15(2), 265–288.

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191–215.

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. New Jersey: Prentice Hall.

Cherrington, A., Wallston, K. A., & Rothman, R. L. (2010). Exploring the relationship between diabetes self-efficacy, depressive symptoms, and glycemic control among men and women with type 2 diabetes. J Behav Med., 33(1), 81–89.

Devarajooh, C., & Chinna, K. (2017). Depression, distress and self-efficacy: The impact on diabetes self-care practices. PLoS ONE, 12(3), e0175096.

Gayathri, N., & Karthikeyan, P. (2016). The Role of Self-Efficacy and Social Support in Improving Life Satisfaction. The Mediating Role of Work–Family Enrichment. Zeitschrift Für Psychologie, 224, 25–33.

Jakovljevi?, M., & Ostoji?, L. (2013). Co-morbidity and multimorbidity in medicine today: Challenges and opportunities for bringing separated branches of medicine closer to each other. Medicina Academica Mostariensia, 1(1), 18–28.

Katon, W. J. (2008). The Comorbidity of Diabetes Mellitus and Depression. Am J Med., 121(11), S8-15.

Kav, S., Yilmaz, A. A., Bulut, Y., & Dogan, N. (2017). Self-efficacy, depression and self-care activities of people with type 2 diabetes in Turkey. Collegian, 24, 27–35.

Lee, L. L., Arthur, A., & Avis, M. (2008). Using self-efficacy theory to develop interventions that help older people overcome psychological barriers to physical activity: A discussion paper. International Journal of Nursing Studies, 45(11), 1690–1699.

Messina, R., Rucci, P., Sturt, J., Mancini, T., & Fantini, M. P. (2018). Assessing self-efficacy in type 2 diabetes management: validation of the Italian version of the Diabetes Management Self-Efficacy Scale (IT-DMSES). Health and Quality of Life Outcomes, 16, 71.

Tovar, E., Raynes, M. K., Gokun, Y., & Clark, M. (2013). Mediators of adherence among adults with comorbid diabetes and depression: The role of self-efficacy and social support. Journal of Health Psychology, 1–11.

Weinberg, R., Gould, D., & Jackson, A. (1979). Expectations and Performance: An Empirical Test of Bandura’s Self-efficacy Theory. Human Kinetics Journal, 1(4), 320–331.