200 Diabetes Mellitus
adults with diabetes warrants further investigation, the exist-
ing literature has provided a basis for Anderson (1996) and
others to offer preliminary guidelines for clinical interactions
with patients and their support systems: (a) Social support
should be individually de“ned for each patient within each
family system; (b) support is dynamic and changes over time
as the patient and family grow and change; (c) at times, it
must be recognized that in families with dysfunctional inter-
action patterns, successful family involvement may not be
feasible; and (d) assistance should be provided to patients in
determining the amount and types of social support that
would be bene“cial to them (Boehm et al., 1997). Systematic
empirical treatment ef“cacy studies focusing on social sup-
port in adults are needed.
Research has highlighted the importance of social„and
especially family„support in the management of diabetes.
Also apparent are the complexities involved in the relation-
ship between social support and a person•s ability to adjust to
and live with this disease, including the impact of age, gen-
der, race, family developmental stage, and type of diabetes
regimen (e.g., insulin- vs. noninsulin-requiring). More tradi-
tional interventions, such as individual, couples, and family
therapy, have proven to be bene“cial in assisting individuals
with communication, assertiveness, and problem-solving
skills. The potential role of multidisciplinary health care in-
terventions with both individuals and families and the use of
technology-based interventions remain to be more fully and
rigorously explored in future studies.
Patient-Practitioner Interactions
The traditional biomedical model of care, in which the prac-
titioner is seen as the expert who sets treatment goals and
standards, is inappropriate for the demands of daily diabetes
care (R. Anderson, 1995). Optimal disease management can
be achieved only through the partnership and active partici-
pation of a knowledgeable, motivated patient and staff.
Research regarding several aspects of the patient practitioner
relationship and their relationships to adherence and health
outcomes are reviewed in the following section.
Patient Participation
In accordance with “ndings in other chronic illness popula-
tions (Garrity, 1981), it has been suggested that by increasing
patients• participation and responsibility in their care, motiva-
tion for adherence and disease management may be enhanced
(Green“eld, Kaplan, Ware, Yano, & Frank, 1988). Several
studies have sought to empirically examine the effects of the
patients• level of involvement in the patient-practitioner
relationship on diabetes outcomes such as adherence and
metabolic control. It should be noted, however, that playing
an active role in medical encounters and decision making
may not be easily achieved for all patients (e.g., Green“eld
et al., 1988).
Poorer metabolic control has been associated with less
patient involvement, less effective information-seeking be-
havior, and less exchange of opinions during of“ce visits
(Kaplan, Green“eld, & Ware, 1989). Physicians• provision of
autonomy support (i.e., providing choice to the patients,
giving information, acknowledging emotions, and providing
minimal pressure for patients to behave a certain way)
has been related to better glycemic control, perceived com-
petence, and autonomous motivation for adherence
(G. Williams, Freedman, & Deci, 1988). Randomized studies
have found that interventions designed to increase patient
participation in medical encounters lead to behavioral
changes in the interactions with practitioners, fewer physical
limitations, and improved glycemic control (Green“eld et al.,
1988; Rost, Flavin, Cole, & McGill, 1991). Green“eld and
colleagues (1988) developed an intervention consisting of
two brief sessions in which patients were taught communica-
tion skills pertaining to information seeking, negotiation,
focused question asking, and asserting control. Patients•
medical charts were reviewed with them, and any perceived
barriers to active participation were discussed and coping
strategies suggested. The patients who were randomized to
the intervention group were twice as effective at eliciting
information from the physician and were more active in the
patient practitioner interaction. Importantly, these patients re-
ported fewer functional limitations and better glycemic con-
trol at follow-up. The authors state that further research is
needed to determine whether the noted improvements are re-
lated to increased information that patients obtained in the
visit or to the increased involvement. Rost et al. (1991) in-
vestigated whether similar improvements could be achieved
by adding a patient activation component to an inpatient dia-
betes education program. Patient activation training involved
reviewing their medical charts and obstacles to active in-
volvement, writing down questions for practitioners, and im-
proving communication. Patients who were randomized to
the activation condition were more active in their discharge
visit and showed a trend for increased decision-making
behaviors. This group reported fewer physical limitations in
activities of daily living four months later and some improve-
ments in metabolic control. Importantly, the physicians• sat-
isfaction was not negatively affected by the interaction. The
active role and personal responsibility of patients are major
tenets of patient empowerment programs (R. Anderson et al.,
1995). R. Anderson and colleagues found that patients in