Handbook of Psychology

Psychosocial Factors in Diabetes Management 201

an empowerment program had improved self-ef“cacy,
diabetes attitudes, and glycemic control at the six-week
follow-up.
Many of the studies reviewed have not evaluated the me-
diating role that adherence may play in the demonstrated out-
come improvements (R. Anderson et al., 1995; Green“eld
et al., 1988; Kaplan et al., 1989; Rost et al., 1991). The effects
of patient participation on adherence may be seen through
several routes: a direct effect on adherence, an indirect effect
on adherence by increasing the understanding of the regimen
and the appropriateness of the regimen, and/or an indirect
negative effect on adherence by decreasing satisfaction with
the relationship when there is a discrepancy between a pa-
tient•s desired role and what is possible (Golin, DiMatteo, &
Gelberg, 1996). Future empirical research in this area needs
to incorporate measures of adherence to fully evaluate and
understand the effects of patient activation interventions on
outcomes.

Patient Satisfaction

Satisfaction with care appears to be more heavily in”uenced
by such factors as information giving, the meeting of patient
expectations, and expressions of empathy than by variables
related to the technical competence of the physician or cost of
care (Golin et al., 1996). Patient satisfaction has been linked
to higher adherence rates in various chronic illness popula-
tions (Sherbourne, Hays, Ordway, DiMatteo, & Kravitz,
1992) and to better adherence (Landel, Delamater, Barza,
Schneiderman, & Skyler, 1995) and health outcomes (Landel
et al., 1995; Viinamaki, Niskanen, Korhonen, & Tahka, 1993)
in diabetes populations speci“cally.
Psychometrically sound measures of patient satisfaction
are available for the general population (e.g., Marshall, Hays,
Sherbourne, & Wells, 1993), as well as for diabetes treat-
ment, including the Diabetes Clinic Satisfaction Question-
naire (A. Wilson & Home, 1993) and the Patient Practitioner
Relationship Questionnaire (Landel, 1995). Other diabetes
satisfaction scales examine speci“c types of satisfaction, for
example, satisfaction with diabetes management programs
(Paddock, Veloski, Chatterton, Gevirtz, & Nash, 2000).

Clinical Suggestions for Enhancing the Relationship

Based on the research “ndings described and on clinical
experiences, a number of suggestions for enhancing the qual-
ity of the patient-practitioner relationship are relevant for a
variety of practitioners working with diabetes patients. The
establishment of a caring, empathetic, and nonjudgmental
partnership between practitioner and patient is seen as integral

(Glasgow, 1995). Through collaborative goal setting and con-

tracting, expectations on each party•s part may be made ex-

plicit. In addition, such interactions allow the patient to voice

concerns, other competing demands, desires for involvement

in diabetes care, and lifestyle factors that may in”uence the “t

of the proposed regimen to the person•s lifestyle at that time.

Glasgow provides pointers for low-cost systemwide interven-

tions to promote better diabetes management, such as paying

attention to the patient•s past medical care experiences, reduc-

ing the number of treatment goals per visit (focusing on one or

two key behaviors), providing adherence prompts to patients,

and distributing appropriate written materials. For patients in

need of further intervention, Glasgow (1995) suggests prepar-

ing patients before medical appointments by reviewing their

medical charts with them, doing relapse-prevention training,

having more frequent follow-up appointments scheduled,

providing further education as needed, and using visual dis-

plays and analyses of their SMBG data.

Clinical recommendations for achieving long-term behav-

ioral change and health bene“ts in patients with diabetes may

also be garnered from the experiences of the DCCT (Lorenz

et al., 1996). The particular behavioral strategies used by the

practitioners and patients involved in the DCCT were not

standardized or speci“cally measured; rather, behavioral

strategies were individualized according to the needs of par-

ticular centers and patients. Lorenz and colleagues (1996)

summarized the types of strategies commonly used and em-

phasized the importance of a collaborative style of interac-

tion and the support provided for the patients involved in the

intensive treatment. Further research is needed to systemati-

cally evaluate these strategies for enhancing patient adher-

ence and outcomes in heterogeneous samples of diabetes

patients.

Summary

As medicine becomes more patient-centered, it is increas-

ingly recognized that successful management of diabetes is

predicated upon a partnership between the person with dia-

betes and his or her medical team. Through such a part-

nership, the individual may establish self-care behaviors that

optimize metabolic control. However, the quality and charac-

teristics of such relationships vary widely, both between and

within individuals. Research indicates that several character-

istics of the patient-practitioner relationship are related to

health outcomes. Persons who take an active role in their

care, assuming appropriate levels of personal responsibility,

are able to achieve better metabolic control. In addition, indi-

viduals achieve better outcomes when their physicians have

congruent diabetes beliefs and speci“c interests in diabetes,