Handbook of Psychology

202 Diabetes Mellitus

and when they are more generally satis“ed with their care.
Suggestions on how to establish a collaborative, supportive
relationship have been developed. In addition, some inter-
ventions have begun to be evaluated for their effects on ad-
herence and health outcomes. As this important moderator of
outcomes receives more attention, additional research should
seek to develop and empirically evaluate interventions to
promote effective patient-physician partnerships. The effect
of such interventions on levels of self-care, psychosocial fac-
tors (e.g., adaptive coping, perceptions of social support), and
health outcomes needs to be examined. Individual differ-
ences in factors such as desire for an active role in care and
communication style should also be studied for their effects
on such interventions.

Barriers to Adherence, Coping, and Problem Solving

Barriers to Adherence

Glasgow, Hampson, Strycker, and Ruggiero (1997) have
proposed two speci“c categories of barriers that impede daily
diabetes self-care: personal and social-environmental. The
personal model includes patients• cognitions about the dis-
ease including health beliefs (e.g., vulnerability to negative
outcomes), emotions, knowledge, and experiences. Such per-
ceptions affect the implementation of speci“c health behav-
iors including disease management and patient-practitioner
interactions. Social-environmental factors include barriers to
self-care (e.g., weather), social support from family or peers,
interactions with health care providers, and community re-
sources and services (Glasgow, 1994). Gaining awareness of
patients• social contexts provides clinically relevant informa-
tion on how patients live and cope with their diabetes on a
daily basis.
Research indicates that diabetes patients experience the
greatest number of barriers to diet and exercise, a moderate
amount of barriers to glucose testing, and the fewest bar-
riers to insulin injections and medication-taking (Glasgow,
Hampson, et al., 1997; Glasgow, McCaul, & Schafer, 1986).
Each of the several components of the diabetes regimen
can have its own set of personal and social-environmental
barriers (Glasgow, 1994). For example, dietary planning has
been shown to be in”uenced by personal factors (e.g., moti-
vation, emotions, food selection knowledge, understanding
of meal plans; El-Kebbi et al., 1996; Travis, 1997), social-
environmental factors (e.g., holidays; Travis, 1997), and lack
of family support (e.g., pressure to deviate from dietary
guidelines; El-Kebbi et al., 1996).
To quantify particular barriers to diabetes self-care, re-
searchers have developed psychometrically sound self-report

scales that encompass multiple components of diabetes

self-care such as the Barriers to Adherence Questionnaire

(Glasgow et al., 1986). Other barriers scales have focused

speci“cally on one aspect of diabetes management. For exam-

ple, the Hypoglycemic Fear Survey (Cox, Irvine, Gonder-

Frederick, Nowacek, & Butter“eld, 1987) was designed to

evaluate four aspects of fear related to hypoglycemia, includ-

ing events precipitating fear, the phenomenological experi-

ence of the fear response, adaptive and maladaptive reactions

to hypoglycemia, and physiological outcomes. In addition to

empirical utility, both of these scales have been shown to be

clinically useful tools for the purpose of assessing and facili-

tating treatment adherence and glycemic control, respectively.

Coping and Problem Solving

Knowing the barriers that diabetes patients encounter is par-

ticularly important since their ability to cope with such barri-

ers will impact regimen adherence (Glasgow, Hampson,

et al., 1997) and possibly metabolic control (Spiess et al.,

1994). A dearth of research, however, examines the coping

abilities of adult diabetes patients. The limited research indi-

cates that active or problem-solving coping is related to

positive disease-related outcome and well-being, whereas

avoidant, passive, or emotion-focused coping is associated

with less favorable psychological and health outcomes (e.g.,

Smári & Valtysdóttir, 1997). Thus, problem-solving skills

seem particularly relevant to diabetes self-care, enabling

patients to be more effective and ”exible in coping with the

variety of barriers they encounter in treatment (Glasgow,

Toobert, Hampson, & Wilson, 1995). To date, the Diabetes

Problem-Solving Interview (Toobert & Glasgow, 1991) is

the only diabetes-speci“c problem-solving measure. The

interview presents a variety of situations to elicit speci“c

problem-solving strategies that patients would employ in at-

tempts to adhere to their treatment regimen. Preliminary re-

sults indicate that this measure signi“cantly and uniquely

predicts levels of dietary and exercise self-care behaviors in

the long term.

Interventions to Cope with Barriers to Care

Behavioral intervention research on diabetes self-care man-

agement with adults has focused primarily on problem-

solving interventions (Glasgow et al., 1995). For example,

training in problem-solving skills has produced favorable

behavioral and metabolic outcomes in studies of older adults

with 102 type 2 diabetes (Glasgow et al., 1992). The inter-

vention, entitled the •Sixty Something.. .Ž program, in-

cluded the following treatment components: (a) modifying