210 Diabetes Mellitus
small sample sizes, which were either not representative of
the larger diabetes population or were inappropriate in the
sense that the participants reported low levels of concern with
the factor on which the treatment was focused. In addition,
Rubin and Peyrot (1992) raise other methodological limita-
tions of previous research, such as the use of poor quality out-
comes measures; ”awed designs (e.g., no control groups
used, no follow-up period); and comprehensive •shotgunŽ
interventions that included a variety of medical and psy-
chosocial components, which precluded the identi“cation of
the effective treatment components. Future treatment out-
come studies may bene“t from increased attention to these
points as well as to long-term follow-up of patients, the clin-
ical signi“cance of obtained changes (Goodall & Halford,
1991), issues of cost containment and cost effectiveness
(Glasgow, Fisher, et al., 1999), and the maintenance of be-
havior change as a separate construct from initial behavior
change (Wing, 2000).
In addition to these improvements in intervention method-
ology, future research should also address more thoroughly
individual differences in psychosocial factors and their
modi“cation. Little research exists on the speci“c needs of
racial and cultural minorities with diabetes. This is especially
noteworthy given the facts that in racial/ethnic minorities
(a) diabetes is more common (CDC, 1998) and (b) metabolic
control and complications are worse (see review by Weller
et al., 1999). Similarly, the unique management issues rele-
vant to women with diabetes also deserve increased attention.
Although there has been some research in areas of women•s
health such as diabetes in pregnancy and weight manage-
ment, there is a dearth of studies on the effects of diabetes on
other aspects of women•s reproductive health (e.g., fertility,
contraception choices), the in”uence of hormonal changes
(e.g., menopause) on diabetes management, eating disorders,
female sexual dysfunction, and the course and management
of depression in women with diabetes (Butler & Wing, 1995;
Ruggiero, 1998). Research into such dimensions of individ-
ual differences will ultimately facilitate the identi“cation of
patients to be targeted for intervention by health psycholo-
gists and what intervention techniques may be most helpful
for certain patients.
Diabetes research also needs to be increasingly directed
by comprehensive theoretical models of patient outcomes.
Such models would specify the interrelationships among psy-
chosocial factors and adherence and would detail how such
factors both in”uence (and are in”uenced by) physiological
outcomes. For example, models would capture the dynamic
and complex relationship between such factors as stress and
outcomes by specifying how stress may affect BG directly
through physiological mechanisms; how stress may affect
BG indirectly through disruptions in self-care; and how
physiological status (e.g., level of BG control, development
of complications) may affect an individual•s stress levels.
Obviously, evaluating such comprehensive models would re-
quire large sample sizes of diverse patients and sophisticated
statistical methodologies. Health psychologists, with their
expertise in theory-based behavior change strategies and
treatment ef“cacy research, are well-positioned to advance
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