Discuss the possible role of psychological factors throughout the course of an illness: Type 2 Diabetes Mellitus
Health psychology is a topical development in the integration of biomedical and social sciences in health care. It addresses the role of psychological factors in the cause, progression, and outcome of health and illness (Ogden, 2007). Psychological theories can guide health education and promotion, and offer the health care practitioner a structured approach to understanding and meeting the health needs of health and social care service users (Morrison and Bennett, 2009). The appraisal of health psychology models can assist practitioners in evaluating their contribution to service users’ understanding of health, behaviours relating to health and the practice of health care. Appraisal and evaluation enable health care workers to apply psychological models and theories when analysing aspects of health and behaviour relevant to practice (Marks et al, 2005).
The ethos of health psychology is that of treating the ‘whole’ person, not just the physical adaptations that transpire associated with illness. This might embrace behaviour change, urging modifications in beliefs, and coping strategies, and acquiescence with medical advice. As the ‘whole’ self is treated, the individual becomes to a certain extent responsible for their treatment. For example, an individual may have a responsibility to take medication, and to change beliefs and behaviour. Therefore, the individual is no longer seen as a victim. From this viewpoint, health and illness are on a continuum. Instead of being either healthy or ill, individuals may move on along a continuum from healthiness to illness and back again. Health psychology also argues that the mind and body act together. It perceives psychological issues as not only potential effects of illness, but as adding to all the phases of health, from maximum healthiness to illness (Morrison and Bennett, 2009).
Health psychology is concerned primarily with intrinsic factors, especially individual perceptions of health-related behaviour. Health behaviour, defined as behaviour related to health status, is becoming increasingly important. Public health policy has increased the emphasis on individual responsibility and choice and because of this; there is a corresponding need to improve understanding of individual motivations that affect those choices and health-related behaviours (Marks et al, 2005). The health behaviours studied by psychologists are varied, but the most commonly studied health behaviours have immediate or long-term implications for individual health, and are partially within the control of the individual (Ogden, 2007).
Type 2 diabetes, formerly known as non-insulin dependent diabetes mellitus, is a serious and progressive disease. It is chronic in nature and has no known cure. It is the fourth most common cause of death in most developed countries (UK Prospective Diabetes Study Group, 1998a). Although no exact figures are available, it has been suggested that by the year 2010 there would be 3.5 million people with diabetes in the United Kingdom (UK). However, approximately 750,000 of the estimated number may be undiagnosed (Diabetes UK, 2008a). Diabetes UK campaigns to raise awareness of type 2 diabetes because if left undiagnosed, the condition can result in long-term complications such as retinopathy, nephropathy, neuropathy, and an increased risk of myocardial infarction and stroke. The total number of people with diabetes has increased by 75% over the last six years and the incidence in the UK is escalating at a faster rate than in the United States (González et al,2009).
There is a higher incidence of type 2 diabetes in people with South Asian or African descent (Department of Health, 2007). One of the reasons for this is thought to be that these ethnic groups have increased insulin resistance. Signs of type 2 diabetes are already present in UK children of South Asian and African-Caribbean origin at ten years of age, according to research funded jointly by the British Heart Foundation and the Wellcome Trust (Whincup et al,2010).
The prevalence of type 2 diabetes increases with age to as much as one in ten in those aged 65 years. The lifetime risk of developing the condition in the UK is greater than 10% (Leese, 1991). Diabetes-related complications can have a major effect on the individual and family members, and are costly to the patient. A study undertaken by Bottomley (2001) examined the costs of living of patients with diabetes complications, including taking time off work and transport costs for hospital appointments. The study showed that the cost of treating someone with type 2 diabetes with microvascular and macrovascular complications was £5,132 compared to £920 for someone who does not have diabetes-related complications (Bottomley 2001). This also has implications for the National Health Service (NHS) in terms of the financial burden of managing and treating the condition and the use of resources. It has been estimated that the cost of treating diabetes nationally adds up to approximately 9% of the NHS annual budget, although most of that is used to treat associated long-term complications, such as kidney failure, blindness, amputations and organ transplantation, rather than the provision of medication (Bottomley, 2001).
With regard to type 2 diabetes, psychological theories and models have a long history of informing attempts to change behaviour and improve emotional well-being. Over recent years, many clinical guidelines in the UK by the National Institute for Health and Clinical Excellence (NICE) have included recommendations for psychological interventions for long-term conditions. Evidence-based recommendations have been made not only for the treatment of associated mental health problems such as depression and anxiety (NICE, 2009; NICE, 2004) but also for physical health conditions such as obesity (NICE, 2007) and changing behaviour related to public health issues such as smoking and lack of exercise (NICE; 2007). The aim of this essay is to explore the psychological implications for a person suffering from type 2 diabetes and others involved in the experience of that illness.
Type 2 diabetes, is caused as the result of reduced secretion of insulin and to peripheral resistance to the action of insulin; that is, the insulin in the body does not have its usual biological effect. It can often be controlled by diet and exercise when first diagnosed, but many patients require oral hypoglycaemic agents or insulin in order to maintain satisfactory glycaemic control and prevent the complications of diabetes (Diabetes UK, 2008a). To reduce the risk of long-term complications, both macrovascular and microvascular, people with type 2 diabetes need access to appropriate, individualised education, which informs them about the risks associated with the condition. Information relating to lifestyle changes such as healthy eating, increasing activity levels, and smoking cessation are vital (Diabetes UK, 2008a).
Some people accept their diagnosis of diabetes and all that this means, and manage to adapt to their new lifestyle, but others find it difficult. Changes will need to be made to the type of food they eat, the amount they eat of particular foods and perhaps to the time at which they eat their meals. As a consequence of the required changes to lifestyle, it is not surprising that many people need some professional psychological support (Diabetes UK, 2008a).
Diabetes may have an impact on people’s careers, driving, and insurance policies (life, driving, and travel). Difficulties surrounding holidays, work or travel abroad may prove insurmountable without support. People with diabetes who are also caring for others, for example children or elderly relatives, may find it very difficult to put themselves first (Diabetes UK, 2008a).
Some people who have been diagnosed as having diabetes feel that they have been condemned to a life where everything has to be planned. There are, however, support networks available. For example Diabetes UK, a charity that supports people with diabetes, their families and the health professionals who care for them, has local and regional branches where people can meet and discuss problems and learn from each other how they manage their day-to-day-life (Diabetes UK, 2008a).
The majority of people with type 2 diabetes are insulin resistant. Obesity exacerbates insulin resistance. As many as 80% of people with type 2 diabetes are obese at the time of diagnosis (Marks, 1996). Weight loss not only improves insulin resistance, but also lowers blood glucose, lipid levels, and blood pressure. Cardiovascular disease is often present in people with type 2 diabetes. The presence of insulin resistance accelerates atherosclerosis, leading to macrovascular complications such as myocardial infarction, stroke, and peripheral vascular disease. The mechanisms responsible for this are thought to be hyperinsulinaemia, dyslipidaemia and hypertension (Garber, 1998). However, microvascular problems such as retinopathy, nephropathy, and neuropathy still occur. The mechanism responsible is thought to be hyperglycaemia (Garber, 1998). Therefore, good blood glucose control is of crucial importance.
Although the prognosis for people with type 2 diabetes mellitus is less than favourable, evidence has shown that making major lifestyle changes, such as having a healthy diet, smoking cessation, and increasing activity levels, can reduce the risk of long-term complications (UK Prospective Diabetes Study Group, 1998a). However, using the threat of long-term complications as a means of inducing lifestyle or behaviour changes has not proved to have any prolonged beneficial effect (Polonsky, 1999). Continued support and appropriate education is required to empower individuals to take charge of their condition and make appropriate and timely therapeutic decisions. The healthcare professional and the individual must decide on the most appropriate treatment regimen to provide optimum care and the best medical outcome (Marks et al, 2005). NICE published a document in 2008 entitled ‘CG66: Type 2 diabetes’ which recommended that all people with diabetes should be offered structured education, provided by a trained specialist team of healthcare professionals (NICE, 2008). The utilisation of theoretical health psychology models can assist these specialist team practitioner in empowering individuals with type 2 diabetes to contemplate and instigate the changes in lifestyle behaviours such as smoking, lack of exercise and unhealthy eating habits that have adverse consequences on long-term health outcomes.
With regard to health psychology, as previously mentioned, health psychology is concerned primarily with intrinsic factors, especially individual perceptions of health-related behaviour. Attributing health-related behaviours to internal or external factors has been discussed in relation to the concept of a health locus of control. Individuals differ as to whether they regard events as controllable by them (an internal locus of control) or uncontrollable by them (an external locus of control) (Ogden, 2007). Accessing diabetes related health services for testing or treatment could be viewed from either perspective. The healthcare professional is perceived to be a powerful individual who can diagnose and treat diabetes (external); however, by accessing services the individual is taking responsibility for determining their own health status (internal). It is useful for the healthcare practitioner to consider that in attending diabetic health services the individual has made an initial step in taking control of their own health needs (Marks et al, 2005).
Individuals with an internal locus of control are more likely to act in concordance with advice from a health professional than those with an external locus of control (Ogden, 2007). Knowing this can assist practitioners in their communication style with individuals who have type 2 diabetes. Identifying the specific needs of the individual, by understanding their locus of control, can help the healthcare practitioner to tailor the assessment (Marks et al, 2005). When an individual has a sense of responsibility for actions or behaviours that exposed them to a potential risk of diabetic complications, the practitioner can work on exploring the circumstances that surrounded those behaviours. The individual may already feel motivated to change these circumstances. In the case of a client who does not recognise that their own behaviour or actions were a contributory factor in posing a risk of behaviour related complications, the practitioner should focus on developing the individual’s level of awareness to shift their locus of control from the external to the internal. For example, the individual who perceives that taking responsibility for healthy eating use is always that of their partner (Ogden, 2007).
Self-management for chronic illnesses such as type 2 diabetes requires adherence to treatment regimens and behavioural change, as well as the acquisition of new coping strategies, because symptoms have a great effect on many areas of life (Glasgow, 1991; Kravitz et al,1993). For many individuals, optimum self-management is often difficult to achieve, as indicated by poor rates of adherence to treatment, reduced quality of life, and poor psychological wellbeing, effects that are frequently reported in several chronic illnesses (Rubin and Peyrot, 1999). Self-management interventions aim to enable individuals to take control of their condition and be actively involved in management and treatment choices. In the 1980s, psychological theory was applied to develop theoretical models and their constructs have had a particular effect on the development of self-management interventions.
The Health Belief Model (Becker 1974) defines two related appraisal processes undertaken by the healthcare practitioner in partnership with an individual: the threat of illness and the behavioural response to that threat. Threat appraisal involves consideration of the individual’s perceived susceptibility to an illness and its anticipated severity. Behavioural response involves considering the costs and benefits of engaging in behaviours likely to reduce the threat of disease. It can be useful for the healthcare practitioner to establish the client’s perception of risk and implications of their adverse health behaviours when discussing the reasons for healthy eating, increasing exercise, and smoking cessation. It is also important to discuss the likely impact of diabetes on the individual’s lifestyle and behaviour (Marks et al, 2005).
The Health Belief Model can be applied to evaluate the risk of lifestyle changes. The healthcare professional can initiate structured discussion with the individual to identify their educational needs, particularly around developing a realistic understanding of risk factors associated with diabetes and unhealthy eating habits, lack of exercise and smoking. It is important for the healthcare practitioner to discuss the efficacy of changes in the above in prevention of diabetic complications, while discussing other methods of behaviour modification in context (Marks et al, 2005). It is also important to establish that the individual feels confident in the practicalities of and behavioural change. Therefore, the healthcare practitioner must support the diabetic in behaviour change by giving practical health education advice on the issues of healthy eating, the benefits of exercise and the importance of giving up smoking (Marks et al, 2005).
The Protection Motivation Theory (Rogers 1975, 1983) expands the Health Belief Model to include four components that predict behavioural intentions to improve health-related behaviour, or intention to modify behaviour. These include self-efficacy, responsive effectiveness, severity, and vulnerability. In social cognitive theory, behaviour is thought to be affected by expectations, with individuals’ confidence in their ability to perform a given behaviour (self-efficacy) particularly important (Bandura, 1992). Therefore, self-efficacy can be said to be the belief in one’s ability to control personal actions (Bandura, 1992), and is comparable with the concept of internal locus of control. It is based on past experience and evokes behaviour concordant with an individual’s capabilities. Self-efficacy is distinct from unrealistic optimism and does not elicit unreasonable risk-taking (Ogden, 2007). Within the context of smoking and diabetes, an example of self-efficacy might be, ‘I am confident that I can take responsibility for protecting myself from increasing the risk of further complications by giving up smoking’. This concept has been used in self-management interventions through the teaching of skills, such as problem solving and goal setting, to increase self-efficacy. Again, in type 2 diabetes, this could mean the acquisition of knowledge relating to healthy eating principles and putting that knowledge into practice by avoiding foods that would make the blood glucose rise quickly. The goal would be to incorporate this behaviour into daily life on a long-term basis (Marks et al, 2005).
Behavioural intention can also be predicted by severity, for example: ‘Diabetes will have serious implications for my health and lifestyle’, but conversely, ‘Good blood glucose control will decrease the risk of diabetic complications’. The fourth predictor of behavioural intention is vulnerability, which in the context of diabetes may be the likelihood of cardiovascular disease or diabetic retinopathy occurring. Rogers (1983) later suggested a fifth component of fear in response to education or information as a predictor of behavioural intention.
The concepts of severity, vulnerability, and fear outlined in Protection Motivation Theory relate to the concept of threat appraisal, as discussed in the context of the Health Belief Model. Self-efficacy and response effectiveness, on the other hand, relate to the individual’s coping response, which is the behaviour intention. If a person has self-efficacy and perceives benefits in taking control of their actions (response effectiveness), they are likely to have the intention to modify their behaviour to reduce health risks (Ogden, 2007). Information or education that influences an individual’s emotional response can be environmental (external influence, such as advice from a health professional), or interpersonal (relating directly to past experience). Information and education contribute to an individual’s self-efficacy. This in turn helps develop a robust internal locus of control and will inform and/or contribute to the individual’s coping response (Marks et al, 2005). The coping response is considered to be adaptive (positive behavioural intention) or maladaptive (avoidance or denial). Assessment of the individual’s capacity to understand and apply information and to have an adaptive response is a vital skill of the health professional. A maladaptive coping response, such as the denial of identified risk factors, has potentially serious consequences for the health of the individual (Marks et al, 2005). Successful implementation of the Protection Motivation Model can enable informed choice and empower the individual to take personal responsibility and control of behaviours influencing their health (Morrison and Bennett, 2009). Skilled questioning and the use of checking skills by the healthcare professional following information-giving are important to evaluate the benefit, if any, to the individual with diabetes (Ogden, 2007).
Readiness to change is a concept derived from Prochaska and DiClemente’s (1983) transtheoretical model. It refers to how prepared or ready individuals are to make changes to their behaviour. Interventions guided by this theory focus on individuals’ motivation to change and the approach is adapted according to differences in participants’ motivation to change behaviour. Success is achieved only when the individual is ready to take on the actions needed to change behaviour. An individual may know that smoking and type 2 diabetes are not a good combination. However, unless the person is ready to quit smoking, no amount of discussion with a healthcare professional will change the person’s decision to continue smoking. Establishing an internal motivator is a good first step to assessing an individual’s readiness to change, however, an individual also needs to feel that the time is right and that they are prepared to change. Readiness to change can be assessed by asking individuals, as soon as the potential problem is identified, whether they have ever attempted to change the behaviour before. Six stages of change were identified in Prochaska and DiClemente’s (1983) Transtheoretical model of behaviour change: Pre-contemplation; Contemplation; Preparation; Action; Maintenance and Relapse.
Most people (around 60%) will be at the pre-contemplation stage when they are identified by the healthcare practitioner and will generally react in a closed way to the idea of change (Prochaska and Goldstein, 1991). They may be rebellious to the idea, they may rationalise their current behaviour or be resigned to it, or they may be reluctant to consider the possibility of change (Prochaska and Goldstein, 1991). In this situation, it is tempting to push people into making an attempt at behaviour change using their health as a motivator or by making them feel guilty. However, this is likely to prompt the individual to either lie about their behaviour or avoid the nurse completely. During the contemplation phase, it is suggested that individuals who are starting to consider change look for information about their current and proposed behaviours, and analyse the risks involved in changing or maintaining their current behaviour. The most appropriate action is to ask the individual to formalise the analytical process by undertaking a decisional balance exercise (Health Education Authority (HEA), 1996). In this exercise the person is asked to consider the positive and negative implications of maintaining or changing their behaviour. The individual then decides whether maintaining or changing the behaviour will give them increased positive outcomes, and if they are willing to attempt the change. To be at the preparation stage, individuals need to believe that their behaviour is causing a problem, that their health or wellbeing will improve if they change the behaviour, and that they have a good chance of success (Prochaska and Goldstein, 1991). Once the healthcare practitioner establishes that the individual has an internal motivator and is ready to make an attempt at behaviour change, a supportive treatment plan is needed. Individuals who are in the process of behaviour change, or who have achieved and are maintaining the new behaviour, need help to avoid relapse (Prochaska and Goldstein, 1991). The most effective way to do this is to ask the individual to reflect on their experiences so far.
Apart from taking into account the management behavioural change for those with type 2 diabetes, it is also of vital importance that there is a consideration the emotional impact of a diabetes diagnosis and living with the condition. How patients feel when presented with the diagnosis of a chronic illness such as diabetes can have an enormous impact on their lives, and on their ability to make emotional adjustments to the disease itself (Marks et al, 2005). Research has found that that the diagnosis of a chronic illness can have a strong emotional impact on individuals, with reactions of grief, denial and depression. The emotional aspects of developing and coping with diabetes can affect overall control of the disease profoundly. Similarly, these feeling may form a barrier to effective listening and learning during the consultation process and any future self-management strategies. Therefore, it is proposed that this should be taken into consideration when developing educational programmes and protocols for people with diabetes (Thoolen et al, 2008).
Coping and adapting to a long-term chronic illness is a major theme in health psychology (Ogden, 2007). Leventhal & Nerenz (1985) propose that individuals have their own common sense beliefs about their illness. These include identity: diagnosis (diabetes) and symptoms (elevated blood sugar levels, excessive hunger and excessive thirst). Perceived cause of illness: stress, a virus, unhealthy lifestyle. Time line: acute or chronic. Consequences: physical (pain, mobility problems) and emotional (lack of social contact, anxiety). Cure and control: for example by taking medication or getting plenty of rest. With regard to adapting to an illness such as diabetes, the stress coping model of Lazarus and Folkman (1984) Transactional model of stress is the concept that is most widely utilised.
The model suggests that there are key factors in adaptation to chronic illness, disease-specific coping efforts, changes in illness representation over time, interaction between psychological reality of disease and affective response, procedures for coping with the disease and interaction with context. The stress coping model (Lazarus and Folkman, 1984) emphasises the value of coping strategies to deal with a particular condition. Self-management strategies based on this model attempt to improve the individual’s coping strategies. In type 2 diabetes, people are faced with the prospect of long-term complications caused by the condition. If people are aware of these possibilities and also that successful treatment is, available it makes a diagnosis of such problems less daunting. However, there are limitations to this model. It is debated that it is a frame of reference, not a theory that ignores specific features of the illness. The situation dimension poorly represented and it is not specific. The model also neglects interactions with context (e.g. social support, other life events) and offers no account of life goals on illness representation and coping (Ogden, 2007). It is of vital importance that stress is controlled and managed in an individual with type 2 diabetes. Research has shown a link between stress as a causal factor and that stress has been found to be a factor in regulation of blood glucose regulation. Sepa et al (2005) found that family stress has a significant impact on the and development of diabetes among infants. With regard to stress and metabolic control, research has found that stressful life events predict poor glucose control. In a study by Surwit et al, (2002) the management of stress was found to improve glucose control.
Therefore, it is posited that the impact of stress can affect diabetes adversely and any interventions to manage stress may be a worthwhile component of diabetes education programs.
An additional influence on coping and adapting to living with diabetes and the development of self-management strategies has come from clinical psychology, particularly Cognitive Behavioural Therapies (CBT). Central to these therapies is the importance of attempting to change how people think about their illness and themselves, and how their thoughts affect their behaviour. Depression is one of the most common psychological problems among individuals with diabetes, and is associated with worse treatment adherence and clinical outcomes (Gonzalez et al, 2010). A randomised controlled trial (RCT) undertaken by Lustman et al, (2008) found that the percentage of patients achieving remission of depression was greater in the CBT group than in the control group. Although the research found that there was no difference in the mean glycosylated haemoglobin levels of the groups post-treatment, follow-up mean glycosylated haemoglobin levels were significantly better in the CBT group than in the control group. Therefore, it is debated that the combination of CBT and supportive diabetes education is an effective non-pharmacologic treatment for major depression in patients with type 2 diabetes. It may also be associated with improved glycaemic control. It is important to note however, that certain limitation apply to the above study that may have an effect on the findings.
The generalizability of the findings is uncertain. The study was limited to a relatively small number of patients. Similarly, the follow-up interval was limited to the 6 months immediately after treatment. Likewise, the researcher cannot exclude the possibility that CBT and diabetes education interacted in a way that potentiated antidepressant effectiveness; analogous interactions may have occurred in many clinical trials. Further studies comparing CBT and diabetes education, individually and in combination, are needed to answer such questions and to see whether successful CBT alone is sufficient to produce glycaemic improvement. Correspondingly, it is worth noting that patients in the CBT group had education almost a full year longer than controls. The difference in education was not statistically significant, but the extra educational experience may have contributed to improved outcome in the CBT group. Finally, treatment was administered by a single psychologist experienced in the use of CBT. Whether treatment would be as effective when administered by other therapists is uncertain.
For any person with type 2 diabetes to engage in any self-management strategy, good mental health is necessary. However, studies have shown reduced self-worth and/or anxiety in more than 40% of people with diabetes (Anderson et al,2001). There are several possible reasons for this. Being diagnosed with diabetes immediately poses major concerns for the individual, including what the future holds in terms of health, finance, and family relationships. Although everyone deals with diagnosis differently, for some it can cause immediate stress, including feelings of shock or guilt. Some individuals may also be ashamed and want to keep the diagnosis a secret. Others may be relieved to know what is causing the symptoms they have been experiencing. An Audit Commission (2000) report acknowledged that: people with diabetes are more likely to suffer from clinical depression than those in the general population. The report then went on to specify that therefore, diabetes services should make explicit provision for psychological support and should monitor the psychological outcomes of care.
In conclusion, to be successful in changing behaviour to negate the complications of type 2 diabetes, individuals need to decide for themselves which behaviours are undesirable, that is, which behaviours could have negative health, financial, social or psychological implications. People with diabetes also need to feel that the negative impact of risky health behaviours will be reduced or altered if they change their behaviour. It is important that individuals have confidence in their ability to make and maintain behavioural changes. It is not the health practitioner’s role to make this judgement or impose his or her beliefs. To support behavioural change, healthcare professionals need to feel comfortable in discussing lifestyle behaviours. They also need to assess an individual’s preparedness to make a change and identify the factors that motivate them to change. The application of health psychology models, such as the Health Belief Model, the Protection Motivation Theory and the Transtheoretical model of behaviour change, to the management process can enable healthcare practitioners to assess contributory factors to health behaviours. Applying models can also help to identify motivators and barriers to health-improving and health-protecting behaviours, and identify strategies which assist the person in behavioural change. The role of the healthcare professional is to enable individuals to make an informed choice by working in partnership with them to decide when and if behaviour change is desirable. By understanding how an individual copes and adapts to living with a long-term condition such as diabetes can assist in empowering individuals to managed stress that appears to have a negative impact on blood glucose levels. Correspondingly, the use of CBT as a non-pharmacological treatment has been shown to improve depression that is often apparent in individuals with diabetes. Healthcare practioners caring for those with diabetes should be trained in the use of CBT.