Does self-efficacy mediate the cross-sectional relationship between perceived quality of health care and self-management of diabetes? Results from Diabetes MILES – Australia

Objective: Quality of health care (QoC) and self-efficacy may affect self-management of diabetes, but such effects are not well understood. We examined the indirect role of diabetes-specific self-efficacy (DSE) and generalised self-efficacy (GSE) in mediating the cross-sectional relationship between self-reported QoC and diabetes self-management.

Design: Diabetes MILES–Australia was a national survey of 3,338 adults with diabetes. We analysed data from 1,624 respondents (age: M = 52.1, SD = 13.9) with type 1 (T1D; n = 680) or type 2 diabetes (T2D; n = 944), who responded to a version of the survey containing key measures.

Main Outcome Measures: self-reported healthy eating, physical activity, self-monitoring of blood glucose frequency, HbA_1c, medication/insulin adherence.

Results: We used Preacher and Hayes’ bootstrapping method, controlling for age, gender and diabetes duration, to test mediation of DSE and GSE on the relationship of QoC with each self-management variable. We found statistically significant but trivial mediation effects of DSE and of GSE on most, but not all, variables (all effect sizes < .06).

Conclusion: Support for mediation was weak, suggesting that relationships amongst these variables are small and that future research might explore other aspects of self-management in diabetes.     

‘It was all intertwined’: Illness representations and self-management in patients with cancer and anxiety/depression

Objective: Cancer and anxiety/depression frequently co-occur, leading to poorer outcomes for these illnesses. However, the majority of existing research investigates how participants view single illnesses alone. This study aimed to explore the content of individuals’ multimorbid representations and how these relate to their coping behaviours and self-management strategies for cancer and anxiety/depression.

Design: A semi-structured qualitative research design with theoretical thematic analysis.

Main Outcome Measures: Multimorbid illness representations, coping behaviours, and self-management strategies.

Results: In interviews with 21 participants multimorbid representations varied, three participants viewed cancer and anxiety/depression as unrelated, five participants were uncertain about the relationship between cancer and anxiety/depression, and the majority of participants perceived cancer and anxiety/depression as related. This third group of participants often described relationships as causal, with representations having both positive and negative influences on coping behaviours and self-management strategies. Representations were shown to change over the course of the cancer experience, with fear of cancer recurrence and the influence of participants’ most challenging illness also discussed.

Conclusions: People hold multimorbid illness representations that can influence self-management. An awareness of these representations by researchers, health professionals, and patients is important for the creation of future interventions that aim to improve and maintain patient wellbeing.     

Moderation of the effects of discrimination-induced affective responses on health outcomes

Objective: The goal of the study was to examine differential mediation of long-term effects of discrimination on health behaviour and health status by internalising (anxiety and depression) and externalising (hostility and anger), and to explore moderation of these effects, specifically, by the presence of support networks and coping tendencies.

Design: The current analyses employed structural equation modelling of five waves of data from Black female participants of the Family and Community Health Study over 11 years (M age 37–48).

Main Outcomes Measures: The main outcome variables were health status and alcohol use (frequency and problematic consumption).

Results: Perceived racial discrimination was associated with increases in internalising and externalising. In addition, internalising reactions to discrimination were associated with deterioration in health status and increases in problematic drinking; externalising reactions were associated with increases in frequency of drinking. These relations were attenuated by availability of support networks, and exacerbated by use of avoidance coping.

Conclusion: The current study (a) replicated previous research suggesting that two different types of affective reactions mediate the relations between perceived racial discrimination and physical health status vs. health-impairing behaviours: internalising and externalising, and (b) revealed moderation of these effects by coping mechanisms.     

The role of the affect heuristic and cancer anxiety in responding to negative information about medical tests

Objective: Little is known about the affective implications of communicating negative information about medical tests. This research explored how affective processes – particularly the Affect Heuristic and cancer anxiety – influence the way in which people respond to such information.

Design: Participants received different types of information about PSA screening for prostate cancer and magnetic resonance imaging (MRI) scans for migraine headaches. This was a 2 (Test harm information: present vs. absent) × 2 (Test benefit information: present vs. absent) × 2 (Test recommendation: present vs. absent) between-participants design.

Outcome Measures: Perceived risk, perceived benefit and general attitudes towards PSA and MRI testing, cancer anxiety, preferences to receive the tests vs. not.

Results: As predicted by the Affect Heuristic, test harm information reduced perceived test benefits. However, information about uncertain test benefit did not increase perceived test risks. Information about the test reduced cancer anxiety, indicating defensive coping. These variables – affect, anxiety, perceived risks and benefits – all uniquely predicted test preferences.

Conclusion: Affective processes play an important role in how people respond to and interpret negative information about medical tests. Information about harms and information about the lack of benefit can both make a test seem less beneficial, and will reduce cancer anxiety as a result.     

The mediating and moderating role of planning on mothers’ decisions for early childhood dietary behaviours

Objective: Examine the roles of action and coping planning on the intention–behaviour relationship for mothers’ decisions for their young children’s dietary behaviours.

Design: Prospective design with two waves of data collection, one week apart.

Main outcome measures: Mothers (N = 197, M_age = 34.39, SD = 5.65) of children aged 2–3 years completed a main questionnaire assessing planning constructs and intentions, and a one-week follow-up of the target behaviours – ‘healthy eating’ and ‘discretionary choices’.

Results: Intention was the strongest predictor of behaviour for both dietary behaviours. For healthy eating, intention moderated the indirect relationship between intention–behaviour via planning; coping planning was less important when intention was strong. Further, intention was not a direct predictor of behaviour when intention was relatively low. Action planning was not a direct predictor of either behaviour after accounting for intention and coping planning; action planning on behaviour was mediated by coping planning (only for healthy eating). Intention was not a direct predictor of coping planning; intention on coping planning was mediated by action planning. Neither type of planning predicted discretionary choices.

Conclusion: Current findings contribute novel information on the mechanisms underpinning the effect of action and coping planning on the intention–behaviour relationship.     

The effect of perceived control on self-reported cardiovascular disease incidence across adulthood and old age

Objective: To examine whether rates of change in perceived control are predictive of cardiovascular disease (CVD) incidence across adulthood and old age.

Design: We used the PATH Through Life Project (n = 7103, M = 40, SD = 16; 52% women), a longitudinal panel survey that encompasses three cohorts at Time 1, ages 20–24, 40–44 and 60–64, who have been assessed three times at four-year intervals.

Method: We examined whether rates of change in perceived control were associated with CVD incidence over 8 years of time, over and above that of baseline levels of perceived control and known risk factors for CVD.

Main Outcome Measures: Self-reported CVD incidence.

Results: Increases in perceived control over time were associated with decreased likelihood of 8-year incidence of CVD and these effects were independent of socio-demographics, covariates and baseline levels of perceived control. The effects were consistent across young adulthood, midlife and old age and for men and women.

Conclusions: Findings demonstrate the importance of changes in perceived control as a predictor of CVD incidence across adulthood and old age. We suggest future research using mediation analysis to test reverse causality and mechanisms underlying the effects of perceived control on CVD incidence.     

What are the combined effects of negative emotions and illness cognitions on self-care in people with type 2 diabetes? A longitudinal structural equation model

Objective: To explore whether negative emotions mediate the effect of diabetes cognitions on diabetes self-care and conversely whether diabetes cognitions mediate the effect of negative emotions on diabetes self-care.

Design: Longitudinal observational study in adults with type 2 diabetes.

Main outcome measures: Self-reported depression and anxiety (Diabetes Wellbeing Questionnaire), cognitions (Illness Perceptions Questionnaire-Revised; Beliefs about Medicines Questionnaire), and diabetes self-care (Summary of Diabetes Self-Care Activities Scale) were completed at baseline and six months. Analyses used structural equation modelling.

Results: Baseline medication concerns were associated with elevated symptoms of depression and anxiety at follow-up, but emotions did not mediate medication concern’s effect on diabetes self-care. Baseline depression and anxiety symptoms were associated with specific diabetes cognitions over time, but these cognition domains did not mediate emotion’s effect on diabetes self-care. Personal control remained independent of emotions and was associated with diabetes self-care over time.

Conclusions: Negative emotions did not act directly or alongside cognitions to influence diabetes self-care. The reciprocal relationship between diabetes cognitions and emotions suggests cognitive restructuring, in addition to other mood management intervention techniques would likely improve the emotional wellbeing of adults with type 2 diabetes. Likewise, personal control beliefs are likely important intervention targets for improving self-care.     

A randomized controlled trial of expressive writing in breast cancer survivors with lymphedema

Objective: Breast cancer survivors who develop lymphedema report poorer quality of life (QoL) than those without lymphedema. Expressive writing is a potential intervention to address QoL.

Design: Adult women (N = 107) with breast cancer and chronic Stage II lymphedema were randomised to writing about thoughts and feelings specific to lymphedema and its treatment (intervention) or about daily activities (control) for four, 20-min sessions.

Main Outcome Measures: Outcome measures were several indicators of QoL assessed at baseline, one, three, and six months post-intervention (total scores and subscales of Upper Limb Lymphedema 27 and Functional Assessment of Cancer Therapy–Breast). Hypothesised moderators of change in QoL were dispositional optimism, avoidant behaviours, and time since lymphedema diagnosis.

Results: There was no statistically significant intent-to-treat main effects of expressive writing on QoL. Statistically significant moderating effects on change in different indicators of QoL were observed for all three moderators. Expressive writing was more effective for improving QoL in women who were higher on optimism, lower on avoidance and had less time since a lymphedema diagnosis.

Conclusion: These results provide further evidence that there are subsets of individuals for whom expressive writing is more effective. Future research may investigate targeting expressive writing based on identified moderators.     

Disease controllability moderates the effect of coping efficacy on positive affect

Objective: This study aims to test experimentally whether coping strategies (approach- vs. avoidance-oriented coping) have differential effects under conditions of high or low stressor controllability.

Design: Undergraduates (62 women, 30 men) participated in a 2 × 2 experimental study where they were introduced to a fictitious disease (tisomerase enzyme deficiency) said to be either controllable or uncontrollable and an approach- or avoidance-oriented coping behaviour induction.

Main Outcome Measures: Changes in positive and negative affect.

Results: A significant disease control x coping interaction on positive affect (f² = .07, p = .011) revealed that approach-coping condition participants had higher positive affect than avoidance-coping condition participants when disease control was high (d = .94, p = .003), but not when it was low (d = .11, p = .93). The experimental conditions did not significantly influence negative affect.

Conclusion: Results demonstrate that disease control moderates the salubrious effects of approach-oriented coping on positive affect. For controllable, but not uncontrollable, health stressors, promoting problem-focused approach-oriented coping strategies may be recommended.     

Effects of perceived weight discrimination on willingness to adopt unhealthy behaviours: influence of genomic information

Objective: Weight-based discrimination negatively influences health, potentially via increased willingness to engage in unhealthful behaviours. This study examines whether the provision of genomic obesity information in a clinical context can lead to less willingness to engage in unhealthy eating and alcohol consumption through a mediated process including reduced perceptions of blame and discrimination.

Design: A total of 201 overweight or obese women aged 20–50 interacted with a virtual physician in a simulated clinical primary care environment, which included physician-delivered information that emphasised either genomic or behavioural underpinnings of weight and weight loss.

Main Outcome Measures: Perceived blame and weight discrimination from the doctor, and willingness to eat unhealthy foods and consume alcohol.

Results: Controlling for BMI and race, participants who received genomic information perceived less blame from the doctor than participants who received behavioural information. In a serial multiple mediation model, reduced perceived blame was associated with less perceived discrimination, and in turn, lower willingness to eat unhealthy foods and drink alcohol.

Conclusion: Providing patients with genomic information about weight and weight loss may positively influence interpersonal dynamics between patients and providers by reducing perceived blame and perceived discrimination. These improved dynamics, in turn, positively influence health cognitions.     

Self-reported stress and psychophysiological reactivity in paramedics

Background: As an important group of health care professionals, paramedics accomplish sophisticated and frequently stressful tasks.

Design: The study investigated self-reported stress burden, self-reported health status, coping strategies, personality traits and psychophysiological reactivity in paramedics.

Methods: 30 paramedics were compared with 30 professionals from other disciplines, in terms of self-reported stress, physical complaints, coping strategies, personality traits and psychophysiological reactivity during aversive visual and acoustic stimuli, and cognitive challenge. Regression analyses were performed for the prediction of stress burden and physical complaints in paramedics according to coping and personality factors.

Results: Paramedics reported lower stress and less somatic complaints, and exhibited reduced electrodermal activity and heart rate responses to experimental stimuli, as well as higher respiratory sinus arrhythmia. They indicated less negative coping strategies, reduced empathy, and higher conscientiousness and sensation seeking. Higher self-reported stress burden and more physical symptoms were associated inter alia with more negative coping strategies, less conscientiousness and lower empathy.

Conclusion: The findings support the notion of reduced self-reported stress burden, and improved general health and stress resistance in paramedics. In addition to health benefits, stress tolerance may contribute to the prevention of performance decline during situations in which health and life are at stake.     

Foot care, ‘spousal’ support and type 2 diabetes: an exploratory qualitative study

Objectives: People with type 2 diabetes (T2DM) should check their feet and protect them against harm, but few do. Living with a spouse contributes to good foot care behaviour. This study explores awareness, perceived susceptibility of, and concern about, foot problems, and reported foot care behaviour, and ways in which a spouse may or may not contribute to foot care in T2DM.

Methods: 1:1 interviews were conducted with 6 individuals with T2DM. Half had a spouse half did not. There was one person at low, medium and high risk in each sample. Each spouse participated in a separate interview, and the dyads were interviewed together. Interviews were analysed using Applied Thematic Analysis.

Results: All participants knew that diabetes was associated with foot problems. Not all people with T2DM thought that they were susceptible; spouses perceived greater susceptibility for the patient. This was unrelated to risk level. Most people with T2DM and all spouses engaged in behaviour to identify problems or protect feet, but rarely both. Spouses’ attitude and behaviour did influence the patients’ own behaviour. At times spouse support was perceived positively, and at times negatively.

Conclusion: Engaging spouses in foot care education may improve foot care behaviour.     

Coping with transphobia in employment: Strategies used by transgender and gender-diverse people in the United States

Background: Transgender and gender-diverse (TGD) individuals face stigma in the general public and in the workplace. Research has suggested that TGD individuals may demonstrate unique coping strategies in the workplace in order to manage transphobia in that setting; however, further research is needed to identify the specific strategies that transgender individuals use to deal with transphobia at work.

Method: The present qualitative study utilized the grounded theory methodology to identify the specific coping strategies utilized to deal with transphobia at work. Participants included 45 TGD participants from the northeastern United States.

Results: The results of the study include the identification of eight coping-strategy themes including gender-presentation strategies, gender detachment, relationship navigating, resource utilization, job-performance strategies, maladaptive coping strategies, structural strategies, and power-acquisition strategies.

Conclusions: Implications of the present study suggest the resilience and diverse coping strategies that mental health providers can help TGD workers draw from in dealing with transphobia at work. In addition, there is a need for greater remediation and prevention of employment-related transphobia, including leadership within employment settings, greater legal protections, and enforcement of these laws in the United States.     

Attachment patterns moderate the relation between coping flexibility and illness acceptance among kidney transplant recipients

Background and Objectives: Post-transplant kidney recipients may experience psychological concerns which have been associated with negative health behaviors. Illness acceptance might have an important role in this process. In line with the Conservation of Resources Theory (COR), the current study aimed to examine the relationship between coping flexibility, attachment patterns and illness acceptance among post-transplant kidney recipients, and to evaluate whether attachment patterns moderate the link between coping flexibility and illness acceptance.

Design: The study employed a cross-sectional design.

Methods: Ninety-four post-transplant kidney recipients completed questionnaires assessing demographic and medical characteristics, illness acceptance, coping flexibility and attachment patterns.

Results: Our results indicated that coping flexibility was positively associated with illness acceptance. Moreover, attachment moderated this link, as high coping flexibility was associated with increased illness acceptance among individuals with low levels of attachment anxiety, a finding which was not significant when high levels of anxiety were reported.

Conclusions: This study highlights the potential importance of building greater flexibility in order to enhance illness acceptance among kidney transplants recipients. Moreover, the role of insecure attachment patterns in health-related outcomes among kidney transplants recipients is emphasized.     

Book reviews and books received

Helping interventions John Heron: Helping the Client: a Creative Practical Guide. London: Sage, 1990. £9.95.

A person-centred perspective on school counselling John McGuiness: A Whole School Approach to Pastoral Care. London: Kogan Page, 1989. £8.95.

How to relate effectively Richard Nelson-Jones: Human Relationship Skills (2nd edition). London: Cassell, 1990. £11.95.

Ripe for research? Dave Mearns and Windy Dryden: Experiences of Counselling in Action. London: Sage, 1989. £9.95.

Issues in action Windy Dryden (ed.): Key Issues for Counselling in Action. London: Sage, 1989. £7.95.

The meaning of death Rosemary Dinnage: The Ruffian on the Stair: Reflections on Death. London: Viking, 1990. £14.99.

The empty cradle Irving G. Leon: When a Baby Dies: Psychotherapy for Pregnancy and Newborn Loss. London: Yale University Press, 1990. £20.

Children against themselves Israel Orbach: Children Who Don't Want to Live: Understanding and Treating the Suicidal Child. San Francisco: Jossey-Bass, 1988. £17.95.     

Coping strategies of former prisoners of war mediate the intergenerational transmission of posttraumatic stress symptoms

Objectives: Certain coping strategies, characterized by emotional coping or disengagement/ avoidance, have been linked to posttraumatic stress disorder (PTSD) and PTSD symptoms (PTSS). However, the role of primary trauma victims’ coping strategies in the intergenerational transmission of PTSS is still lacking. This prospective study assessed the mediating role of former prisoners of war’s (ex-POWs) coping strategies in the associations between ex-POWs’ PTSS and their adult offspring’s secondary PTSS in relation to their fathers’ captivity and psychiatric symptomatology.

Design: A correlational, prospective study.

Method: A sample from the 1973 Yom Kippur War composed of 79 Israeli ex-POW father-offspring dyads completed self-report measures. Fathers were assessed in 2001 and 2008, and their adult offspring participated in 2014.

Results: ex-POWs’ problem-focused coping strategies of active coping and planning, as well as disengagement-oriented coping strategies of alcohol and substance use and venting of emotions, were negatively associated with offspring’s PTSS and psychiatric symptomatology. Importantly, ex-POWs’ venting of emotions mediated the link between ex-POWs’ PTSS and their offspring’s secondary PTSS.

Conclusions: Ex-POWs with PTSS might expose their offspring to dysregulated mood, behaviors, and cognitions. Special awareness should be given to the venting of emotions coping style as possible mechanism for the intergenerational transmission of captivity-related PTSS.     

Book reviews and books received

Practical help for family therapists John Carpenter and Andy Treacher: Marital and Family Therapy. Oxford: Blackwell, 1989. €29.50 (hardback); €9.95 (paperback).

Survival for the guidance teacher W.P. Gothard and E. Goodhew: Guidance and the Changing Curriculum. London: Croom Helm, 1987. €22.50.

Second-class male Michael S. Kimmel (ed.): Changing Men: New Directions in Research on Men and Masculinity. London: Sage, 1987. €35 (hardback); €14.50 (paperback).

Analysing the analyst Rosemary Dinnage: One to One: Experiences of Psychotherapy. London: Viking, 1988. €12.95.

Practical counselling skills revisited Richard Nelson-Jones: Practical Counselling and Helping Skills. London: Cassell, 1988. €7.95.

Snakes and pyramids Jocelyn Chaplin: Feminist Counselling in Action. London: Sage, 1988. €7.95.

The person-centred approach: a key text Dave Mearns and Brian Thome: Person-Centred Counselling in Action. London: Sage, 1988. €7.95.     

Predicting jet lag in long-haul cabin crew: The role of illness cognitions and behaviour

Objective: Established risk factors for jet lag are mostly physiological including circadian preference, age, gender, the number of flight zones crossed and to some extent direction of travel. Some research has also highlighted a role for psychosocial factors including sleep, diet and ‘circadian’ health behaviours and illness cognitions although this remains relatively untested. The aim of this study was to evaluate the role of sleep, diet and illness cognitions in predicting perceived jet lag amongst long-haul crew.

Design: Sixty long-haul crew took part in a longitudinal study. Profile characteristics (including chronotype), preparation strategies (sleep, eating and ‘circadian’ behaviours) and illness cognitions were measured at baseline (before a trip).

Main outcome measures: Subjective jet lag (unidimensional and multidimensional) was measured on the crews’ second day off (post-trip).

Results: Hierarchical regression analyses showed that unidimensional jet lag was predicted by the belief in a cyclical timeline, whereas multidimensional jet lag was predicted by multidimensional jet lag at baseline and to a lesser extent by identity. No role was found for profile characteristics and preparation strategies.

Conclusion: Illness cognitions partly explain the experience of perceived jet lag in long-haul cabin crew indicating that jet lag is in part a psycho-social construct, not just a biological one.     

“Why me?” – women’s use of spiritual causal attributions in making sense of breast cancer

Objective: This study addressed the role of positive (event is due to God’s Love or to God’s Will) and negative (event is due to God’s Anger) spiritual causal attributions in women’s adjustment to breast cancer.

Design: Ninety-three women diagnosed with breast cancer were assessed at six times from pre-diagnosis through two years post-surgery.

Main outcome measures: Women completed positive and negative measures of spiritual causal attributions (e.g. God’s Love), cognitive appraisals (e.g. threat), coping behaviour (e.g. avoidance) and well-being (e.g. distress).

Results: Positive spiritual attributions were consistently related to positive aspects of adjustment (e.g. positive appraisal, acceptance coping, and/or emotional well-being) while negative spiritual attribution was related to negative factors (e.g. appraisals of loss and uncontrollability, avoidance coping, and/or emotional distress). Path analyses revealed that the effects of positive and negative spiritual attributions on well-being were mediated by general cognitive appraisal and coping behaviour. Cross-lagged correlational analysis revealed a ‘downward spiral’ effect wherein the negative attribution of God’s Anger at pre-diagnosis predicted greater distress at 1 week pre-surgery which in turn predicted an increase in the negative attribution and so on across time.

Conclusion: Although positive spiritual attributions may help women maintain an attitude of hope and acceptance in the face of cancer, results indicate that the effects of negative spiritual attribution can play a significant role in undermining their well-being.