A Prospective Examination of Illness Beliefs and Coping in Patients With Type 2 Diabetes

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621
The
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British Journal of Health Psychology (2007), 12, 621–638
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A prospective examination of illness beliefs and

coping in patients with type 2 diabetes
Aidan Searle1*, Paul Norman2, Rachel Thompson3 and

Kav Vedhara1
1
MRC Health Services Research Collaboration, University of Bristol, UK
2
Department of Psychology, University of Sheffield, UK
3
Institute of Human Nutrition, School of Medicine, University of Southampton, UK
Objective. According to the common-sense model of illness behaviour, illness

representations are directly related to coping and, via coping, to adaptive or
maladaptive outcomes. However, it may be more appropriate to conceptualize coping
by assessing what patients actually do – i.e., their coping behaviours – rather than what
they say they do in coping scales – i.e., their coping cognitions. The aim of this study was
to examine the relationships between illness representations and the relative
importance of coping cognitions and coping behaviours in the context of the
management of type 2 diabetes.
Design. The relationship between illness representations and coping variables was
explored within a prospective design.
Methods. The illness representations of 134 patients were assessed with the IPQ-R
(Moss-Morris et al., 2002) along with coping cognitions and coping behaviours
(medication, physical activity, diet).
Results. Illness representations predicted coping cognitions and coping behaviours
but coping cognitions did not mediate the relationships between illness representations
and coping behaviours.
Conclusion. The results demonstrate that illness representations are direct
predictors of both coping cognitions and coping behaviours in patients with type 2
diabetes. In addition, coping cognitions and coping behaviours appear to be distinct
mechanisms that operate independently. The findings suggest that rather than
manipulating patients’ coping cognitions to improve patients’ health behaviours it may
be beneficial to focus on their beliefs about diabetes.
The common sense model (CSM) of illness behaviour posits that the patient is an active
participant in the health care process (Weinman & Petrie, 1997; Leventhal, Nerenz, &
* Correspondence should be addressed to Aidan Searle, MRC Health Services Research Collaboration, University of Bristol,
Department of Social Medicine, Canynge Hall, Whiteladies Road, Bristol, UK (e-mail: A.J.Searle@bristol.ac.uk).
DOI:10.1348/135910706X164935
622 Aidan Searle et al.
Steel, 1984). It is also argued that an individual experiencing illness may perceive a range
of problems that are pertinent only to that individual. In order to make sense of, and
respond to these problems, patients create their own ‘models’ or representations of
their illness which then influence their coping and care-seeking behaviour (Cameron,
Leventhal, & Leventhal, 1993). The CSM is regarded as self-regulatory because the three
components of the model, interpretation, coping and appraisal, are believed to
interrelate in order to maintain the status quo. Therefore, if an individual’s normal state
of health is disrupted by illness, or the threat of illness, the model proposes that they are
motivated to regain the balance (Leventhal & Diefenbach, 1991; Leventhal et al., 1984).
Furthermore, it is argued that illness representations act as a framework for guiding and
evaluating coping efforts that are evoked to deal with the illness. Indeed, it is proposed
that illness representations are directly related to coping and, via coping, to adaptive or
maladaptive outcomes (Leventhal et al., 1984). Accordingly, the self-regulation process
is dynamic as appraisal of coping efforts may influence cognitive representations and
future coping efforts (Leventhal, Meyer, & Nerenz, 1980; Leventhal et al., 1984).
In defining and elaborating the CSM model, Leventhal and colleagues posited that
coping procedures are the cognitive and behavioural actions we take (or do not take)
to enhance health and to prevent, treat (i.e. cure or control) and rehabilitate from
illness’ (Leventhal, Leventhal, & Contrada, 1998, p. 722). Previous research that has
utilized the CSM has focused on the examination of coping in cognitive terms. In
particular, these studies examined relationships between illness representations and
cognitive coping through the measurement of coping styles as assessed in coping
inventories (i.e. Heijmans, 1998, 1999; Helder et al., 2002; Kemp, Morley, & Anderson,
1999; Moss-Morris, Petrie, & Weinman, 1996; Rutter & Rutter, 2002).
A meta-analytic review of the illness representations literature has shown
theoretically predictable relations between illness representations and measures of
coping cognitions (Hagger & Orbell, 2003). The studies included in this review have
largely employed generic coping measures such as the COPE (Carver, Scheier, &
Weintraub, 1989). This review demonstrated that representations of illness identity
were significantly and positively related to the use of the coping strategies of avoidance
and emotion expression. In addition, perceived controllability of the illness was
significantly associated with cognitive reappraisal, expressing emotions and problem-
focused coping strategies. In keeping with the proposed role of coping in the CSM, it
would appear that illness representations are predictive of both emotion-focused and
problem-focused coping strategies. For example, in a study of patients with chronic
fatigue syndrome (CFS), Moss-Morris et al. (1996) showed that perceived control/cure
was associated with problem-focused strategies and perceived consequences were
associated with more emotion-focused and disengagement strategies. A study with
epilepsy patients found a number of associations between illness representations and
avoidance coping but only perceived control was associated with problem-focused
strategies (Kemp et al., 1999). In patients with CFS, perceived control was associated
with less cognitive-avoidant coping and more problem-focused coping (Moss-Morris
et al., 1996). In patients with Addison’s disease (Heijmans, 1999), a stronger timeline
was associated with more avoidance coping, and identity was associated with more
avoidance and more adaptive (emotion venting) coping. In patients with Huntington’s
disease, Helder et al. (2002) reported that perceptions of cure and control were
associated with emotion-focused coping. Furthermore, in the only study examining
coping behaviours, perceived control was shown to be predictive of doctor visits in
discharged MI patients (Weinman, Petrie, Moss-Morris, & Horne, 1996). Thus, these
Coping in type 2 diabetes 623
studies demonstrate that illness representations, in particular, control beliefs are

associated with a variety of coping strategies within a variety of disease groups.
There is also a body of work that has specifically examined the relationships between
illness representations and health behaviours of patients with diabetes. Although not
conceptualized as coping studies, the findings show consistent relationships between
illness representations and adaptive behaviour. For example, Griva, Myers, and Newman
(2000) reported that the perceived control of diabetes was associated with health
behaviours among a sample of young adults with type 1 diabetes, with 39% of the
variance in adherence with glucose monitoring, insulin, diet and exercise being
explained by patients’ control beliefs. Similarly, other investigations utilizing the
Personal Models of Diabetes Interview (PMDI; Hampson, Glasgow, & Foster, 1995) have
reported significant relationships between illness beliefs and adherence behaviours. For
example, beliefs about the effectiveness of self-care and the perceived seriousness of
diabetes have been found to predict physical activity (Glasgow, Hampson, Strycker, &
Ruggiero, 1997; Hampson et al., 1995, 1990 ; Skinner, Hampson, & Fife-Schaw, 2002).
The perceived effectiveness of treatment (Glasgow et al., 1997; Hampson et al., 1995;
Hampson, Glasgow, & Toobert, 1990; Skinner et al., 2002) and the perceived
seriousness of diabetes have been found to be predictive of the dietary behaviour
(Glasgow et al., 1997; Hampson et al., 1990; Skinner et al., 2002). Finally, Lawson,
Bundy, Lyne, and Harvey (2004) have shown that treatment effectiveness and control
beliefs were the most important predictors of clinic attendance. In summary, the
findings from this body of work demonstrate that representations of diabetes,
particularly regarding the treatment and control of the condition are associated with
key behaviours for the management of diabetes.
Studies reporting relationships between illness representations and coping
cognitions have tended to rely on cross-sectional correlations between beliefs and
coping scales making meaningful interpretation of the findings difficult. In addition, the
hypothesized mediating role for coping on the relationships between illness
representations and adaptive outcomes has not been examined in prospective studies.
In fact, past studies have provided little evidence to suggest that illness representations
are mediated by coping variables as illness representations appear to be stronger
predictors of adaptive outcomes than coping (Heijmans, 1999; Moss-Morris et al., 1996;
Scharloo et al., 1998). For example, in patients with Addison’s disease, illness
representations continued to predict adaptive functioning when coping was included in
the analysis (Heijmans, 1999). Similarly, in a study of patients with chronic fatigue
syndrome, Moss-Morris et al. (1996) showed that illness representations were superior
to coping in the prediction of disability.
At present, there are no studies that have examined illness representations and their
relationships with both coping cognitions and coping behaviours in the same study. In
particular, it is not clear if coping cognitions mediate the path between illness
representations and adaptive coping (i.e. health behaviours). Therefore, it is necessary
to determine whether coping cognitions and coping behaviours operate independent of
each other or if coping cognitions and coping behaviours are both aspects of coping
per se.
These issues were examined in a cohort of patients with type 2 diabetes. This patient
group was considered appropriate for this investigation because the patient with
diabetes has the principal responsibility for the daily management of the condition. In
addition, previous research has shown a consistent relationships between illness
representations and health behaviours in this patient group.
Therefore, the aims of this study were to (1) describe coping cognitions and coping
behaviours in a large cohort of patients with diabetes; (2) determine the relationships
between illness representations and indices of coping cognitions and coping behaviour
and (3) determine if coping cognitions mediate the relationships between illness
representations and coping behaviours.
Method
Ethical approval
Ethical approval was granted by the Central and South Bristol Research Ethics
Committee. All participants gave approval via postal consent forms and no incentive
was offered for participation in the study.
Procedure
The data collection was undertaken within a prospective design: baseline and at 12
months. First, socio-demographic variables and illness representations were assessed
with questionnaire booklets that were posted to the participant’s home address. At
follow-up, questionnaires assessing coping cognitions and coping behaviours were sent
to participants. Independent t tests confirmed that there were no differences between
participants completing both phases of data collection and those completing phase 1
only. Analyses presented here are based on participants completing both phases of data
collection.
Participants
Potential study participants were recruited in two phases. In the first phase, a cohort of
506 patients with type 2 diabetes was approached from the Somerset and Avon Survey
of Health (SASH; Department of Social Medicine, University of Bristol, UK). The SASH
cohort consists of 28,080 individuals aged greater than 35 years who were originally
enrolled by randomly sampling a fixed number of patients within each 10-year age and
sex band from 40 general practices between 1993 and 1995. The practices were
selected from a mix of rural, suburban and inner-city locations (Eachus et al., 1996).
General practitioners gave approval to contact diabetic patients who had a diagnosis
of type 2 diabetes (. 6 months). A total of 29 practices from SASH gave consent to
contact eligible patients. These practices yielded 225 patients of the original 506 with
type 2 diabetes. Each patient was sent a study pack and a FREEPOST envelope to return
the completed questionnaires.
Out of the 225 patients from the SASH cohort, 95 consented to participate (42%
response rate). A further 150 patients (who were not part of the original SASH cohort)
were identified through the SASH practices and 6 additional GP practices yielding a
further 89 participants (59% response rate). The two-phase recruitment procedure
yielded a final sample of N ¼ 164 patients (50.5% combined response rate). All
participants were sent a postal reminder at 3 weeks and those not returning
questionnaires by 6 weeks received a telephone reminder.
Independent t tests were conducted to explore whether there were differences in
the demographic (age and years married) and clinical (disease duration, BMI, weight,
insulin status) characteristics of the patients recruited through the two procedures.
Patients who participated in SASH, had a longer standing diagnosis of type 2 diabetes
(mean 6.6 years vs. 10.4 years, tð222Þ ¼ 2:72, p , :01). A total of 38 patients were
treated with insulin and were more likely to be selected from the SASH cohort
(tð122Þ ¼ 2:14, p , :05). Further, analyses were conducted to determine if the final
patient sample (N ¼ 164) differed significantly from patients participating in the ‘SASH
Diabetes Study’, a t test did not reveal any significant differences for age and chi-squared
tests revealed no significant differences for gender and ethnic origin.
Complete outcome data at 12 months were collected for 134 patients, that is 82%
of the original sample. Independent t tests were conducted to determine if
differences existed between the demographic characteristics and the illness
representations of patients who did (N ¼ 134) and did not (N ¼ 30) complete the
follow-up questionnaire 12 months later. No significant differences were found for
age, disease duration, weight, BMI, number of prescribed medications and illness
representations.
Socio-economic and clinical data

Patients were asked to report their ethnicity, occupation, educational status, diabetes
medications, weight and height Table 1.
Table 1. Demographic data for study sample completing illness representations measure (N ¼ 164)
Patients
Age 32–86 years

Mean ¼ 67 years
Gender Male: N ¼ 97
Female: N ¼ 67
Ethnicity 95% White European
Disease duration 6 months–38 years
Mean ¼ 8.8 (7.07) years
Diabetes medication (oral) N ¼ 107 (80%)
Insulin N ¼ 37 (28%)
BMI Mean ¼ 31.5 (SD ¼ 5:53)
Range 17–47, 54% ‘obese’
Occupation 54% retired
10% professional
32% semi-skilled manual
4% unemployed
School leaving age 14 years ¼ 28%
15 years ¼ 32%
16 years ¼ 25%
Other age ¼ 15%
Comorbidity (in last 12 months) Arthritis ¼ 31%
Asthma ¼ 11%
Nervous disorders ¼ 11%
Angina ¼ 12%
MI ¼ 6%
Hypertension ¼ 43%
Other heart trouble ¼ 9%
Stroke ¼ 6%
Cancer ¼ 6%
The mean age of the patients was 67 years (SD ¼ 10:5). Only 5% of the participants
were from non-European ethnic groups. All participants were married or living with a
partner. The mean body mass index (BMI) was calculated giving a mean of 31.5 (5.53)
and scores ranged from 16 to 48 with 90% scoring above the cut-off for being
overweight (. 25). Only 37 (27.6%) patients reported injecting insulin to control their
diabetes.
Illness representations
Illness representations were measured with the Revised Illness Perceptions
Questionnaire (IPQ-R; Moss-Morris et al., 2002). However, to ensure greater specificity
for diabetes patients, the present study also included the assessment of the control and
identity variables from the Personal Models of Diabetes Interview (PMDI; Hampson
et al., 1995).
The IPQ-R encompasses 38 items within subscales reflecting the ‘core’ dimensions of
the illness representations framework (i.e. timeline, consequences, control, identity,
cause) and includes three new related concepts: (1) emotional representations (fear,
anxiety and anger as a response to illness); (2) illness coherence (the extent illness
‘makes sense’ to the patient) and (3) timeline cyclical (day-to-day variability in
symptoms of the illness). All subscales are scored on a 5-point scale (1, not important to
5, very important).
The consequences dimension measures the perceived impact the illness has on a
patient’s life (6 items; e.g. ‘My illness has major consequences on my life’). The timeline
dimension measures the perceived course or duration of the illness (3 items; e.g. ‘I
expect to have this illness for the rest of my life’). The cyclical timeline subscale
measures the extent of illness variability and unpredictability (4 items; e.g. ‘My
symptoms come and go in cycles’). The treatment control dimension measures patients’
belief that treatment is effective in controlling the illness (5 items; e.g. ‘My treatment
will be effective in controlling my illness’). The personal control subscale measures
patients’ perceived efficacy in controlling their illness (6 items; ‘There is a lot that I can
do to control my illness’). In addition, 13 items from the PMDI assessed the relative
importance of specific aspects of diabetes treatment for controlling diabetes now and
avoiding complications in the future. Items for the emotional representation subscale
measures perceived emotional states, such as anger, fear, anxiety and depression that a
patient may associate with the illness (6 items; e.g. ‘My illness makes me feel angry’).
A higher score on this scale is indicative of a greater emotional impact of the condition.
The illness coherence dimension measures the extent to which a patient’s illness
representations are collectively helpful in providing a coherent understanding of the
illness. A higher score on this subscale is indicative of an increased awareness of the
illness and the degree to which it makes sense to the patient (5 items; e.g. ‘I have a clear
understanding of my illness’). A list of 10 symptoms associated with high blood glucose
and 11 symptoms associated with low blood glucose replaced the 14 general illness
symptoms included in the original IPQ-R identity subscale. The participants were
instructed to tick either ‘Yes’ or ‘No’ as applicable to indicate their experience of each
symptom.
Finally, beliefs regarding the cause of diabetes were assessed with a list of 13 possible
causes for their diabetes (i.e. ‘stress or worry’, ‘hereditary’, ‘germ or virus’, ‘diet or
eating habits’, ‘chance or bad luck’, ‘poor medical care in past’, ‘own behaviour’,
‘pollution’, ‘smoking’, alcohol, ‘lack of exercise’, ‘my weight’ and ‘other people’).
The participants were asked to rate on a 5-point scale (1, strongly disagree to 5, strongly
agree) the extent to which they perceived each possible causal item was responsible for
their diabetes. Beliefs regarding the cause of diabetes were entered into a principal
components analysis in line with Moss-Morris et al. (2002). This procedure led to the
creation of 3 subscales representing ‘own behaviour’ (6 items), ‘external’ (6 items) and
‘hereditary’ (1 item) as possible causes of diabetes.
Measurement of coping behaviour

Diet
The Food Frequency Questionnaire was originally developed by the Health Education
Authority (HEA 3; Little et al., 2000; Little et al., 1999) as a simple self-report dietary
assessment tool. The measure has been shown to perform as well as more time
consuming methods and almost as well as the accepted standard reference, a 7-day
weighed record (Little et al., 2000).
The respondents were asked to indicate how often, on average, they have eaten a
range of foods over the past month. The HEA 3 categorizes individual food items into the
following groups (i.e. bread/cereal/potatoes; fruit/vegetables; meat/alternatives;
cakes/puddings; sugar; drinks; fats; milk and dairy products). Respondents were
requested to indicate their average portion size (i.e. small, medium, large; an example of
a medium serving is given) for each item on the list. The respondents were also asked to
state how often they consumed each item (i.e. day, week, month).
Weights of foods were calculated from the frequency and portion size reported in the
Food Frequency Questionnaire. Food weights were converted to energy, fat, saturated
fat, carbohydrate, sucrose, non-starch polysaccharides (fibre), starch using McCance and
Widdowson food tables (Holland et al., 1991).
Physical activity
To assess levels of intentional physical activity, two subscales from the Baecke Habitual
Physical Activity Questionnaire (Baecke, Burema, & Frijters, 1982) were used. First, the
‘sports index’ asks patients to state their two most frequently played sports and indicate
how many hours per week and how many months per year he/she engaged in the sport.
The ‘sports index’ includes a further 3 items concerned with the level of physical
activity (e.g. ‘In comparison with others my own age, I think my physical activity during
leisure time is 1, much more; 2, more; 3, the same; 4, less; 5, much less’). The ‘non-
sports index’ assesses exercise taken in going about everyday life, such as walking to
shops, housework and includes 4 items. For example, respondents are asked to rate
their extent of agreement or disagreement to statements such as: ‘During leisure time I
watch TV’; 1, never; 2, seldom; 3, sometimes; 4, often; 5, very often). The mean scores
for the two scales are summed to provide a composite measure of physical activity. The
measure has been shown to have high reliability and provides an accurate assessment of
both heavy intensity exercise as well as light intensity activities which in-turn has been
associated with measures of aerobic fitness and body fatness in expected directions
(Richardson et al., 1995).
Medication
The extent of patients’ adherence to oral medication was assessed with the Medication
Adherence Report Scale (MARS; Horne & Hankins, in submission). The MARS is a
validated 6-item scale that assesses the frequency of medication lapses in the previous 7
days. The respondent is asked to rate their extent of agreement or disagreement to each
statement on a 5-point scale (e.g. ‘I avoid using my medicines if I can’, 1, always true; 2,
often true; 3, sometimes true; 4, rarely true; 5, never true).
Measurement of coping cognitions

Coping styles of diabetic patients were assessed with an adapted version of the Medical
Modes of Coping Questionnaire (MCMQ: Fiefel, Strack, & Nagy, 1987). The MCMQ is a
19-item scale specifically designed to measure three distinct coping modes which
measures confrontation, acceptance and avoidance coping derived from a principal
components analysis of responses from patients with cancer, MI and a range of chronic
non-life-threatening illness. Therefore, the measure is short and considered to have good
face validity and has the scope to capture both emotion- and problem-focused strategies.
The confrontation coping scale of the MCMQ is broadly similar with regard to the items
comprising the ‘active’ and ‘planning’ coping scales found in the measures such as the
COPE (Carver et al., 1989).
The derived scales were confrontation (8 items, a ¼ :70; e.g. ‘How much do want to
be involved in decisions regarding your treatment’), avoidance (7 items, a ¼ :66; e.g.
‘To what extent do you try to forget about your diabetes’) and acceptance-resignation (4
items, a ¼ :67; e.g. ‘How often do you feel like giving in to your diabetes’). Responses to
items were assessed with a 4-point Likert Scale (e.g. How much do want to be involved
in decisions regarding your treatment? (1) Very much; (2) Moderately; (3) Somewhat
and (4) Very little). Higher scores indicate higher levels of a particular mode of coping.
Results
Diabetes representations
Individual items of the subscales of the IPQ-R and PMDI were summed. The mean scores
and alpha coefficients are shown in Table 2. The internal reliability alpha coefficients of
the scales were all above .6. Examination of the mean scores revealed that diabetes
patients held strong beliefs in a chronic timeline, such that diabetes was perceived to be
a long-lasting illness. Patients also believed the consequences of diabetes to be serious,
while believing they had a high degree of illness coherence or understanding of the
condition. In addition, scores for treatment control demonstrated strong beliefs in the
efficacy of the treatment for diabetes. Finally, strong treatment beliefs were evident with
regard to the importance of treatment to control diabetes now and the effectiveness of
treatment to avoid future complications.
Coping cognitions
The mean scores for the three coping modes were: confrontation ¼ 16.6 (SD ¼ 3:5,
range ¼ 7–26), avoidance ¼ 11.6 (SD ¼ 3:4, range ¼ 3–22) and acceptance-
resignation ¼ 6.9 (SD ¼ 2:3, range ¼ 3–14). The Cronbach alpha coefficients were
a ¼ :75 for confrontation, a ¼ :58 for avoidance and a ¼ :54 for acceptance-
resignation. Confrontational coping and avoidance coping were strongly correlated
(rð132Þ ¼ :29, p , .01) as were acceptance coping and avoidance coping
(rð132Þ ¼ :49, p , :01).
Table 2. Descriptive statistics for patients’ diabetes representations (N ¼ 164)
Representation Max score Mean (SD) Cronbach’s a
Timeline-acute 30 23.4 (4.1) .63

Timeline-cyclical 15 11.6 (3.4) .60
Consequences 25 17.3 (4.0) .61
Personal control 30 22.6 (3.9) .61
Treatment control 30 22.3 (5.2) .68
Illness coherence 25 16.0 (4.3) .85
Emotional reps 25 12.6 (3.9) .80
Cause-behaviour 30 14.7 (3.2) .71
Cause-external 30 13.3 (3.5) .67
Cause-hereditary 5 2.8 (1.2) –
Identity-high bg 10 3.6 (2.3) –
Identity-low bg 11 3.5 (2.5) –
Note. bg, blood glucose.
Coping behaviours
Medication
A total of 107 patients reported taking oral medication to control their diabetes. Scores
on the MARS ranged from 6 to 30 with a mean of 28.3 (SD ¼ 5:1).
Physical activity
Scores for the Baecke Physical Activity Questionnaire (N ¼ 134) ranged from 2 to 16,
with a mean of 7.6 (SD ¼ 3:0). The data demonstrated that 72% of patients engaged in
low intensity exercise.
Diet
The dietary behaviour of participants can be seen in Table 2 which shows the mean
grams per day/percentage calories per day for each dietary component. These scores
were evaluated according to the Health Education Authority approximated values on
which the HEA3 Food Frequency Questionnaire was based (Little et al., 2000). The
mean carbohydrate consumption of the patients almost reached the recommended
target of 50% of total calories per day. The total fat intake was within the recommended
maximum of 33% of total calories per day as was saturated fat. The mean for fruit and
vegetable consumption did not quite reach the recommended minimum of 400 g/day.
Sugar intake was less than the recommended maximum of 10% of total calories per day.
Fibre intake almost reached the recommended 18 g/day.
Correlations between illness representations, coping cognitions and coping behaviours

Correlation analyses were conducted to assess the strength of the relationships between
illness representations, coping cognitions and coping behaviours. To reduce the
possibility of type 1 errors due to conducting multiple tests and to reduce the number of
illness representation variables to be used in subsequent analyses, a more conservative p
value ( p , .01) was adopted. The correlations between illness representations, coping
cognitions and coping behaviours are shown in Table 3.
Table 3. Dietary intake for patients (N ¼ 134)
Food type Mean % calories per day Mean grams per day (g/d)
Total fat 31.4 (8.0) 60.7 (38)

Saturated fat 11.3 (3.8) 22.1 (15.3)
Carbohydrate 46.9 (9.9) 212.1 (132.7)
Sugar 7.22 (3.4) 34.0 (34.3)
Fibre – 16.5 (8.8)
Fruit & vegetables – 359.2 (243.9)
Demographic and clinical variables

A number of demographic and clinical variables were associated with illness
representations. First, patients’ gender was negatively associated with perceived
personal control (rð132Þ ¼ : 2 244, p , :01) such that male patients were less likely to
perceive they had personal control of their diabetes. Patients’ age was positively
associated with perceived timeline (rð132Þ ¼ :25, p , :01) and illness coherence
(rð132Þ ¼ :29, p , .01). The insulin status of individuals was associated with perceived
identity (low blood glucose) (rð36Þ ¼ :27, p , :01) such that patients managing their
diabetes with insulin perceived more symptoms when their blood glucose was low. The
duration of diabetes was negatively associated with the personal control of diabetes
(rð132Þ ¼ :26, p , :01) and the patients’ BMI was associated with perceived identity
(high blood glucose; rð132Þ ¼ :29, p , :01). Patients’ BMI scores were negatively
associated with exercise (rð132Þ ¼ 2:23, p , :05). None of the demographic or clinical
variables were associated with coping cognitions Table 4.
Illness representations and coping cognitions

A number of illness representations were positively associated with coping cognition
variables. Confrontation coping was positively associated with perceived consequences
(rð132Þ ¼ :33, p , :01). Avoidance coping was positively associated with identity (high
blood glucose; rð132Þ ¼ :23, p , :01). Acceptance coping was positively associated
with emotional representations (rð132Þ ¼ :34, p , :01) and identity (high blood
glucose; rð132Þ ¼ :35, p , :01).
Illness representations and coping behaviours

There were also positive associations between coping behaviours and illness
representations. Physical activity was associated with timeline (rð132Þ ¼ :22,
p , :01) and treatment control (r(132) ¼ .25, p , :01). Fruit and vegetable intake
was associated with timeline (rð132Þ ¼ :26, p , :01). Fibre intake was associated with
timeline (rð132Þ ¼ :25, p , :01) and consequences (rð132Þ ¼ :26, p , :01), and sugar
intake was associated with timeline (rð132Þ ¼ :25, p , .01).
Coping cognitions and coping behaviours

None of the coping cognition variables were significantly associated with coping
behaviour variables.
Table 4. Correlations of illness representations with coping cognitions and coping behaviour (N ¼ 134)
Med Activity Fruit & Veg Fat Sat fat Fibre Carbs Sucrose Confront Avoid Accept
Timeline acute .171 .223** .258** .153 .116 .251** .187* .254** .194* 2 .007 .113
Timeline cyclical 2.154 2 .087 .005 .052 .048 2 .006 .047 2 .054 .207* .183* .246*
Consequences 2.088 .011 .088 .160 .112 .260** .176* .111 .336** .118 .215*
Personal control .180 .217* .109 .121 .097 .112 .117 .181* .126 2 .016 .065
Treatment control .209* .246** .023 .060 .041 .066 .105 .147 .216* 2 .012 2.113
Illness coherence .126 .096 .096 .070 .067 .081 .012 .135 .201* .207* .119
Emotional reps 2.138 2 .132 2.132 .007 2.029 .158 .085 .032 .123 .207* .341**
Identity-high bg 2.117 2 .205* 2.002 .163 .161 2 .011 .080 .038 .233** .233** .346**
Identity-low bg 2.167 2 .106 .108 .092 .084 .144 .137 .122 .173* .096 .179*
Cause-behaviour .041 2 .080 .039 .239** .224* .117 .006 .134 2 .045 2 .062 .088
Cause-external 2.063 .044 2.025 2 .015 2.016 2 .088 .027 2 .191* .023 .019 .126
Cause-hereditary 2.059 2 .036 .218* .037 2.016 2 .088 .108 .059 .001 2 .027 2.032
Coping-confront .043 .091 .014 2 .016 2.033 .119 .167 .027 1.00 .293** .159
Coping-avoid .160 2 .037 2.050 2 .105 2.120 2 .108 2 .166 2 .103 .293** 1.00 .496**
Coping-accept .118 2 .178* 2.001 2 .097 2.117 2 .038 2 061 2 .087 .159 .496* 1.00

Coping in type 2 diabetes

631
Regression analyses: Predicting coping cognitions and coping behaviours

The next step of the analyses was to test the predictive validity of these representations
after controlling for demographic and clinical variables (Table 5). Thus, a series of
hierarchical regressions was conducted. For each regression model, the demographic
and clinical variables were controlled for in the first block (i.e. age, gender, duration of
diabetes, body mass index, insulin status). In the second block, the relevant illness
representation variables identified through the correlational analysis were entered (i.e.
timeline, consequences, personal control, treatment control, control-now, control-
future).
Table 5. Regression coping cognitions and coping behaviours on illness representations
Variable b % R2 F Value p Value 95% CI
Coping-confront
Diabetes duration 2.10 5.7% 1.37 .031 2.197– 2 .010
Control-future .27 .005 .084–.464
Consequences .29 29.8% 3.74 .002 .105–.475
Coping-accept
Identity high-bg .30 .003 .114–.530
Emotional reps .28 26.4% 3.16 .010 .44–.317
Medication
Control-now .49 17.1% 1.37 .021 .008–.092
Exercise
Age .24 .009 .18–.121
BMI 2.27 14.5% 3.79 .005 2.244– 2 .046
Fibre
Consequences .33 21.0% 2.16 .003 .194–.946
Fruit and veg
Gender .23 .032 7.457–16.25
Timeline .29 18.7% 1.87 .009 2.668–18.50
Saturated fat
Age 2.22 10.5% 1.04 .039 2.584– 2 .015
Carbohydrate
Age 2.22 14.1% 1.33 .05 23.682– 2 .016
Sugar
Timeline .25 11.7% 1.08 .031 2.118–2.38
Coping cognitions
In the first block, confrontational coping was predicted by disease duration
(Fð5; 113Þ ¼ 1:37, p , :05, R 2 ¼ :06) explaining 6% of the variance. In the second
block, patients’ beliefs in consequences (p , :01) and treatment to control the future
complications of diabetes (p , :01) were both independent predictors of confronta-
tional coping (Fð12; 106Þ ¼ 3:74, p , :05, R 2 ¼ :30) explaining 30% of the variance.
For acceptance coping diabetes identity when blood glucose is high was an
independent predictor (p , :01) as were stronger emotional representations (p , :01)
(Fð5; 113Þ ¼ 1:37, p , :01, R 2 ¼ :26) explaining 26% of the variance. There were no
significant predictors of avoidance coping.
Coping behaviours
For the behavioural coping measures, medication was solely predicted by beliefs that
treatment could control diabetes now (Fð12; 80Þ ¼ 1:37, p , :05, R 2 ¼ :17) accounting
for 17% of the variance. However, illness representations did not predict physical
activity, fat and carbohydrate intake.
Exercise was predicted only by two variables age (p , :01) and BMI (p , :01) in the
first block of equation (Fð5; 112Þ ¼ 3:79, p , :01, R 2 ¼ :15) accounting for 14% of the
variance.
The perceived consequences of diabetes emerged as an independent predictor of
fibre intake (Fð12; 98Þ ¼ 2:16, p , :01, R 2 ¼ :21) solely explaining 21% of the variance.
Gender emerged as an independent predictor of fruit and vegetable intake
(Fð12; 98Þ ¼ 1:87, p , :05), together with perceived timeline (Fð12; 98Þ ¼ 1:87,
p , :01, R 2 ¼ :19) accounting for 19% of the variance. Only patients’ age was an
independent predictor of carbohydrate intake accounting for 14% of the variance
(Fð12; 98Þ ¼ 1:33, p , :05, R 2 ¼ :14). Finally, perceived timeline emerged as a
predictor of sugar consumption (Fð12; 98Þ ¼ 1:08, p , :05, R 2 ¼ :12).
Discussion
The primary aims of this study were to (1) describe coping cognitions and coping
behaviours in-patients with type 2 diabetes; (2) determine the relationships between
illness representations and indices of coping cognitions and coping behaviour and (3)
determine if coping cognitions mediate the relationships between illness represen-
tations and coping behaviours.
Confrontational coping was the most frequently reported cognitive way of coping
with type 2 diabetes and is indicative of a problem-focused, care-seeking approach to
managing the disease. However, confrontational coping and avoidance coping were
strongly correlated as were acceptance coping and avoidance. The inter-correlations of
coping measures in the study indicate that people with type 2 diabetes may use a
combination of coping strategies in dealing with the disease rather than one specific
strategy and reflect the findings of Macrodimitris and Endler (2001). Furthermore, the
present results should be evaluated in the context of the current critical debate
regarding the use of coping questionnaires (Coyne & Racioppo, 2002). It may be that
coping cognitions (as described in the coping scales) do not reflect coping behaviours,
indeed, it is possible that cognitions are too generalized and have no bearing on the
processes that lead to individuals adopting a particular behaviour. The authors assert
that the retrospective nature of coping assessments renders it difficult to determine how
a stressful situation is resolved and the contribution of individual coping efforts to that
resolution.
Stronger beliefs in consequences and that treatment could control the future
complications of diabetes were predictors of confrontational coping. A stronger
diabetes identity for high blood glucose was an independent predictor of acceptance
coping as were stronger emotional representations. Stronger identity scores for
high blood glucose were also predictive of avoidance coping. With regard to coping
behaviours, consequences predicted fibre intake. This was followed by timeline as a
predictor of fruit and vegetable intake. Medication was solely predicted by beliefs
that treatment could control diabetes now. Thus, in line with previous studies, it
would appear that control beliefs are implicated in both coping cognitions (i.e. Helder
et al., 2002; Moss-Morris et al., 1996) and coping behaviours (Griva et al., 2000;
Skinner et al., 2002).
The results of regression analyses also show that illness representations predict a
sizable percentage of variance in coping cognitions and coping behaviour. Indeed, 30%
of the variance was explained in confrontational coping, 26% in acceptance coping
followed by 21% of the variance in fibre intake. Thus, it would appear that illness
representations are direct predictors of both coping cognitions and coping behaviour
indices with the largest percentage of variance explained within confrontational and
acceptance coping variables. However, illness representations failed to predict a
number of key behavioural coping variables including engagement in physical activity,
saturated fat and carbohydrate consumption.
Beliefs in the consequences of diabetes and the effectiveness of treatment to control
future complications were both independent predictors of confrontational coping.
Therefore, such positive results are indicative of a logical pathway from the
representation of diabetes and coping through actively engaging with the disease.
However, a longer duration of diabetes was negatively associated with confrontational
coping suggesting that engagement with the disease may decline over the course of the
illness. Experiencing more symptoms resulting from high blood glucose was predictive
of acceptance coping indicating that with the repeated experience of such symptoms
the patient becomes resigned to the threat of the disease and become less inclined to
control glucose levels.
With regard to taking medication as a coping behaviour, it was found that stronger
beliefs in treatment predicted frequency of use. However, illness representations were
not predictive of exercise and only featured as predictors of three of the measures of
dietary behaviour. Thus, the relationships between illness representations and coping
behaviour yield a less coherent picture. For example, while a stronger timeline
predicted higher fruit and vegetable consumption it was also predictive of sugar intake
and is contradictory with regard to the self-management of diabetes. However, the
representations of diabetes associated with coping behaviours share some commonality
with previous work. For example, the perceived seriousness (timeline and
consequences) of diabetes have been found to be predictive of behavioural outcomes
(Glasgow et al., 1997; Hampson et al., 1990; Skinner et al., 2002).
Although illness representations were associated with both coping cognitions and
coping behaviours, coping cognitions were not associated with coping behaviours. This
finding demonstrates that coping cognitions and coping behaviours are operating
independent of each other and the absence of this relationship, excludes the application
of Baron and Kenny’s (1986) analytical procedure for identifying mediating variables.
Thus, although illness representations appear to be as important in predicting coping
behaviours as they are in predicting coping cognitions, the present data suggest that
coping cognitions do not mediate the relationships between illness representations and
coping behaviours. Therefore, the results appear contrary to the CSM which posits
that coping is a mediating factor between illness representations and (behavioural or
emotional) outcomes. This may be explained, in part, by conceptual differences in the
coping assessments utilized in studies. Indeed, it is questionable whether a coping
measure such as the MCMQ which assesses coping as a static state can capture the
dynamic nature of coping cognitions.
However, the results are consistent with a range of cross-sectional studies in a variety
of disease populations that have demonstrated direct associations between illness
representations and adaptive outcomes in chronic disease (Heijmans et al., 1999;
Moss-Morris et al., 1996; Scharloo et al., 1998). The present findings also share some
similarity with the only previous study examining the mediating role of coping in the
context of diabetes (Edgar & Skinner, 2003). Contrary to the authors’ hypothesis, coping
did not mediate the association between illness representations and emotional well-
being in adolescents with type 1 diabetes. Thus, the present prospective analysis
suggests that illness representations are directly related to coping behaviours. Moreover,
with regard to the clinical relevance of the findings, it may not be beneficial to
manipulate patients’ coping cognitions to improve health behaviours. It may be more
beneficial to improve patients’ health behaviours by targeting diabetes beliefs rather
than their coping cognitions. Indeed, challenging and manipulating erroneous beliefs
has been shown to be beneficial in improving the health behaviours in patients
recovering from myocardial infarction (Petrie, Cameron, Ellis, Buick, & Weinman, 2003).
Beliefs and coping in type 2 diabetes

A meta-analysis of empirical research conducted within the illness representations
framework has shown that the perceived controllability of the illness was significantly
associated with problem-focused coping strategies (Hagger & Orbell, 2003). In line with
these findings, the present results showed that beliefs in control-future predicted
confrontational coping and control-now predicted medication use. Such represen-
tations of control are also in keeping with the intrinsic nature of perceived control in the
coping appraisal process. Furthermore, as confrontational coping style is akin to
problem-focused approaches it is proposed that the connections among perceptions of
control and coping style are best explained within Conway and Terry’s (1992)
‘goodness-of-fit’ hypothesis. The goodness-of-fit hypothesis contends that a stressor
perceived as controllable is best dealt with through problem-focused strategies, whereas
stressors perceived as uncontrollable are better dealt with through avoidance or
emotion-focused strategies. This implies that problem-focused strategies may be more
adaptive when an illness is perceived to be controllable than when it is perceived as
uncontrollable.
Further evidence to support this assertion comes from the emotional
representation dimension. Such representations were also significant predictors of
avoidance coping (11% variance) and acceptance coping (along with chronic timeline
beliefs) explaining 22% of the variance. Thus, patients who feel that they are not in
control of their diabetes and display a tendency to react more emotionally to their
illness. Such patients may also be more likely to avoid efforts to effectively deal with
diabetes. Patients in the current study appear to be characterized as having either strong
control beliefs that favour a problem-focused approach to dealing with the condition or
characterized by a more emotion-focused approach defined by withdrawal or avoidance
of dealing with the condition. Thus, the hypothesis and the present results are
particularly pertinent in the context of a chronic disease such as type 2 diabetes that is
potentially controllable through behaviour.
Study limitations
First, there are some issues regarding the representativeness of our study participants
when compared with the general population with type 2 diabetes, especially in relation
to ethnic minorities. Indeed, there were few participants from ethnic minorities;
the majority were in retirement and obese. However, the age and body mass of the
participants reflects the aetiology of type 2 diabetes that is defined by late onset and a
propensity for obesity. Furthermore, these participants were identified through the
original SASH diabetes cohort sampled from GP registers incorporating socially and
geographically diverse areas.
The behavioural outcomes in the study were reliant on patients’ self-reports of
behavioural outcomes of dietary behaviour, physical activity and medication adherence.
The subjective measurement of such outcomes may permit respondents to under- or
over-report their behaviour (Myers & Midence, 1998). However, a recent review has
shown that patients’ own reports generally have moderate to high concordance with
‘objective’ measures (Garber, Nau, Erickson, Aikens, & Lawrence, 2004). It should also
be acknowledged the retrospective time frame adopted for the completion of the
coping behaviour scales was not consistent and the coping cognitions scale assessed
coping styles in the present tense. Therefore, participants’ cognitions and behaviour
were not assessed over comparable time-frames.
With regard to the level of comorbidity in the study sample, it is possible that the
measurement of coping cognitions with the MCMQ elicited coping responses to chronic
disease per se as opposed to the behavioural measures which may be considered to be
diabetes-specific. However, the coping cognitions measure was adapted so that
respondents were instructed to focus on coping with their diabetes when completing
the measure. Finally, the generalizability of the results should be considered in the light
of the moderate response rate and the predominantly male sample.
To conclude, the present study demonstrates that illness representations are direct
predictors of both coping cognitions and coping behaviours in patients with type 2
diabetes. However, in the present context in which both coping cognitions and coping
behaviours have been measured, it appears that they are mechanisms that operate
independently. Nonetheless, further research is warranted to substantiate these findings.
Acknowledgements
Thanks to Sue Williams, research secretary for the Somerset and Avon Survey of Health (SASH) and
all the patients and partners who kindly participated in this study. This work was funded by the
MRC. Bristol is the lead centre of the MRC Health Services Research Collaboration. The lead author
is funded by the Economic and Social Research Council.
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Received 27 February 2006; revised version received 19 October 2006

A Prospective Examination of Illness Beliefs and Coping in Patients With Type 2 Diabetes

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A Prospective Examination of Illness Beliefs and Coping in Patients With Type 2 Diabetes

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Copyright © The British Psychological Society

A prospective examination of illness beliefs and

Aidan Searle1*, Paul Norman2, Rachel Thompson3 and

Objective. According to the common-sense model of illness behaviour, illness

622 Aidan Searle et al.

Coping in type 2 diabetes 623

studies demonstrate that illness representations, in particular, control beliefs are

624 Aidan Searle et al.

Coping in type 2 diabetes 625

Socio-economic and clinical data

Age 32–86 years

626 Aidan Searle et al.

Coping in type 2 diabetes 627

Measurement of coping behaviour

628 Aidan Searle et al.

Measurement of coping cognitions

Coping in type 2 diabetes 629

Table 2. Descriptive statistics for patients’ diabetes representations (N ¼ 164)

Representation Max score Mean (SD) Cronbach’s a

Timeline-acute 30 23.4 (4.1) .63

Note. bg, blood glucose.

Correlations between illness representations, coping cognitions and coping behaviours

630 Aidan Searle et al.

Table 3. Dietary intake for patients (N ¼ 134)

Total fat 31.4 (8.0) 60.7 (38)

Demographic and clinical variables

Illness representations and coping cognitions

Illness representations and coping behaviours

Coping cognitions and coping behaviours

Note. bg, blood glucose.

Coping in type 2 diabetes

632 Aidan Searle et al.

Regression analyses: Predicting coping cognitions and coping behaviours

Table 5. Regression coping cognitions and coping behaviours on illness representations

Variable b % R2 F Value p Value 95% CI

Note. bg, blood glucose.

Coping in type 2 diabetes 633

634 Aidan Searle et al.

Coping in type 2 diabetes 635

Beliefs and coping in type 2 diabetes

636 Aidan Searle et al.

Coping in type 2 diabetes 637

638 Aidan Searle et al.

Received 27 February 2006; revised version received 19 October 2006

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