O L D E R PE O P L E

Self-care behaviour and related factors in older people with Type 2

diabetes
Yu-Ling Bai, Chou-Ping Chiou and Yong-Yuan Chang

Aim. The present study examined the factors related to self-care behaviour in type 2 diabetic patients aged ‡65 years. In
addition, this study tested the effect of the important explanatory factors on self-care behaviour.
Background. Along with the development of an ageing society, diabetes occurs frequently among older people. Diabetes
requires continual medical treatment, with patients responsible for self-care. Although the relationships among social support,
depression and self-care have been widely studied, little is know about older diabetic patients, especially in Taiwan.
Design. A correlational design was adopted. In total, 165 patients recruited using convenience sampling were diabetic outpa-
tients at three hospitals in southern Taiwan from January–March 2005.
Methods. The participants were interviewed using the Personal Resource Questionnaire 2000 (PRQ 2000), Diabetes Self-Care
Scale and Taiwan Geriatric Depression Scale (TGDS). Data were analysed using descriptive statistics and multiple regression
analysis.
Result. Self-care behaviour scores were significantly influenced by different gender, education level, economic status and
religious beliefs of older diabetic patients. Depression and self-care behaviour were negatively correlated. Social support,
education and duration of diabetes significantly affected self-care behaviour, accounting for 35Æ6% of total variance.
Conclusions. Social support plays a vital factor in contributing to the facilitation of self-care behaviour. These analytical
findings demonstrate the importance of social support, education and duration of diabetes in determining self-care behaviour for
diabetic older diabetic patients and serve as references for future studies of self-care behaviour in type 2 older diabetic patients.
Relevance to clinical practice. Implication for nurses highlights the significance of providing patients with social support that
will enable them to have good support systems during their disease treatment to enhance self-care abilities and improve quality
of life.

Key words: depression, elderly, self-care behaviour, social support, type 2 diabetes

Accepted for publication: 4 April 2009

definition. In Taiwan, diabetes was the fourth leading cause

Introduction
Since August 2009, the population of Taiwanese aged
‡65 years increased to 10Æ55% (Ministry of the Interior
2009), making Taiwan an aged society by the United Nations
of death due to disease in 2006 and 8Æ8% of those aged ‡65
died due to diabetes (Department of Health 2006). According
to the Bureau of National Health Insurance, in the 1998 fiscal
year, expenditures for treating diabetes accounted for 11Æ5%

Authors: Yu-Ling Bai, MSN, RN, Instructor, Department of
Nursing, Chung Hwa Univerisity of Medical Technology, Tainan
County, Taiwan; Chou-Ping Chiou, PhD, RN, Associate Professor,
School of Nursing, I-Shou University, Kaohsiung County, Taiwan;
Yong-Yuan Chang, ScD, Associate Professor, Institute & Department
of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
Correspondence: Chou-Ping Chiou, I-Shou University, No. 8, E-Da
Road, Jiau-shu Tsuen, Yan-chau Shiang, Kaohsiung County 824,
Taiwan. Telephone: +886 9212 99091.
E-mail: chouping@isu.edu.tw

3308  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315
doi: 10.1111/j.1365-2702.2009.02992.x
Older people
of all medical costs and diabetes patients, on average, cost 4Æ3
times that of for treating non-diabetic patients (Lin et al.
2001). These statistics indicated a high mortality rate for
diabetics among the aged population and that treatment costs
and economic burden to the health care system and families
will increase.
Current literature has emphasised the importance of self-
management of diabetes. McCollum et al. (2005) emphasised
that effective self-care is an essential component of diabetes
care. Diabetic individuals must manage diet, exercise, med-
ication, blood glucose monitoring and routine visits to health
care professionals. Diabetes is a complex chronic metabolic
disorder that requires continual medical treatment with
patients responsible for self-care (American Diabetes Associ-
ation 2003). Ninety-five percent of diabetes treatment relies
on self-care behaviours (Anderson 1995) and effective treat-
ment for diabetics aged ‡65 years depends on the success of
self-care (Polly 1992). Regardless of the diabetes type,
diabetic patients must adjust their behaviour and follow
prescribed treatments to control their metabolism and
prevent diabetic complications which may be potentially
deadly especially for older people (Toljamo & Hentinen
2001a). Little is know about self-care behaviour among
diabetics aged ‡65 years in Taiwan. Therefore, this study
examines self-care behaviour and related factors in diabetic
patients aged ‡65 years in Taiwan.
Background
Diabetes mellitus as a chronic disease requires active patient
participation in self-care. Ruggiero et al. (1997), who
examined self-care behaviour among diabetics, concluded
that most diabetic patients regularly take prescribed medicine
according to instructions, however, few controlled their diet
and exercised and up to 42% failed to monitor their blood
sugar levels. Polly (1992) showed that older patients with
type 2 diabetes are likely to follow medical instructions for
regular diet times, oral administration of medication and
control caloric intake and less likely to exercise, reduce intake
of sweets, monitor blood levels and carry medical
identification card. While surveying diabetic patients ranging
from 40–70 years old, Clark and Hampson (2001) found that
type 2 diabetic patients follow diet instruction better than
they do physical activities instruction.
It is important to be aware of the factors associated with
self-care behaviour in diabetic patients. Based on recent
studies on self-care behaviour, age (Albright et al. 2001,
Toljamo & Hentinen 2001a), gender and education (Aljasem
et al. 2001, Toljamo & Hentinen 2001a) were identified as
factors associated with self-care behaviour. In addition,
 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315
Self-care in diabetic elderly
Murata et al. (2003) demonstrated that the clinical, psycho-
logical and social factors affected diabetes knowledge of
veterans with established Type 2 diabetes. They found that
age, years of schooling, duration of treatment, cognitive
function, sex and level of depression were independent
determinants of the knowledge score. Hopper and Schecht-
man (1985) found that the factors associated with poor
control include being older, lack of belief in control over
health, lack of belief in the efficacy of treatment, a belief that
diabetes is less serious than three curable illnesses, reported
lack of social support in a crisis with diabetes, reported low
satisfaction with the clinic and finally, higher levels of
reported problems with the self-care regimen, particularly
diet.
Social support is suggested as a vital factor contributing to
facilitate self-care behaviour in managing chronic illness.
Gallant (2003) analysed 29 studies of chronic patients and
proposed that a moderate correlation exists between support
and self-care behaviours (in particular for diabetic patients).
Wang and Lee (1999) noted that social support has a
significant impact on self-care behaviour and that without
adequate social support, patients may be unmotivated to
adopt self-care behaviour and lack the ability to care for
themselves properly. Albright et al. (2001) also reported that
social context was significantly associated with three out of
the four self-care behaviours for diabetic patients: attention
to medicines, exercise and diet. Wen et al. (2004) suggested
that as family support for diet increased, perceived barriers to
diet self-care decreased. Scollan-Koliopoulos et al. (2007)
suggested that explorations of patients’ recollections of a
family member’s experiences with diabetes can affect their
illness perceptions and behaviour.
Depression also affects self-care behaviour. Jacobson and
Weinger (1998) suggested that depressed patients commonly
deny their abilities to perform and complete daily living
goals; this negative and pessimistic mindset further hinders
their ability to make self-management decisions. DiMatteo
et al. (2000) preformed a meta-analysis of the relationship
between self-care instructions and depression and concluded
that non-depressed patients are three times more likely than
depressed patients to follow self-care instructions. Ciecha-
nowski et al. (2000), who studied diabetic patients with
depression, determined patients in the medium- and high-
severity tertiles were significantly less adherent to dietary
recommendations and had a higher percentage of days in
nonadherence to oral hypoglycemic regimens than patients in
the low-severity depression symptom tertile. Ciechanowski
et al. (2003) evaluated 276 type 1 diabetic patients and 199
type 2 diabetics and demonstrated that high levels of
depression are associated with ignoring instructions for
3309
Y-L Bai et al.
dietary intake, diet type and exercise. Lin et al. (2004), who
studied diabetic patients, determined that a high percentage
of diabetic patients with depression fail to exercise (62Æ1%),
eat more fat and less vegetables and fruit and more days of
ignoring medication instructions (24Æ5%) compared with
those with no depression (18Æ8%). Gonzalez et al. (2007)
found that major depression was significantly associated with
poorer adherence to general dietary recommendations, con-
suming less fruit and vegetables, less frequent spacing of
carbohydrates over the course of the day, poorer adherence to
exercise recommendations and less frequent SMBG (self-
monitoring of blood glucose). In summary, passive behaviour
related to depression result in unwillingness to follow
prescribed medical care and low levels of performing self-
care behaviour, such as controlling dietary intake, remaining
active and taking medication.
The objective of the study was to identify the important
explanatory factors of self-care behaviour among type 2 older
diabetic patients. To that end, the following research ques-
tions were posed for investigation as follows:
1 Are there significant relationships among socio-demo-
graphic characteristics, disease condition, social support,
depression level and self-care behaviour?
2 Do socio-demographic characteristics, disease condition,
social support and depression level affect self-care behav-
iour among type 2 older diabetic patients?
Methods
This correlational study used convenience sampling at three
hospitals in southern Taiwan. Face-to-face interviews were
used to collect data between January–March 2005. Inclusion
criteria were as follows: (1) aged ‡65 years; (2) diagnosed
with type 2 diabetic patients; (3) ability to communicate; (4)
no other significant dysfunction caused by another disease;
and (5) no dementia or significant mental disease. Based on a
power analysis using a moderate effect size and probability
level of 0Æ05 and 0Æ80 power, a sample size of 145
participants deemed adequate (Cohen 1988). During clinical
visits, physicians identified patients who met the inclusion
criteria. Of the 193 participants referred five did not meet
inclusion criteria, 19 chose not to participate and four were
unable to complete the questionnaires. In total, 165 partic-
ipants were enrolled.
Instruments
The Personal Resource Questionnaire 2000 (Weinert 2003)
has 15 items; responses are graded using a seven-point Likert
scale ranging from 1 (strongly disagree) –7 (strongly agree).
3310  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315
Weinert conducted reliability and validity testing on the
PRQ2000 and identified a Cronbach’s a of 0Æ90–0Æ91.
The Diabetes Self-Care Scale (DSC) was developed by
Hurley and Shea (1992) and revised by Wang et al. (1998)
Factor analysis identified five factors that are: exercise, diet,
medication and blood sugar monitoring, foot care and
prevention of unstable blood sugar levels. The scale has 27
items; responses are graded using a five-point Likert scale
ranging from 1 (not following instructions) –7 (following
instructions). Wang et al., who used the DSC to analyse of
self care for type 2 diabetic patients, identified a Cronbach’s a
of 0Æ82. In this study, Cronbach’s a was 0Æ88 and ICC was
0Æ91 after a two week interval.
The Taiwan Geriatric Depression Scale (TGDS), contain-
ing 30 items, was developed by Liao et al. (2004). People
were asked to evaluate their physical and emotional feelings
over the past week; each ‘yes’ answer is scored as 1 and each
‘no’ answer is scored as 0. Those with ‡15 points are
suspected of having depression. Kuder-Richardson (KR-20)
of this scale is 0Æ94 and test-retest reliability is 0Æ82. The area
under the Receiver Operating Characteristic Curve (ROC) in
the TGDS equals 0Æ97, indicating that the scale is a very
effective screening tool. The optimal cutoff point of 15 has a
sensitivity of 93Æ3% and a specificity of 92Æ3%. In this study,
the KR-20 value was 0Æ89 and the ICC was 0Æ90 after a two-
week interval.
Procedure
Permission to conduct this study was granted by the Ethics
committee at the University. Each participant enrolled
provided written informed consent. Participants were
informed of the purpose of the research and allowed to
withdraw from the study at will. Anonymity and confi-
dentiality of participants were assured. The Statistical
Package for the Social Sciences (SPSS) 12.0 for Windows
was used for statistical analysis. Differences and correla-
tions between variables were analysed by independent-
sample t-tests, one-way ANOVA and Pearson’s product
moment correlation. Multiple regression analysis was
applied to identify the factors that significantly affect self-
care behaviour in this population. Colinearity diagnostics
and correlation matrix were examined to exclude multico-
linearity. Multicolinearity of independent variables was
examined by calculating the variance inflation factor (VIF).
To avoid multicolinearity bias in linear regression, variables
with small tolerance (<0Æ01) and VIF exceeding 10 have to
be discard (Schroder 1990). In this study, the tolerance of
each independent variable was close to 1Æ0 and VIF less
than 10.
Older people
Findings
Distribution of socio-demographic characteristics and
medical condition
Respondents’ mean age was 72Æ8 (SD 5Æ24) years. Of the 165
participants, 87 (52Æ7%) were male. Forty-nine respondents
were illiterate (29Æ7%). In total, 122 (73Æ9%) respondents
have spouse; 119 (72Æ1%) respondents relied on their own
economic resources: 59 respondents (35Æ7%) had incomes of
NT$20 000–49 000 and 48 (29Æ1%) had incomes of
NT$10 000–19 000. Most, 152 (92Æ1%), respondents lived
with their families and 120 respondents (72Æ7%) held
religious beliefs.
Disease duration for all participants was 0Æ3–41 years
(mean = 14Æ29; SD 9Æ40). Ninety-five (57Æ6%) respondents
had diabetes for >10 years. Most respondents were treated
with oral hypoglycemic agents (OHAs) (76Æ4%) and com-
bined OHAs with insulin injections (10Æ3%); few received
diet only treatments (4Æ2%). Notably, 61Æ2% of respondents
had diabetic complications. In addition to diabetic compli-
cations, 78Æ8% respondents had other chronic diseases
(Table 1).
The scores for PRQ2000 were 38–105 (mean score, 80Æ78;
index score, 77) (index score = mean score value of mea-
surement ‚ the perfect score · 100) indicating that respon-
dents generally considered their social support as moderate.
Mean TGDS score was 7Æ45 (SD 6Æ00; range, 0–28) and index
score was 25. In total, 141 respondents (85Æ5%) had scores
<15, indicating a low level of depression. Mean DSC was
98Æ06 (range, 45–134) and index score was 73, indicating a
moderate level self-care behaviour.
Relationships between socio-demographic characteristics
and medical condition as well as self-care behaviour
Males had significantly higher self-care behaviour scores than
females (t = 3Æ369, p < 0Æ01). There were significant dif-
ferences in the self-care behaviour scores due to educational
level (F = 8Æ321, p < 0Æ001). Those with educational levels
of senior high school, college, or university level had higher
self-care behaviour scores than illiterate respondents. More-
over, college and university graduates had higher self-care
behaviour scores than those with only elementary school
educations. There were significant differences in the self-care
behaviour scores due to a difference in incomes (F = 6Æ714,
p < 0Æ001). Participants with incomes of <NT$10 000 had
significantly poorer self-care behaviour scores than those with
incomes of NT$20 000–50 000 and those with incomes
>NT$50 000. Religious beliefs is also a significant indicator
 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315
Self-care in diabetic elderly
of self-care behaviour (t = 2Æ383, p < 0Æ05); non-religious
respondents had higher self-care scores than religious respon-
dents (Table 1).
Economic status, disease duration were positively corre-
lated with self-care behaviour (r = 0Æ322, p < 0Æ001;
r = 0Æ197, p < 0Æ05); respondents with high economic status
and long disease duration typically had higher self-care scores
than those with poor economic status and a short disease
duration. Social support was also significantly correlated with
self-care behaviour (r = 0Æ498, p < 0Æ001), indicating those
with a sufficient social support had higher self-care scores
than those with insufficient social support. Depression and
self-care behaviour were negatively correlated (r = 0Æ299,
p < 0Æ001) (Table 2).
Important predicators of self-care behaviour
Only significant independent variables in univariate analysis
were entered to multiple regression analysis using the
forward selection method. After adjusting for all variables
in the model, three variables significantly predictive of self-
care behaviour were social support, education level and
disease duration; these three variables explained 35Æ6% of
total variances (Table 3).
Discussion
Socio-demographic characteristics and self-care behaviour
Analytical results in this study demonstrated that males care
for themselves better than do females. This finding is similar
to that obtained by Lin (2004) who investigated adult
diabetic patients. However, Wang et al. (1998) and Toljamo
and Hentinen (2001a) determined that gender does not
result in different levels of self-care. Further study is
required to determine the effect of gender on self-care. In
this study, older diabetics with higher education levels were
better at self-care than illiterate older people. This finding
corresponds to that obtained by Polly (1992), who investi-
gated self-care behaviour among the older diabetics. Chen
et al. (2001) observed that those with a high level of
education are more aware of diabetes than those with a low
level of education. Murata et al. (2003) also reported that
stable, insulin-treated veterans have major deficiencies in
diabetes knowledge that could impair their ability to provide
self-care.
This study indicated that economic status is positively
correlated with self-care behaviour, a finding that differs
from that in Wang et al. (1998), who found no correlation
between economic status and self-care behaviour. Hunt et al.
3311
Y-L Bai et al.

Table 1 Demographic and medical

Variables n % M ± SD t/F Post-hoc
condition data in relation to self-care
Gender behavior (N = 165)
Male 87 52Æ7 101Æ55 ± 16Æ71 t= 3Æ369**
Female 78 47Æ3 93Æ92 ± 12Æ33
Age (yrs)
65–69 56 33Æ9 97Æ70 ± 14Æ08 F = 1Æ485
70–74 52 31Æ5 97Æ60 ± 15Æ60
75–79 42 25Æ5 101Æ95 ± 17Æ04
‡80 15 9Æ1 97Æ95 ± 15Æ21
Education
(1) Illiterate 49 29Æ7 90Æ53 ± 14Æ76 F = 8Æ321*** (4) > (1)
(2) Elementary school 38 23Æ0 94Æ55 ± 14Æ81
(3) Junior high school 23 13Æ9 101Æ26 ± 11Æ14 (5) > (1)
(4) Senior high school 27 16Æ4 105Æ52 ± 12Æ58
(5) College and above 28 17Æ0 105Æ50 ± 14Æ88 (5) > (2)
Marital status
No spouse 43 26Æ1 96Æ93 ± 16Æ35 t= 0Æ508
Spouse 122 73Æ9 98Æ30 ± 14Æ84
Economic resources
Self 119 72Æ1 99Æ03 ± 15Æ93 t = 1Æ484
Family 46 27Æ9 95Æ13 ± 12Æ89
Income (NT$ /month)
(1) NT$ 9999 or below 46 27Æ9 91Æ78 ± 13Æ88 F = 6Æ714***
(2) NT$10,000–19,999 48 29Æ1 96Æ52 ± 14Æ18
(3) NT$20,000–49,999 59 35Æ7 101Æ56 ± 15Æ31 (3) > (1)
(4) NT$ 50,000 or more 12 7Æ3 109Æ50 ± 13Æ46 (4) > (1)
Living status
Living without families 13 7Æ9 99Æ46 ± 20Æ09 t = 0Æ374
Living with families 152 92Æ1 97Æ82 ± 14Æ79
Religion
Yes 120 72Æ7 96Æ24 ± 14Æ16 t = 2Æ383*
No 45 27Æ3 102Æ49 ± 17Æ04
Duration of diabetes (yrs)
<1 6 3Æ6 91Æ00 ± 13Æ52 F = 1Æ036
1–5 33 20Æ0 95Æ36 ± 16Æ71
6–10 31 18Æ8 97Æ55 ± 14Æ39
>10 95 57Æ6 99Æ41 ± 15Æ00
Type of treatment
Diet 7 4Æ2 100Æ00 ± 16Æ83 F = 0Æ409
Oral hypoglycemic agents 126 76Æ4 97Æ52 ± 16Æ02
Insulin 15 9Æ1 101Æ20 ± 8.62
Oral + insulin 17 10Æ3 99Æ41 ± 13Æ49
Complications
Yes 101 61Æ2 97Æ32 ± 15Æ50 t = 0Æ666
No 64 38Æ8 98Æ94 ± 14Æ80
Chronic diseases
Yes 130 78Æ8 97Æ58 ± 15Æ52 t = 0Æ599
No 35 21Æ2 99Æ31 ± 14Æ10

*p < 0Æ05, **p < 0Æ01, ***p < 0Æ001.

(1998) noted that treatment cost for many diabetic patients is
a significant burden. During interviews, some participants
stated that blood sugar test strips, preparation of special
diets, use of sports facilities, medical treatments and expenses
for frequent hospital visits were a burden.
Wang et al. (1998) determined that no significant differ-
ence existed for self-care between religious and non-religious
patients; however, this study determined that non-religious
patients had better self-care behaviour than religious patients.
They who tend to attach their health to religious beliefs may

3312  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315
Older people Self-care in diabetic elderly

Table 2 Pearson’s correlation of self-care behaviour (N = 165) support and self-care behaviour are positively correlated,
Self-care behaviour
implying that social support has a positive impact on self-care
behaviour.
Variables r p-value

Age 0Æ123 0Æ114

Depression and self-care behaviour
Income 0Æ322 <0Æ001
Duration of diabetes 0Æ197 0Æ011 Relevant diabetic studies determined that severity of depres-
Social support 0Æ498 <0Æ001
sion is related to poor diet and medication self-care behaviour
Depression 0Æ299 <0Æ001
(Ciechanowski et al. 2000, 2003). Gonzalez et al. (2007)
found that depression as a risk factor for nonadherence and
suggested that even low levels of depressive symptomatology
Table 3 Multiple regression analysis for self-care behavior (N = 165) are associated with nonadherence to important aspects of
diabetes self-care. These analytical data also indicated that a
Variables B b t F R2
negative correlation exists between depression and self-care
Constant 86Æ626 36Æ388** 29Æ651** 0Æ356 behaviour. Depressed patients are less likely to follow
Social support 0Æ544 0Æ434 6Æ564**
medical advice than non-depressed patients. Wing et al.
Education 2Æ671 0Æ259 3Æ883**
Duration of 0Æ291 0Æ180 2Æ807* (2002) believed that depression appears to be related, at least
diabetes moderately, to poorer adherence to a variety of treatment
components. Exactly why depressed patients are less adherent
*p < 0Æ01, **p < 0Æ001.
must be understood. Various explanations are available.
Depressed patients express greater feelings of hopelessness
neglect their self-care. This point should be studied further (and thus may doubt the effectiveness of treatment). They are
more. often more socially isolated and social support has been
related to adherence. Failure to carry out treatment recom-
mendations also resulted from poor memory associated with
Disease condition and self-care behaviour
depression and the inability of depressed patients to follow
In this study, disease duration were positively correlated with treatment suggestions.
sufficient self-care behaviour, a finding similar to that
obtained by Chen et al. (1998), which indicated that self-
Important predictors of self-care behaviour
care behaviour of patients with diabetes ‡11 years can learn
from previous disease and treatment experience. According to Multiple regression analysis determined that social support
our results, self-care behaviour scores did not significantly is an important predictor of self-care behaviour in older
differ in terms of different treatment types which supports the diabetic patients; this analytical result corresponds to those
finding of Chen et al. However, self-care behaviour is a obtained by Tillotson and Smith (1996) and Chiang (2003).
complex issue. Whether different treatments affect self-care When diagnosed with a chronic disease, one may need care
behaviour requires further examination. Additionally, this assistance from friends and family. Therefore, nurse prac-
study obtained similar results to those acquired by Toljamo titioners should understand and provide the adequate social
and Hentinen (2001a) for the relationship between diabetic support when teaching self-care management to diabetic
complications and self-care behaviour; however, due to the patients thereby strengthens disease control. Education level
difficulty in evaluating and categorising diabetic complica- and disease duration were also significant predictors of self-
tions, further studies are required. care behaviour in this study; this finding is similar to that
obtained by Chen et al. (1998), indicating that disease
duration and education level should also be considered by
Social support and self-care behaviour
nurses. Those with a high education and long disease
Toljamo and Hentinen (2001b) noted that social support and duration generally have an adequate understanding of the
self-care behaviour were positively correlated among type 1 importance of self-care behaviour and have better com-
diabetic patients. Wang and Fenske (1996) and Albright et al. mand of self management skills to make use of diabetic
(2001) suggested that type 2 diabetic patients performed self- caring information obtained through various channels than
care behaviour better when they receive support from those with low levels of education and short disease
families and friends. This study also determined social duration.

 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315 3313
Y-L Bai et al.
Conclusion
This study enrolled patients from three hospitals. Due to the
non-probability sampling, conclusions and suggestions in this
study results are limited and cannot be generalised to all older
diabetic patients. This study demonstrated significant differ-
ences in self-care behaviour scores when participants were
groups according to gender, education level and economic
status. Depression was negatively correlated with self-care
behaviour. Social support and self-care behaviour were posi-
tively correlated. Social support, education level and disease
duration are significant predictors of self-care behaviour. Our
results are limited by the cross-sectional nature of our data.
Therefore, a discussion of changes over time is not possible.
This study only focused on correlations among socio-demo-
graphic characteristics, disease condition, social support,
depression and self-care behaviour. Other lifestyle variables,
such as personality and smoking, require further study.
Relevance to clinical practice
This study found that among older diabetics, special attention
needs to be paid to influential factors such as gender,
education level, social and economic status, disease duration
and religious belief on self-care behaviour. Different nursing
techniques must be used with patients according to individual
conditions and based on respect and caring. When caring for
older diabetics, psychological evaluations should be con-
ducted from time to time during disease treatment and in
particular, when caring for groups with a high risk of
depression. The psychological impact of complications,
disease duration and different treatment methods should be
taken into consideration for early detection of psychological
problems. Psychological support or suggestions for solutions
to health problems should also be offered. Furthermore,
nurses should also provide patients with social support that
will enable them to have good support systems during their
disease treatment to enhance self-care abilities and improve
quality of life.
Contributions
Study design: C-PC, Y-LB; data collection and analysis: Y-LB,
C-PC, Y-YC and manuscript preparation: C-PC, Y-LB.
References
Albright TL, Parchman M & Burge SK (2001) Predictors of self-care
behavior in adults with type 2 diabetes: an RRNeST study. Family
Medicine 33, 354–360.
3314  2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315
Aljasem LI, Peyrot M, Wissow L & Rubin RR (2001) The impact of
barriers and self-efficiency on self-care behaviors in type 2 diabetes.
Diabetes Educator 27, 393–404.
American Diabetes Association (2003) Standard of medical care for
patients with diabetes mellitus. Diabetes Care 26(Suppl. 1), S33–
S50.
Anderson RM (1995) Patient empowerment and the traditional
medical model: a case of irreconcilable. Diabetes Care 18, 412–
415.
Chen ZT, Chang M & Lin YC (1998) The relationship between self-
efficacy, social support and self-care behaviors in diabetes mellitus
patients. Journal of Nursing Research 6, 31–42.
Chen YM, Liao KM, Shu YH, Wu MH, Wang SH & Tsai HC (2001)
Relationships between personal perceptions and healthy behaviors
of middle-aged diabetic patients. Journal of Chinese Medical
Sciences 2, 315–324.
Chiang FW (2003) Family support, life satisfaction, self-care behav-
iors and diabetic control for patients with non-insulin-dependent
diabetes mellitus. Journal of Chang Gung Institute of Technology
2, 27–50.
Ciechanowski PS, Katon WJ & Russo JE (2000) Depression
and diabetes: impact of depressive symptoms on adherence,
function and costs. Archives of Internal Medicine 160, 3278–
3285.
Ciechanowski PS, Katon WJ, Russo JE & Hirsch IB (2003) The
relationship of depressive symptoms to symptom reporting, self-
care and glucose control in diabetes. General Hospital Psychiatry
25, 246–252.
Clark M & Hampson SE (2001) Implementing a psychological
intervention to improve lifestyle self-management in patient with
type 2 diabetes. Patient Education and Counselling, 42, 247–256.
Cohen J (1988) Statistical Power Analysis for the Behavioral Science,
3rd edn. Academic Press, New York.
Department of Health (2006) Statistics of Causes of Death. Taiwan
Government, Taipei.
DiMatteo MR, Lepper HS & Croghan TW (2000) Depression is a
risk factor for noncompliance with medical treatment: meta-
analysis of the effects of anxiety and depression on patient
adherence. Archives of Internal Medicine 54, 403–425.
Gallant MP (2003) The influence of social support on chronic illness
self-management: a review and directions for research. Health
Education and Behavior 30, 170–195.
Gonzalez JS, Safren SA, Cagliero E, Wexler DJ, Delahanty L,
Wittenberg E, Blais MA, Meiggs JB & Grant RW (2007) Depres-
sion, self-care and medication adherence in type 2 diabetes: rela-
tionships across the full range of symptom severity. Diabetes Care
30, 2222–2227.
Hopper SV & Schechtman KB (1985) Factor associated with diabetic
control and use patterns in a low-income, older adult population.
Patient Education and Counseling 7, 275–288.
Hunt LM, Pugh J & Valenzuela M (1998) How patients adapt
diabetes self-care recommendations in everyday life. Journal of
Family Practice 46, 207–215.
Hurley CC & Shea CA (1992) Self-efficay: strategy for enhancing
diabetes self-care. Diabetes Educator, 18, 146–150.
Jacobson AM & Weinger KE (1998) Treating depression in diabetic
patients: is there an alternative to medications? Annals of Internal
Medicine 129, 656–657.
Older people
Liao YC, Yeh TL, Yang YK, Lu FH, Chang CJ, Ko HC & Lo CM
(2004) Reliability and validation of the Taiwan Geriatric Depres-
sion Scale. Taiwanese Journal of Psychiatry 18, 30–41.
Lin KP (2004) The relationships among the perception of interactions
with public health nurses, knowledge of disease, attitude toward
disease and self-care behaviors of diabetes mellitus. Taiwan Jour-
nal of Public Health 23, 479–486.
Lin T, Chou P, Lai MS, Tsai ST & Tai TY (2001) Direct costs-of-
illness of patients with diabetes mellitus in Taiwan. Diabetes
Research and Clinical Practice 54(Suppl. 1), S43–S46.
Lin EHB, Katon W, Von Korff M, Rutter C, Simon GE, Oliver M,
Ciechanowski P, Ludman EJ, Bush T & Young B (2004) Rela-
tionship of depression and diabetes self-care, medication adherence
and preventive care. Diabetes Care 27, 2154–2160.
McCollum M, Hansen LS, Lu L & Sullivan PW (2005) Gender dif-
ferences in diabetes mellitus and effects on self-care activity.
Gender Medicine 2, 246–254.
Ministry of the Interior (2009) Monthly bulletin of interior statistics:
population by age of 0–14, 15–64, 65+ and by 6-year age group.
Available at http://www.moi.gov.tw/stat/english/monthly.asp
(accessed 9 September 2009).
Murata GH, Shah JH, Adam KD, Wendel CS, Bokhari SU, Solvas PA,
Hoffman RM & Duckworth WC (2003) Factors affecting diabetes
knowledge in Type 2 diabetic veterans. Diabetologia 46, 1170–1178.
Polly RH (1992) Diabetes health beliefs, self-care behaviors and
glycemic control among older adults with non-insulin-dependent
diabetes mellitus. Diabetes Educator 18, 321–327.
Ruggiero L, Glasgow RE, Dryfoos JM, Rossi JS, Prochaska JO,
Orleans CT, Prokhorov AV, Rossi SR, Greene GW, Reed GR,
Kelly K, Chobanian L & Johnson S (1997) Diabetes self-manage-
ment: self-reported recommendations and patterns in a large
population. Diabetes Care 20, 568–576.
 2009 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 3308–3315
Self-care in diabetic elderly
Schroder MA (1990) Diagnosing and dealing with multicolinearity.
Western Journal of Nursing Research 12, 175–187.
Scollan-Koliopoulos M, O’Connell KA & Walker EA (2007) Legacy
of diabetes and self-care behavior. Research in Nursing & Health
30, 508–517.
Tillotson LM & Smith MS (1996) Locus of control, social support
and adherence to the diabetes regimen. Diabetes Educator 22,
133–139.
Toljamo M & Hentinen M (2001a) Adherence to self-care and gly-
caemic control among people with insulin-dependent diabetes
mellitus. Journal of Advanced Nursing 34, 780–786.
Toljamo M & Hentinen M (2001b) Adherence to self-care social
support. Journal of Clinical Nursing 10, 618–627.
Wang CY & Fenske MM (1996) Self-care of adults with non-insulin-
dependent diabetes mellitus: influence of family and friends. Dia-
betes Educator 22, 465–470.
Wang HH & Lee I (1999) A path analysis of self-care of elderly
women in a rural area of southern Taiwan. Kaohsiung Journal of
Medicine Science 15, 94–103.
Wang JS, Wang RH & Lin CC (1998) Self-care behaviors and related
factors in outpatients newly diagnosed with non-insulin-dependent
diabetes mellitus. The Journal of Nursing 45, 60–73.
Weinert C (2003) Measuring social support: PRQ2000. In Mea-
surement of Nursing Outcome (Strickland O & DiIorio C eds).
Springer, New-York, pp. 161–172.
Wen LK, Parchman ML & Shepherd MD (2004) Family support and
diet barriers among older Hispanic adults with type 2 diabetes.
Family Medicine 36, 423–430.
Wing RR, Phelan S & Tate D (2002) The role of adherence in
mediating the relationship between depression and health out-
comes. Journal of Psychosomatic Research 53, 877–881.
3315