Journal of Diabetes and Its Complications 26 (2012) 10–16

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Journal of Diabetes and Its Complications

j o u r n a l h o m e p a g e : W W W. J D C J O U R N A L . C O M

Self-efficacy, self-management, and glycemic control in adults with type 2

diabetes mellitus☆,☆☆,★
Omar Abdulhameed Al-Khawaldeh a,⁎, Mousa Ali Al-Hassan b, Erika Sivarajan Froelicher c, d, e
a
Faculty of Nursing, Mutah University, P.O. Box (7), Al-Karak, Jordan
b
Faculty of Nursing, Jordanian University of Science and Technology, P.O. Box (3030), Irbid 22110, Jordan
c
Department of Physiological Nursing, School of Nursing, University of California, San Francisco, CA, USA
d
Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, CA, USA
e
University of Jordan, Amman, Jordan

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The objective was to evaluate the relationships between diabetes management self-efficacy and
Received 7 August 2010 diabetes self-management behaviors and glycemic control.
Received in revised form 2 November 2011 Methods: A cross-sectional design was used. A convenience sample of 223 subjects with type 2 diabetes, ≥25
Accepted 3 November 2011 years old, who sought care at the National Diabetes Center in Amman, Jordan, was enrolled. A structured
Available online 5 January 2012
interview and medical records provided the data. The instruments included a sociodemographic and clinical
questionnaire, a diabetes management self-efficacy scale, and a diabetes self-management behaviors scale.
Keywords:
Diabetes mellitus
Glycosylated hemoglobin was used as an index for glycemic control. The analyses are presented as
Self-management proportions, means (±S.D.), odds ratios, and 95% confidence intervals obtained from logistic regressions.
Education–counseling–behavioral interventions Results: Diet self-efficacy and diet self-management behaviors predicted better glycemic control, whereas
insulin use was a statistically significant predictor for poor glycemic control. In addition, subjects with higher
self-efficacy reported better self-management behaviors in diet, exercise, blood sugar testing, and taking
medication. The findings showed that more than half of the subjects did not have their diabetes under control
and that only 42% had attended diabetes education programs.
Conclusions: The majority of subjects did not have their diabetes controlled; their self-efficacy was low, and
they had suboptimal self-management behaviors. Therefore, strategies to enhance and promote self-efficacy
and self-management behaviors for patients are essential components of diabetes education programs.
Furthermore, behavioral counseling and skill-building interventions are critical for the patients to become
confident and be able to manage their diabetes.
© 2012 Elsevier Inc. All rights reserved.

1. Introduction
Diabetes mellitus (DM) is a major health problem worldwide with
its prevalence increasing, thus becoming a pandemic (Hjlem,
Mufunda, Nambozi, & Kemp, 2003). According to the World Health
☆ The dissertation study received some funding from the Deanship of Scientific
Research, University of Jordan.
☆☆ Contributors: Dr. Omar Al-Khawaldeh conceived the study questions;
designed the study; and did all data collection and analysis under the supervision,
direct guidance, and input from Dr. Al-Hassan and Dr. Froelicher. Dr. Al-Hassan read
numerous drafts of this manuscript and offered Arabic specific input for translation and
interpretation of this study. Dr. Froelicher provided conceptual and methodological
input into the study design and methods, provided expertise for theoretical approach
to the study of chronic disease management, guided all data analysis and reporting, and
cowrote the manuscript.
★
Conflict of interest: None.
⁎ Corresponding author. Faculty of nursing, Mutah University, P.O. Box (7),
Al-Karak, Jordan. Tel.: +962 777407911; fax: +962 532386789.
E-mail address: okhawaldh@yahoo.com (O.A. Al-Khawaldeh).
Organization (WHO, 2008), more than 180 million people worldwide
have DM. Moreover, a recent global estimation by the WHO indicated
that there would be 366 million people with DM by the year 2030
(Wild, Roglic, Green, Sicree, & King, 2004). In Jordan, the prevalence of
diabetes in adults ≥25 years of age is 13.4%, while an additional 9.8%
of Jordanians have impaired glucose tolerance (Ajlouni, Jaddou, &
Batiha, 1998). However, a recent study in Jordan reported that the age
standardized prevalence rate of diabetes and impaired fasting blood
glucose was 17.1% and 7.8%, respectively, with no significant
differences between women and men (Ajlouni, Khader, Batieha,
Ajlouni, & El-Khateeb, 2008). These results confirmed that the
prevalence of diabetes in Jordan is increasing. Diabetes has a
significant impact on the lives of individuals, their families, and the
health care system. The chronicity of DM and the potential for serious
complications often result in a significant financial burden and
decreased quality of life (Coffey et al., 2002), and major lifestyle
changes are needed for patients and their families. Poorly controlled
diabetes too often results in complications such as heart disease,
stroke, high blood pressure, blindness, kidney disease, nervous

1056-8727/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.jdiacomp.2011.11.002
 O.A. Al-Khawaldeh et al. / Journal of Diabetes and Its Complications 26 (2012) 10–16
system disease, amputations of legs, and premature death (Sratton
et al., 2000).
The burden of diabetes in Jordan is very high. Diabetes as a chronic
disease is one of the leading causes of morbidity and mortality in
Jordan (Zindah, Belbeisi, Walke, & Mokdad, 2004). Diabetes mellitus
was identified as a major risk factor for cardiovascular disease (Jaffe,
Nag, Landsman, & Alexander, 2006). Cardiovascular diseases are the
leading causes of death in many countries in the world and in Jordan
(Brown et al., 2009; International Diabetes Federation, 2006).
However, estimating the mortality burden has been challenging
because more than a third of countries of the world do not have any
data on diabetes-related mortality and also because existing routine
health statistics have been shown to underestimate mortality from
diabetes (Roglic et al., 2005). The increasing prevalence, the
emergence of complications as a cause of early morbidity and
mortality, and the enormous burden on health care systems make
diabetes a priority health concern.
The American Diabetes Association (ADA, 2007) describes type 2
DM as the most common form of DM, and its frequency increases with
advancing age. Self-management approaches have become a key
strategy of health care providers (Norris, Engelgau, & Narayan, 2001).
The majority of researchers and clinicians advocate that DM is a disease
that requires essential diabetes self-management (DSM) care abilities,
and that patients need to be taught the diabetes self-management skills
to become reliable, capable, and sufficiently responsible to take care of
themselves (Sousa, Zauszniewski, Musil, McDonald, & Milligan, 2004).
Self-management of type 2 DM is challenging and often requires
adherence to complex treatment regimen that requires skilful integra-
tion of healthy diet, regular exercise, optimum weight control, self-
monitoring of blood glucose, and medication adjustment into the daily
routine over long periods (Montague, Nichols, & Dutta, 2005). Diabetes
self-management is of great importance because the adoption of
healthy lifestyles behaviors will produce optimum glycemic control for
DM, which in turn will help minimize or prevent subsequent acute and
long-term complications of the disease (Norris et al., 2001; Sousa,
Zauszniewski, Musil, Price Lea, & Davis, 2005).
Diabetes is a lifelong disease that needs behavioral changes, most
often through education, counseling, skill building, and support
through behavioral interventions offered by health care providers, to
enable diabetic patients to perform self-care activities. Behavioral
changes are complex processes that are influenced by such factors as
knowledge, beliefs, attitudes, skills, motivation, and social support.
One of the key factors in attaining behavioral goals is self-efficacy, the
belief in one's capability to perform specific behaviors necessary to
achieve his or her goals (Bandura, 1997). The theory of self-efficacy by
Bandura in 1986, and advanced in 1997, was derived from social
learning theory and guides this study.
The theory of self-efficacy proposes that individual beliefs about
personal capabilities predict behavioral performance. In the case of
DSM, self-efficacy is the patient's confidence in his/her ability to
perform a variety of DSM behaviors. Improving DSM, prevention of
DM complications, and reducing health service utilization for patients
with DM are ongoing challenges for nurses and other health care
providers globally and in Jordan. Therefore, addressing the task-
related issues of DSM behaviors required by people with DM and
gaining a better understanding of factors that influence glycemic
control are of vital importance. Information about the current DSM
behaviors and their relationships with glycemic control can help to
identify groups at high risk for poor glycemic control. Identifying DSM
behaviors and diabetes management self-efficacy and examining
their effects on glycemic control can assist nurses in planning and
developing interventions and educational programs that enhance
self-care management and improve glycemic control. In addition,
results may enable nurses to evaluate those areas of diabetes
management self-efficacy and DSM behaviors in which patients
with DM may need additional support.
11
1.1. Study questions
This study proposes to answer the following research questions:
1. What are the levels of diabetes management self-efficacy?
2. What are the levels of DSM behaviors?
3. Does diabetes management self-efficacy predict DSM behaviors?
4. Do sociodemographic and clinical characteristics, self-efficacy
beliefs for diabetes management, and DSM behaviors predict
glycemic control in patients with type 2 diabetes?
2. Methods
2.1. Design, setting, and sample
A cross-sectional research was conducted using face-to-face
interviews. The study setting was an outpatient clinic in a National
Diabetes Center in Amman, Jordan. A consecutive–convenience
sampling technique was used to recruit the subjects. The sample
was Jordanian adults with type 2 DM who sought care for periodic
follow-up between July 15, 2008, and September 16, 2008. Subjects
were invited to participate if they (a) had type 2 DM for at least 1 year
prior to data collection, (b) were aged ≥25 years, (c) were mentally
competent and able to communicate verbally, and (d) were able to
provide informed consent. Pregnant women with gestational diabetes
and persons experiencing cognitive impairment and major compli-
cations of DM that might affect performance of DSM behaviors, such
as end-stage renal disease and blindness, were excluded. Stroke
patients who exhibited speech difficulties were also excluded. A
sample size calculation was used to determine the number of subjects
that would be needed to answer the study questions. The study was
approved by the University of Jordan Research and Ethics Committee.
Permission to access the subjects and their medical records was also
obtained from the Director of the National Diabetes Center.
2.2. Measurements
A structured interview guide was used that included three
questionnaires. The following section briefly describes the measure-
ments used in this study.
2.2.1. The sociodemographic and clinical characteristics
The sociodemographic (six items) and clinical characteristics
(five items) questionnaire was developed by the researcher based
on the literature. It contain questions about age, gender, years of
formal education, employment status, marital status, duration of
DM diagnosis, previous formal diabetes education, and monthly
income of the family. The presence of diabetes-related complica-
tions such as retinopathy, heart disease, dyslipidemia, and other
data including current type of treatment were extracted from the
subjects' medical records.
2.2.2. The Diabetes Management Self-Efficacy Scale (DMSES)
The Dutch–English version of the DMSES (Van der Bijl, van
Poelgeest-Eeltink, & Shortridge-Baggett, 1999) was used to measure
the diabetes management self-efficacy. The DMSES is a self-
administered summated rating scale containing 20 items that
assesses the extent to which respondents are confident that they
can manage their blood glucose level, foot care, medication, diet, and
level of physical activity. The DMSES asked the respondents to rate
their confidence using a scale ranging from 0 (can't do at all) to 10
(certain can do). Since an individual's self-efficacy is likely to vary
across self-management behaviors (i.e., one's ability to inject insulin
is not necessarily related to one's ability to follow a specific diet plan),
closer examination of behavior-specific self-efficacy was required in
this study. Factor analysis of DMSES in previous studies (Kara, Van der
12 O.A. Al-Khawaldeh et al. / Journal of Diabetes and Its Complications 26 (2012) 10–16

Bijlb, Shortridge-Baggettc, Astı, & Erguney, 2006; Van der Bijl et al.,
1999; Wu et al., 2007) revealed that the 20 items were clustered into
the following five subscales: diet or nutrition self-efficacy—represent-
ing the patients' confidence in carrying out tasks for figuring out meal
plans; exercise self-efficacy—representing self-efficacy related to
carrying out physical exercise; blood sugar testing and control—
reflecting self-efficacy related to monitoring and control of blood
sugar levels; foot care self-efficacy—representing self-efficacy to carry
out tasks of examining and inspecting feet for any changes such as
cuts; and medical treatment self-efficacy—representing self-efficacy
related to tasks like taking medication and taking care of their health.
The reported internal consistency of the total scale was adequate
(α=0.81) and test–retest reliability was acceptable (r=0.79) (Van
der Bijl et al., 1999). In this study, the Cronbach's alpha coefficient of
internal consistency reliability of DMSE was 0.91 for the total scale.
data collection. The final questionnaires of the interview guide were
designed based on the suggestions given by the panel of experts and
the respondents to the pilot study. Data of these 10 subjects were not
included in this report.
2.4. Procedures for data collection
The medical records of the subjects were reviewed while they
were waiting in the DM clinic, and those who met the inclusion
criteria were invited to participate. Before the interview, the primary
researcher approached the subjects in the waiting room and briefly
explained the purpose of the study. Those who met the inclusion
criteria were asked to sign a consent form. After the interviews were
completed, subjects' medical records were abstracted for the clinical
and laboratory data.

2.2.3. The revised Summary of Diabetes Self-Care Activities 2.5. Data analysis
Scale (SDSCA)
The SDSCA scale is a self-reporting measure of the frequency of For data management and analyses, the Statistical Program for
performing 13 diabetes self-care tasks and consisted of six subscales Social Sciences version 13 was used. The mean for each self-efficacy
of the DSM behaviors: diet, exercise, blood glucose testing, medica- subscale was calculated for the DMSES; a higher score indicated a
tion taking, foot care, and smoking behavior (Toobert, Hampson, & higher level of self-efficacy. For SDSCA scale, the mean number of days
Glasgow, 2000). The SDSCA asked the subjects to report the number for each subscale was calculated; higher scores indicated a higher
of days in the last 7 days in which they performed each self-care level of DSM performance. Descriptive statistics were used to describe
activity. If they were sick during the past 7 days, they were asked to sociodemographic and clinical characteristics of the sample. Multi-
reflect on the 7 days before they became sick. The SDSCA scale has variate logistic regression analyses were used to estimate relation-
been used widely, and evidence for the scale's reliability and validity ships between the subsets of sociodemographic characteristics,
has been demonstrated (Toobert et al., 2000). clinical characteristics, self-efficacy subscales, and DSM behaviors
and glycemic control. Significant predictors from each subset were
included in the final regression model to estimate variables that
2.2.4. Physiological measurements
predicted glycemic control. Also, a regression analysis examining the
The main outcome variable in this study was glycemic control as
effect of each self-efficacy subscale on its respective DSM behavior
measured by glycosylated hemoglobin (HbA1c). The HbA1c reflects
was carried out.
the average blood glucose level over the past 2 to 3 months and is
the primary indicator of whether a subject with diabetes has
maintained control over his or her blood glucose levels (Goldstein 3. Results
et al., 2004). According to ADA (2008) standards, glycemic control is
best judged by a combination of subjects' blood sugar testing results 3.1. Sociodemographic and clinical characteristics of the sample
and the current HbA1c. However, because not all subjects were
performing blood sugar testing at home, the result of HbA1c level on The sample consisted of 223 subjects; 56.1% were men, 89.7%
the day of interview was used in this study as an indicator of were married, 39% reported being employed, and 45.4% had a
glycemic control. The routine evaluation at each patient follow-up monthly income of less than 500 Jordanian dinars. Their average
visit required that HbA1c blood test was performed before the age was 56.9 (S.D.=±8.4) years, with a range of 33 to 77 years.
patient saw the physician. Therefore, all subjects' blood results for The average years of education were 13.43 (S.D.=±4. 6) years. The
HbA1c were obtained from the medical records, which were done in clinical characteristics of the sample are displayed in Table 1. The
the same day of the interview. Current guidelines for glycemic
control recommend HbA1c values of b7% as a treatment goal for
Table 1
most patients (ADA, 2008). Therefore, the HbA1c value was
Clinical characteristics of the sample (n=223)
categorized into controlled (good glycemic control) if HbA1c values
are b7% and uncontrolled (poor glycemic control) if HbA1c values Variables % n
are ≥7%. The HbA1c was analyzed using a high-performance Medication, oral only 58.7 131
chromatography method (Bio-Rad). Medication, insulin only 3.6 8
Medication, both oral and insulin 37.7 84
Diabetes complications
2.3. Translation procedure and pilot study Retinopathy 30.0 67
Dyslipidemia 85.2 190
Comorbidities
Once permissions to use the questionnaires were obtained, the
Hypertension 69.5 155
translation method described by Beaton, Bombardier, Guillemin, and Heart diseases 22.0 49
Ferraz (2000) was used. A panel of two DM experts, two doctoral- Lung diseases 4.0 9
prepared nurses who specialized in DM, and two laypersons who Kidney diseases 2.2 5
were competent in both Arabic and English languages was asked to BMI (kg/m2)
Normal (b25) 7.2 16
translate and back-translate the questionnaires. Any discrepancies
Overweight (25–29.9) 32.7 73
between the original and translated versions were discussed and Obese (≥30) 60.1 134
resolved based on the panel's suggestions. The instruments were pilot HbA1C level (most recent)
tested in 10 subjects who met the inclusion criteria at the same clinic b7 43.5 97
≥7 56.5 126
where the actual data collection was planned to verify the feasibility
Previous diabetes education 41.7 93
and acceptability of the instrument and to establish the time frame for
 O.A. Al-Khawaldeh et al. / Journal of Diabetes and Its Complications 26 (2012) 10–16 13

average duration since diagnosis with DM was 9.4 (S.D.=±6.9) Table 3

years. Only 7.2% had ideal body mass indexes (BMIs); 32.7% were Means (±S.D.) self-management behaviors per week by subjects with diabetes
(n=223)
overweight, and 60.1% were obese. The two most frequent comorbid
conditions were hypertension (69.5%) and heart disease (22%). A Subscale Subscale items Mean (±S.D.)
history of dyslipidemia was present in 85.2% of the sample. Current meana (±S.D.)

pharmacological treatment consisted of oral hypoglycemic medica- Diet 4.39 (1.4) Follows a healthy eating plan 3.85 (2.5)
tions in 8.7% and insulin only in 6%, and 37.7% used a combination of Follows eating plan over the 3.89 (2.3)
past month
insulin and oral hypoglycemic medications. Only 41.7% recalled
Eats 2 to 3 servings of fruits 5.07 (1.5)
having received DM education sessions. The mean value for Eats 5 or more servings of vegetables 5.26 (1.5)
glycemic control as measured by HbA1c was 7.5 (S.D.=±1.3); Eats high-fat foods 3.91 (1.7)
using a cut point according to the ADA, 43.5% or less than half had Exercise 1.84 (1.8) Participates in at least 30 min of 2.96 (2.7)
controlled DM, whereas 56.5% had a level of ≥7, suggesting that physical activity
Participates in specific exercise session 0.71 (1.7)
they were not having their DM under control. Results for each of the
Blood sugar testing Tests for blood sugar 1.71 (2.37)
four research questions are given next. 1.69 (2.4) Tests blood sugar as recommended 1.50 (2.8)
by health care provider (n=54)b
Foot care 3.79 (1.2) Checks feet 5.60 (2.4)
3.2. What are the levels of diabetes management self-efficacy? Inspects the inside of shoes 1.09 (2.1)
Washes feet 6.96 (0.3)
The highest self-efficacy score was for efficacy to carry out Dries between toes after washing 1.51 (2.6)
Taking medication Takes insulin (n=92) 6.01 (1.8)
prescribed medical treatment [mean (M)=8.9, S.D.=±1.0], and
6.13 (1.2) Takes oral hypoglycemic (n=215) 6.11 (1.8)
the lowest self-efficacy score was for efficacy to exercise
a
(M=6.2, S.D.=±1.7). Table 2 illustrates the mean (±S.D.) for Range: 0–7.
b
Subjects stated that they were not given any recommendation; therefore, 169
each item of the DMSE scale. The item “I am confident that I am participants were unable to answer this question.
able to visit my doctor according to treatment plan to monitor my
DM” scored the highest (M=9.3, S.D.=±1.4), followed by “I am
confident that I am able to take my medications as prescribed” reported DSM behaviors were blood sugar testing behavior (M=1.7,
(M=8.9, S.D.=±1.9). The lowest-scored items were “I am confident S.D.=±2.4) and exercise behavior (M=1.8, S.D.=±1.9). Table 3
that I am able to do enough exercise” (M=5.0, S.D.=±2.8) and “I shows also means and S.D.'s for the 15 items of the SDSCA calculated
am confident that I am able to adjust my eating plan when I am for the whole sample per week. The most frequently reported DSM
feeling stressed or anxious” (M=6, S.D.=±2.1). behaviors were washes feet (M=6.9, S.D.=±0.3) and taking oral
hypoglycemic agents (M=6.1, S.D.=±1.8). The lowest frequently
reported DSM behaviors were participation in specific exercise
3.3. What are the levels of DSM behaviors? sessions (M=0.7, S.D.=±1.7) and inspects the inside of shoes
(M=1.1, S.D.=±2.1).
Table 3 shows the means and S.D.'s for the five DSM subscales
behaviors. The most frequently reported DSM behaviors were
3.4. Does diabetes management self-efficacy predict DSM behaviors?
medication taking (M=6.1, S.D.=±1.7) followed by diet self-
management behavior (M=4.4, S.D.=±1.4). The least frequently
The univariate logistic regression analysis identified four of the
five self-efficacy subscales that were statistically significant predictors
of their respective DSM behaviors (Table 4). Namely, that stronger
Table 2
Means (±S.D.) for the DMSES (n=223) perceptions of diet [odds ratio (OR)=0.13, 95% confidence interval
(CI): 0.07–0.23], exercise (OR=0.07, 95% CI: 0.03–0.13), blood sugar
Items (scale 0=cannot do, 10=certain can do) Mean (±S.D.)
testing and control (OR=0.33, 95% CI: 0.12–0.91), and medical
I am confident that I am able to: treatment (OR=0.09, 95% CI: 0.03–0.31) self-efficacy were associated
Check my blood sugar if necessary 8.20 2.86 with higher levels of diet, exercise, blood sugar testing, and
Correct blood sugar when the sugar level is too high 8.08 1.33
medication taking self-management behaviors.
Correct my blood sugar when the blood sugar 8.80 1.00
level is too low
Choose the correct foods 6.83 2.02 3.5. Do sociodemographic and clinical characteristics, self-efficacy beliefs
Choose different foods and stick to a healthy 6.72 1.91 for diabetes management, and DSM behaviors predict glycemic control
eating pattern
in patients with type 2 diabetes?
Keep my weight under control 6.58 2.20
Examine my feet for cuts 8.38 1.43
Do enough exercise 5.04 2.79 A separate logistic regression analysis that estimated each of the
Adjust my eating plan when ill 7.25 1.30 three subsets of variables with glycemic control was conducted.
Follow a healthy eating pattern most of the time 6.52 2.01
Do more exercise if the doctor advises me to 6.46 1.84
When taking more exercise, I am able to adjust 6.98 1.31
my eating plan Table 4
Follow a healthy eating pattern when I am away 6.72 1.65 Logistic regression: prediction of association between self-efficacy subscales and
from home respective self-management behaviors (univariate analysis)
Adjust my eating plan when I am away from home 6.67 1.61
Self-efficacy variable OR 95% CI P value
Follow a healthy eating pattern when I am on holiday 6.64 1.77
Follow a healthy eating pattern when I am eating out 6.66 1.62 Diet 0.13 0.07–0.23 .00
or at a party Exercise 0.07 0.03–0.13 .00
Adjust my eating plan when I am feeling stressed 5.96 2.14 Blood sugar testing and control 0.33 0.12–0.91 .03
or anxious Medical treatment 0.09 0.03–0.31 .00
Visit my doctor according to treatment plan to 9.35 1.36 Foot care 0.43 0.09–2.05 .29
monitor my diabetes
Reference group: diet self-efficacy N7; exercise self-efficacy N7; blood sugar testing and
Take my medication as prescribed 8.87 1.87
control self-efficacy N7; medical treatment self-efficacy N7; foot care self-efficacy N7.
Adjust my medication when I am ill 8.45 1.41
Dependent variable: respective self-management behavior.
14 O.A. Al-Khawaldeh et al. / Journal of Diabetes and Its Complications 26 (2012) 10–16

Table 5 Table 6
Logistic regression between sociodemographic and clinical characteristics, diabetes Multivariate logistic regression of five variables and glycemic control (n=223)
management self-efficacy subscales, self-management behaviors, and glycemic control
(n=223) Variable OR 95% CI

Exercise self-management 0.60 0.30–1.17

Variable OR 95% CI P value
Diet self-management 0.21 0.10–0.43
Sociodemographic variables Blood sugar testing and control self-efficacy 0.29 0.07–1.10
Gender 1.11 0.57–2.15 .76 Diet self-efficacy 0.49 0.24–0.98
Age 1.62 0.90–2.93 .10 Insulin use 0.44 0.23–0.87
Income 0.90 0.50–1.60 .72
Reference group: exercise self-management N1.84; diet self-management N4.39; blood
Education 0.65 0.31–1.35 .25
sugar testing and control self-efficacy N7; diet self-efficacy N7; no insulin use. Outcome
Marital status 1.29 0.51–3.27 .58
measure: glycemic control b7.
Employment 0.75 0.38–1.46 .39
Clinical variables
Duration of diabetes 0.89 0.45–1.74 .73
Oral hypoglycemic agents use 1.38 0.24–7.94 .71
Insulin use 0.29 0.14–0.59 .00
Diabetes education 1.38 0.78–2.47 .27 and insulin use (OR=0.4, 95% CI: 0.2–0.9)—were statistically
BMI 0.62 0.20–1.87 .39 significant independent predictors of glycemic control.
Self-efficacy variables
Diet 0.30 0.15–0.59 .00
Exercise 0.58 0.30–1.14 .11
Blood sugar testing and control 0.19 0.05–0.69 .01 4. Discussion
Medical treatment 0.60 0.18–3.10 .54
Foot care 1.69 0.39–7.28 .48 The main purpose of this study was to examine the significance of
Self-management variables diabetes management self-efficacy and DSM behaviors in predicting
Diet 0.13 0.07–0.26 .00
Exercise 0.46 0.24–0.88 .02
glycemic control in adult subjects with type 2 DM. The sample was
Blood sugar testing 1.66 0.86–3.20 .13 composed of Jordanian adult patients with type 2 DM who were
Taking medication 0.81 0.36–1.79 .60 visiting the outpatient clinics of the National Diabetes Center for
Foot care 0.65 0.34–1.26 .21 regular follow-up. The study findings indicated that more than half of
Reference group: female; age ≥58; income ≥500; education ≥12; married; not the participants had uncontrolled HbA1c levels, suggesting poor
employed; duration of DM b9 years; no oral hypoglycemic agents; no insulin use; no control of their DM. These study findings were consistent with the
diabetes education; BMI b25 kg/m2; diet self-efficacy N7; exercise self-efficacy N7; ADA (2001) findings in that less than half of subjects with type 2
blood sugar testing and control self-efficacy N7; medical treatment self-efficacy N7; foot
care self-efficacy N7; diet self-management N4.39; exercise self-management N1.84;
diabetes achieve ideal glycemic control (HbA1cb7.0%). One possible
blood sugar testing N1.69; medication taking N6.13; foot care N3.79. Outcome measure: explanation of this finding is that this sample of Jordanian subjects
glycemic control b7. demonstrated low levels of self-management behaviors that may
contribute to their higher levels of HbA1c. The low levels of DSM
behaviors may be attributed to a number of potential barriers to DSM
behaviors such as social, cultural, financial, medical, and other factors
not measured in this study that complicated the subjects' regimen
The significant predictors of glycemic control from each subset of and may have resulted in low adherence to self-care recommenda-
variables were included in a logistic regression model to estimate tions and subsequently contributed to poor glycemic control. The
their independent effects on glycemic control. In the first set, the most frequently performed self-care behaviors were medication
sociodemographic and clinical variables were entered separately in taking and dietary adherence; whilst the least performed behaviors
the regression model. Table 5 illustrates that of the five clinical were blood sugar testing, exercise, and foot care. Most likely, each
variables, only insulin use had a statistically significant indepen- DSM behavior requires different types of knowledge, skills, as well as
dent effect on glycemic not being controlled (OR=0.3, 95% CI: 0.1– different levels of motivation and confidence. The subjects may differ
0.6). The finding shows that subjects who were using insulin were in their perceptions of the importance of each DSM behavior,
more likely to have a high HbA1c values (uncontrolled). The perceiving medication taking as most important for DM management.
second regression analysis indicated that two of the five self- In addition, it may be that there are more barriers to diet, exercise,
efficacy subscales were statistically significant predictors of blood sugar testing, and foot care practices. The study findings
glycemic control (Table 5). Participants who perceived stronger indicated that the most statistically significant predictors of glycemic
diet self-efficacy were more likely to have a lower value of HbA1c control were diet self-efficacy, diet self-management behavior, and
(controlled) (OR=0.3, 95% CI: 0.1–0.6); also, those who perceived insulin use. Furthermore, the analysis suggested that subjects with
stronger blood sugar testing and control self-efficacy were more greater diet self-efficacy and greater diet self-management behavior
likely to have a low value of HbA1c level (controlled) (OR=0.2, had lower HbA1c levels, whereas being on insulin was associated with
95% CI: 0.05–0.7). In the third regression analysis, we found that higher HbA1c levels. These findings are consistent with previous
two of the five self-management behaviors were statistically studies that indicated that greater diet self-efficacy (Johnston-Brooks,
significant predictors of glycemic control (Table 5). Namely, Lewis, & Garg, 2002; Sturt, Whitlock, & Hearnshaw, 2006; Wattana,
subjects who more frequently reported diet self-management Srisuphan, Pothiban, & Upchurch, 2007) and greater diet self-
behaviors were more likely to have a lower value of HbA1c management behavior (Heisler, Smith, Hayward, Krein, & Kerr,
(controlled) (OR=0.1, 95% CI: 0.1–0.3). In addition, those who 2003; Johnston-Brooks et al., 2002; Jones et al., 2003) were associated
more frequently reported exercise self-management behaviors with better glycemic control. However, in our study, insulin use was a
were more likely to have a lower value of HbA1c (controlled) significant predictor of poor glycemic control; a likely explanation
(OR=0.5, 95% CI: 0.2–0.9). might be that insulin is added to the treatment therapy in subjects
Table 6 shows results of a final parsimonious regression model with type 2 DM as a result of worsening glycemic control. The study
that included all statistically significant predictors from the subsets findings showed that more than the half of the subjects who used
analysis shown in Table 5. This model shows that three out of the five insulin as part of their treatment plan had HbA1c levels higher than
variables tested simultaneously—diet self-efficacy (OR=0.5, 95% CI: the recommended level of b7% as suggested by the ADA. This result
0.2–0.98), diet self-management behavior (OR=0.2, 95% CI: 01–0.4), may suggest that insulin self-management (injection compliance),
 O.A. Al-Khawaldeh et al. / Journal of Diabetes and Its Complications 26 (2012) 10–16
the prescribed regimen, or both were inadequate to achieve glycemic
control. Alternatively, subject's needing to use insulin may have more
severe DM, and insulin use is therefore a confounder by indication
rather than a predictor of poor control. A prospective longitudinal
study would be needed to further discern these relationships.
Furthermore, the findings that insulin users have poor glycemic
control may be an indication that subjects did not have sufficient
knowledge, abilities, or skills to manage their insulin optimally,
suggesting a need for further education, counseling, and behavioral
skill building. Given that the setting where subjects were recruited
offers a comprehensive physician-directed, nurse-led self-manage-
ment education program, it is possible that additional education,
counseling, and behavioral skill building may be needed as part of an
ongoing program. It is likely that patients may have forgotten the
content required for self-management and are in need of a “booster
dose” for optimal long-term self-management of their chronic illness.
The study findings suggested that subjects' beliefs in their
capabilities to perform self-management behaviors varied according
to the required behavior. For example, subjects who may be more
confident in following a healthy diet plan may have lower confidence
in their ability to exercise regularly. This study finding supports
Bandura's (1977) theory that people tend to avoid tasks and
situations that they believe exceed their capabilities, while pursuing
those that they feel competent to perform. In this sample, greater self-
efficacy significantly predicted greater self-management behaviors
with respect to diet, exercise, blood sugar testing, and medication
taking. These study findings are consistent with numerous previous
studies that have shown that specific self-efficacy ratings were
significant predictors of DSM behaviors (Nelson, McFarland, & Reiber,
2007; Wang & Shiu, 2003; Wu et al., 2007). The study findings
indicated that less than half of the subjects had attended previous DM
education programs, of whom more than half had uncontrolled
HbA1c levels which may account for the low DM self-management
behaviors. Also, it was demonstrated that attending diabetes
education classes did not predict glycemic control. This finding may
suggest that education alone may not have been sufficient to build the
necessary confidence, motivation, and required skills to perform all
necessary self-management behaviors. Most likely, a comprehensive
program of education, counseling, and behavior interventions
through skill building is needed over a period for a person with DM
to acquire, use, and maintain the necessary self-management skills.
Patients with DM need counseling and behavioral skill building
involving practical problem-solving techniques and coping skills in
order to overcome barriers to a complex and long-term regimen.
Additionally, a one-time educational intervention may not be
sufficient for some subjects, and refresher courses may need to be
provided for those who demonstrated low self-management skills on
follow-up assessment to raise self-efficacy and improve self-
management.
4.1. Limitations
Like most studies, the study has a number of limitations that need
to be considered when interpreting the study findings. The study used
a cross-sectional design which precludes definitive causal interpre-
tations between self-efficacy beliefs and DSM behaviors and glycemic
control. A second limitation is that the subjects were recruited from a
single clinic using convenience sampling. However, the National
Diabetes Center does receive referrals from all over Jordan, which
would have increased the representativeness of the sample. Third, the
inclusion criteria allowed for subjects to learn and manage their DM
by requiring at least 1 year since diagnosis. Furthermore, severely ill
subjects with DM have also been excluded to avoid subject burden.
Both the inclusion and exclusion criteria, while well justified, were
likely to not represent subjects with less than 1 year since diagnosis
15
and those with severe complications of DM, affecting generalizability.
Therefore, given the reported limitations, the sample may not be
representing all Jordanian adult subjects with DM. Finally, data on
self-management were measured with self-report scales and may be
limited by recall bias and/or social desirability biases, making findings
from this study contingent upon the accuracy of subject's self-
evaluation. Nevertheless, our study yielded a number of new insights
and confirmed previous findings from other studies.
4.2. Implications for diabetes educators
The findings of this study have important implications for DM
education and clinical practice. The key findings of this study suggest
the importance of incorporating self-efficacy enhancing interventions
in DSM programs, emphasizing the need to build confidence specific
to a given self-management behavior as part of the clinician's
communication or as a component of an educational, counseling,
and skill-building program that can increase the likelihood of
maintaining the preferred outcomes of glycemic control. Diabetes
nurse educators and other health care providers need to develop
effective methods for promoting self-management for adult Jordanian
subjects. A combined approach of education, counseling, and
behavioral interventions in DSM behaviors is recommended to
enhance effective DSM. Diabetes educators must emphasize to
subjects and their families that the DM education needs to be an
ongoing process starting initially at the time of diagnosis as well as
throughout the lifelong disease process. Optimal use of blood sugar
testing requires proper interpretation of the data. Subjects should be
taught how to interpret and use the data to adjust food intake,
exercise, or pharmacological therapy to achieve specific glycemic
goals. While physical activity is known to be an important aspect of
DSM, those who did even minimal levels of exercise reported walking
as the most common form of exercise. This finding suggests that
nurses need to spend additional efforts to encourage diabetic subjects
to increase and maintain a regular habit of walking as part of a
comprehensive lifestyle intervention. The results suggest that insulin
self-management should be assessed and evaluated regularly to
monitor the accuracy of insulin dosing. Nurses and other health care
providers' initial interactions with subjects should include not only an
assessment of their knowledge about DM but also a thorough review
of their current levels of self-efficacy in relation to their ability to
manage their own care. This assessment may assist in determining
subject's individualized goals and strategies.
5. Conclusions
This study provides an understanding of the factors contributing to
glycemic control in adult Jordanian subjects with type 2 DM. The
suboptimal self-management behaviors reported and the low levels
of subjects' participation in diabetes education programs are alarm-
ing. Education, counseling, and behavioral skill-building programs
that focus on self-efficacy enhancing interventions are required to
achieve better glycemic control and better health outcome. This study
was carried out in Arabs with type 2 diabetes; the findings from this
study can guide health professionals to better understand the extent
to which different self-efficacy perceptions and self-management
behaviors affect glycemic control. Furthermore, these study findings
provide valuable information about the types of assessment necessary
for the long-term management of persons with a type 2 diabetes.
Since immigrant populations take their health practices with them
when they resettle, the key study findings may also be relevant to
Arabs living in Europe and the United States. The extent to which our
findings pertain to other Arabic populations and Arabs who have
emigrated to the West needs further assessment.
16 O.A. Al-Khawaldeh et al. / Journal of Diabetes and Its Complications 26 (2012) 10–16
Acknowledgment
We would like to extend our deep appreciation to Professor Kamel
Al-Ajlouni, president of the National Center for Diabetes, Endocrino-
logy, and Genetics, and all the staff for providing access, support, and
facilitating data collection from the center. Lastly, the authors are
indebted to the patients who generously volunteered their time and
participated in the study.
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