hej

Article

Health Education Journal

Applying the transtheoretical

72(2) 189­–202
© The Author(s) 2012
Reprints and permission: sagepub.
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DOI: 10.1177/0017896912437495
change in type 2 diabetic patients hej.sagepub.com

Shu-Ping Lina and Ming-Jye Wanga,b

aDepartment of Technology Management, Chung Hua University, Taiwan
bNational Taiwan University Hospital Hsin-Chu Branch, Taiwan

Abstract
Background: Long-term behaviour change in type 2 diabetic patients may provide effective glycemic
control.
Purpose: To investigate the key factors that promote behaviour change in diabetic subjects using the
transtheoretical model.
Methods: Subjects were selected by purposive sampling from type 2 diabetes outpatients. Self-admin-
istered questionnaires were used to collect the data related to the stages of behavioural change. HbA1C*
values were measured to evaluate glycemic control. Data were analyzed with analysis of variance (ANOVA),
multiple regression and multinomial logistic regression.
Results: Routine management of diabetes was a key factor in behaviour change, which correlated indi-
rectly with HbA1C values through compliance and was positively affected by social support. Undermining
from family or friends was directly associated with HbA1C.
Conclusions: Based on factors influencing stages of behaviour change in diabetic subjects, tailoring a pro-
gramme to help patients balancing life-style with diabetes, strengthening the patients’ perceived confidence
in routine management, and establishing a patient-friendly environment as well as support systems may show
promise for changing the behaviours in all diabetic patients.

Keywords
self-efficacy, social support, stages of change, transtheoretical model, type 2 diabetes

Introduction
Type 2 diabetes is a major global public health challenge facing the 21st century.1 It is estimated
that, globally, there are currently 245 million people with diabetes and within 20 years that number
will increase to 380 million.2 In order to achieve effective diabetes control, patients are being

Corresponding author:
Ming-Jye Wang, National Taiwan University Hospital Hsin-Chu Branch, No. 25, Lane 442, Sec.1, Jingguo Rd., Hsinchu
City 300, Taiwan
Email: jye9129@gmail.com

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190 Health Education Journal 72(2)

educated to eat a healthy diet, exercise regularly, monitor blood glucose, and take medications as
prescribed. However, many healthcare professionals have expressed frustration and concern that,
regardless of their best efforts, patients do not regularly monitor their blood glucose, do not follow
the recommended diet and exercise programme, and do not comply with doctors’ orders.3,4 To date,
fewer than one-half of all diabetic patients receive appropriate care and enjoy a good quality of
life.5,6 In addition, more than 95% of diabetes care is done by the patient.3 Long-lasting behaviour
change is needed for patients to achieve more effective self-care, but this change is complex and
not easily achieved by the patients because it requires a strong intention to change,4 and also more
emotional and psychological support.7 In consideration of improving the overall quality of care for
diabetic patients, the psychological factors and supporting mechanism are of great importance.
Bandura8 proposed that a change in human behaviour is not just determined by a single factor
but by the results of interaction among three factors, including personal factors, environmental
influences and behaviour. Behaviour change, in other words, is explored from multiple perspec-
tives, emphasizing the importance of individual cognition process on behaviour change. Social
cognitive theory, which recognizes that social interactions and experiences influence an individu-
al’s cognitive development, has been widely applied to health behaviour and other fields. Social
support is an important step in the self-regulation process of social cognitive theory9 and self-
efficacy is the core of psychological determinants of behaviour.10 Previous studies have reported
that social support has a positive impact on glycemic control and adherence,11,12 and plays an
important role in helping patients make and maintain meaningful behavioural changes success-
fully.11,13,14 Yet, to sustain the behavioural changes persistently, patients should adhere to the belief
– that is, the self-efficacy – which relates to achieving glycemic control and good compliance.15–17
According to the study of Nakahara et al.,18 social support influences HbA1C values indirectly
through increased self-efficacy. Self-efficacy directly reinforces adherence, and adherence corre-
lates directly with HbA1C, so psychosocial interventions may be useful for long-term good blood
glucose control in patients with type 2 diabetes.
The transtheoretical model is another model that can be applied in intervention designed to
assess behaviour change in people with diabetes. Characterized by treating behaviour change as a
dynamic process,19 it includes five stages of change that individuals progress through when chang-
ing behaviour: (1) pre-contemplation; (2) contemplation; (3) preparation; (4) action; and (5) main-
tenance.20,21 These five stages of behaviour change rarely follow a linear path from beginning to
end,22,23 and may be more like a spiral pattern of change by beginning at any one stage and moving
around through different stages.21 The majority of previous studies that have applied the transtheo-
retical model to the field of diabetes have demonstrated significant positive effects; that is, increases
in the frequency of self-monitoring of blood glucose levels in diabetic patients who accepted inter-
ventions based on the transtheoretical model,24,25 significantly higher percentages of patients
improving exercise behaviour,26 improved eating behaviour of participants after intervention,27 and
significantly lower mean HbA1C values in later stages of change rather than earlier stages.25
Therefore how or what factors have contributed to maintaining behaviour change continuously,
without resulting in relapse, is an issue worth probing.
In overview, to achieve effective self-management, it would be helpful to set priorities for
implementation and develop effective strategies by further identifying the factors that influence the
stages of change. Therefore this research combined the concepts of social cognitive theory and the
transtheoretical model to investigate the key factors of behaviour change in people with diabetes.
The aims of this study were: (1) to assess the differences in social support, self-efficacy, compli-
ance, and HbA1C values among diabetic patients at different stages of behaviour change, based on
their daily behaviours of blood glucose monitoring, regular exercise and diet control; (2) to

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Lin and Wang 191

examine the relationships between social support, self-efficacy, compliance, and HbA1C values;
(3) to investigate the key factors that influence daily behaviours of blood glucose monitoring, regu-
lar exercise, and diet control at stages of behaviour change; and (4) to provide references for dia-
betic patients to develop behaviour change strategies.

Methods
Study participants
Subjects were selected from outpatients with type 2 diabetes who had visited the Department of
Metabolism of a regional teaching hospital in Hsinchu City, Taiwan, for one or more years. We
used a purposive sampling method to recruit eligible patients during all clinic sessions occurring in
December 2009. Inclusion criteria were to have a primary diagnosis including up to three diagnos-
tic codes in the International Classification of Diseases, Ninth Revision, Clinical Modification:
250. A total of 317 self-administered questionnaires were collected.

Research scale design

The data used in this study were collected from self-administered questionnaires and HbA1C val-
ues of patients’ laboratory assays on the date closest to the study period. The contents of the ques-
tionnaires included: patients’ characteristics; compliance; stages of behaviour change; social
support; and self-efficacy. The questionnaire was constructed through literature review and refer-
enced according to the diabetes care profile of the University of Michigan Diabetes Research and
Training Centre.28 It was reviewed by an expert panel, including two specialist physicians, two
dietitians, one social worker, and one health educator, then amended, pre-tested, and revised before
the final version. Detailed items were described as follows:

Patients’ characteristics. Patients’ characteristics included gender, age, education, duration of diabe-
tes, family history of diabetes, and treatment pattern.

Compliance. Compliance was derived from the patients’ perception of following physicians’ orders
for taking medicine within one year prior to the study. It was scored by a five-point Likert scale
ranging from 1 = rarely compliant to 5 = fully compliant.

Stages of behaviour change. The five stages of change are evaluated according to Prochaska and
Diclemente,20,21 who proposed the transtheoretical model. The questionnaire used in this study
consisted of three dimensions: blood glucose monitoring, regular exercise, and diet control, for
which patients checked the best description of their stage at present for each separate dimension.
Questions were stated as previously reported by Byrd-Bredbenner and Finckenor;29 for example,
which statement best describes you? (self-monitoring at least one time per week): (1) I am not
monitoring my blood sugar, and I have no plan to do in the next six months; (2) I am not monitoring
my blood sugar, but I plan to do in the next six months; (3) I am not monitoring my blood sugar,
but I plan to do in the next 30 days; (4) I am monitoring my blood sugar, but I have been doing so
for less than the past six months; (5) I am monitoring my blood sugar, and I have been doing so for
more than the past six months. For the other dimensions, another action phrase is substituted, such as
exercising regularly at least three times every week, 30 minutes/each time, doing diet control every
day. The numbering of answers (one through five) corresponds to the five stages of change20,21 as

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192 Health Education Journal 72(2)

follows: (1) pre-contemplation stage; (2) contemplation stage; (3) preparation stage; (4) action
stage; and (5) maintenance stage.

Social support. The questionnaire used in this study was referenced by the diabetes care profile of
the University of Michigan Diabetes Research and Training Centre28 and included three dimen-
sions and 11 items; that is, the patient felt support from his family or friends, emotional support
(three items); his/her family or friends did not express critical or negative behaviour, no under-
mining (three items); and his/her family or friends gave assistance and support, helping relation-
ships (five items). Each item was scored on a five-point Likert scale (from 1 = strongly disagree
to 5 = strongly agree).

Self-efficacy. The measurement of self-efficacy in this study was referenced by the Diabetes Self-
Efficacy Scale (DSES)30 and Perceived Diabetes Self-Management Scale (PDSMS),31 and
included five dimensions and 20 items; that is, the patient’s belief of routine management in dia-
betes care (six items); the efficacy of diet management (four items); the confidence of self-treat-
ment (seven items); the perceived ability of coping with problems (two items); and the regular
exercise intention (one item). Each item was scored on a five-point Likert scale (1 = strongly
disagree to 5 = strongly agree)

HbA1C measurement. HbA1C data were collected from each patient’s laboratory assay on the date
closest to this study, performed by Cation-Exchange high-performance liquid chromatography
(HPLC) with demonstrated specificity and sensitivity of < 5%.

Data analysis
Descriptive statistics, such as mean, standard deviation, and frequency were used to investigate the
distribution of patient characteristics, HbA1C values and stages of behaviour change. Analysis of
variance (ANOVA) was used to analyze the psychosocial factors, compliance, and HbA1C values
in relation to the differences in stages of behaviour change. Multiple regression analysis was used
to examine the relationship between psychosocial factors, compliance, stages of behaviour change
and HbA1C values. Multinomial logistic regression was used to assess the influences of psychoso-
cial factors and compliance in stages of behaviour change. SPSS 15.0 was used for all analyses. A
confirmatory factor analysis (CFA) was used to examine the reliability and validity of the self-
administered questionnaires.

Results
Study participant characteristics
Among the 317 participants, 45.4% were men and 54.6% were women. Those aged > = 65 accounted
for 34.7% and those with 5–14 years of duration of diabetes for 45.4%. Those with family history
of diabetes accounted for 64.7%, and 70.3% were receiving oral medication. About one-third
(36.6%) had a primary school education. Mean HbA1C values were 7.88%, for which 42.3% were
higher than 8%. In terms of stages of behaviour change, approximately three-quarters of diabetic
patients (74.1% and 77.6% had blood glucose monitoring and diet control behaviours respectively)
were in action and maintenance stages, 14.5% or 11.0% were in pre-contemplation stage. Of the
diabetic patients, 65.6% had regular exercise and were in action and maintenance stages and 18.3%
were in pre-contemplation stage (Table 1).

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Lin and Wang 193

Table 1. Patient characteristics, HbA1C, and stage of change

N % n %
Sex Family history of diabetes
Male 144 45.4 Yes 205 64.7
Female 173 54.6 No 112 35.3
Age Duration of diabetes
< 49 <4
= 55 17.4 = 75 23.7
50–54 49 15.5 5–9 64 20.2
55–59 65 20.5 10–14 80 25.2
60–64 38 12.0 15–19 48 15.1
> 65 > 20
= 110 34.7 = 50 15.8
Treatment pattern Education
Oral medication 223 70.3 Elementary school 116 36.6
Insulin use 51 16.1 Middle school 62 19.6
Both of the above 43 13.6 High school 79 24.9
HbA1C (%) 246 College or higher 60 18.9
Mean(SD): 7.88(1.39)
<7 73 29.7
7–8 69 28.0
>8
= 104 42.3
Stage of change glucose monitoring regular exercise diet control
glucose monitoring     regular exercise      diet control
             n        %          n          %         n         %
Pre-contemplation      46      14.5      58      18.3     35     11.0
Contemplation         18       5.7      18       5.7     12             3.8
Preparation             18       5.7      33      10.4     24             7.6
Action                34      10.7      53      16.7     73          23.0
Maintenance         201      63.4        155      48.9      173          54.6

Reliability and validity of the measurement

The variables of psychosocial factors derived from the two main core concepts of social cognitive
theory are social support and self-efficacy. Based on the implications, the items in the social sup-
port questionnaire were classified into three dimensions and the items in the self-efficacy question-
naire were classified into five dimensions. The confirmatory factor analysis (CFA) was used to
examine the reliability and validity of the self-administered questionnaires, the results were as
follows: social support included three dimensions (emotional support, no undermining and helping
relationships) and 11 items, for which Cronbach’s α ranged from 0.70 to 0.84, the factor loadings
by CFA were 0.66–0.91, 0.42–0.86, and 0.74–0.85 respectively. Self-efficacy included five dimen-
sions (routine management, diet management, self-treatment, perceived ability, and regular exer-
cise intention) and 20 items, for which Cronbach’s α ranged from 0.79 to 0.89, the factor loadings
by CFA were 0.47–0.89, 0.60–0.96, 0.36–0.81, 0.66–0.99, and 1, respectively. The Cronbach’s α
mentioned above were all > 0.70 demonstrating higher consistency of the scales. Factor loadings
were almost all >= 0.4, indicating good construct validity.

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194 Health Education Journal 72(2)

Table 2. ANOVA of the social support, self-efficacy, compliance, and HbA1C values at stages of behaviour
change

Pre-contemplation Contemplation/ Action (3) Maintenance F Post Hoc

(1) preparation(2) (4)
Mean SD Mean SD Mean SD Mean SD
Glucose
monitoring
HbA1C 7.35 1.15 8.25 1.40 7.87 1.42 7.95 1.42 2.64* 1 < 2
Compliance 4.36 .84 4.29 .71 4.33 1.02 4.59 .65 3.09* 2 < 4
Self-efficacy 3.11 .63 3.40 .41 3.43 .45 3.49 .44 7.57*** 1 < 3, 1 < 4
Social support 3.55 .44 3.56 .38 3.64 .47 3.67 .48 1.09
Regular exercise
HbA1C 7.80 1.28 8.11 1.55 7.94 1.33 7.80 1.41 .61
Compliance 4.43 .74 4.13 .82 4.45 .92 4.66 .58 6.9*** 2 < 4
Self-efficacy 3.10 .50 3.16 .40 3.45 .41 3.60 .42 25.02*** 1 < 3, 1 < 4
2 < 3, 2 < 4
Social support 3.49 .49 3.46 .41 3.63 .49 3.75 .43 7.85*** 1 < 4,2 < 4
Diet control
HbA1C 7.85 1.12 8.50 1.57 7.95 1.32 7.70 1.41 2.66* 4 < 2
Compliance 4.15 .87 4.06 1.06 4.41 .75 4.69 .54 11.57*** 1 < 4, 2 < 4
Self-efficacy 2.87 .47 3.27 .35 3.41 .43 3.56 .44 24.98*** 1 < 2, 1 < 3
1 < 4, 2 < 4
Social support 3.42 .46 3.51 .43 3.70 .43 3.68 .48 4.39** 1 < 3, 1 < 4
*P < .05; ** P < .01; *** P < .001.

Differences in social support, self-efficacy, compliance, and HbA1C values at

stages of behaviour change
The stages of change in the contemplation and preparation stages represented patients who had
already planned but not yet acted, which accounted for a lower percentage of participants, 3.8–
10.4% (Table 1); therefore we combined them into contemplation/preparation stage (currently do
not but have plans to do) to analyze in this study. Thus the stages became four stages: pre-contem-
plation, contemplation/preparation, action, and maintenance stages. The results are shown in Table
2, and were determined by ANOVA. With regard to regular exercise and diet control, the scores of
social support in later stages of behaviour change were higher than those in the earlier stages and
had statistical significance. The scores of self-efficacy and compliance in blood glucose monitoring,
regular exercise, and diet control in later stages of behaviour change were higher than those in the
earlier stages. Especially self-efficacy showed a gradually increasing trend from pre-contemplation
to maintenance stages of behaviour change. HbA1C values in contemplation/preparation stage were
higher than those in other stages.

Relationship between social support, self-efficacy, compliance, and HbA1C values

First, we identified the impact of social support, self-efficacy and compliance on HbA1C values
using multiple regression analysis controlling for stages of change, as shown in Table 3. The
greater patients’ compliance, the lower their HbA1C values; and the more family or friends
expressed critical or negative behaviour, the higher HbA1C values. Second, we examined the

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Lin and Wang 195

Table 3. Multiple regression analysis for the relationship among social support, self-efficacy, compliance,
stages of behaviour change, and HbA1C values

Independent variable Dependent variable

HbA1C Compliance
(Intercept) 9.09*** 3.27***
Pre-contemplation 0 0
Contemplation/preparation −.04 −.22
Action .28 −.31
Maintenance −.26 −.22
Compliance −.28*
Social support
Emotional support .12 .08
No undermining −.28* .08
Helping relationships .31 −.09
Self-efficacy
Routine management −.04 .31**
Diet management −.03 .02
Self-treatment .02 −.08
Perceived ability −.06 .05
Exercise intention −.08 .00
F 1.79* 2.80**
R2 .09 .10
*P < .05; **P < .01; ***P < .001.

effects of social support and self-efficacy on compliance, and the results demonstrated stronger
efficacy of routine management in diabetic patients corresponding to higher compliance. Finally,
we analyzed the influence of social support on various dimensions of self-efficacy: the three
dimensions of social support (emotional support, no undermining and helping relationships)
enhanced the efficacy of routine management; increased confidence of diet management required
the support of helping relationships and no undermining from family or friends; the ability of self-
treatment depended on emotional support and helping relationships; and the perceived ability of
coping with problems relied on emotional support and no undermining which also affected the
exercise intention (Table 4), among the relationships shown in Figure 1.

Key factors influencing the stages of behaviour change

Multinomial logistic regression was used to further assess the influences of psychosocial factors
and compliance in stages of behaviour change. As shown in Table 5, the routine management of
diabetes was the key factor that influenced the stages of behaviour change in blood glucose moni-
toring, regular exercise, and diet control. The efficacy of routine management was higher in other
stages than that in the pre-contemplation stage, which was 13.32 times higher, especially in blood
glucose monitoring. Regular exercise and diet control were 8.76, 9.45, 14.56 times and 9.86, 5.46,
7.24 times higher in other stages than that in the pre-contemplation stage, respectively. Factors
affecting the maintenance stage were self-treatment, exercise intention and diet management,
which were 5.63, 2.32, and 4.45 times higher by comparing maintenance to pre-contemplation
respectively. Social support did not have a significantly direct effect on stages of behaviour change.

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196 Health Education Journal 72(2)

Table 4. Multiple regression analysis for the relationship among stages of behaviour change, social support,
and self-efficacy

Independent variable Dependent variable

Self-efficacy
Routine Diet Self-treatment Perceived Exercise
management management ability intention
(Intercept) 1.59*** 1.42*** 2.10*** 1.06** 1.22**
Pre-contemplation 0 0 0 0 0
Contemplation/preparation .11 −.12 .02 −.13 .09
Action .10 −.11 .01 .18 .03
Maintenance −.04 −.01 −.05 .14 .01
Social Support
Emotional support .18** −.03 .23*** .22* −.04
No undermining .07* .11* .04 .31*** .43***
Helping relationships .31*** .49*** .18*** .03 .15
F 14.35*** 9.48*** 12.92*** 7.28*** 5.83***
R2 .22 .16 .21 .13 .11
*P < .05; **P < .01; ***P < .001.

Figure 1. Relationship among social support, self-efficacy, compliance, and HbA1C

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 Table 5. Influences of compliance, self-efficacy, and social support at stages of behaviour change used by multinomial logistic regression analysis

Contemplation/preparationVs. pre- Action vs. pre-contemplation Maintenance vs.

contemplation pre-contemplation
B Exp(B) 95%CI B Exp(B) 95%CI B Exp(B) 95%CI
Lin and Wang

Glucose monitoring
(Intercept) −3.54 −4.08 −5.76**
Compliance −.51 .60 .32–1.11 −.39 .68 .37–1.25 .01 1.01 .60–1.70
Self-efficacy
Routine management 2.59*** 13.32 3.19–55.57 1.05 2.86 .69–11.80 1.71** 5.53 1.87–16.35
Diet management −.95* .39 .15–.97 −.02 .98 .35–2.75 −.40 .67 .31–1.44
Self-treatment 1.31 3.70 .91–14.97 .89 2.44 .61–9.79 1.73*** 5.63 1.94–16.33
Perceived ability −.47 .62 .31–1.25 −.37 .69 .34–1.39 −.42 .66 .38–1.15
Exercise intention .11 1.11 .67–1.86 .23 1.26 .75–2.14 .11 1.12 .75–1.66
F and Cox-Snell R2 F = 66.85*** Cox-Snell R2 = .21
Regular exercise
(Intercept) 2.95 −3.57 −8.59***
Compliance −.68* .51 .29–.89 −.29 .75 .42–1.35 .07
Self-efficacy
Routine management 2.17*** 8.76 2.39−32.03 2.25*** 9.45 2.75–32.50 2.68*** 14.56 4.82–43.96
Diet management −.55 .58 .26–1.30 −.34 .71 .31–1.63 −.39 .68 .33–1.39
Self-treatment −1.04 .35 .11–1.15 −1.38* .25 .08–.83 −.97 .38 .13–1.08
Perceived ability −.11 .89 .50–1.61 .07 1.08 .61–1.90 .33 1.40 .85–2.29
Exercise intention −.01 .99 .61–1.62 .83*** 2.30 1.44–3.68 .84*** 2.32 1.54–3.51
F and Cox-Snell R2 F = 123.12*** Cox-Snell R2 = .35
Diet control

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(Intercept) −3.87 −7.81** −11.07***
Compliance −.40 .67 .35–1.28 .23 1.25 .68–2.32 .72* 2.05 1.09–3.88
Self-efficacy
Routine management 2.29** 9.86 1.92–50.76 1.70* 5.46 1.37–21.78 1.98** 7.24 1.83–28.57
Diet management .45 1.57 .62–3.99 .74 2.10 .92–4.81 1.49*** 4.45 1.92–10.32
Self-treatment −.22 .80 .18–3.63 −.47 .63 .17–2.32 −.32 .73 .20–2.64
Perceived ability .33 1.39 .61–3.16 −.06 .94 .45–1.98 .03 1.03 .50–2.13
Exercise intention −.02 .98 .52–1.82 .41 1.51 .87–2.61 .50 1.65 .96–2.85
F and Cox-Snell R2 F = 126.72*** Cox-Snell R2 = .36
197

*P < .05; **P < .01; *** P < .001.

Note: Items of social support were not listed in table because of non-significance.
198 Health Education Journal 72(2)

Discussion
Summary of the main findings
This research combined partial concepts of social cognitive theory and the transtheoretical model
to investigate the key factors of behaviour change in people with diabetes. The main findings were
as follows: social support, self-efficacy, and compliance had significant differences in stages of
behaviour change. Especially self-efficacy showed a gradually increasing trend. HbA1C values in
contemplation/preparation stage were higher than those in other stages. Compliance and no under-
mining from family or friends were both directly negatively associated with HbA1C values.
Routine management of diabetic patients was a key factor in behaviour change, which had a direct
positive correlation with compliance, and was positively affected by social support (emotional sup-
port, no undermining, and helping relationships). The behaviour change of blood glucose monitor-
ing was also influenced by the factor of self-treatment which was further strengthened through
emotional support and helping relationships. The behaviour change of regular exercise was also
impacted by the factor of exercise intention which was further enhanced through no undermining.
The behaviour change of diet control was also affected by the factor of diet management which was
further improved by no undermining and helping relationships.

Interpretation of results
Studies have shown that social support and self-efficacy were associated with glycemic con-
trol;11,12,15–18 however, to our knowledge, the influence of each dimension on the social support and
self-efficacy has not been previously investigated and reported in the literature. In our research, we
investigated and identified the dimensions that were most critical for influencing behaviour
changes in diabetic patients.
However, life-long behaviour change is bound to vary with each individual. To understand the
current situation of the patient’s behaviour change and to tailor an optimal action plan could help
to increase the probability of successful behaviour change. In this study results demonstrated that
social support (except for on blood glucose monitoring) and self-efficacy were significantly higher
in the action or maintenance stage than those in the pre-contemplation or contemplation stage. The
compliance was significantly higher in maintenance stage than that in contemplation stage.
Therefore the majority of studies suggested that reinforced social support, self-efficacy and com-
pliance worked together to maintain good blood glucose control,18,32 some researchers also reported
positive results by applying the transtheoretical model to behaviour change in patients with diabe-
tes.24–27 Helitzer et al.33 proposed that stage of behaviour change may be a good predictor of atten-
dance in diabetes prevention programmes. However, the HbA1C values (except for on diet control)
were not significantly lower in the later stages of behaviour change than those in the earlier stages.
The HbA1C values, in any case, on blood glucose monitoring, regular exercise, and diet control
behaviour, were 8.0% higher (which signified a poor glycemic control) in the contemplation/prep-
aration stage than in other stages. This unexpected finding might be due to the fact that this study
was a cross-sectional study, which had the difference between the time the HbA1C values were
collected and the time of the patients’ completion of the questionnaire with their perception of
stage of behaviour change. The other possible explanation was that the patients recognized that
having an HbA1c around 7.0% was within the range of acceptance in pre-contemplation stage, so
they had no intention and no plan to make behaviour changes. Yet when higher values were
obtained for HbA1C, patients became alert of the severity of their illness, and took action towards

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Lin and Wang 199

behaviour change. This finding coincided with the health belief model that patients’ perceived
severity of illness could contribute to taking preventive action.34
Social support includes multiple dimensions and self-efficacy as well.35,36 The question is which
dimensions within the social support and self-efficacy are most critical for influencing behaviour
change. In order to identify the path of relationships among variables in detail, multiple regression
analysis was further used in controlling the stages of behaviour change, which showed that compliance
and no undermining (one dimension of social support) had direct negative effects on HbA1C, while
routine management (one dimension of self-efficacy) had a direct positive impact on compliance, the
routine management was also influenced directly by social support (Figure 1). This result was consis-
tent with the findings by Rhee et al.37 which stated that patient adherence was directly associated with
substantial improvements in HbA1C values, and Nakahara et al.18 stated that social support influences
HbA1C values indirectly through increased self-efficacy, which directly reinforces adherence, and
adherence correlates directly with HbA1C. As compared to previous studies, our study further clarified
the impacts of various dimensions on the social support and self-efficacy; particularly no undermining
was directly negatively associated with HbA1C. Rose et al.17 indicated that the mood status of people
with diabetes affected blood glucose control. Therefore social support may improve the psychosocial
adjustment to diabetes.38 However, negative criticism or behaviour (i.e. undermining) may lead to
reductions in social motivation. As a result, the vicious cycle of behaviour impeded the adoption of
effective self-management behaviours that directly influenced glycemic control. The explanation
power of routine management toward compliance was stronger than that of the other four factors, and
routine management was positively influenced by social support. This result was in accordance with
the findings by Rapley et al.30 In their review, diabetic routine management, which covered diabetes
self-care in general, was the strongest factor on the diabetes self-efficacy scale.
This study, based on the transtheoretical model using multinomial logistic regression analysis,
was to investigate the key factors influencing patients’ behaviour in stages of change. The routine
management was the most critical factor influencing the behaviours change of self-management
(blood glucose monitoring, regular exercise, and diet control) in people with diabetes. The patients’
perceived confidence in routine management may be sufficient to represent self-efficacy. Therefore
patients should be able to control blood glucose successfully, even without any further detailed
diabetes-related knowledge, as long as they follow through with routine management and patients’
training programme enhancing self-management confidence.17 This would further help patients
progress through the stages of behaviour change to an advanced stage without going backwards.19
Finally, with the increased access of support from family, friends, workplace, community, and the
media,39 and appropriate assistance in a timely manner,7 glycemic control for diabetic patients
could be achieved effectively.

Strength and limitations

There are some limitations to this study. First, study participation depended on the patient’s con-
sent so there may have been a selection bias. Second, the questionnaire itself may have been
biased, despite expert review. Third, results from a single hospital may not be generalized. Fourth,
time effect on HbA1C was not considered in this study.

Conclusions
In this study, social support, self-efficacy, and compliance demonstrated differences in stages of
behaviour change in type 2 diabetic patients. Routine management was a key factor in maintaining

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200 Health Education Journal 72(2)

lasting behaviour changes, which had a direct positive correlation with compliance, and was posi-
tively affected by social support. Therefore the behaviour change strategies should depend on
individuals’ stages of behaviour change to understand the specific demands in depth and the need
for a social network is necessary to develop a tailored self-management plan. In addition, strength-
ening the social education of positive support to patients, establishing a patient-friendly environ-
ment (especially avoiding negative criticism or behaviour towards the patients), and designing a
support system with social resources to improve the patients’ perceived confidence in routine man-
agement and find a balance in life-style with diabetes may be the best way to achieve sustainable
behaviour change and promote better blood glucose control.

Note
*HbA1C is the abbreviation of glycated hemoglobin. HbA1C values represent a 2–3 month aver-
age of blood glucose concentrations. Therefore the HbA1C test has been suggested as a tool for
detection of type 2 diabetes.

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