Strategic management of behavioural change in type 2 diabetic patients

Article Outline

• Summary
• Introduction
• Methods
  • Study participants
  • Research scale design
  • Data analysis
• Results
  • Study participant characteristics
  • Key factors in blood glucose monitoring/regular exercise/diet control
  • Priorities determined by the IPGA model
  • Relationships between patient characteristics, health status and performance gaps
• Discussion
• Conclusions
• Ethical approval
• Funding
• Competing interests
• References
• Copyright

Summary 

Objectives

To investigate the key factors in and gap between perception and performance of daily blood glucose monitoring, regular exercise and diet control in individuals with type 2 diabetes, and to help develop patient-centric healthcare management strategies.

Study design

Cross-sectional study.

Methods

A focus group interview was conducted and questionnaires were collected from outpatients with type 2 diabetes. Paired sample t-tests, importance–performance gap analysis and regression analysis were performed.

Results

Perseverance was the key factor affecting blood glucose monitoring and regular exercise; the association was stronger in men than women. The critical factor in diet control was the desire to eat. Patients’ perceived severity of diabetes and limited daily activities due to diabetes correlated with regular exercise, patients’ compliance correlated with glucose monitoring, and perceived health status correlated with diet control.

Conclusions

The cultivation of perseverance and strengthening psychological coping is critical. Health professionals should design tailored services, avoid didactic intervention education programmes, and develop a ‘meaning-centred’ rather than a ‘message-centred’ philosophy of exercise. Such a campaign may help to improve self-management and promote health behaviours for people with type 2 diabetes.

Keywords: Type 2 diabetes, Diet, Exercise, Importance–performance gap analysis

Back to Article Outline

Introduction 

Type 2 diabetes is a major global public health challenge facing the 21st Century.¹ Research in China,² Europe,³ the USA⁴ and Japan⁵ has confirmed that changes in lifestyle can prevent its incidence, and proper control of blood glucose can reduce the risk of complications.⁶, ⁷ Therefore, patients have been educated to eat a healthy diet, exercise regularly, monitor blood glucose and take medications as prescribed. Measurements of healthy behaviour have become important indicators in assessing the quality of diabetes care.⁸ However, to date, less than one-half of diabetic patients receive appropriate care and enjoy a good quality of life.⁹, ¹⁰ Many healthcare professionals have expressed frustration and concern that, despite their best efforts, patients do not check their blood glucose regularly, do not follow their diet and exercise programme, or do not comply with doctor’s orders.¹¹, ¹² This indicates that there are considerable differences in the beliefs and attitudes between healthcare professionals and patients. The Institute of Medicine¹³ and Berwick¹⁴ emphasized that ‘patient-centred’ care in response to patient performance is real quality care. Clark and Hampson¹⁵ found that healthcare providers tended to regard diabetes as more serious than patients; patients did not yet perceive the negative impact of diabetes, so it was very important to intervene from their perspective.

Despite the increasing complexity of type 2 diabetes treatment,¹⁶ physicians are still the main providers of education for patients with diabetes. However, most healthcare professionals consider that they do not have enough time and resources to treat patients effectively.¹⁵ Therefore, control of type 2 diabetes is not simply a clinical problem but also involves strategic management for providers and patients. A two-dimensional strategic matrix [importance–performance gap analysis (IPGA)]¹⁷ has been applied to various fields as it can quickly offer useful information to decision makers. This study aimed to use the IPGA model to create an effective, feasible and relevant strategy for the management of type 2 diabetes.

The treatment of type 2 diabetes requires three major approaches: a balanced diet, regular exercise and medication. The aims of this study, from the patients’ perspectives, were: (1) to investigate the key factors which influence daily behaviours of blood glucose monitoring, regular exercise and diet control; (2) to analyse the gaps between patients’ perceived importance and behavioural performance for the factors influencing daily behaviours; (3) to examine the relationship between patient characteristics, health status and performance gaps; and (4) to develop patient-centric healthcare strategic management for type 2 diabetes. This study indicates the key factors that can help patients improve their ability to self-manage, and help policy makers and professionals with valuable reference information and insight into improving the effectiveness of the healthcare system.

Back to Article Outline

Methods 

Study participants 

The subjects were outpatients who had had type 2 diabetes for at least 1 year (main diagnoses included up to three diagnostic codes in the International Classification of Diseases, Ninth Revision, Clinical Modification: 250) attending the Department of Metabolism of a regional teaching hospital in Hsinchu City, Taiwan. The study was approved by the hospital’s review board and all patients provided informed consent. A purposive sampling method was used to recruit eligible patients during all clinic sessions in December 2009. In total, 317 self-administered questionnaires were collected.

Research scale design 

This research was conducted in two stages. The first stage included a literature review and a focus group interview to develop the preliminary questionnaire. This approach was based on the concept of the ‘expert patient’,¹⁸ and referred to the diabetes care profile of the University of Michigan Diabetes Research and Training Center¹⁹ as a guide for the focus group interview. The interviewees were selected by a health educator from the outpatients with type 2 diabetes. The researcher served as host and six voluntary participants were asked to discuss their own experiences and views. The 2-h discussion focused on daily blood glucose monitoring, regular exercise and diet control.

The second stage was carried out with a questionnaire, the contents of which included three dimensions: impact factors collected by the focus group interview, health status and patient characteristics. A total of 22 items assessed blood glucose monitoring, regular exercise and diet control. Blood glucose monitoring factors included nine items: forgot testing (B1), troublesome (B2), need other’s assistance (B3), time or place was not convenient (B4), fear of prick pain (B5), buy glycaemic metre (economic factors) (B6), test materials too expensive (B7), humanized glycaemic metre design (B8) and perseverance (B9). Regular exercise factors included nine items: physical problem (E1), sports ground (E2), sports equipment (E3), exercise at public facilities (E4), sports partners (E5), regard as daily activities (E6), know exercise benefits (E7), exercise campaign (E8) and perseverance (E9). Diet control factors included four items: desire to eat (N1), diet records (N2), calorie conversion (N3) and balanced diet (N4). Each item was scored on the patient’s perception of importance (1 = very unimportant to 5 = very important) and level of influence on patient’s behaviour (i.e. behavioural performance, 1 = always influenced to 5 = not influenced at all).

Health status included: perceived health status (1 = poor to 5 = excellent), perceived severity (1 = mild to 5 = very severe), knowledge of care (1 = no understanding to 5 = much understanding), treatment compliance (1 = scarcely comply to 5 = fully comply) and limited daily activities (1 = no limitation to 5 = always limited).

Patient characteristics included gender, age, education, duration of diabetes, family history of diabetes, treatment pattern and history of chronic disease. After the questionnaire was reviewed by specialist physicians, dietitians and a health educator, it was amended, pre-tested and revised before the final version.

Data analysis 

Descriptive statistics, such as mean, standard deviation, frequency and rank order, were used to investigate the key factors influencing daily behaviours of blood glucose monitoring, regular exercise and diet control.

Paired sample t-tests were used to analyse the gaps between the patients’ perceived importance and behavioural performance for the factors influencing daily behaviours. Factors with statistical significance (P < 0.05) were defined as performance gaps. Gaps between the patients’ perceived importance and behavioural performance were described briefly as gaps between perception and performance in the full text.

Regression analysis was used to examine the relationship between patient characteristics, health status and performance gaps.

The IPGA matrix was used to develop patient-centric healthcare strategic management for type 2 diabetes. The IPGA tool is a simple graphical tool enabling comparison of perceived importance against performance, which is expected to help make service decisions through a simple strategic matrix. Furthermore, it includes the gap theory enabling the identification of service failures to be based on the user’s expectation against perception of provided services. Therefore, understanding patient demand will provide effective management for people with diabetes. The IPGA model included the following six steps:

Step 2: Calculate the average importance value of each item , the average performance value of each item , the average importance value of all items , and the average performance value of all items .

Step 4: Compute the relative importance (RI) and relative performance (RP), . If and the t-test was significant, . If and the t-test was significant, . If or and the t-test was non-significant, RP(j) = 0.

The distance D(j) indicates the priority for improvement:

Back to Article Outline

Results 

Study participant characteristics 

Among the 317 participants, 45.4% were men and 54.6% were women. Those aged ≥65 years accounted for 34.7% and those with a duration of diabetes of 5–14 years accounted for 45.4%. Those with other chronic diseases accounted for 75.1%, and 70.3% received oral medication. Approximately one-third (36.6%) of patients had a primary school education (Table 1).

Table 1. Patient characteristics.

	n	%		n	%
Sex			Family history of diabetes
Male	144	45.4	Yes	205	64.7
Female	173	54.6	No	112	35.3
Age (years)			Duration of diabetes
≤49	55	17.4	≤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	110	34.7	≥20	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
History of chronic disease			College or higher	60	18.9
No	79	24.9
Yes	238	75.1

Key factors in blood glucose monitoring/regular exercise/diet control 

The rankings are shown in Table 2. Perseverance and forgot testing were the key factors influencing blood glucose monitoring, while fear of prick pain was not a problem (only 20.5% of patients). Perseverance, physical problem and know benefits of exercise were the key factors related to regular exercise, while desire to eat and calorie conversion were key to diet control. Only about 20% of patients’ behaviours were affected by sports equipment and exercise at public facilities, and approximately one-third of behaviours were affected by diet records.

Table 2. Items affecting the blood glucose monitoring/regular exercise/diet control: importance and influence on the performance.

Priorities determined by the IPGA model 

Fourteen items had a statistically significant (P < 0.05) gap (Table 3). According to the IPGA model, 11 items in Quadrant II needed urgent improvement (Fig. 1). The first priority was strengthening perseverance, and the second priority was overcoming the desire to eat. The other priority in blood glucose monitoring was forgot testing. In terms of regular exercise, know benefits of exercise, physical problem, regard as daily activities and exercise campaign were priorities, as were calorie conversion and balanced diet for diet control.

Table 3. Results of importance–performance gap analysis.

RI, relative importance; RP, relative performance.

Relationships between patient characteristics, health status and performance gaps 

To further evaluate the relationships between patient characteristics, health status and performance gaps, multiple regression analysis was performed. As shown in Table 4, men persevered in blood glucose monitoring; for them, physical problem, regard as daily activities, know benefits of exercise, exercise campaign and perseverance also influenced regular exercise. Patients’ perceived severity of diabetes had a positive correlation with regular exercise, while the perception of diabetes as limiting daily activities had a negative correlation. Patients’ compliance had a positive impact on perseverance with blood glucose monitoring, and perception of health status had a positive effect on the desire to eat.

Table 4. Regression analysis based on patient characteristics, health status and the items showing in Quadrant II of the importance–performance gap analysis grid.

Independent variables	Dependent variables
	Perseverance (B9)	Physical problem (E1)	Regard as daily activities (E6)	Know exercise benefits (E7)	Exercise campaign (E8)	Perseverance (E9)	Desire to eat (N1)
(Intercept)	0.767*	1.302*	1.393**	1.447**	1.444**	0.863	1.287*
Sex
Male	0.135*	0.186**	0.113*	0.116*	0.191**	0.163**	0.080
Female	0	0	0	0	0	0	0
Perceived health status	0.102	0.090	0.193**	0.066	0.047	0.112	0.204**
Perceived severity	0.095	0.204**	0.188**	0.157*	0.221**	0.135*	0.025
Knowledge of care	0.027	0.121*	−0.094	0.032	0.030	0.059	0.026
Limited daily activities	−0.082	−0.250***	−0.147*	−0.171*	−0.186**	−0.091	−0.041
Treatment compliance	0.135*	0.031	0.100	0.111	0.093	0.070	0.016
R2	0.058	0.129	0.090	0.065	0.091	0.063	0.054

^*P<0.05, ^**P<0.01, ^***P<0.001.

Note: the table shows significant items.

Back to Article Outline

Discussion 

Lifestyle changes, healthy eating habits and regular exercise are the keys to prevention and treatment of diabetes; however, previous studies have shown these to be very difficult to achieve. This study, from the patients’ perspectives, tried to investigate the key factors influencing their health behaviours and identify the gaps between patients’ perception and performance. The approach combined qualitative and quantitative research methods and applied management theory to evaluate priorities of the gaps. The main findings were as follows. Perseverance was the key factor affecting blood glucose monitoring and regular exercise. The critical factor in diet control was the desire to eat. Men rated their perseverance in implementing blood glucose monitoring and regular exercise more highly than women. Patients’ perceived severity of diabetes and limited daily activities due to diabetes affected regular exercise; patients’ compliance correlated with blood glucose monitoring, and perceived health status correlated with diet control.

Type 2 diabetes is a lifelong chronic disease. It is necessary for patients with diabetes to learn self-management skills and long-term lifestyle changes in order to better control their blood glucose levels. The current challenge is how to put numerous research findings into routine practice.²⁰ In this study of factors related to blood glucose monitoring, patients indicated that their behaviour was influenced by the following factors: the time or place was not convenient (27.2%), test materials were too expensive (27.4%) or they feared prick pain (20.5%). These findings were similar to those of Gregoire Nyomba²¹ who reported that patients were not self-monitoring more often because it was not convenient (29%), materials were too expensive (10%) and they were afraid of prick pain (17%). Patients reported that the key factors in self-monitoring were perseverance (80.1%) and forgetting testing (71.7%). Multiple regression was carried out the relationships between patient characteristics (gender, age, education, duration of diabetes, family history of diabetes, treatment pattern, chronic disease history), health status (perceived health status, perceived severity, knowledge of care, compliance, limited daily activities) and performance gaps (perseverance, forgot testing). The results demonstrated that gender was related to perseverance, as men rated their perseverance in implementing blood glucose monitoring more highly than women. This might be relevant to more self-reliance for men.²² Compliance was related to perseverance. Adherence to medication has always been a challenge for healthcare professionals, and was the major obstacle to patients acquiring proper care during drug treatment of type 2 diabetes.²³ Dimatteo²⁴ reported that the patient non-adherence rate was 24.8%. Many aids are available to help patients with compliance,²⁵ and it is acknowledged that self-monitoring is necessary to achieve success.²⁶

In terms of regular exercise, 79.1% of the patients felt that perseverance was the most important factor. Known exercise benefits (74.7%), physical problems (65.6%), regarded as daily activities (64.5%) and exercise campaign (61.0%) were also major factors. Most research has shown that lack of exercise is an obstacle to the self-management of diabetes.²⁷, ²⁸ Nelson et al.²⁹ found that nearly one-third of patients took no regular exercise, and an exercise habit, persistence and motivation were necessary. Multiple regression was used to analyze the relationships between patient characteristics, health status and performance gaps (perseverance, known exercise benefits, physical problems, regarded as daily activities, exercise campaign). The results showed that gender and patients’ perceived severity of diabetes had a positive impact, while limited daily activities had a negative impact. Men were more likely to exercise than women. Previous studies reported the same findings.³⁰, ³¹, ³² There were gender differences in motivation to exercise, as men emphasized the acquisition of knowledge and skill development for disease control, and promoted the effective utilization of health resources, while women emphasized the emotional support and the pleasure of doing something together.³³, ³⁴ There may also be cultural differences in that men generally perform outdoor tasks, while women work inside or take care of children/grandchildren, and are unable to do even moderate exercise.

With regard to diet control, the desire to eat (76.1%) was the key factor. As with regular exercise, diet control is a lifestyle factor that patients with type 2 diabetes need to change; however, most patients could not adhere to the advice given.²⁹, ³⁵, ³⁶ Multiple regression was conducted the relationships between patient characteristics, health status and performance gaps (desire to eat, diet records, calorie conversion, balanced diet). The results showed that perceived health status had a positive impact on the desire to eat. This was consistent with research by Petrovici and Ritson,³⁷ which found that the perceived threat of disease was based on the perceived severity of disease, and this had a positive impact on healthy eating behaviours. On the other hand, better perceived health status will reduce the perceived threat of disease and lead patients not to adopt healthy dietary behaviours.

This study found that the factors influencing healthy behaviour could be divided into physical and psychological factors. The former were concrete and patients could overcome them, while psychological factors (e.g. perseverance, forgetting testing, having a desire to eat and exercise campaign) became major obstacles. Venkat Narayan²⁰ reported that it was time to put research findings into routine practice, and many other researchers³⁸, ³⁹, ⁴⁰, ⁴¹declared that psychological issues should play a key role in improving the quality of life for all people with type 2 diabetes.

This study had some limitations. First, study participation depended on the patient’s consent, so there may have been sampling bias. Second, results from a single hospital may not be generalizable.

Back to Article Outline

Conclusions 

Compared with previous literature focussing on discussion of the antecedents of patients’ behaviours, this study aimed to provide more specific management guidelines by applying the IPGA approach for patient’s self-management to clinical practice. In this study, potential lifestyle changes in people with type 2 diabetes clearly demonstrated a gap between perception and performance. The cultivation of perseverance will be key to patients’ successful self-management and there are gender differences. The application of intervention programmes cannot be ‘one-size-fits-all’. Strengthening the treatment of psychological barriers, especially overcoming the desire to eat, is critical. Health professionals should design tailored services and avoid didactic intervention education programmes, and put into use a ‘meaning-centred’ rather than a ‘message-centred’ philosophy of exercise. Such a campaign could help improve self-management skills and promote health behaviours for people with type 2 diabetes.

Back to Article Outline

Ethical approval 

Research hospital’s review board.

Back to Article Outline

Funding 

None declared.

Back to Article Outline

Competing interests 

None declared.

Back to Article Outline

References 

1. Hussain A, Claussen B, Ramachandran A, Williams R. Prevention of type 2 diabetes: a review. Diabetes Res Clin Pract. 2007;76:317–326
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (295 KB)
   • CrossRef
2. Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, et al. Effects of diet and exercise in preventing IDDM in people with impaired glucose tolerance: the Da Qing IGT and diabetes study. Diabetes Care. 1997;20:537–544
   • View In Article
   • MEDLINE
3. Tuomilehto J, Lindström J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344:1343–1350
   • View In Article
   • MEDLINE
   • CrossRef
4. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Diabetes prevention program research group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393–403
   • View In Article
   • CrossRef
5. Kosaka K, Noda M, Kuzuya T. Prevention of type 2 diabetes by lifestyle intervention: a Japanese trial in IGT males. Diabetes Res Clin Pract. 2005;67:152–162
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (200 KB)
   • CrossRef
6. DCCT. The Diabetes Control and Complications Research Group . The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977–986
   • View In Article
   • MEDLINE
   • CrossRef
7. Turner RC, Millns H, Neil HAW, Stratton IM, Manley SE, Matthews DR, et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS 23). BMJ. 1998;316:823–828
   • View In Article
   • MEDLINE
   • CrossRef
8. Zgibor JC, Peyrot M, Ruppert K, Noullet W, Siminerio LM, Peeples M, et al. Using the AADE outcomes system to identify patient behavior change goals and diabetes educator responses. Diabetes Educ. 2007;33:841–844
   • View In Article
9. The DAWN International Expert Advisory Board. From practice and research to large-scale implementation: the 3rd DAWN summit. Diabetes Voice. 2006;51:43–45
   • View In Article
10. Kristensen JK, Bro F, Sandbaek A, Dahler-Eriksen K, Lassen JF, Lauritzen T. HbAlc in an unselected population of 4438 people with type 2 diabetes in a Danish county. Scand J Prim Health Care. 2001;19:241–246
    • View In Article
    • MEDLINE
    • CrossRef
11. Funnel MM, Anderson RM. The problem with compliance in diabetes. JAMA. 2000;284:1709
    • View In Article
    • MEDLINE
    • CrossRef
12. Sullivan ED, Joseph DH. Struggling with behavior changes: a special case for clients with diabetes. Diabetes Educ. 1998;24:72–77
    • View In Article
    • MEDLINE
    • CrossRef
13. Institute of Medicine . Crossing the quality chasm: a new health system for the 21st century. Board on Health Care Services. Washington, DC: National Academy Press; 2001;
    • View In Article
14. Berwick DM. A user’s manual for the IOM’s ‘Quality Chasm’ report: patients’ experience should be the fundamental source of the definition of ‘quality’. Health Aff. 2002;21:80–90
    • View In Article
15. Clark M, Hampson SE. Comparison of patients’ and healthcare professionals’ beliefs about and attitudes towards type 2 diabetes. Diabet Med. 2003;20:152–154
    • View In Article
    • MEDLINE
    • CrossRef
16. UKPDS Group. United Kingdom Prospective Diabetes Study . Quality of life in type 2 diabetic patients is affected by complications but not by intensive policies to improve blood glucose or blood pressure control (UKPDS 37). Diabetes Care. 1999;22:1125–1136
    • View In Article
    • MEDLINE
    • CrossRef
17. Lin SP, Chan YH, Tsai MC. A transformation function corresponding to IPA and gap Analysis. Tot Qual Manag Busin Excell. 2009;20:829–846
    • View In Article
18. Department of Health. The expert patient: a new approach to chronic disease management for the 21st century. Norwich: The Stationery Office. Available at: www.dh.gov.uk. [accessed 10.01.09].
    • View In Article
19. Michigan Diabetes Research and Training Center. Diabetes Care Profile. The University of Michigan, Ann Arbor; 1998. Available at:http://www.med.umich.edu/mdrtc/profs/survey.html[accessed 23.09.09].
    • View In Article
20. Venkat Narayan KM, Gregg EW, Engelgau MM, Moore B, Thompson TJ, Williamson DF, et al. Translation research for chronic disease: the case of diabetes. Diabetes Care. 2000;23:1794–1798
    • View In Article
    • MEDLINE
    • CrossRef
21. Gregoire Nyomba BL. The cost of self-monitoring of blood glucose is an important factor limiting glycemic control in diabetic patients. Diabetes Care. 2002;25:1244–1245
    • View In Article
    • MEDLINE
    • CrossRef
22. Penning MJ, Strain LA. Gender differences in disability, assistance, and subjective well-being in later life. J Gerontol. 1994;49:202–208
    • View In Article
23. Osterberg L, Blaschke T. Drug therapy: adherence to medication. N Engl J Med. 2005;353:487–497
    • View In Article
    • CrossRef
24. Dimatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42:200–209
    • View In Article
    • MEDLINE
    • CrossRef
25. Dulmen S, van Sluijs E, van Dijk L, der Ridde D, Heerdrink R, Bensing J. Patient adherence to medical treatment: a review of reviews. BMC Health Serv Res. 2007;7:55
    • View In Article
    • MEDLINE
    • CrossRef
26. Harris MI. Frequency of blood glucose monitoring in relation to glycemic control in patients with type 2 diabetes. Diabetes Care. 2001;24:979–982
    • View In Article
    • MEDLINE
    • CrossRef
27. Ford ES, Herman WH. Leisure-time physical activity patterns in the U.S. diabetic population: findings from the 1990 national health interview survey – health promotion and disease prevention supplement. Diabetes Care. 1995;18:27–33
    • View In Article
    • MEDLINE
28. Glasgow RE, Hampson SE, Strycker LA, Ruggiero L. Personal-model beliefs and social–environmental barriers related to diabetes self-management. Diabetes Care. 1997;20:556–561
    • View In Article
    • MEDLINE
29. Nelson KM, Reiber G, Boyko EJ. Diet and exercise among adults with type 2 diabetes. Diabetes Care. 2002;25:1722–1728
    • View In Article
    • MEDLINE
    • CrossRef
30. Fitzgerald JF, Anderson RM, Davis WK. Gender differences in diabetes attitudes and adherence. Diabetes Educ. 1995;21:523–529
    • View In Article
    • MEDLINE
    • CrossRef
31. Verbrugge LM. Gender and health: an update on hypotheses and evidence. J Health Soc Behav. 1985;26:156–182
    • View In Article
    • MEDLINE
32. Uitenbroek DG, Kerekovska A, Festchieva N. Health lifestyle behavior and socio-demographic characteristics: a study of Varna, Glasgow, and Edinburgh. Soc Sci Med. 1996;43:367–377
    • View In Article
    • MEDLINE
    • CrossRef
33. Albarran NB, Ballesteros MN, Morales GG, Ortega MI. Dietary behaviour and type 2 diabetes care. Patient Educ Counsel. 2006;61:191–199
    • View In Article
34. Fisher KL. Assessing psycho-social variables: a tool for diabetes educators. Diabetes Educ. 2006;32:51–58
    • View In Article
    • MEDLINE
    • CrossRef
35. Harris MI. Medical care for patients with diabetes: epidemiologic aspects. Ann Intern Med. 1996;124:117–122
    • View In Article
    • MEDLINE
36. Wing RR, Goldstein MG, Acton KJ, Birch LL, Jakicic JM, Sallis JR, et al. Behavioral science research in diabetes. Diabetes Care. 2001;24:117–123
    • View In Article
    • MEDLINE
    • CrossRef
37. Petrovici DA, Ritson C. Factors influencing consumer dietary health preventative behaviours. BMC Public Health. 2006;6:222
    • View In Article
    • MEDLINE
    • CrossRef
38. International Diabetes Federation . Global guideline for type 2 diabetes: recommendations for standard, comprehensive, and minimal care. Diabet Med. 2006;23:579–593
    • View In Article
    • MEDLINE
    • CrossRef
39. Wroe J. The 3rd international DAWN summit: from research and practice to large-scale implementation. Pract Diabetes Int. 2006;23:313–316
    • View In Article
40. Glasgow RE, Peeples M, Skovlund SE. Where is the patient in diabetes performance measures?. Diabetes Care. 2008;31:1046–1050
    • View In Article
    • CrossRef
41. Lindahl B. An illness behavior view on coping with diabetes. Int J Behav Med. 2008;15:165–166
    • View In Article
    • CrossRef