Type 2 Diabetes: A Couples Study 1 Running Head: TYPE 2 DIABETES: A COUPLES STUDY Type 2 Diabetes: A Couples Study on Spousal Relationship and Health Behaviors

This study is designed to examine how the spousal relationship is related to the health behavior of people with type 2 diabetes. Participants consisted of 21 persons with type 2 diabetes and their spouses. Both patients and spouses completed a brief questionnaire that consisted of questions related to health behavior, partner communication, and marital quality. We hypothesized that when spouses engage in more positive diabetes behaviors, patients will engage in better self-care behavior, have higher self-efficacy, and have higher well-being. We also hypothesized that patient and spouse active engagement will be associated with better patient outcomes, whereas patient and spouse protective buffering will be associated with worse patient outcomes. We hypothesized that relationship quality and communal coping would be associated with better patient outcomes. Results showed that spouse positive behaviors were related to better patient self-care behaviors, and spouse negative behaviors were related to lower levels of patient self-efficacy. Neither positive nor negative behaviors were associated with patient well-being. Active engagement was related to better patient self-care behaviors but not patient well-being. There was some suggestion that protective buffering was related to a couple of poor patient outcomes. Marital satisfaction was related to some indicators of patient wellbeing, but communal coping was associated to better self-care behaviors. These results suggest that spouses may have an impact on how patients take care of their diabetes. Type 2 Diabetes: A Couples Study 3 Type 2 Diabetes: A Couples Study on Spousal Relationship and Health Behaviors Diabetes mellitus affects more than 23 million Americans and is the fifth deadliest disease in the United States. Diabetes mellitus is a chronic illness in which the body does not properly produce or use insulin. Insulin is a hormone that is necessary for converting sugar and other food into energy for daily use. There are two types of diabetes. The first type of diabetes is type 1 diabetes, and is relatively rare. Type 1 diabetes occurs when the body’s immune system destroys pancreatic beta cells. Pancreatic beta cells are the cells in the body that produce insulin. People with type 1 diabetes must have insulin delivered into their bodies by injection or pump. The second type of diabetes, type 2 diabetes, is much more common. Type 2 diabetes usually occurs because the body develops insulin resistance. This means the cells in the body do not use insulin properly or the body does not produce sufficient amounts of insulin. Type 2 diabetes is associated with older age, family history of diabetes, obesity, physical inactivity and race (American Diabetes Association, 2008). Although type 1 diabetes is not limited to children and type 2 diabetes is not limited to adults, type 1 diabetes usually affects children and type 2 diabetes usually develops in adulthood. The focus of this research is on type 2 diabetes. The management of type 2 diabetes involves making drastic lifestyle changes. People with type 2 diabetes have to change their diets and the amount of physical activity they perform. In addition, people with type 2 diabetes have to test their blood glucose levels and closely monitor these levels on a regular basis. In order to maintain an optimal level of blood glucose, people have to take oral medication or administer insulin. Without either, blood glucose levels increase. Research has shown that long term high blood glucose levels are associated with devastating complications (American Diabetes Association, 2008). People with diabetes who have poor blood glucose control are more prone to having nerve damage, eye problems, kidney Type 2 Diabetes: A Couples Study 4 disease and amputations. Thus, it is important to find ways to help people with diabetes take better care of themselves to maintain optimal blood glucose control. Adherence to proper self-care is a significant problem for two reasons. First, diabetes is mostly an invisible problem, meaning that people with diabetes, may not know they have this incurable disease. Second, people who have diabetes might not understand that there are harmful effects of having high blood sugar levels because the consequences are not immediate. Thus, people with diabetes may not be motivated to adhere to proper self-care behaviors. Factors that are associated with good self-management of type 2 diabetes belong to one of four broad categories: characteristics of patients, nondisease-related stress, characteristics of the doctor, and characteristics of social networks (Fisher et al., 1998). Past studies have identified several characteristics of patients, including the way patients’ understand diabetes and their concern about controlling symptoms, that are predictive of self-management behaviors (Hemera et al., 1988; Toobert & Glasgow, 1994). People with diabetes who have to manage other stressors may not have the time or energy to adhere to and follow the recommendations for proper self-management behavior (Peyrot, McMurry, & Hedges, 1988). Research has shown that physician attitudes about diabetes and diabetes management are associated with patient selfcare behaviors. For instance, patient self-care behaviors are positively associated with physicians’ beliefs about how serious diabetes is and how important glucose control is, physicians’ expertise in diabetes, and the way physicians communicate with patients (Anderson & Zimmerman, 1993; Ho, Marger, Beart, Yip, & Shekelle, 1997; Johnson, 1992). However, much less attention has been devoted to the issue of social support among adults with type 2 diabetes (Trief, Grant, Elbert, & Weinstock, 1998). Thus, this is the focus of the present investigation. Below, we briefly review the literature on social support and diabetes. Type 2 Diabetes: A Couples Study 5 Family Support and Chronic Illnesses Emotional, instrumental, and informational support are the three main types of social support that are usually provided to patients with chronic diseases. Emotional support includes providing empathy, care, love and trust. Instrumental support includes aid in money, time, or labor. Informational support includes advice, suggestions, directives and information. Studies have shown that patients with chronic illnesses receive different kinds of social support from different people. One study suggests that people with type 1 diabetes receive emotional and instrumental support from their family and informational support primarily from health care staff (Aalto, Uutela, & Aro, 1997). It is not clear which kind of support is most strongly related to adherence. A study that examined the relation of emotional and instrumental support to adherence among 86 patients with rheumatoid arthritis, showed that emotional support provided more motivation to improve adherence than instrumental support (Taal, Rasker, Seydel, & Wiegman, 1993). Each of these kinds of support can be further divided into general support or diseasespecific support. General support is support that is provided overall and does not pertain to a particular disease. Disease-specific support is support that is provided in the context of the specific disease. For example, general support includes listening or assisting in everyday problems, whereas diabetes-specific support includes helping with insulin injections, reminding to take medication, helping to monitor blood glucose, eating meals and exercising with the person with diabetes. Studies have shown that both general support and disease-specific support from family members and friends are related to better self-care behaviors among people with diabetes. For instance, one study of 80 people with diabetes showed that patient satisfaction with general Type 2 Diabetes: A Couples Study 6 support from family members and friends was associated with better self-care behaviors but only during times of stress (Griffith, Field, & Lustman, 1990). During nonstressful times, patient satisfaction with general social support was not associated with self-care behaviors. Two studies of people with diabetes showed that diabetes-specific social support was associated with better self-care behavior (Garay-Sevilla et al., 1995; Toljamo & Hentinen, 2001). Thus, assistance with everyday diabetes-related tasks, as well as, general support may be helpful to those with diabetes. Some social support research has focused specifically on the spouse relationship and how it is related to self-care behaviors of people with diabetes. Studies have shown that higher marital quality and greater marital intimacy is associated with better self-care behavior (Trief, Ploutz-Snyder, Britton, & Weinstock, 2004; Trief, Wade, Britton, & Weinstock, 2002) and less diabetes-related stress and better diabetes adaptation (Trief et al., 2002; Trief et al., 2004). Marital quality is a vague and diffuse construct. To more fully understand how marital quality affects self-care behavior, we need to understand more about the specific patient-spouse interactions surrounding self care. Some studies have tried to determine what behaviors are perceived as supportive by patients with diabetes. In a qualitative study of couples, partners were asked to describe what they did to help manage diabetes (Trief et al., 2003). Both patients and spouses provided a number of answers relating to dietary control. For example, spouses assisted in grocery shopping or food preparation, and shared a diet plan. Patients generally perceived these behaviors as helpful. Adjusting to the timing and location of meals, assisting with shots or medication, and checking blood sugar levels also were perceived as beneficial by patients. Reminding in general was considered to be a helpful behavior, whether it was a quick reminder to take medication or to pack extra snacks. Type 2 Diabetes: A Couples Study 7 However, the same study showed that some spouse behaviors were con