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Gender differences in the psychological adjustment to type 1 diabetes mellitus: an explorative study
Patient Education and Counseling 48 (2002) 139±145
Gender differences in the psychological adjustment to type 1 diabetes mellitus: an explorative study Paul Enzlina,c,*, Chantal Mathieub, Koen Demyttenaerea,c a
Department of Psychiatry, University Hospitals Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium b Department of Endocrinology, University Hospitals Gasthuisberg, Leuven, Belgium c Institute of Family and Sexuality Studies, Catholic University Leuven, Leuven, Belgium
Received 10 April 2001; received in revised form 10 December 2001; accepted 27 December 2001
Abstract This study examined gender differences in (1) the psychological adjustment to diabetes and (2) the relation between psychological adjustment and metabolic control in patients with type 1 diabetes. The 280 adult patients attending the outpatient diabetes clinic completed psychological self-rating questionnaires evaluating coping, depression, marital satisfaction, cognitive and emotional adjustment to diabetes. Glycaemic control was measured with HbA1c-values. This study revealed that men used signi®cantly more active coping, less avoiding, less social support seeking and less depressive coping. Despite these differences, glycaemic control was not signi®cantly better in men than in women. Women reported more depressive symptomatology than men did and more women were depressed. Signi®cant gender differences were also found in psychological adjustment to diabetes. The psychological factors negatively related with the psychological adjustment to diabetes in men and women are depressive coping and depressive symptomatology. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Type 1 diabetes mellitus; Gender differences; Psychology; Psychological adjustment
1. Introduction Diabetes is a devastating chronic disease and especially poorly controlled diabetes is associated with multiple longterm complications. The occurrence and severity of diabetes related complications can, however, be decreased by maintenance of blood glucose concentrations close to the normal range [1]. Maintenance of good glycaemic control is achieved in most patients through a very complex treatment regimen. The ef®cacy of a treatment regimen is based on the effectiveness of the doctor's prescribed regimen and on the patient's adherence to the self-care prescriptions. This means that the ultimate responsibility for daily care rests with the patient who has to decide every meal to adhere or not to the self-care prescriptions. Therefore, research has started to focus on psychosocial factors that were hypothesised to in¯uence adherence to the self-care prescriptions and/or glycemic control. The literature on psychosocial factors affecting metabolic control has grown tremendously over the last decades and has evolved over several stages in which different psychological variables have been the focus of study. Early research * Corresponding author. Tel.: 32-16-34-87-01; fax: 32-16-34-87-00. E-mail address: [email protected] (P. Enzlin).
hypothesised that personality characteristics could in¯uence blood glucose control [2,3] but the attempts to identify a speci®c `diabetic personality' have been discredited [4]. Later research showed that stress can have both acute and longterm effects on glycaemic control in diabetic patients while other research showed that stress management can improve control [5±9]. Other researchers focussed on the relationship between coping style and metabolic control [10±13]. In these studies coping is seen as a stable behavioural predisposition that may have direct or indirect effects on metabolic control. Two interpretations have been offered on the way in which coping can have an in¯uence on glycemic control. The stress buffering model suggests that coping could serve as a source of protection against the harmful effect of stress on glycaemic control. The main effect model deals with the immediate in¯uence of coping on glycaemic controlÐindependent of stress [14]. Problem-focussed and cognitive coping strategies have been found to be associated with better metabolic control, emotional status and better adjustment to diabetes [15]. Avoidance and emotion focussed coping strategies are generally associated with poor adjustment and adherence [16]. Interpersonal coping (social support) has been identi®ed as an important factor in adjustment to chronic illness: low levels of social support tend to be associated with poorer
0738-3991/02/$ ± see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 7 3 8 - 3 9 9 1 ( 0 2 ) 0 0 0 0 9 - 5
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physical functioning and emotional well-being for chronically ill adults [17]. Higher levels of social support contribute to better adjustment and better control for patients with diabetes [18]. Psychosocial adjustment of the individual is another factor that has been shown to be positively related to the level of metabolic control [19,20]. Depression is linked with both hyperglycemia and an increased risk for diabetic complications and there is evidence that treatment of depression improves glycemic control [21±23]. Health related quality of life (HRQOL) is the latest variable that has been found to be related to metabolic control [24±26]. In conclusion, different factors have been the focus of research and there is indeed evidence that psychological factors do in¯uence glycaemic control of patients with diabetes, however, the nature of these inter-relationships remains poorly understood and has not been suf®ciently established for clinical purposes [21]. Attempts to integrate the existing ®ndings have inspired several authors to present different conceptual models in which different pathways of association have been proposed [19±27]. The absence of a deeper understanding of this interrelationship, however, could be due to methodological ¯aws including the heterogeneity of the study groups (including types 1 and 2 diabetes), restricted sample size, inclusion of different age groups (children, adolescents, adults) and the heterogeneity in the instruments used to measure psychological factors and metabolic control. Another methodological problem neglected in the literature is that gender differences were rarely taken into account. It is known, however, that men and women differ in the way they cope with problems [28±31], that the prevalence of depression is higher in women [32±34] and that there are signi®cant differences in marital satisfaction for men and women [35± 37]. Although these differences are well known in the psychological literature, they are rarely taken into account in the literature on diabetes. StenstroÈm et al. [38,39] studied the potential impact of life events on metabolic control and found that the relation between both only became apparent when the two genders were analysed separately. One study focused on ``gendered meanings of diabetes, gendered management strategies and gendered dependencies'' and found that gender has
a major impact on how adolescents managed their diabetes [40]. Wikblad et al. [26] reported that the only difference between males and females was that males experienced signi®cant less pain than females and that males had a slightlyÐthough not signi®cantlyÐbetter metabolic control. These studies suggest that for both genders the relationship between psychological factors and adherence and/or metabolic control could be different. There are however also studies that did not con®rm the gender difference hypothesis. A study on gender differences in attitudes to diabetes in patients with types 1 and 2 diabetes, concluded that there are many similarities in the reactions of men and women who have been diagnosed with diabetes [41]. In a study on 48 patients no differences were found between both genders on different (psychosocial) measures: HbA1c, insulin dosage, weight, duration of diabetes, diabetes knowledge, overall adherence, psychosocial or hassles variables, depression [42]. Hanestad et al. [24] also did not ®nd differences in metabolic control between the genders. Considering the possible implications for the approach to diabetes counselling and education the present study aimed to examine gender differences (1) in the psychological adjustment to diabetes and (2) in the relation between psychological adjustment to diabetes and metabolic control (HbA1c) in patients with type 1 diabetes on intensive insulin treatment with multiple injection therapy. As shown in Fig. 1, it was hypothesised (1) that coping, depression, the quality of the partner relation and age and duration could have an in¯uence on psychological adjustment to diabetes and that the relation between these variables is different in men and women and (2) that psychological adjustment could have an in¯uence on glycaemic control and that the relation between these variables is different in men and women. 2. Patients and methods 2.1. Setting and sample selection During a 2-year period, 380 consecutive adult patients with type 1 diabetes who came to the outpatient diabetes
Fig. 1. Visual presentation of the assumptions taken into account when performing the hierarchical multiple regression analyses.
P. Enzlin et al. / Patient Education and Counseling 48 (2002) 139±145
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clinic of the University Hospitals of the Catholic University of Leuven (UZ Gasthuisberg) for regular visits were asked to participate in this study. Patients were eligible for inclusion if they met the following criteria: (1) 18 years or older; (2) type 1 diabetes (all patients were treated with an intensi®ed insulin therapy with four injections daily); (3) no other health problems except complications secondary to diabetes. The 280 (response rate (RR): 73.7%) patients who agreed to participate were given questionnaires to ®ll out in the waiting room. Established self-report questionnaires were used to assess different psychological factors (coping, depression and marital satisfaction) hypothesised to in¯uence psychological adjustment to diabetes and metabolic control. Blood samples for HbA1c-determination were obtained the day patients were invited to participate in the study.
of 19 items such as e.g. ``I dislike to be referred to as a diabetic;'' ``I try not to let people know about my diabetes.'' Each item is scored on a 5-point scale form 1 to 5, which means that scores can vary between 19 and 95. Higher scores indicate that patients are accepting their diabetes, are comfortable with public awareness of their diabetes, have a sense of self-control and feel well adjusted to their diabetes [47]. The dyadic adjustment scale (DAS) was used to assess the quality of marital relation and consists of 32 items as e.g. ``in general, how often do you think that things between you and your partner are going well?'' ``Do you con®de in your mate?'' Each item is scored on a 6-point scale form 0 to 5, which means that scores can vary between 0 and 160. Higher scores indicate a higher degree of marital satisfaction [36].
2.2. Instruments
2.3. Glycaemic control
The utrechtse coping list (UCL), a well-validated questionnaire derived from the Westbrook coping scale that is often used in the Dutch speaking countries, was used to assess seven different coping styles: active coping (seven items, e.g. ``to interfere immediately if there are problems''), palliative coping (eight items, e.g. ``try to relax''), avoiding (eight items, e.g. ``to avoid dif®cult situations as much as possible''), social support seeking (six items, e.g. ``to ask someone for help''), depressive±regressive coping (seven items, e.g. ``you don't feel able to do something at all''), expression of negative emotions (three items, e.g. ``to express your anger to the one who is responsible for the problem'') and comforting ideas (®ve items, e.g. ``to encourage yourself when confronted with a problem''). Each item is scored on a 4-point scale from `never or rarely' to `very often' with subscores ranging between 12 and 32. The validity of the subscales of the UCL has been con®rmed by several studies [43]. Higher scores indicate that this coping style is more prominent. The beck depression inventory (BDI) was used to assess current self-reported symptoms of depression [44]. The BDI consists of 21 items. Each item measures the presence and severity of a symptom of depression and by adding the item scores a total score is determined. Each item is scored on a 4-point scale ranging from 0 to 3, which means that scores can vary between 0 and 63. A cut-off score of 16 on the BDI indicates a clinical depression [45]. Higher scores indicate higher number of epressive symptoms. The appraisal of diabetes scale (ADS) was used to assess patients' cognitive adjustment to diabetes [46]. The ADS consists of seven items. For example, ``how effective are you in coping with your diabetes?'' and ``to what degree does your diabetes get in the way of your developing life goals?'' Each item is scored on a 5-point scale form 1 to 5 which mean that scores can vary between 5 and 35. Higher scores indicate a more negative appraisal of diabetes. The ATT19 or diabetes integration scale was used to assess emotional adjustment to diabetes. This scale consists
HbA1c was determined on a venous blood sample using the Cobas Intergra assay (Roche, Basel, Switzerland) with a normal range of 4±6%. 2.4. Statistical analysis Analyses were performed using the statistical package SPSS 10.0 (SPSS Inc., Chicago, IL). Student's t-test and one-way analysis of variance (ANOVA) were used to calculate differences between groups; predictions were made using hierarchical stepwise multiple linear regression analyses. Where appropriate scores are presented as mean scores S:D: 3. Results The 280 patients agreed to participate of which 141 were men (RR: 70.5%) and 139 women (RR: 73.2%). Mean age for this sample was 38 years. Duration of diabetes for the total sample ranged from 1 month to 44 years with a mean duration of 14.3. Mean HbA1c-values for the whole sample was 7.9%. More speci®cally, 35% of men and 26% of women had low HbA1c-scores (6.9%); 35% of men and 33% of women had average HbA1c-scores (7.0±8.5%) and 30% of men and 41% of women had high HbA1c-scores (8.6%), respectively. Patient characteristics are shown separately for men and women in Table 1. No signi®cant differences were found between men and women for age (P 0:7), duration of diabetes (P 0:2) or glycemic control (P 0:07). 3.1. Gender differences in psychological adjustment As shown in Table 1, signi®cant gender differences were found in the psychological adjustment to diabetes. Men had signi®cant lower scores on cognitive adjustment to diabetes than women, which means that men had a more positive
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Table 1 Patient characteristics and scores on different psychological measures Variable
Mean score of women
Mean score of men
Age Duration of diabetes Glycaemic control Cognitive adjustment Emotional adjustment Depression Active coping Palliative coping Avoidance Social support seeking Depressive coping Expression of emotions Comforting ideas Marital satisfaction
38.0 12.7 (18±76) 15.1 10.8 (0.1±44) 8.1 1.6 (4.4±12.7%) 18.3 61.8 10.0 16.8 17.2 15.9 13.5 12.1 6.6 12.6 104.0
38.5 12.0 (19±71) 13.4 9.4 (0.5±38) 7.7 1.4 (5.1±15.0%) 16.8 63.6 6.0 18.9 16.4 14.6 12.1 10.9 6.5 12.8 110.0
appraisal of their diabetes. Men were also signi®cantly more satis®ed with their partner relation than women were. Women reported signi®cantly more depressive symptoms than men did and more women had a clinical depression: 24.7% of women versus 7.4% of men. Men and women also differed signi®cantly in their overall coping strategies: men used more active coping than women, were less avoiding, were less social support seeking and used less depressive coping. Men and women however did not differ signi®cantly in emotional adjustment to diabetes, expression of negative emotions, palliative coping and the use of comforting ideas as coping strategy. Tests for interaction showed only one signi®cant gender interaction for the relation between social support seeking and the emotional adjustment to diabetes: in men social support seeking did not signi®cantly improve the emotional adjustment to diabetes, while in women social support seeking and emotional adjustment were clearly positively related. 3.2. Psychological adjustment to diabetes in men and women A ®rst hierarchical regression analysis was performed based on the assumptions shown in Fig. 1 (research question 1). Coping variablesÐassumed to be a traitÐwere entered as a group in the ®rst step of the equation followed by age and duration in the second and the quality of the partner relation and depression in the third step. All these independent variables were entered in a forward-selection stepwise fashion and were regressed onto the dependent variables emotional and cognitive adjustment to diabetes in both men and women. In men, depressive coping and depression scores were the signi®cant predictors accounting for 18% of the variance in emotional adjustment to diabetes and for 35% of the variance in cognitive adjustment to diabetes (Table 2). All these predictors were negatively related to both measures of psychological adjustment to diabetes which means that
t-Value
P-Value
0.34 1.36 1.83 2.86 1.19 4.28 4.79 1.93 2.55 3.53 3.20 0.36 0.49 1.98
0.70 0.20 0.07 0.005 0.24 0.000 0.000 0.054 0.011 0.000 0.002 0.72 0.63 0.048
higher scores on depressive coping and higher depressive symptoms scores resulted in less well emotional and cognitive adjustment to diabetes. In women, depressive coping, expression of negative emotions and depression scores were the signi®cant predictors accounting for 39% of the variance in emotional adjustment to diabetes and 41% of the variance in cognitive adjustment to diabetes (Table 3). In women higher depression scores and higher depressive coping resulted in less well emotional and cognitive adjustment to diabetes, while higher expression of negative emotions score resulted in better emotional and cognitive adjustment to diabetes. 3.3. Relation between psychological adjustment and glycemic control in men and women A second hierarchical multiple regression analysis was performed based on the assumptions shown in Fig. 1 (research question 2). In the ®rst step depression scores Table 2 Statistics for the variables in two multiple regression equations performed for men with the emotional (ATT19), respectively, cognitive adjustment (ADS) to diabetes as dependent variable and coping, age, duration, depression score and quality of the partner relation as independent variables Variable
Beta
Standardised beta
t-Value
Significance
Eq. (1)a,b,c Depressive coping BDI
0.83 0.63
0.23 0.29
2.1 2.5
0.044 0.014
Eq. (2)b,d,e Depressive coping BDI
0.19 0.41
0.15 0.52
1.5 5.2
0.149 0.000
a
Dependent variable: ATT19. Independent variables: (coping) (age, duration) (depression score, quality of the partner relation). c R 0:44; F 9:8 (P < 0:001); R2 0:20; adjusted R2 0:18. d Dependent variable: ADS. e R 0:60; F 23:0 (P < 0:001); R2 0:37; adjusted R2 0:35. b
P. Enzlin et al. / Patient Education and Counseling 48 (2002) 139±145 Table 3 Statistics for the variables in two multiple regression equations performed for women with the emotional (ATT19), respectively, cognitive adjustment (ADS) to diabetes as dependent variable and coping, age, duration, depression score and quality of the partner relation as independent variables Variable Eq. (1)a,b,c Depressive coping Expression of negative emotions Depression score Eq. (2)b,d,e Depressive coping Expression of negative emotions Depression score
Beta
Standardised beta
t-Value
Significance
1.13 1.76
0.30 0.24
02.39 2.78
0.02 0.007
0.69
0.40
3.34
0.001
0.21 0.61
0.16 0.25
1.33 2.91
0.19 0.005
0.30
0.51
4.35
0.000
a
Dependent variable: ATT19. Independent variables: coping, age, duration, depression score, quality of the partner relation. c R 0:64; F 20:9 (P < 0:001); R2 0:41; adjusted R2 0:39. d Dependent variable: ADS. e R 0:66 F 22:3 (P < 0:001); R2 0:43; adjusted R2 0:41. b
and quality of the partner relation were entered in the equation followed by emotional and cognitive adjustment to diabetes in a second step. All these independent variables were regressed onto glycemic control in both men and women. In men, depression score was a signi®cant predictor of glycemic control accounting for 5% of the variance in glycemic control (Table 4). In women, no signi®cant predictors were found for glycemic control. Another method to study the relation between psychological adjustment and metabolic control also revealed no signi®cant relation between both variables. The total group was divided into three groups based on HbA1c-levels: 6.9% (low), 7.0±8.5% (average) and 8.6% (high). To detect differences between these groups a one way-ANOVA with Bonferroni post hoc tests was performed. These analyses, however, did not reveal any signi®cant difference Table 4 Statistics for the variables in two multiple regression equations (one for men and one for women) with HbA1c as dependent variable and depression score, quality of the partner relation, emotional and cognitive adjustment to diabetes as independent variables Variable
Beta
Standardised beta
t-Value
Significance
Equation for womena,b No significant predictors Equation for mena,b,c Depression score
0.06
0.25
2.5
0.015
a
Dependent variable: HbA1c. Dependent variable: (depression score, quality of the partner relation) and (emotional and cognitive adjustment to diabetes). c R 0:25; F 6:1 (P 0:015); R2 0:06; adjusted R2 0:05. b
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in psychological variables either between men with low, average or high HbA1c-scores nor between women with low, average or high HbA1c-scores, respectively. 4. Discussion and conclusion From the psychological literature it is known that men and women differ on several psychological variables, e.g. coping, depression and marital satisfaction [28±37]. The present study focused on the question if such differences contribute to the adjustment to diabetes and its treatment and con®rmed that there are signi®cant differences between men and women in the psychological adjustment to type 1 diabetes. Firstly, men and women differed in their overall coping strategies as measured with the UCL, a questionnaire often used in research in Dutch speaking countries. An assumption of this questionnaire is that coping style is a relative stable quality, a kind of trait [43]. The UCL measures general coping strategies with all kinds of stressors in a person's life (e.g. discharge, loss of a signi®cant other, illness). In this study, we found that men use more active coping, are less frequently avoiding, less social support seeking and use less depressive coping than women. These differences in coping style, however, are very similar to those seen between men and women in the general population [40], which suggests that patients with type 1 diabetes do not use other coping styles than men and women in general, do. A possible interpretation of these differences in the context of diabetes could be distilled from an analysis of the pathway by which coping style and depressive symptomatology in¯uence adjustment to diabetes in men and women. Depressive symptomatology and depressive coping seem to be the crucial factors that negatively affect psychological adjustment to diabetes, in both men and women. The pro®le of the scores men and women had on the UCL re¯ect different general coping styles. For men, the used coping styles re¯ect `mastery' and `autonomy'. Women's coping strategies re¯ect more `dependence on others'. This was also con®rmed by the signi®cant gender interaction effect found for social support seeking in their relation to emotional adjustment to diabetes. Gender differences in the link between social support and good metabolic control have also been reported elsewhere. StenstroÈm et al. [38,39] found that women use social support seeking more frequently and that they mobilise their social support networks more easily in time of need. Secondly, women reported twice as much depressive symptoms as men and even three times more women were clinically depressed in our sample. These results support ®ndings in surveys on the prevalence of depression in the general population showing a female/male ratio of 3/1 [34] and are in accordance with the results of a meta-analysis on the prevalence of comorbid depression in adults with diabetes [23]. It is not yet clear, however, whether the female/ male ratio found in studies re¯ects a higher prevalence of
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depression in women or whether it is an artefact given that gender role expectations make it more socially acceptable for women to report feelings of depression [48]. The present study revealed gender differences in the psychological adjustment to diabetes. Psychological adjustment comprises cognitive (thoughts about diabetes) and emotional (feelings of acceptance of diabetes, feelings of self-control) adjustment to diabetes. Although cognitive and emotional adjustment were highly inter-correlated in this study, an interesting ®nding was that although men and women had comparable feelings of acceptance of diabetes, men had a more positive appraisal of diabetes. A possible explanation for this ®nding could be found in three other studies of which one revealed that men were less likely to agree that diabetes has a signi®cant impact on a patient's life [38] and the other that men found their illness less of a hindrance than women [49]. It has also been suggested that men may have a greater need to deny the problems related to their illness [48] in an effort to keep the diabetes out of their personal and social identity [50]. Another ®nding in this study was the weak relation between psychological factors and glycaemic control. In the present study, it was found that in men only depression scores predicted to some extend glycaemic control. In women, no signi®cantly predicting variables were found. At least two explanations can be given for the weak relation found in this study between psychological variables and glycaemic control. Firstly, we did not ®nd a relation because there is no relation between psychological variables and glycaemic control. Secondly, there is a relation but we could not ®nd it since other psychological/behavioural variables than those assessed in this study are related to glycaemic control. Indeed, the importance of adherence in diabetes treatment has often been discussed in the literature [16,24]. It is possible that psychological variables indirectly have an in¯uence on glycaemic control by their in¯uence on adherence to the prescribed regimen, a factor that was not assessed in this study. Another problem might be that a single measurement of HbA1c might be not the most accurate index to study the in¯uence of psychological adjustment to diabetes on glycaemic control. The in¯uence of psychology on metabolic control may be acting over years and HbA1c is re¯ecting glycaemic control over too short a period of time (6±8 weeks). Finally, this study has several limitations. Due to the cross-sectional design, we could not evaluate the temporality of the relation between the different psychosocial variables and/or glycaemic control. Therefore, future studies in this ®eld should use a longitudinal design to clear out the differences between men and women in the temporal evolution of psychological adjustment to diabetes. Secondly, caution should be exercised in interpreting these results because the percentage explained variance is not always large. Thirdly, potentially confounding demographic and clinical factors (e.g. kind, number and severity of complications) have not been considered in this study.
4.1. Conclusion In conclusion, men and women with diabetes do not use other coping styles than men and women in general do and we found that men used more active coping, less avoiding, less social support seeking and less depressive coping. Despite these differences in coping style, glycaemic control was not signi®cantly better in men than in women. Women reported more depressive symptomatology than men did and more women were depressed. There were also signi®cant gender differences in psychological adjustment to diabetes. The psychological factors negatively related with the psychological adjustment to diabetes in men and women are depressive coping and depressive symptomatology. 4.2. Practice implications To our knowledge, this is the ®rst study dealing with the impact of gender on psychological adjustment to diabetes and on metabolic control in patients with diabetes type 1. Our results suggest that it could be important to analyse males and females separately when studying psychological adjustment to diabetes. Further research should con®rm the results of this exploratory study and should focus on the fact that these ®ndings could have implications for diabetes care in general. Improving psychological adjustment to diabetes may necessitate addressing other themes in men and women and this study suggests that social support could be such a gender sensitive theme. References [1] DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications. New Engl J Med 1993;329:977±86. [2] Brickman A, Yount S, Blaney N, Rothberg S, Kaplan De-Nour A. Personality traits and long-term health status. The influence of neuroticism and conscientiousness on renal deterioration in type 1 diabetes. Psychosomatics 1996;37:459±68. [3] Orlandini A, Pastore M, Fossati A, Clerici S, Sergi A, Balini A, et al. Effects of personality on metabolic control in IDDM patients. Diabet Care 1995;18:206±9. [4] Dunn SM, Turtle JR. The myth of the diabetic personality. Diabet Care 1981;4:640±6. [5] Wales J. Does psychological stress cause diabetes? Diabet Med 1995;12:109±12. [6] Surwit RS, Schneider MS, Feinglos MN. Stress and diabetes mellitus. Diabet Care 1992;15:1413±22. [7] Demers RY, Neale AV, Wenzloff NJ, Gronsman KJ, Jaber LA. Glycosylated hemoglobin levels and self-reported stress in adults with diabetes. Behav. Med. 1989;15(4):167±72. [8] Inui A, Kitaoka H, Majima M, Takamiya S, Uemoto M, Yonenga C, et al. Effect of the Kobe earthquake on stress and glycemic control in patients with diabetes mellitus. Arch Intern Med 1998; 158:274±8. [9] Surwit RS, Feingloss MN. The efffects of relaxation on glucose tolerance levels in diabetic persons. Diabet Care 1983;6:176±9. [10] Peyrot M, Mcmurry J. Stress buffering and glycemic control. The role of coping styles. Diabet Care 1992;15:842±6.
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[30] Lindqvist R, Carlsson M, Sjoden PO. Copings strategies and quality of life among patients on hemodialysis and continuous ambulantory peritoneal dialysis. Scand J Caring Sci 1998;12:223±30. [31] Jordan C, Revenson TA. Gender differences in coping with infertilty: a meta-analysis. J Behav Med 1999;22:341±58. [32] Kornstein SG, Schatzberg AF, Thase ME, Yonkers KA, McCullough JP, Keitner GI. Gender differences in chronic major and double depression. J Affect Disorders 2000;60:1±11. [33] Piccinelli M, Wilkinson G. Gender differences in depression: critical review. Br J Psychiat 2000;177:486±92. [34] Weissman MM, Leaf PJ, Tischler GL, et al. Affective disorders in five Unite States communities. Psychol Med 1988;18:141±54. [35] Benazon N, Wright J, Sabourin S. Stress, sexual satisfaction and marital adjustment in infertile couples. J Sex Marital Ther 1992;18:273±84. [36] Spanier G. Measuring dyadic adjustment: new scales for assessing the quality of marriage and similar dyads. J Marriage 1976;38:15±28. [37] Gottman JM, Krokoff LJ. Marital interaction and satisfaction: a longitudinal view. J Consult Clin Psychol 1989;7:47±52. [38] StenstroÈm U, Wikby A, HoÈrnqvist JO, Andersson PO. Recent life events, gender, and the control of diabetes mellitus. Gen Hos Psychiat 1993;15:82±8. [39] StenstroÈm U, Wikby A, HoÈrnqvist JO, Andersson PO. Recent life events, gender differences, and the control of insulin-dependent diabetes mellitus: a 2-year follow-up study. Gen Hos Psychiat 1995;17:433±9. [40] Williams C. Gender, adolescence and the management of diabetes. J Adv Nurs 1999;30:1160±6. [41] Fitzgerald J, Anderson R, Davis W. Gender differences in diabetes attitudes and adherence. Diabet Edu 1995;21:523±9. [42] Niemcryk SJ, Speers MA, Travis LB, Gary H. Psychosocial correlates of hemoglobin A1c in young adults with type 1 diabetes. J Psychosom Res 1990;34:617±27. [43] Schreurs PJG, Van de Willige G. Omgaan met problemen en gebeurtenissen. De utrechtse coping lijst. Coping with problems and events. The utrechste coping list. Lisse: Zwets & Zeitlinger, 1988. [44] Beck A, Beamersderfer A. Assessment of depression: the depression inventory. Mod Prob Pharmacopsychiat 1974;7:151±69. [45] Lustman PJ, Clouse RE, Griffith LS, Carney RM, Freedland KE. Screening for depression in diabetes using the Beck depression inventory. Psychosom Med 1997;59:217±42. [46] Carey M, Jorgensen R, Weinstock R, Sprafkin R, Latinga L, Carnrike C, et al. Reliability and validity of the appraisal of diabetes scale. J Behav Med 1991;14:43±51. [47] Welch G, Beeney LJ, Dunn S. The development of the diabetes integration scale: a psychometric study of the ATT39. Multivar Exp Clin Res 1996;11:75±88. [48] Gafvels C, Lithner F, BoÈrjeson B. Living with diabetes: relationship to gender, duration and complications: a survey in northern Sweden. Diabet Med 1993;10:768±73. [49] Sharpe PA, Clark NM, Janz NK. Differences in the impact and management of heart disease between older women and men. Women and Health 1991;17:25±43. [50] Williams C. Doing health, doing gender: teenagers, diabetes and asthma. Soc Sci Med 2000;50:387±96.
Gender differences in the psychological adjustment to type 1 diabetes mellitus: an explorative study Paul Enzlina,c,*, Chantal Mathieub, Koen Demyttenaerea,c a
Department of Psychiatry, University Hospitals Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium b Department of Endocrinology, University Hospitals Gasthuisberg, Leuven, Belgium c Institute of Family and Sexuality Studies, Catholic University Leuven, Leuven, Belgium
Received 10 April 2001; received in revised form 10 December 2001; accepted 27 December 2001
Abstract This study examined gender differences in (1) the psychological adjustment to diabetes and (2) the relation between psychological adjustment and metabolic control in patients with type 1 diabetes. The 280 adult patients attending the outpatient diabetes clinic completed psychological self-rating questionnaires evaluating coping, depression, marital satisfaction, cognitive and emotional adjustment to diabetes. Glycaemic control was measured with HbA1c-values. This study revealed that men used signi®cantly more active coping, less avoiding, less social support seeking and less depressive coping. Despite these differences, glycaemic control was not signi®cantly better in men than in women. Women reported more depressive symptomatology than men did and more women were depressed. Signi®cant gender differences were also found in psychological adjustment to diabetes. The psychological factors negatively related with the psychological adjustment to diabetes in men and women are depressive coping and depressive symptomatology. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Type 1 diabetes mellitus; Gender differences; Psychology; Psychological adjustment
1. Introduction Diabetes is a devastating chronic disease and especially poorly controlled diabetes is associated with multiple longterm complications. The occurrence and severity of diabetes related complications can, however, be decreased by maintenance of blood glucose concentrations close to the normal range [1]. Maintenance of good glycaemic control is achieved in most patients through a very complex treatment regimen. The ef®cacy of a treatment regimen is based on the effectiveness of the doctor's prescribed regimen and on the patient's adherence to the self-care prescriptions. This means that the ultimate responsibility for daily care rests with the patient who has to decide every meal to adhere or not to the self-care prescriptions. Therefore, research has started to focus on psychosocial factors that were hypothesised to in¯uence adherence to the self-care prescriptions and/or glycemic control. The literature on psychosocial factors affecting metabolic control has grown tremendously over the last decades and has evolved over several stages in which different psychological variables have been the focus of study. Early research * Corresponding author. Tel.: 32-16-34-87-01; fax: 32-16-34-87-00. E-mail address: [email protected] (P. Enzlin).
hypothesised that personality characteristics could in¯uence blood glucose control [2,3] but the attempts to identify a speci®c `diabetic personality' have been discredited [4]. Later research showed that stress can have both acute and longterm effects on glycaemic control in diabetic patients while other research showed that stress management can improve control [5±9]. Other researchers focussed on the relationship between coping style and metabolic control [10±13]. In these studies coping is seen as a stable behavioural predisposition that may have direct or indirect effects on metabolic control. Two interpretations have been offered on the way in which coping can have an in¯uence on glycemic control. The stress buffering model suggests that coping could serve as a source of protection against the harmful effect of stress on glycaemic control. The main effect model deals with the immediate in¯uence of coping on glycaemic controlÐindependent of stress [14]. Problem-focussed and cognitive coping strategies have been found to be associated with better metabolic control, emotional status and better adjustment to diabetes [15]. Avoidance and emotion focussed coping strategies are generally associated with poor adjustment and adherence [16]. Interpersonal coping (social support) has been identi®ed as an important factor in adjustment to chronic illness: low levels of social support tend to be associated with poorer
0738-3991/02/$ ± see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 7 3 8 - 3 9 9 1 ( 0 2 ) 0 0 0 0 9 - 5
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physical functioning and emotional well-being for chronically ill adults [17]. Higher levels of social support contribute to better adjustment and better control for patients with diabetes [18]. Psychosocial adjustment of the individual is another factor that has been shown to be positively related to the level of metabolic control [19,20]. Depression is linked with both hyperglycemia and an increased risk for diabetic complications and there is evidence that treatment of depression improves glycemic control [21±23]. Health related quality of life (HRQOL) is the latest variable that has been found to be related to metabolic control [24±26]. In conclusion, different factors have been the focus of research and there is indeed evidence that psychological factors do in¯uence glycaemic control of patients with diabetes, however, the nature of these inter-relationships remains poorly understood and has not been suf®ciently established for clinical purposes [21]. Attempts to integrate the existing ®ndings have inspired several authors to present different conceptual models in which different pathways of association have been proposed [19±27]. The absence of a deeper understanding of this interrelationship, however, could be due to methodological ¯aws including the heterogeneity of the study groups (including types 1 and 2 diabetes), restricted sample size, inclusion of different age groups (children, adolescents, adults) and the heterogeneity in the instruments used to measure psychological factors and metabolic control. Another methodological problem neglected in the literature is that gender differences were rarely taken into account. It is known, however, that men and women differ in the way they cope with problems [28±31], that the prevalence of depression is higher in women [32±34] and that there are signi®cant differences in marital satisfaction for men and women [35± 37]. Although these differences are well known in the psychological literature, they are rarely taken into account in the literature on diabetes. StenstroÈm et al. [38,39] studied the potential impact of life events on metabolic control and found that the relation between both only became apparent when the two genders were analysed separately. One study focused on ``gendered meanings of diabetes, gendered management strategies and gendered dependencies'' and found that gender has
a major impact on how adolescents managed their diabetes [40]. Wikblad et al. [26] reported that the only difference between males and females was that males experienced signi®cant less pain than females and that males had a slightlyÐthough not signi®cantlyÐbetter metabolic control. These studies suggest that for both genders the relationship between psychological factors and adherence and/or metabolic control could be different. There are however also studies that did not con®rm the gender difference hypothesis. A study on gender differences in attitudes to diabetes in patients with types 1 and 2 diabetes, concluded that there are many similarities in the reactions of men and women who have been diagnosed with diabetes [41]. In a study on 48 patients no differences were found between both genders on different (psychosocial) measures: HbA1c, insulin dosage, weight, duration of diabetes, diabetes knowledge, overall adherence, psychosocial or hassles variables, depression [42]. Hanestad et al. [24] also did not ®nd differences in metabolic control between the genders. Considering the possible implications for the approach to diabetes counselling and education the present study aimed to examine gender differences (1) in the psychological adjustment to diabetes and (2) in the relation between psychological adjustment to diabetes and metabolic control (HbA1c) in patients with type 1 diabetes on intensive insulin treatment with multiple injection therapy. As shown in Fig. 1, it was hypothesised (1) that coping, depression, the quality of the partner relation and age and duration could have an in¯uence on psychological adjustment to diabetes and that the relation between these variables is different in men and women and (2) that psychological adjustment could have an in¯uence on glycaemic control and that the relation between these variables is different in men and women. 2. Patients and methods 2.1. Setting and sample selection During a 2-year period, 380 consecutive adult patients with type 1 diabetes who came to the outpatient diabetes
Fig. 1. Visual presentation of the assumptions taken into account when performing the hierarchical multiple regression analyses.
P. Enzlin et al. / Patient Education and Counseling 48 (2002) 139±145
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clinic of the University Hospitals of the Catholic University of Leuven (UZ Gasthuisberg) for regular visits were asked to participate in this study. Patients were eligible for inclusion if they met the following criteria: (1) 18 years or older; (2) type 1 diabetes (all patients were treated with an intensi®ed insulin therapy with four injections daily); (3) no other health problems except complications secondary to diabetes. The 280 (response rate (RR): 73.7%) patients who agreed to participate were given questionnaires to ®ll out in the waiting room. Established self-report questionnaires were used to assess different psychological factors (coping, depression and marital satisfaction) hypothesised to in¯uence psychological adjustment to diabetes and metabolic control. Blood samples for HbA1c-determination were obtained the day patients were invited to participate in the study.
of 19 items such as e.g. ``I dislike to be referred to as a diabetic;'' ``I try not to let people know about my diabetes.'' Each item is scored on a 5-point scale form 1 to 5, which means that scores can vary between 19 and 95. Higher scores indicate that patients are accepting their diabetes, are comfortable with public awareness of their diabetes, have a sense of self-control and feel well adjusted to their diabetes [47]. The dyadic adjustment scale (DAS) was used to assess the quality of marital relation and consists of 32 items as e.g. ``in general, how often do you think that things between you and your partner are going well?'' ``Do you con®de in your mate?'' Each item is scored on a 6-point scale form 0 to 5, which means that scores can vary between 0 and 160. Higher scores indicate a higher degree of marital satisfaction [36].
2.2. Instruments
2.3. Glycaemic control
The utrechtse coping list (UCL), a well-validated questionnaire derived from the Westbrook coping scale that is often used in the Dutch speaking countries, was used to assess seven different coping styles: active coping (seven items, e.g. ``to interfere immediately if there are problems''), palliative coping (eight items, e.g. ``try to relax''), avoiding (eight items, e.g. ``to avoid dif®cult situations as much as possible''), social support seeking (six items, e.g. ``to ask someone for help''), depressive±regressive coping (seven items, e.g. ``you don't feel able to do something at all''), expression of negative emotions (three items, e.g. ``to express your anger to the one who is responsible for the problem'') and comforting ideas (®ve items, e.g. ``to encourage yourself when confronted with a problem''). Each item is scored on a 4-point scale from `never or rarely' to `very often' with subscores ranging between 12 and 32. The validity of the subscales of the UCL has been con®rmed by several studies [43]. Higher scores indicate that this coping style is more prominent. The beck depression inventory (BDI) was used to assess current self-reported symptoms of depression [44]. The BDI consists of 21 items. Each item measures the presence and severity of a symptom of depression and by adding the item scores a total score is determined. Each item is scored on a 4-point scale ranging from 0 to 3, which means that scores can vary between 0 and 63. A cut-off score of 16 on the BDI indicates a clinical depression [45]. Higher scores indicate higher number of epressive symptoms. The appraisal of diabetes scale (ADS) was used to assess patients' cognitive adjustment to diabetes [46]. The ADS consists of seven items. For example, ``how effective are you in coping with your diabetes?'' and ``to what degree does your diabetes get in the way of your developing life goals?'' Each item is scored on a 5-point scale form 1 to 5 which mean that scores can vary between 5 and 35. Higher scores indicate a more negative appraisal of diabetes. The ATT19 or diabetes integration scale was used to assess emotional adjustment to diabetes. This scale consists
HbA1c was determined on a venous blood sample using the Cobas Intergra assay (Roche, Basel, Switzerland) with a normal range of 4±6%. 2.4. Statistical analysis Analyses were performed using the statistical package SPSS 10.0 (SPSS Inc., Chicago, IL). Student's t-test and one-way analysis of variance (ANOVA) were used to calculate differences between groups; predictions were made using hierarchical stepwise multiple linear regression analyses. Where appropriate scores are presented as mean scores S:D: 3. Results The 280 patients agreed to participate of which 141 were men (RR: 70.5%) and 139 women (RR: 73.2%). Mean age for this sample was 38 years. Duration of diabetes for the total sample ranged from 1 month to 44 years with a mean duration of 14.3. Mean HbA1c-values for the whole sample was 7.9%. More speci®cally, 35% of men and 26% of women had low HbA1c-scores (6.9%); 35% of men and 33% of women had average HbA1c-scores (7.0±8.5%) and 30% of men and 41% of women had high HbA1c-scores (8.6%), respectively. Patient characteristics are shown separately for men and women in Table 1. No signi®cant differences were found between men and women for age (P 0:7), duration of diabetes (P 0:2) or glycemic control (P 0:07). 3.1. Gender differences in psychological adjustment As shown in Table 1, signi®cant gender differences were found in the psychological adjustment to diabetes. Men had signi®cant lower scores on cognitive adjustment to diabetes than women, which means that men had a more positive
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Table 1 Patient characteristics and scores on different psychological measures Variable
Mean score of women
Mean score of men
Age Duration of diabetes Glycaemic control Cognitive adjustment Emotional adjustment Depression Active coping Palliative coping Avoidance Social support seeking Depressive coping Expression of emotions Comforting ideas Marital satisfaction
38.0 12.7 (18±76) 15.1 10.8 (0.1±44) 8.1 1.6 (4.4±12.7%) 18.3 61.8 10.0 16.8 17.2 15.9 13.5 12.1 6.6 12.6 104.0
38.5 12.0 (19±71) 13.4 9.4 (0.5±38) 7.7 1.4 (5.1±15.0%) 16.8 63.6 6.0 18.9 16.4 14.6 12.1 10.9 6.5 12.8 110.0
appraisal of their diabetes. Men were also signi®cantly more satis®ed with their partner relation than women were. Women reported signi®cantly more depressive symptoms than men did and more women had a clinical depression: 24.7% of women versus 7.4% of men. Men and women also differed signi®cantly in their overall coping strategies: men used more active coping than women, were less avoiding, were less social support seeking and used less depressive coping. Men and women however did not differ signi®cantly in emotional adjustment to diabetes, expression of negative emotions, palliative coping and the use of comforting ideas as coping strategy. Tests for interaction showed only one signi®cant gender interaction for the relation between social support seeking and the emotional adjustment to diabetes: in men social support seeking did not signi®cantly improve the emotional adjustment to diabetes, while in women social support seeking and emotional adjustment were clearly positively related. 3.2. Psychological adjustment to diabetes in men and women A ®rst hierarchical regression analysis was performed based on the assumptions shown in Fig. 1 (research question 1). Coping variablesÐassumed to be a traitÐwere entered as a group in the ®rst step of the equation followed by age and duration in the second and the quality of the partner relation and depression in the third step. All these independent variables were entered in a forward-selection stepwise fashion and were regressed onto the dependent variables emotional and cognitive adjustment to diabetes in both men and women. In men, depressive coping and depression scores were the signi®cant predictors accounting for 18% of the variance in emotional adjustment to diabetes and for 35% of the variance in cognitive adjustment to diabetes (Table 2). All these predictors were negatively related to both measures of psychological adjustment to diabetes which means that
t-Value
P-Value
0.34 1.36 1.83 2.86 1.19 4.28 4.79 1.93 2.55 3.53 3.20 0.36 0.49 1.98
0.70 0.20 0.07 0.005 0.24 0.000 0.000 0.054 0.011 0.000 0.002 0.72 0.63 0.048
higher scores on depressive coping and higher depressive symptoms scores resulted in less well emotional and cognitive adjustment to diabetes. In women, depressive coping, expression of negative emotions and depression scores were the signi®cant predictors accounting for 39% of the variance in emotional adjustment to diabetes and 41% of the variance in cognitive adjustment to diabetes (Table 3). In women higher depression scores and higher depressive coping resulted in less well emotional and cognitive adjustment to diabetes, while higher expression of negative emotions score resulted in better emotional and cognitive adjustment to diabetes. 3.3. Relation between psychological adjustment and glycemic control in men and women A second hierarchical multiple regression analysis was performed based on the assumptions shown in Fig. 1 (research question 2). In the ®rst step depression scores Table 2 Statistics for the variables in two multiple regression equations performed for men with the emotional (ATT19), respectively, cognitive adjustment (ADS) to diabetes as dependent variable and coping, age, duration, depression score and quality of the partner relation as independent variables Variable
Beta
Standardised beta
t-Value
Significance
Eq. (1)a,b,c Depressive coping BDI
0.83 0.63
0.23 0.29
2.1 2.5
0.044 0.014
Eq. (2)b,d,e Depressive coping BDI
0.19 0.41
0.15 0.52
1.5 5.2
0.149 0.000
a
Dependent variable: ATT19. Independent variables: (coping) (age, duration) (depression score, quality of the partner relation). c R 0:44; F 9:8 (P < 0:001); R2 0:20; adjusted R2 0:18. d Dependent variable: ADS. e R 0:60; F 23:0 (P < 0:001); R2 0:37; adjusted R2 0:35. b
P. Enzlin et al. / Patient Education and Counseling 48 (2002) 139±145 Table 3 Statistics for the variables in two multiple regression equations performed for women with the emotional (ATT19), respectively, cognitive adjustment (ADS) to diabetes as dependent variable and coping, age, duration, depression score and quality of the partner relation as independent variables Variable Eq. (1)a,b,c Depressive coping Expression of negative emotions Depression score Eq. (2)b,d,e Depressive coping Expression of negative emotions Depression score
Beta
Standardised beta
t-Value
Significance
1.13 1.76
0.30 0.24
02.39 2.78
0.02 0.007
0.69
0.40
3.34
0.001
0.21 0.61
0.16 0.25
1.33 2.91
0.19 0.005
0.30
0.51
4.35
0.000
a
Dependent variable: ATT19. Independent variables: coping, age, duration, depression score, quality of the partner relation. c R 0:64; F 20:9 (P < 0:001); R2 0:41; adjusted R2 0:39. d Dependent variable: ADS. e R 0:66 F 22:3 (P < 0:001); R2 0:43; adjusted R2 0:41. b
and quality of the partner relation were entered in the equation followed by emotional and cognitive adjustment to diabetes in a second step. All these independent variables were regressed onto glycemic control in both men and women. In men, depression score was a signi®cant predictor of glycemic control accounting for 5% of the variance in glycemic control (Table 4). In women, no signi®cant predictors were found for glycemic control. Another method to study the relation between psychological adjustment and metabolic control also revealed no signi®cant relation between both variables. The total group was divided into three groups based on HbA1c-levels: 6.9% (low), 7.0±8.5% (average) and 8.6% (high). To detect differences between these groups a one way-ANOVA with Bonferroni post hoc tests was performed. These analyses, however, did not reveal any signi®cant difference Table 4 Statistics for the variables in two multiple regression equations (one for men and one for women) with HbA1c as dependent variable and depression score, quality of the partner relation, emotional and cognitive adjustment to diabetes as independent variables Variable
Beta
Standardised beta
t-Value
Significance
Equation for womena,b No significant predictors Equation for mena,b,c Depression score
0.06
0.25
2.5
0.015
a
Dependent variable: HbA1c. Dependent variable: (depression score, quality of the partner relation) and (emotional and cognitive adjustment to diabetes). c R 0:25; F 6:1 (P 0:015); R2 0:06; adjusted R2 0:05. b
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in psychological variables either between men with low, average or high HbA1c-scores nor between women with low, average or high HbA1c-scores, respectively. 4. Discussion and conclusion From the psychological literature it is known that men and women differ on several psychological variables, e.g. coping, depression and marital satisfaction [28±37]. The present study focused on the question if such differences contribute to the adjustment to diabetes and its treatment and con®rmed that there are signi®cant differences between men and women in the psychological adjustment to type 1 diabetes. Firstly, men and women differed in their overall coping strategies as measured with the UCL, a questionnaire often used in research in Dutch speaking countries. An assumption of this questionnaire is that coping style is a relative stable quality, a kind of trait [43]. The UCL measures general coping strategies with all kinds of stressors in a person's life (e.g. discharge, loss of a signi®cant other, illness). In this study, we found that men use more active coping, are less frequently avoiding, less social support seeking and use less depressive coping than women. These differences in coping style, however, are very similar to those seen between men and women in the general population [40], which suggests that patients with type 1 diabetes do not use other coping styles than men and women in general, do. A possible interpretation of these differences in the context of diabetes could be distilled from an analysis of the pathway by which coping style and depressive symptomatology in¯uence adjustment to diabetes in men and women. Depressive symptomatology and depressive coping seem to be the crucial factors that negatively affect psychological adjustment to diabetes, in both men and women. The pro®le of the scores men and women had on the UCL re¯ect different general coping styles. For men, the used coping styles re¯ect `mastery' and `autonomy'. Women's coping strategies re¯ect more `dependence on others'. This was also con®rmed by the signi®cant gender interaction effect found for social support seeking in their relation to emotional adjustment to diabetes. Gender differences in the link between social support and good metabolic control have also been reported elsewhere. StenstroÈm et al. [38,39] found that women use social support seeking more frequently and that they mobilise their social support networks more easily in time of need. Secondly, women reported twice as much depressive symptoms as men and even three times more women were clinically depressed in our sample. These results support ®ndings in surveys on the prevalence of depression in the general population showing a female/male ratio of 3/1 [34] and are in accordance with the results of a meta-analysis on the prevalence of comorbid depression in adults with diabetes [23]. It is not yet clear, however, whether the female/ male ratio found in studies re¯ects a higher prevalence of
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depression in women or whether it is an artefact given that gender role expectations make it more socially acceptable for women to report feelings of depression [48]. The present study revealed gender differences in the psychological adjustment to diabetes. Psychological adjustment comprises cognitive (thoughts about diabetes) and emotional (feelings of acceptance of diabetes, feelings of self-control) adjustment to diabetes. Although cognitive and emotional adjustment were highly inter-correlated in this study, an interesting ®nding was that although men and women had comparable feelings of acceptance of diabetes, men had a more positive appraisal of diabetes. A possible explanation for this ®nding could be found in three other studies of which one revealed that men were less likely to agree that diabetes has a signi®cant impact on a patient's life [38] and the other that men found their illness less of a hindrance than women [49]. It has also been suggested that men may have a greater need to deny the problems related to their illness [48] in an effort to keep the diabetes out of their personal and social identity [50]. Another ®nding in this study was the weak relation between psychological factors and glycaemic control. In the present study, it was found that in men only depression scores predicted to some extend glycaemic control. In women, no signi®cantly predicting variables were found. At least two explanations can be given for the weak relation found in this study between psychological variables and glycaemic control. Firstly, we did not ®nd a relation because there is no relation between psychological variables and glycaemic control. Secondly, there is a relation but we could not ®nd it since other psychological/behavioural variables than those assessed in this study are related to glycaemic control. Indeed, the importance of adherence in diabetes treatment has often been discussed in the literature [16,24]. It is possible that psychological variables indirectly have an in¯uence on glycaemic control by their in¯uence on adherence to the prescribed regimen, a factor that was not assessed in this study. Another problem might be that a single measurement of HbA1c might be not the most accurate index to study the in¯uence of psychological adjustment to diabetes on glycaemic control. The in¯uence of psychology on metabolic control may be acting over years and HbA1c is re¯ecting glycaemic control over too short a period of time (6±8 weeks). Finally, this study has several limitations. Due to the cross-sectional design, we could not evaluate the temporality of the relation between the different psychosocial variables and/or glycaemic control. Therefore, future studies in this ®eld should use a longitudinal design to clear out the differences between men and women in the temporal evolution of psychological adjustment to diabetes. Secondly, caution should be exercised in interpreting these results because the percentage explained variance is not always large. Thirdly, potentially confounding demographic and clinical factors (e.g. kind, number and severity of complications) have not been considered in this study.
4.1. Conclusion In conclusion, men and women with diabetes do not use other coping styles than men and women in general do and we found that men used more active coping, less avoiding, less social support seeking and less depressive coping. Despite these differences in coping style, glycaemic control was not signi®cantly better in men than in women. Women reported more depressive symptomatology than men did and more women were depressed. There were also signi®cant gender differences in psychological adjustment to diabetes. The psychological factors negatively related with the psychological adjustment to diabetes in men and women are depressive coping and depressive symptomatology. 4.2. Practice implications To our knowledge, this is the ®rst study dealing with the impact of gender on psychological adjustment to diabetes and on metabolic control in patients with diabetes type 1. Our results suggest that it could be important to analyse males and females separately when studying psychological adjustment to diabetes. Further research should con®rm the results of this exploratory study and should focus on the fact that these ®ndings could have implications for diabetes care in general. Improving psychological adjustment to diabetes may necessitate addressing other themes in men and women and this study suggests that social support could be such a gender sensitive theme. References [1] DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications. New Engl J Med 1993;329:977±86. [2] Brickman A, Yount S, Blaney N, Rothberg S, Kaplan De-Nour A. Personality traits and long-term health status. The influence of neuroticism and conscientiousness on renal deterioration in type 1 diabetes. Psychosomatics 1996;37:459±68. [3] Orlandini A, Pastore M, Fossati A, Clerici S, Sergi A, Balini A, et al. Effects of personality on metabolic control in IDDM patients. Diabet Care 1995;18:206±9. [4] Dunn SM, Turtle JR. The myth of the diabetic personality. Diabet Care 1981;4:640±6. [5] Wales J. Does psychological stress cause diabetes? Diabet Med 1995;12:109±12. [6] Surwit RS, Schneider MS, Feinglos MN. Stress and diabetes mellitus. Diabet Care 1992;15:1413±22. [7] Demers RY, Neale AV, Wenzloff NJ, Gronsman KJ, Jaber LA. Glycosylated hemoglobin levels and self-reported stress in adults with diabetes. Behav. Med. 1989;15(4):167±72. [8] Inui A, Kitaoka H, Majima M, Takamiya S, Uemoto M, Yonenga C, et al. Effect of the Kobe earthquake on stress and glycemic control in patients with diabetes mellitus. Arch Intern Med 1998; 158:274±8. [9] Surwit RS, Feingloss MN. The efffects of relaxation on glucose tolerance levels in diabetic persons. Diabet Care 1983;6:176±9. [10] Peyrot M, Mcmurry J. Stress buffering and glycemic control. The role of coping styles. Diabet Care 1992;15:842±6.
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