Physical activity among women with type 2 diabetes Using of social cognitive theory: predictors of physical activity among women with diabetes type 2
Nooshin Peyman1, Habibollah Esmaily 2, Ali Taghipour3, Mehrsadat Mahdizadeh4
Journal of Research & Health Abstract Social Development & Health Promotion Research Center Physical activity is a complex behavior and its determinants are Vol. 3, No.2, 2013 different in various groups. Due to the chronic nature of type 2 Pages: 345-354 Original Article diabetes, treatment Adherence requires lifestyle changes that are difficult for many people to adopt and maintain it. This study 1. PhD in Health Education, Associate Professor of Health and Management aimed to determine predictive structure of social cognitive Department, Health Sciences Research theory on physical active among women with type 2 diabetes. Center, School of Health, Mashhad University of Medical Sciences, This study was cross sectional -correlative that were randomly Mashhad, Iran 2. PhD in Biostatistics, Associate selected 300 people with type 2 diabetes by multi-stage cluster professor of Biostatistics and sampling method. Tools for data collection, a questionnaire was Epidemiology Department, Health Sciences Research Center, School of consistent with social cognitive theory constructs and IPAQ that Health, Mashhad University of Medical Sciences, Mashhad, Iran had been used in the scientific sources and texts. Reliability and 3. PhD in Epidemiology, Assistant validity was determined for use in this study in a pilot study. Professor of Biostatistics and Epidemiology Department, Health Data were analyzed by using analysis of variance and Sciences Research Center, School of Health, Mashhad University of regression testes. The results showed the structure of social Medical Sciences, Mashhad, Iran. cognitive theory, Self-regulation (P=0.001), Social Support 4. Correspondence to: MSc in Health Education and Promotion, Health (P=0.001), and self-efficacy (P=0.005), had the significant Sciences Research Center, School of Health, Mashhad University of effect on the Physical activity among the research sample. Medical Sciences, Mashhad, Iran According to the results, the self-regulation, self-efficacy and Tel/Fax: +98 511 8514548 E-mail:[email protected] social support were important influences on the physical Received: 29 Sep 2012 activity and they must be considerate in designing and Accepted: 09Jan 2013 implementing of educational interventions. How to cite this article: Peyman N, Esmaily H, Taghipour A, Mahdizadeh M. Using of social cognitive theory: Keywords: Diabetes mellitus, Physical activity, Social Cognitive Theory, Predictors of physical activity among women with diabetes type 2. J Research Woman Health 2013; 3(2): 345-354.
Introduction Physical activity is part of a healthy lifestyle [1] lifestyle [6]. Given the growth in the and a complex behavior, with different elderly population of Iran, and the rapidly determinants in various groups [2]. Diabetes increasing trend of this disease, this type 2 used to be considered an adult disease, country is considered one of the Middle- today; it affects younger age groups, young Eastern countries affected by this problem [4]. adults, and even teenagers, with over 800,000 The positive role of exercise and physical adolescent victims [3]. In 2010 approximately activity in people’s health and in prevention 285 million people worldwide were estimated and control of many disease complications, to be affected by diabetes [4], and a rise to including diabetes has been confirmed [7]. 439 million people is expected by 2030 Regular physical activity is one of the most [5], primarily due to obesity and sedentary important factors in becoming healthy and 345 Peyman et al. preserving health, and has been considered as and also how to motivate, guide, and enable one of the 15 behavior change priorities in people to adapt to health promoting promotion of health. Positive behavior change behaviors, and reduce inability in them [13]. can significantly reduce risk associated with According to SCT, effective factors in chronic diseases [8]. It is estimated that lack intervention are self-efficacy, self-efficacy of of physical activity causes 1.9 million deaths overcoming obstacles, outcome expectations, and loss of 19 million Disability Adjusted outcome values, self-regulation, behavioral Life per Year (DALYs) globally [9]. capabilities (knowledge and skills), emotional Inactivity doubles the risk of cardiovascular adjustment, modeling, environment, and understanding of situation [13,14]. In SCT, diseases in people. Yet, inactivity, particularly human behavior is explained in two-way and among women with type 2 diabetes is very dynamic interactions of personal, high due to the prevalence of obesity. A very environmental, and behavioral factors. Hence, high proportion of women with type 2 physical activity behavior is considered in a diabetes in this society are inactive during dynamic and interactive system. their leisure time, and even most of their Various studies have shown that different household activities are light or very light personal factors including demographic [10]. parameters, attitude, and beliefs, and social and Health researchers and professionals suggest environmental factors affect performing physical social-cognitive theories and models to activity [15], and directly and indirectly predict determine the pattern of acceptance and physical activity [4, 8, and 16]. Martin Jeans et al., persistent personal behavior and factors in a study in 2011, aimed to determine the power associated with these changes for effective of SCT constructs in predicting physical activity intervention in health promoting behaviors and to provide a structural model in a sample of including physical activity [11]. 160 patients with spinal injury concluded that self- In last few decades, experimental research has regulation construct directly predicted performing been conducted in the field of biological, physical activity in these patients, and self- environmental, social, and psychological efficacy and outcome expectations described factors which are effective in adjusting and physical activity indirectly through self-regulation maintaining physical activity in the public and the [17]. people with chronic diseases. They showed that Given that self-care behaviors in diabetes, as changeable and unchangeable factors are effective physical activity is deeply rooted in cultural in adopting and maintaining physical activity. values and beliefs, thus, interventions must be Change-resistant factors include age, gender, and suited to the society [11]. Also, considering race, and change-flexible factors are access to high prevalence of diabetes in the population, environmental facilities, stress, and cognitive- and the financial and psycho-social costs social processes, which are the target factors in imposed on the person, family, and the clinical and experimental interventions. In many community [4], this study was conducted to cases, these factors are considered as a determine predicting constructs of SCT in problem and motivational factor in adopting physical activity in women with type decisions to adopt physical activity [12]. 2 diabetes, so that an effective educational The Social Cognitive Theory (SCT) attempts intervention can be designed and to introduce behavior predictors as well as implemented accordingly. principles on which behavior is formed, 346 Physical activity among women with type 2 diabetes Method This was a correlative sectional study in option questions (0-20), self-regulation with two which type 2 diabetic women were selected goal setting questionnaires with 6 questions (6-30), from the population covered by diabetes units planning with 4 questions (4-16), self-efficacy in in Mashhad city health centers. Subjects were overcoming barriers with 10 questions (10-50), self- selected in two-stage cluster sampling. In the efficacy 4 questions (4-20), outcome expectations 4 first stage, 3 out of 5 health centers in questions (4-20), modeling 10 questions (10-50), 10- Mashhad were randomly chosen (by drawing question short form of depression assessment with lots), and in the second stage, from diabetes one question added by experts to assess anxiety (11- units in health centers, 6 were randomly 440), social support 10 questions (10-50), considered, and based on the population environmental understanding 7 questions (7-35), density in each cluster, and study inclusion physical environment 8 questions (0-8), evaluated and exclusion criteria, study samples were participants’ opinions on items in each section. randomly chosen from their records. After Questions in all questionnaires (except depression telephone contacts, they were invited to attend form and planning that were based on Likert 4-point at a certain time to complete the style) were scored based on the 5-point Likert style questionnaires if they wished. The sample from totally disagree to totally agree (with score size required for this study, according to the of 1-5). The physical activity questionnaire, with 7 results of similar studies, given correlation questions assesses level of physical activity coefficient of self-efficacy with physical according to intensity of activity (severe, activity (r=0.16) (which is the key construct moderate, and light), and duration of activity in SCT) with 95% confidence and power of based on hours and minutes during the day and in 80% was determined 300 people [4]. the past one week. Using Metabolic Equivalent of Questionnaires were completed in (MET) level of consumed energy in terms of researcher’s structured interviews with intensity of activity is determined [18]. The participants lasting 15-20 minutes each. The validity and reliability of this questionnaire have study inclusion criteria were type 2 diabetes been determined in studies in the country [19] based on patients’ records, age between 35 and abroad [20]. Content validity of relevant and 65 years, no diabetes complications, questionnaires to SCT constructs was desire to participate, literacy, performing determined by utilizing experts’ opinions, and physical activity, and no insulin therapy. Non- calculation of Content Validity Ratio (CVR). Iranian nationals and patients with duration of Cronbach’ alpha was calculated to determine diabetes less than 6 months were excluded internal consistency of questionnaires, in a from the study. Data collection tool was a pilot study on 90 women with type 2 diabetes. questionnaire based on SCT constructs used In addition, to find external reliability, in foreign studies. To localize the correlation coefficient was calculated in a questionnaire to adapt to socio-cultural test-retest with interval of 10 days on 15 Iranian society, questionnaires were translated women with diabetes. Cronbach’s alpha and into Persian and back to English by two correlation coefficient were found for experts separately, and their validity and awareness questionnaire 0.89 (r=0.84), goal reliability were examined. Tools used in the setting 0.92 (r=0.71), social support 0.91 study were the short form of International (r=0.86), outcome expectations 0.72 (r=0.65), Physical Activity Questionnaire, demographic modeling 0.87 (r=0.75), environmental questionnaire (patients’ records were used to understanding 0.76 (r=0.83), self-efficacy complete some of its questions) including 0.96 (r=0.77), practical planning 0.91 hemoglycolized hemoglobin level in the last 3 (r=0.69), depression short form 0.75 (r=0.94), months, and the related questionnaire to SCT and self-efficacy of overcoming obstacles 0.78 constructs with sections on awareness with 11 4- (r=0.74) respectively. The data collected were
347 Peyman et al. analyzed with SPSS-11.5 software, and after 30±4.17, and the mean level of hemoglycolized determining frequency distribution of parameters hemoglobin 7.67±1.68, and the median of diabetes using Kolmogrov-Smirnov test, independent t- duration 48 months. Most participants were high test, one-way variance analysis, chi-squared, school dropouts (79%), were mostly housewives Pearson-Spearman correlation and regression (95.3%), with hemoglycolized hemoglobin level 7% tests were used to analyze relationship between and higher, which is considered inadequate control of parameters. diabetes in clinical terms. Majority of subjects (65%) introduced their doctors or nurses as source of Results obtaining information about their disease (Table 1). The results showed the mean age of participants 52.49±7.12 years, the mean body mass index
Table 1 The frequency distribution of demographic parameters in study subjects (n=300) n % Literacy 49 16.3 Elementary 127 42.3 Education level Middle school 55 18.3 High school diploma 58 19.3 University education 11 3.7 Housewife 286 95.3 Employment status Employed 14 4.7 Married 262 87.3 Marital status Widowed 30 10 Separated 8 2.7 Private 237 79 Home ownership status Rental 63 21 House 181 60.3 Type of house Apartment 119 39.7 < 4700000 Rials 92 43.6 Income level ≥4700000 Rials 119 56.4 < 25 34 11.3 Body mass index 25-30 125 41.7 Over 30 141 47 < 7% 119 39.7 Hemoglycolized hemoglobin level ≥ 7% 162 54 Diabetes specialist and 197 65 Preferred information source nurse Others 103 35
Pearson correlation results showed parameters emotional adjustment (r=-0.214) had a of age (P=0.032, r=0.124), body mass index significantly negative correlation with (P=0.042, r=0.118) hemoglycolized physical activity (P<0.001). Spearman hemoglobin (P=0.02, r=0.139) had a significant coefficient results showed a significantly and inverse correlation with women’s physical positive correlation (P<0.001) between physical activity, and level of physical activity decreased activity and construct of environmental with increasing levels of these parameters. understanding (r=0.266), physical environment Pearson correlation coefficient showed a (r=0.204), self-efficacy (r=0.537), outcome positive and significant correlation between expectations (r=0.211), and awareness physical activity and construct of self- (r=0.371). regulation (r=0.534), self-efficacy of Based on linear regression analysis, constructs overcoming obstacles (r=0.429), modeling of self-regulation, social support, and self- (r=0.462), and social support (r=0.457), but efficacy predicted 27.9% of physical activity
348 Physical activity among women with type 2 diabetes performance variance, but constructs of self- determine Social Cognitive Theory constructs efficacy of overcoming obstacles, outcome to explain physical activity in a sample of expectations, modeling, emotional adjustment, 1717 adults with diabetes, found SCT environmental understanding, and physical constructs predicted 59% of physical activity environment were not significant predictors of physical activity (Table 2). variance in type 2 diabetics [21]. The difference between the current and Plotnikoff Table 2 Regression analysis of social cognitive theory studies is probably due to the large sample constructs in predicting physical activity in study size in the latter study. Dunlop in a study with subjects Standard application of social cognitive theory in F P-value beta explaining influencing factors on physical Self-regulation 0.247 3.875 <0.001 activity found SCT constructs predicted 41% Social support 0.216 3.66 <0.001 of physical activity variance. Dunlop also Self-efficacy 0.176 2.80 <0.005 showed environmental, traffic, and social 2 R =0.279 support factors were important predictors of General Linear Model results showed body physical activity in MS patients [16]. Dunlop mass index, education level, hemoglycolized study was conducted on a small sample size hemoglobin, and constructs of self-regulation, of both sexes, and percentage of variance perceived social support, and self-efficacy calculated for SCT constructs predicting predicted 39.6% of physical activity physical activity was higher than that found in performance variance in study subjects. In this this study. This was probably due to the model, of the demographic parameters, only peculiarities associated with MS (since MS hemoglycolized hemoglobin could significantly patients are faced with movement problems). predict physical activity (Table 3). Physical environment factors like traffic, self- efficacy in overcoming obstacles, and Table 3 General linear model results in effects of demographic variables and social cognitive theory outcome expectations constructs had a high constructs on physical activity in study subjects predicting power in Dunlop’s study, but these F P-value constructs were insignificant physical activity Self-regulation 18.76 <0.001 predictors in the present study. In Resnick Social support 14.05 <0.001 Self-efficacy 13.63 <0.001 study conducted on healthy adults, SCT Hemoglycolized constructs predicted 40% of physical activity 6.84 0.009 hemoglobin variance in study subjects [22]. The difference Body mass index 3.07 0.081 in variance calculated between the current and Education level 2.88 0.091 R2=0.396 Resnick’s study was probably due to the health status of the participants, including Discussion chronic nature and problems of the disease, The results of the study showed that of the and daily management of the diabetes Social Cognitive Theory constructs, self- compared to the healthy status of Resnick’s regulation, social support, and self-efficacy participants. The results of Norouzi et al. were the strongest physical activity predictors study confirms this, which showed perceived in study subjects. health status was an important predictor of In line with the findings of this study, physical activity in women with type 2 Plotnikoff, in a study with the aim to diabetes in health promotion model [8].
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Self-regulation was the strongest predictor of and physical activities [28]. The present study physical activity in all SCT constructs, which also emphasizes its importance in physical was similar to the results obtained in behavior of women with type 2 diabetes. Anderson’s study that investigated social The same as findings of the present study, cognitive predictors of physical activity in Bonner’s results also showed Self-Efficacy adults in Virginia [23]. In a study by Amistad predicted intention of physical activity in type et al., self-regulation was again the strongest 2 diabetics [29]. In Norouzi et al. study physical activity predictor in adults [24]. In conducted in relation to physical activity this respect, Bandura emphasizes that determinants based on health promotion utilization of self-regulation strategies is model in diabetic women [8], and also in necessary for aiming and planning regular Didarloo et al. study on physical activity physical activity [25]. determinants based on developed rational As in Plotnikoff [21] and Anderson et al. [23] action theory in women with type 2 diabetes studies, perceived social support was another [4], self-efficacy was an important predictor predictor of participants’ physical activity in of physical activity in study subjects. Self- the present study. In Plotnikoff study, social efficacy is the person’s confidence in the support was a direct determining factor of ability to carry out minor aspects of behavior. physical activity in diabetic patients, and in For example, a person’s belief in the ability to Anderson et al. study, family social support perform walking exercise at moderate had both direct and indirect effect on physical intensity for 30 minutes is important in activity, and its indirect effect on behavior behavior adoption [30]. Lee et al. in a study was through self-efficacy and self-regulation aiming to apply the theory of self-efficacy of strategies. In a study by Tulloch social and overcoming psychological obstacles to physical environment were indirect predictors increase physical activity in the elderly, of physical activity through self-efficacy and revealed that self-efficacy in exercise has a outcome expectations [26]. As opposed to the strong correlation with the amount of physical results of the present study, in another study, activity in the elderly [30]. perceived social support was not correlated In this study, biological and personal factors with physical activity [27]. In Norouzi et al. including age, education, household income, study, social support did not predict physical and hemoglycolized hemoglobin and body activity of women with type 2 diabetes [8]. mass index, only hemoglycolized hemoglobin The difference between the results of these affected physical activity. Conversely, a studies and the present study is probably due cross-sectional study showed household to personal, social, and cultural differences in income and education, in addition to the study subjects. Social environment that psychological factors, influenced adults’ includes attitudes of the family, friends, peers, physical activity, as well[28]. In a similar and health workers, and having an exercise study to the present one, the results indicated partner are aspects that influence compliance that age and education level did not have a with physical exercise behavior. significant effect on physical activity [8]. Encouragement of people by their families, However, in Didarloo et al. study, opposite friends, and health workers is a potential results to those of the present study was determinant in following exercise programs
350 Physical activity among women with type 2 diabetes reported, and in demographic parameters determining factor in physical activity could investigated, education significantly affected be associated with this issue. physical activity in women with type 2 Although the findings of the present study diabetes [4]. According to the findings of the provided a complete description of physical present study, since most participants had activity determinants according to Social similar education and age, these parameters Cognitive Theory, and attempts were made to were probably not predictors of physical consider different aspects (personal, activity in study subjects. In the present study, cognitive, behavioral, and environmental) despite a significant and inverse correlation associated with physical activity in study between body mass index and physical subjects, there were some limitations, too; 1) activity (indicating lower activity of people Non-generalizability to male patients with type 2 diabetes or other population groups, 2) with higher body mass index), this parameter Self-reporting physical activity, 3) did not significantly affect physical activity, Limitations associated with tools used which in the final regression model, which disagrees consisted of a large number of SCT construct with Norouzi et al. results that showed body questionnaires that made answering mass index indirectly through self-efficacy somewhat difficult. This was realized in the affected physical activity of women with type pilot study and the researcher tried to reduce 2 diabetes [8]. In the present study, since most this limitation through structured interviews. participants had moderate to high body mass However, this study had some strong points indices, BMI was not a predictor of physical that were not observed in other studies, activity. including random collection of data from In the present study, hemoglycolized diabetes units in health centers in Mashhad, hemoglobin was a predictor of physical which naturally eliminated volunteer bias, and activity, but in similar studies, the increased generalizability of the study importance of this parameter on physical population. activity was not investigated [4,8]. In this respect, Doosti et al., in a phenomenological Conclusion study, stated that knowing laboratory test Based on the results of this study, self- results were effective (based on participants’ regulation, self-efficacy and social support are statements) in increasing motivation to the important factors in predicting physical continue self-care behaviors including activity that can influence adoption of and physical activity [31]. Considering that in compliance with an active lifestyle. Given the diabetic patient care program, special nature of this aspect of healthy lifestyle attention is paid to level of hemoglycolized that is a complex behavior, in design and hemoglobin to assess and control blood implementation of interventions to change inactive lifestyle, it is necessary glucose by the patient (and doctors and nurses for health promotion professionals to take in diabetic units recommend patients to into account a series of personal, maintain it at a proper level to protect against cognitive, and environmental factors. complications and consequences of diabetes), accordingly, the reason for this being a
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