To and behaviours can promote or hinder the


To discuss the ways in which illness beliefs
and behaviours can promote or hinder the management of long-term conditions.



It is
vital to understand that long-term conditions (LTC) are recognized as
conditions which are not curable, but can be managed through forms of
medications and other treatments (Naylor et al.,
2012). Around 30% of the population in England (15 million people) have one or
multiple LTC, as predictions have stated figures to continue to rise (Edwards
et al., 2012). Recent reports (e.g. NHS Confederation, Kings Fund and Coalition
for Collaborative Care) have highlighted that the NHS need to develop major
changes to respond effectively to the number of people living with LTC
increases (Kennedy et al., 2013). This includes further changes the way in
which services have been organised to deliver greater emphasis to target
interventions/strategies to help individuals manage their LTC (Small et al.,
2013). One psychological approach which is widely used is the Self-Regulatory
Model of Illness Behaviour or commonly known as the common-sense model (CSM). This
approach proses the response to illness or health threats which people form
their own common-sense of illness beliefs/perceptions about their condition and
treatment. Illness beliefs have influence towards the types of health-related
behaviours as well as coping behaviours in the ways individuals manage their
conditions which impact their illness health outcome (Leventhal et al., 2003).
The CSM suggests they cover five broad dimensions: identity, timeline, causes,
consequences and curability/controllability (Lau & Hartman, 1983). People’s
illness beliefs of their diabetes have found to be influential on
self-management behaviours, which may have an impact on glycaemic control (Griva
et al., 2000). People who have poor control of their diabetes have found to
distinctly have different beliefs on their LTC compared to those in good
control. This was evidently shown in research which found that compared to
patients in good control with their diabetes; those with poor control had shown
stronger beliefs that their illness was caused by genetic factors, suffered
from more symptoms diabetic-related, perceived diabetes to have a significant
impact to their lives, and more report on negative emotions in relation to
their illness/LTC (White et al., 2007).

Research which has used CSM has found beliefs about diabetes
to be an important role to instigating illness management, as well as
interventions to either challenge or change beliefs (Philips et al., 2012).
However, research which has used CSM has been conducted on those who are
Europeans or Caucasian (Bames et al., 2004). Qualitative studies were able to
provide an insight into casual beliefs abut diabetes as well as self-management
behaviours in this population.  For
example, controlling intake of sugar, followed by information which may be
provided by General Practitioner (GP) and passive beliefs (attributing diabetes
control towards God and believing that deities have more power in controlling
illness and health) have relation towards self-management of diabetes, although
these factors require explanation within the domains of CSM (Fleming &
Gillibrand, 2009). Success to self-management requires better understanding of
diabetes. However, poor understanding and cultural health beliefs of diabetes
have reported to hinder self-management practises, which results in poor
outcomes of diabetes (Stone et al., 2010). Educational programmes tailored to
diabetes have been designed to improve diabetes self-management in British
South Asian have had limited success to improving diabetes outcome. Given that
there is an elevated risk of diabetes in the population, more compete
explanation is needed to have better knowledge to understanding the underlying
illness beliefs about diabetes and self-management (Zeh et al., 2012). To
manage illness, this is often shared involving the patients family or friends,
and is likely that the beliefs about diabetes influenced this context. Strong
family ties in South Asian populations have shown a link to shaping illness
beliefs and delivery of information about diabetes (Searle et al., 2007).

In consideration to the background knowledge in understanding
illness beliefs and CSM, this essay will explore the ways in which illness
beliefs and behaviours can promote or hinder the management of diabetes through
the role of family, education and empowerment for self-management.


Family Support

An understanding of how people think, and manage their LTC
can be beneficial to take account of cognitive representations through family
and social context in which beliefs/thoughts were developed. DiMatteo (2004)
explained he possibility that family context may impact on illness beliefs is
relevant for diabetes, considering how most of self-regulatory behaviours are
involved in self-management of diabetes. The association between managing an
illness and social support has shown extensive research. The precise mechanism social
support has a to health outcomes in yet to be understood. However, research
does suggest social support can be beneficial to people’s health by buffering
the stress, and changing affective states, increasing their self-efficacy and a
change in their negative health behaviours. Research had found emotional and
practical support received by individual’s family and friends was a positive
influence on global measures in illness management with patients with diabetes
(Rosland et al., 2008). DiMatteo (2004) had carried out a meta-analysis
reviewed 122 empirical studies and had fund adherence to be 27% higher when
individuals revived practical support. Additionally, research has also
indicated strong association with family dimensions for example, cohesion and
guidance to show better glycaemic control among diabetic patients (Pereira et
al., 2008). DiMatteo (2004) further explained in regards to family cohesion,
families described as accepting, close and warm, adherence was three times
higher compared to non-cohesive families. Furthermore, DiMatteo (2004), in the
same study, functional social support such as emotional and practical support had
shown stronger effects to adherence than did structural social support, which
suggests quality of a family-patient relationship has most importance than a
mere presence of individuals who a part of a patient’s network of support.

support has shown active support and care for people with diabetes in changing
illness beliefs. However, for most individuals living in a household has
greater influence in diabetic managing behaviours. A study had found that over
5000 adults with diabetes highlighted importance of family, friends and
colleges to improve self-management (Nicolucci
et al., 2013). Family members have often been asked to share the individual’s
responsibility to manage the LTC. They are able to provide forms of support,
helping to inject insulin or driving to appointments as well as emotional and
social support in aiding people to cope with their condition (Wagner et al.,
2001). Through their communication and illness beliefs, family members are able
to have a significant impact on their well-being, decisions to follow
recommended medical treatment, and the ability to maintain and initiate changes
to their diet and exercise (Armour et al., 2005). Among people with type 2
diabetes who are middle-aged and older adults, social support from family has
shown to be associated to improve self-reported health in a long-term follow-up
(Nicklett et al 2013). In relation to family cohesion, family functioning has
shown to be positively related to patients’ self-care behaviours and
improvements to control blood glucose levels (Walker et al., 2015). Among
middle and older aged adults with types 2 diabetes, social support has also
found to provide diabetes education only to just individuals who have type 2
diabetes could limit impact on individuals, considering family to play a huge
role in managing LTC. Family-based approaches to long-term conditions to
emphasize the background in which the condition occurs, this includes the
physical environment of the family, as well as educational, social and personal
needs of the individual and family members (Armour et al., 2005; Hu et al.,
2014). Educational interventions including family members may be able to
provide support to individuals with diabetes, be able to develop healthy family
behaviours and promote self-management in diabetes (Hu et al., 2014).


targets have demonstrated that research using diabetes self-management
education and support (DSME/S) to provide a foundation to help people with
diabetes and navigate their activities and decision to improve health outcomes.
Diabetes self-management support (DSMS) makes reference to the support which is
implemented to sustain coping skills and behaviours and self-manage through an
on-going basis (Brunisholz et al., 2014). DSME/S
has shown to improve hemogloblin (A1C) as much as 1% to those who have type 2
diabetes, this important reduction and show positive effect on psychosocial,
clinical and behavioural aspects of diabetes (Norris et al., 2002). DSME/S is
has also reduced the onset and/or the advancement of diabetes complications,
improving quality of life, lifestyle behaviours such as healthy eating pattern
and engagement with regular physical activity, enhancing self-efficacy and
empowerment, increase coping skills and be able to decrease diabetic-related
distress and depression (Hermanns et al., 2015). Regardless of the setting, communicating
this information and teaching supporting skills which are necessary in
promoting effective coping skills self-management which is required day to day
living with diabetes through a personalized and wide-ranging approach. An
effective result from the delivery involves experts in clinical, psychosocial,
behavioural and educational diabetes care (Bowen et al., 2010). Through clear
communication and effective collaboration among health care teams which include
an educator, provider and a person who has diabetes is critical to ensure goals
are clear and they progress towards the goals which have been made, as well as
appropriate interventions are being used. A patient centred approach to DSME/S
at the diagnosis is able to provide the individual for current and future
needs. On-going, DSME/S is able to support the individual to overcome the
carries they may face and cope with the on-going demand in order to enable
changes during the course of their treatment and life changes (Haas et al.,

people who are diagnosed with diabetes can often feel overwhelmed. The
emotional response from the diagnosis has shown to be a significant barrier for
self-management and education (Skovlund et al.,
2005). Therefore, research has explained educating interventions should have
more emphasis on the importance which involves family members or significant
others for the on-going support and education (De Groot et al., 2012). Health
care team and others care can help and promote and manage diabetes, by
withstanding these behaviours which may frequently be difficult. Therefore,
annual assessments of knowledge, necessary skills, and behaviours are important
for those who do meet the goals set as well as those who do not (Funnell et
al., 2007). In consideration for people who are living with diabetes,
importance has shown to maintain visits by asking the indivudal about the success
or concerns, struggles and further questions. The main focus during each
sessions have shown to be patient decisions and issues – the choices they have
made, reason for these choices and if the decisions are helping the individual
to attain his or her goals, but not towards perceived adherence to
recommendations (Parchman et al., 2010). Therefore, it is important for the
close members of the individual who has diabetes to determine their
psychosocial, clinical and behavioural goals to create realistic plans to
maintain those goals. In order to reinforce these plans it is vital for health
care communities to deliver quality care in order to mobilize the efforts and
address barriers which explore resources of DSME/S to promote and maintain the
needs of those living with diabetes (Funnell et al., 2014).


Considering recent evidence on the importance of illness beliefs of
diabetes to be promoted and managed through family support or education, CSM
components identify controllability and identity. Patients with diabetes have
to make decisions on their own decisions managing diabetes on a day to day
routine basis without a constant helping hand from professionals. This
empowerment (diabetes empowerment scale) was used to emphasise psychosocial
skills in achieving behavioural change, change in social situations and other
factors which may influence their lives (Funnell & Anderson,
2004). People with diabetes may be questioned on the difficulties they face
with diabetes, and these illness beliefs can most willingly change to manage
their LTC. Researchers had designed a program which was designed to enhance
appropriate goal settings, problem solving to challenge beliefs and eliminate
barriers to when achieving a set goal, coping with change, managing stress of
diabetes and general life, identifying and obtaining the appropriate social
support and improving the ability to be self-motivated. The results had shown
self-efficacy and illness beliefs in diabetes improved. Blood glucose levels
had reduced by 0.7% from the intervention group, but no significant change in
controls. Empowerment-based
program for type 2 diabetes patients improved quality of life and glycemic
control (0.7%) at 6 months compared to control groups. The sessions were able
to address coping with diabetes and stress, seeking social support, problem
solving, and goal setting and staying motivated (Wong et al., 2015).
Furthermore, a 6-week Spanish language programme based on self-efficacy had
generated behavioural benefits. As the sessions were help weekly and monthly
support was given in group meetings until 12 months based on empowerment
approach which showed an improvement in blood glucose levels (?0.5%) and was
continued over 3 years (Ritter et al., 2016). Research had also found that
patients who were insulin-treated, training in adjusting their own insulin dose
for meal size, fasting or correction with hyperglycemia, produced better
glycemic control as predicted but produced greater perceptions of self-efficacy
and feeling of empowerment (Rossi et al., 2015). Research which has included
self-regulatory theory to promote and manage diabetes indicates that an
individual’s personal control is an important part of the patient’s personal
illness belief to their diabetes. Empowerment has the ability to increase the
individual’s personal control and is therefore consistent with CSM and the
self-regulatory theory.


Limitations to
Promote and Manage Diabetes

As family support,
education and empowerment have stated the ways in which promoting or managing
diabetes can be beneficial, implications have been taken into account that
there is rareness of research which explains diabetes illness beliefs among
college/university students.  Considering
the few studies which have looked upon type 2 diabetes, little research has
been conducted focusing on students which may be afflicted with type 1
diabetes. The following studies have examined the difficulties which is faced
by students in order to maintain good health and control as well as adapting
their ways living with the illness being an independent young adult (Miller-Hagan & Janas, 2002). That being said,
diabetes-related complications and other factors may influence self-management
should be considered as a critical indicator for diabetes education which
requires immediate attention acceptable resources. During a routine of medical
care, the individual may identify the factors which influence their treatment
and their related self-management plan (Nam et al., 2011). These factors are
able to include the patient’s ability in managing and coping diabetic
complications, medications, other health conditions, emotional needs, physical
limitations and basic living needs. These factors may be present in the initial
diabetes encounter or may arise during any time, and have influences the
patients psychosocial, behavioural and clinical aspects of diabetes care
(Powers et al., 2015). Consequently, potential need and additional health
conditions for medication can complicate self-management for the individual. Therefore,
focused and additional support may be needed for stress, anxiety and
diabetes-related distress or depression (Xu et al., 2008).

Furthermore, emotional and psychosocial factors have multiple
contributors which include diabetes-related distress, anxiety, depression and
life stressors. These factors have been considered complications of diabetes,
and result to poorer outcomes of diabetes (Chew et al., 2014). As prevalence
rates for diabetes-related distress is common (18%-35%), there has been a
greater impact on metabolic and behavioural outcomes compared to depression
(Fisher et al., 2012). Although, National Standards for DSME/S have included
developmental strategies in addressing psychosocial concerns and issues,
additional help is needed for mental health resources which are generally
required when addressing severe diabetes-related distress, anxiety and clinical
depression to promote and manage this LTC (Fisher et al., 2013). Also, social
factors which includes difficulty paying for medication, food, medical care,
monitoring and other supplies, utilities, or housing, have a negative affect
towards an individual’s metabolic control and increase with resource use. If
basic living needs have not been met, managing diabetes becomes difficult
gradually (Berkowitz et al., 2015). Through education staff, this can be
addressed and such issues are able to provide information on available
resources and collaborate with the care needed for the patents self-management
plan which reflects these illness belief challenges. If these complicating
factors are present in the initial maintenance or education session, the DSME/S
educators are able to directly address the factors or have arrangements for
additional resources. However, that being said, complicating factors are still
likely to arise at any time; the providers should promptly be prepared to be
able to refer patients who may develop complications or any other issues for diabetes
education and any on-going support (Li et al., 2014).

Lastly, less research has
emphasized the ways in which illness beliefs promote management the impact of
type 1 diabetes in young children’s and their quality of life. A study had
found parents to have reported greater adoptive symptoms which included
anxiety, depression and somatization symptom present in young children (4-10
years) with type 1 diabetes compared to health controls (Cato et al., 2014). A
recent study have evaluated a routine mental health and behavioural screening
from a paediatric diabetes clinic and found children
ages 4-7 were more likely to have elevations from parents reporting back from
the Strengths
and Difficulties Questionnaire (SDQ), which suggest that young children with
type 2 diabetes have a greater risk towards anxiety, depression or psychological
disorders hindering their management (Zenlea et al., 2014). Further, normative behaviour problems,
such as slow at meal times, refusing to eat, and dawdling before going to
sleep, are perceived more problematic for parents with children who have type 1
diabetes compared to a normative samples (Hilliard et al., 2011).



In conclusion, this essay highlighted
the ways in which illness beliefs and behaviours can either promote or hinder
the management of a long-term condition like diabetes. Further research in
still needed to investigate a wider range of population, therefore acceptable
interventions can be made and address to ensure a healthy quality of life for
the individual. Also, diabetes-related complications can improve over time
through family support, education and empowerment.