The role of collective efficacy in exercise adherence: a qualitative study of spousal support and Type 2 diabetes management

Abstract

Adhering to increased exercise is often reported as one of the greatest challenges facing adults living with diabetes, a perception shared by the married middle-aged and older adults living with diabetes who participated in this study. Understanding how that challenge can best be met is both research and program relevant. Drawing on the social cognitive theory and social support literature, this qualitative study explored the powerful couple relationship in Type 2 diabetes management. The overarching goal of this paper was to illuminate the potentially key role of collective efficacy in exercise adherence in order to develop and test interventions that provide more effective supports for adults living with diabetes. Analyses revealed three core themes used by the couples to describe their perceived beliefs: ‘Collective support’, ‘Collective motivation’ and ‘Collective responsibility’. Our findings provide insights regarding how collective beliefs of spousal support may influence the adoption and maintenance of an exercise program. As health educators look for approaches to improve exercise adherence in diabetes management, it is important to understand how couples can be empowered to assume responsibility for their management.

Introduction

Management of Type 2 diabetes requires adhering to multiple lifestyle and medical surveillance self-care behaviors to achieve and sustain optimal glycemic control, behaviors that are inherently modifiable. Individuals are expected to quickly integrate these behaviors, which are the cornerstones of treatment and often the most difficult components of self-management. Of these major lifestyle changes, one of the most difficult behaviors is adhering to increased exercise [1–3].

Exercise has significant physiological and psychological benefits for individuals with diabetes. For example, exercise significantly decreases hemoglobin A1c, an index of blood glucose control [4], in addition to improving cardiovascular risk factors [5–13], joint flexibility [14] and quality of life [15]. Despite the obvious benefits of exercise, many individuals with diabetes fail to initiate and/or adhere to a regular exercise program. An estimated 37–60% of individuals with diabetes do not exercise [16–18], and for those who do, more often than not the majority of individuals discontinue the program within 3–6 months [19, 20].

Given the complex nature of diabetes, it is understandable that most adults will suffer lapses in exercise adherence at some point in their diabetes management [21]. Lack of adherence is a major contributing factor to therapeutic failure, ultimately interfering with the effectiveness of diabetes management [22]. As Type 2 diabetes chiefly affects middle-aged and older adults, understanding the challenges to exercise adherence may be all the more important given recent evidence that participation in and adherence to exercise are relatively low in middle-age and older adults [23].

Background

Prior research has identified a variety of factors affecting adherence. Non-adherence in chronic disease management has been linked to personal control over health outcomes [24], perceived health status [25], patients’ attitude toward himself/herself and the illness [26, 27], exercise adherence to previous illness [26], illness intrusiveness [24], cultural barriers [26, 28], communication between patient and physician [26, 29] and psychosocial factors including low social support [30]. In older adults’ functional mobility, exercise experience and perceived social support are indicated in exercise adherence [31]. Moreover, research has shown that interpersonal factors, and particularly support of significant others, appear to be even more significant factors in increasing or sustaining exercise adherence [32]. Therefore, attitudes and beliefs of spouses may have an important impact on exercise adherence. Although some factors are not modifiable (e.g. sex, age, race), psychological and environmental factors may be modifiable through interventions [33].

Diabetes-specific studies have demonstrated that social relationships, and particularly marriage, may mediate lifestyle and medical surveillance behaviors, glycemic control and other health outcomes [34–41]. For example, some studies have found increased marriage quality leads to enhanced diabetes-related quality of life but not to better glycemic control [40, 42]. Other studies have found that spousal support was more strongly related to adherence to lifestyle changes than to medical surveillance such as medication use and foot care [42] and that joint decision making about behavior changes was facilitated by longer term relationships between spouses or partners. Individual factors such as self-efficacy [43], prior health knowledge [44], age and depressive symptoms [45] as well as environmental factors such as family norms, health behaviors and culture [46–48] have also been identified as salient in decision making and response to treatment regimens.

Despite the growing body of literature on spousal support and diabetes management, we do not yet know how to best support couples living with diabetes. Understanding the key role spouses play in optimizing diabetes management may be all the more important, given recent evidence that the spouses of adults with diabetes may be at increased risk of developing diabetes themselves because of the marital context and shared environment [49, 50]. Therefore, to provide the highest quality of care for couples living with diabetes, we must first understand the social challenges faced by couples managing Type 2 diabetes.

Toward this goal, the purpose of this study was to explore the powerful couple relationship in diabetes management. In this paper, we report the findings from a qualitative study on the individual and spousal experiences of exercise adherence in Type 2 diabetes. We adopted a conceptual framework derived from social cognitive theory (SCT) [51–55] and relevant literatures on social support and marital status [56–59]. The paper's overarching goal was to illuminate the potentially key role of collective efficacy in exercise adherence in order to develop and test interventions that provide more effective supports for middle-aged and older adults living with diabetes. The following sections describe the conceptual framework, methods utilized, findings from the focus groups and implications of those findings.

Conceptual framework

The use of theoretical models and constructs is critical for understanding behavior change and guiding the development of interventions to provide more effective supports for middle-aged and older adults living with diabetes. To date, the mechanisms underlying exercise adherence are not well understood. Research has not established a strong theoretical foundation for the promotion of exercise adherence. Therefore, to assist adults living with diabetes in adhering to a regular exercise program, effective strategies and techniques would benefit from developed theoretical models. SCT holds promise as a model to understand exercise adherence and develop effective interventions to promote the initiation and maintenance of exercise.

SCT incorporates a triadic causation reciprocal model to represent the dynamic interplay of personal, behavioral and environmental factors [52]. According to this theory, an individual's actions are based on the concept of human agency or self-efficacy which derive from both the individual's behavioral capabilities (e.g. knowledge, beliefs and skills) as well as influences of the environment (e.g. social, economic and political) surrounding the person. Human agency distinguishes three different modes: (i) direct personal agency that is expressed individually; (ii) proxy agency that relies on others to act on their behalf and (iii) collective agency that has people working together to shape their future [53]. Because the adoption and adherence of multiple self-care behaviors require motivation and self-regulation, individuals need to monitor their behaviors, motivate themselves, create incentives and enlist social support as needed to enhance their agency and maintain their efforts [55]. To the extent that people are influenced by their environment, health promotion needs to consider both personal and collective efficacy.

Research on the concept of human agency has focused almost exclusively on personal efficacy and the cognitive, affective, motivational and selection processes through which personal efficacy operates. Personal efficacy plays an influential role in human functioning because it affects behavior directly as well as indirectly through its impact on other classes of determinants (e.g. goals, outcome expectations, perceived barriers and facilitators in the social environment) [54]. However, individuals do not live their lives as isolates. In many situations, people do not have direct control over the conditions and practices in their social system. For that reason, individuals often work together to produce the outcomes they desire, which are achievable only through interdependent effort [60]. SCT therefore extends the concept of human agency to include the interactive, coordinative and synergistic dynamics, or the collective efficacy, of a group.

Collective efficacy refers to a group's shared perception of its capability to successfully perform a behavior [53]. Within a group's collective efficacy, their shared beliefs influence the actions they take, the amount of effort they put forth and their collective perseverance to produce the outcomes they desire. In forming these beliefs, an individual assesses his/her own capabilities as well as other group members’ capabilities (e.g. spousal competency). Collective efficacy is therefore an emergent process developing from observed behaviors and interactions between group members.

Purpose

Given the behavioral and psychosocial demands of diabetes, a deeper exploration of the marital relationship is relevant to diabetes management. Recognizing the importance of the social context in helping older adults adhere to an exercise program is essential to developing more effective interventions for middle-aged and older adults living with diabetes. Exploring the role of collective efficacy in exercise adherence may be particularly helpful to health educators as the behavior regimen often involves spouses. Therefore, this study aimed to understand the role of collective efficacy in exercise adherence for married adults living with diabetes.

Method

Design

Focus group methods were used in this study to explore the role of collective efficacy in exercise adherence for couples striving to manage Type 2 diabetes (the study also explored diet and medical surveillance behaviors in the diabetes regimen). The group dynamic was structured to stimulate participants with diabetes and their spouses to examine the influence of their marital relationships on needs for care with others who were in similar situations. The groups were segmented into persons with diabetes (PWD) and spouses of persons with diabetes (SPWD), so the researchers could use the shared experiences as a springboard for deeper examination and discussion of related issues, thus promoting greater depth in understanding without the potential influence or constraint exerted by the spousal partners’ presence. The research protocol was approved by the Pennsylvania State University Institutional Review Board prior to the initiation of the study.

In order to maximize the phenomenon of interest, intensity sampling (a form of purposive sampling) was used to identify and select spousal partners living with diabetes. Potential participants were screened by telephone for eligibility and other sociodemographic information (e.g. birth date, age, gender, race–ethnicity, years married or partnered, parental education, participant education, occupation, year of diabetes diagnosis). Couple eligibility was determined on the basis of three criteria: couple participants were married or cohabitating; couple participants were aged 50 or older and at least one member of the couple had received a physician diagnosis of Type 2 diabetes at least 1 year previously. Participants were excluded if they had any difficulties with bathing, dressing, personal hygiene or walking and were diagnosed with a stroke, cancer or Alzheimer's disease in the past year. Recruitment efforts were focused on the Pennsylvania State University Diabetes Registry as well as through advertisements in newspapers, diabetes support group meetings, public service announcements and flyers in community buildings. Responding couples were mailed a cover letter describing the study's purpose and procedures, along with two informed consent forms which were completed and returned to researchers in provided pre-addressed, pre-paid envelopes.

In qualitative studies, the size of the sample is determined by the quality of data. Recruitment, data collection and analysis are reiterative, occurring simultaneously. Two criteria are used to evaluate sampling: adequacy and appropriateness [61]. Adequacy addresses the volume of the data or, in other words, there are adequate data to support the emergent insights. Appropriateness refers to the quality of that data; that is, the data provide the descriptive and interpretive depth required to clearly delineate the theoretical derivation. Using these criteria, data are collected until saturation is reached, that is when no new information is generated from the participants and the derived theoretical scheme accounts for the reported experiences or insights.

In this study, recruitment efforts were suspended when 30 couples (60 adults) were successfully enrolled. Of these, 23 couples included one person with diabetes and a spouse who did not have diabetes. In the seven remaining couples, both adults had diabetes; however, one was diagnosed with diabetes within the previous year and did not meet the eligibility criteria for participation as a person with diabetes. For the remaining six couples, the researchers assigned individuals who had been diagnosed with diabetes for the shorter period of time to the spouse group and individuals with longer standing diagnoses to the PWD group. Group members varied by age (50 and older), gender, race–ethnicity and occupation; however, all group members lived in central Pennsylvania and shared the experience of living with Type 2 diabetes themselves or by being married to a Type 2 diabetic partner.

Procedure

Twelve 90-min focus groups, each consisting of 5–10 participants, were conducted at the General Clinical Research Center in University Park, Pennsylvania, and at the Hershey Medical Center in Hershey, Pennsylvania. A structured discussion guide was devised, field tested for flow and clarity of the discussion questions and then used by trained moderators and co-moderators to promote consistency across the groups. Moderators were instructed in the use of directive probes to elicit additional information and clarify ambiguous comments; co-moderators wrote field notes to capture key points in and observations about the discussion. All focus group sessions were audio recorded and transcribed verbatim. All names and identifiers were removed from the text to protect participant confidentiality (for example, ‘Dr Smith from Hershey’ would be replaced by Dr (Endocrinologist) from (medical center)’]. These clean transcripts (i.e. transcripts purged from identifiers) were used in analysis.

Data analysis

Qualitative data were analyzed using techniques described by Morgan [62] and Krueger [63]. Specifically, the discussion was summarized immediately following each of the focus groups; codes were developed for relevant themes, using the research questions as guides; the codes of new transcripts were compared with existing codes following each focus group to more fully develop the properties of the overarching categories. This process continued until saturation was reached; that is, until no new codes or categories emerged, and the research team, consisting of a registered dietitian, a gerontologist and graduate research assistant, reached consensus that coding additional transcripts would only repeat themes.

Credibility of the data was supported in three ways: (i) one investigator and the research assistant independently coded the data to check for inter-rater agreement; (ii) other investigators reviewed the independent coding sheets to resolve discrepancies in retaining and combining transcript data and (iii) common themes were independently summarized by the first investigator and research assistant and discrepancies were reviewed and resolved by the other investigators. Dependability of the data interpretations was supported with an audit trail to track the decision-making process.

Results

Table I provides general demographic and health characteristics of the 30 couples (n = 60) who participated in the study's focus groups based on the data obtained during eligibility screening. As shown, the mean age of participants overall was 65 years and the mean length of marriage was 38 years, with the overwhelming majority in their first marriage. The average PWD (61.7% of participants) was a college-educated man who had lived with diabetes for 10 years, had a body mass index (BMI) (kg/m²) classified as obese and took oral medications rather than insulin. The SPWDs were, on average, college educated, younger, somewhat healthier and had a lower BMI.

Table I.

Sociodemographic characteristics of participants with diabetes and their spouses

	Mean (SD)		Range
	PWD	SPWD	PWD	SPWD
Age (years)	66.7 (8.40)	63.3 (8.10)	51.0–81.0	50.0–76.0
College graduation and above (%)	56.7	50.0
BMI (kg/m2)	32.2 (6.9)	27.4 (5.2)	20.0–45.6	19.6–44.3
Comorbid conditions (%)	97.3	82.6
Length of marriage (years)	38.7 (11.0)	38.7 (11.0)	12.0–54.0	12.0–54.0
First marriage (%)	82.8	82.8
Male (%)	70.0	30.0
Years with diabetes	10.1 (10.7)		1.0–46.0
Prescribed insulin injections (%)	24.3
Prescribed oral hypoglycemic medications (%)	62.2

Defining the themes

Through the discussions in the focus groups, PWD and SPWD were able to reflect on their spouses’ support and gain insight into their beliefs. As the focus groups progressed, the participants revealed greater depth about their experiences with exercise. Through these disclosures, we were able to describe the beliefs couples shared in their perceived collective efficacy and its impact on exercise adherence. With that said, the participants were asked to describe their collective beliefs concerning their capability to adhere to a regular exercise program. The core themes used by the couples to describe their beliefs were characterized by: ‘Collective support’, ‘Collective motivation’, and ‘Collective responsibility’. These three themes represented overlapping beliefs that couples shared about themselves and their capabilities to adhere to an exercise program. For example, how couples interpreted their collective support toward exercise informed and altered the collective motivation and responsibility they possessed which, in turn, informed and altered subsequent support. In the following sections, we describe each of these interrelated themes and provide relevant quotations supporting the themes.

Collective support

Collective support, a perception of encouragement, was prominent in those with diabetes and their spouses. Couples who felt they were ‘in this together’ were better able to communicate and thus support each other in their daily management. Moreover, encouragement between the spouses appeared to reinforce their self-care behaviors and, in turn, improve their adherence. A husband stressed the importance of support by saying:

Here I am a diabetic and the same thing a year or so later she was diagnosed. I think at the time you need support and she gave it to me. Then later on when she needed it, I tried to give all the support I could. I make sure that she exercises! (Participant 1 in PWD Focus Group 4).

While couples acknowledged the importance of reinforcement, they also conveyed a sense of restraint. As one wife of a PWD remarked:

You encourage your spouse to adopt better habits, but you do not do it a whole lot because there are limits to how much your spouse is willing to listen. Some of it is letting them know what the consequences are and letting them make up their own mind (Participant 6 in SPWD Focus Group 1).

SPWDs felt that they walked a fine line between encouraging and nagging their spouses to exercise. A wife described her experience by saying, ‘You do not tell him what to do. He knows what to do. He knows about walking and he is doing that. I am supportive, but I cannot get in the way. I know that’(Participant 3 in SPWD Focus Group 5). Wives perceived more resistance from PWDs in their support efforts compared with husbands. Men with diabetes were more likely to feel constrained by their wives’ attempts to control their exercise behaviors. An effective strategy that SPWDs used to avert this dilemma was eliciting the support of significant others outside the couple. As one woman shared: ‘If your spouse won't listen to you, contact an objective third party. Sometimes it is difficult to hear things from a spouse because even if it is not meant to be critical, it sounds like it is sometimes’ (Participant 4 in SPWD Focus Group 3).

In sum, successful exercise management often requires significant changes in established routines in the marriage. For that reason, spousal support appeared to be a critical element when encouraging PWDs to adopt and maintain an exercise program. Both PWDs and SPWDs echoed the importance of support when someone was diagnosed with diabetes. This sentiment was articulated best by a husband of a PWD:

I cannot force her to follow her regimen. I have to understand that it is really hard. I need to support her and understand it. That is how you need to do it. You need to radically change your thoughts. So it is a communication thing. We need understanding. Even though it is her diabetes, I can support her whenever it is possible (Participant 3 in SPWD Focus Group 5).

Collective motivation

All the couples acknowledged the importance of exercise in their diabetes management. Most participants reported that their physicians told them to incorporate exercise into their daily routine. However, the majority of participants reported that they did not participate in a regular exercise program. In fact, of the 30 couples, only 8 reported exercising together on a regular basis.

Couples suggested that motivation to exercise was an important factor in their capability to successfully adhere to an exercise program. When both the PWD and SPWD were highly motivated to exercise, their shared beliefs seemed to influence the actions (both individually and collectively) they took as well as the amount of effort they put forth to adhere to a program. As one man with diabetes explained: ‘You can't make somebody do anything, whether it be exercising or not exercising. They have to want to do it’ (Participant 4 in PWD Focus Group 1). Another woman with diabetes added: ‘I think if your partner has an active lifestyle in terms of cycling outside or wanting to go for walks that can have an effect on you. I think it is very possible to exercise together’ (Participant 2 in PWD Focus Group 1). This concept of modeling, or the influence that observing others has on behaviors, motivated PWDs to try new activities with their spouses and stick to their exercise programs.

Not all couples shared a collective motivation to exercise. In fact, lack of motivation was the most commonly stated barrier for couples striving to incorporate exercise into their daily management. Many PWDs stated that they knew they should exercise, but lacked the drive to do so. As one PWD shared: ‘My wife is always after me to exercise, but I am the lethargic one’ (Participant in PWD Focus Group 1). PWDs also acknowledged differences in viewpoints toward exercise between them and their spouses. This difference was expressed by a man with diabetes: ‘She feels as though I should be more actively involved in an actual exercise program. She feels as though I should be doing that. So it is kind of a struggle’ (Participant 1 in PWD Focus Group 3). Men with diabetes consistently reported lower levels of motivation compared with their female counterpart. Consequently, many wives expressed frustration with their husbands’ lack of motivation to exercise. A SPWD conveyed her frustration by saying, ‘One month he's a serious diabetic and then the next month he's not. What I am constantly doing with him is he exercises really well one month—he's focused. Then the next month he is totally off of it’ (Participant 7 in SPWD Focus Group 2). Participants verbalized frustration in part because of their discordant beliefs toward exercise, for example:

Sometimes my wife may be more motivated to exercise than I am and it frustrates her. I either can't or don't or I promised I would and it did not happen. She is flexible about it and she knows that it would be in my best interest. So she is going to keep pushing me (Participant 5 in PWD Focus Group 1).

All in all, incorporating exercise into their daily routines was a significant challenge for the couples participating in the focus groups. When asked how they could overcome this challenge, couples described a process of finding motivation through the identification of shared goals. A SPWD described how their shared goal motivated them to exercise: ‘My goal in life, I have one goal in life and that is to have our 50th wedding anniversary. So I do not care what happens in between but we have to get to that goal’ (Participant 1 in SPWD Focus Group 6). Comments provided by the couples alluded to the concepts of outcome expectations and expectancies. For these couples, positive outcome expectations, such as ‘regular exercise will make me live a longer and healthier life’, are beliefs about the benefits of regular exercise in the management of diabetes. The relative value, or expectancies, that a couple places on each outcome expectation may then influence the behaviors that couple practices. As evidenced in the following quote:

Sometimes when I get discouraged and I do not feel like paying attention to my diet and exercise. Then I think of things like I want be here to see my first grandchild. I got to dance at my daughter's wedding and I hope to dance at my son's wedding so I want my feet there (Participant 6 in PWD Focus Group 2).

Collective responsibility

Sharing the responsibility reflected couples actively participating in a regular exercise program. Participants recognized that diabetes management, particularly exercise, was not the sole responsibility of the PWD but rather the responsibility of the couple. Thus, a joint effort appeared to be as important as the exercise itself. As one SPWD remarked: ‘For thirty years we have shared everything. So when she became diabetic, it was not an inconvenience in our life. We worked it in’ (Participant 2 in SPWD Focus Group 2). Couples felt it was critical to approach exercise as a team, with both the PWD and SPWD getting involved: ‘Work together as a team when it comes to managing diabetes—one person does not really take the lead over the other’ (Participant 2 in SPWD Focus Group 4) Another woman with diabetes added: ‘When you have someone to exercise with it's not as hard’ (Participant 2 in PWD Focus Group 4). However, not all spousal involvement was welcomed by the PWDs. One PWD voiced his discontent with his wife's participation by saying:

When I go for walk with my wife, she's in better shape and lighter than me so she likes to walk faster. In fact I'm unable to keep up with her. She is six steps in front of me. I say to her, ‘Do you want to walk with me or do you want to walk by yourself? Because you are not walking with me!’ (Participant 3 in PWD Focus Group 5).

Despite the importance of collective responsibility, not all SPWDs played an active role in their spouses’ exercise management. Husbands were more likely to passively support their wives with diabetes. This is evidenced by the following quotation from a husband of a PWD. He shared what he believed to be a significant challenge in his wife's management:

I am not what I would say really involved in my wife's diabetes regimen. I know she follows it, but I also know that she cheats and I really cannot say anything about that to her because she would have my head. So I have had to adjust. I can say if you want to go for a walk sometime, I will gladly go with you. I really do not feel comfortable saying to her let's go for a walk. I kind of have to let her take the lead on that (Participant 5 in SPWD Focus Group 5).

SPWDs explained that their lack of involvement was attributable to frustration with their spouse, insufficient knowledge or skill on how to perform exercise and/or a general unwillingness to get involved. PWDs sensed these challenges and felt they were the result of nagging and differing goals for exercise. When asked how they could resolve such issues, both PWDs and SPWDs stressed the need for open communication. As one SPWD put into words:

You might rant and rave for a little bit and then you say okay let's talk about this …. You say, “Okay let's sit down. What do we do? What do we have to change? How can we rectify it?” In our case, to keep it so he does not have to go on insulin” (Participant 3 in SPWD Focus Group 3).

For the couples participating in the focus groups, managing diabetes was not a solitary experience, and managing the exercise program was either enhanced or limited by the cooperation of the spouse. PWDs appreciated the commitment shown by their spouses: ‘I have to give my husband the credit for walking with me every night. I found that if I walk at night before I go to bed that is when it really matters’ (Participant 1 in PWD Focus Group 6). Perhaps a man with diabetes said it best when he replied, ‘You really cannot expect something from a spouse that you are not going to do anyway!’ (Participant 6 in PWD Focus Group 6).

Discussion

The management of Type 2 diabetes requires a considerable amount of effort to achieve and sustain optimal glycemic control. Individuals living with diabetes must assume responsibility for their management, which is achieved through self-care behaviors, including medical surveillance (i.e. taking needed medications and maintaining proper foot care), blood glucose testing, adherence to a healthful diet and increased physical activity. Because diabetes management permeates everyday living, the effects of diabetes may impact the quality of life and productive life of adults, including relationships with significant others. Therefore, understanding the implications of the growing problem of diabetes, coupled with the unique social challenges that arise from adherence to self-care behaviors, give good reason for more comprehensive information on the challenges faced by middle-aged and older adults with diabetes.

Our study is unique in that we examined couples living with Type 2 diabetes and their perceived collective efficacy to adopt and maintain an exercise program. Research in other fields, including education, business and sociology, has demonstrated that perceived collective efficacy is strongly related to student achievement, work group effectiveness and neighborhood safety [64–71]. Thus, collective efficacy is critically important in predicting the long-term success of groups, whether dyadic or larger. Such examples demonstrate the power of collective efficacy to influence group processes and outcomes. For couples in this study, perceived collective efficacy referred to their ability to work together to maintain and adhere to an exercise program. Analyses revealed three core themes describing the collective beliefs couples shared in adhering to an exercise program: collective support, collective motivation and collective responsibility. In particular, focus group findings from those 30 couples showed that collective efficacy, a major construct of SCT, may have represented their shared confidence to perform exercise to accomplish diabetes management goals. Further, the reciprocal nature of SCT emphasized its perspective of collective efficacy as a dynamic interplay of support, motivation and responsibility. For example, how couples interpreted their support may have informed and altered their motivation and responsibility to exercise. Thus, the reciprocal nature of couples managing diabetes is relevant for designing health education and health behavior programs.

At the heart of SCT lies this concept of reciprocal determinism, which proposes that behavior is dynamic, with continuous interactions between aspects of the person, the behavior and the environment; thus, a change in one factor will, in turn, affect the other two factors [52]. If couples with diabetes understand that exercise is a controllable behavior, they can draw on their own capabilities (or collective efficacy) to modify their lifestyle to incorporate regular exercise. For example, if a PWD observes that his/her spouse is actively participating in the diabetes management (e.g. sharing the responsibility to exercise, encouraging PWD to exercise), then that PWD's collective efficacy beliefs should theoretically increase. Therefore, collective efficacy is derived from the exchange and assimilation of information about each other and about the behavior and context in which the behavior occurs [72]. Furthermore, when PWDs consider the overall capabilities of their spousal relationship, they may draw on their spouse's behavior. Thus, a couple's collective efficacy may increase or decrease if they observe their spouses demonstrating or failing to demonstrate teamwork behaviors. The diabetes health care team should experiment with creative strategies to encourage positive spousal involvement in the daily management of diabetes.

Our study also demonstrated potential gender differences in the collective beliefs couples shared in their ability to adhere to an exercise program. Men with diabetes felt that their spouses’ encouraging, reminding or urging to exercise interfered with their ability to manage their diabetes. This is in line with the notion that overprotective actions by a spouse undermine a patient's efficacy to manage their disease [73] and a patient's feeling of control over their lives [74]. Wives reported greater active engagement in their husbands’ exercise management; however, wives also encountered greater resistance and frustration in their support attempts. Marked gender differences have also been identified in the family caregiving literature [e.g., 75, 76], such that in later life, both men and women primarily receive support from women (i.e. wives or adult daughters). Because women provide the majority of support to older family members and serve as gatekeepers for the health of their families, they may be more practiced and better equipped to provide effective support to their spouses living with diabetes than vice versa. Wives more often are nominated by their husbands as their primary source of social control than husbands are nominated by their wives [77]. As a result, wives may better judge when their husbands need assistance and may be better able to modulate their efforts accordingly, with men receiving greater benefit of that assistance. Thus, the potential gender differences observed in the couples’ perceived collective beliefs may be related to the spouses’ support or control of the PWD's health behavior. We recognize that additional research is needed to fully appreciate gender differences in the types and quality of support received and given by the spouse.

As health educators look for approaches to improve exercise adherence in diabetes management, it is important to understand how couples can be empowered to assume responsibility for their management. Specific strategies to enhance collective efficacy include learning contracts in which couples set their goals and establish effective strategies for achieving them, skill development directed toward the couple as a unit and community training offered to family, friends and other settings (e.g. worksites, recreational facilities). Additionally, the diabetes health care team can build collective efficacy by modeling their own exercise behaviors and having role models conduct group (couple and family) exercise programs. For example, modeling behavior can occur in the form of showing a couple new exercises. By ensuring attention and encouraging visualization, followed by a replication of the modeled behavior, learning can be improved. Finally, the diabetes health care team can enhance collective efficacy by coaching couples to positively appraise physiological and emotional responses associated with exercise. Couples can write journals about their collective experiences with exercise to monitor their progress and its relationship to glycemic control and other health outcomes (e.g. quality of life, marital satisfaction). In this view of SCT, couples not only observe but also reflect on and participate in their diabetes management.

Limitations

Several limitations of the current study should be noted. Study limitations include the overall small study sample recruited largely by convenience. Thus, these findings may have limited generalizability to the population at large. Cultural and social variations regarding marital roles, diabetes beliefs and management among varied ethno-cultural groups have not been addressed and warrant further study. Further, although focus groups were segmented by PWD and SPWD to stimulate open discussions without the potential influence or constraint exerted by the spousal partners’ presence, focus groups conducted with the dyads may have revealed greater insight into the interactional process of the married couple. Moreover, transcription of the focus group discussions identified participants by a number rather than by spousal pair. Therefore, data analysis was unable to take into account the spousal pairs across the focus groups. Finally, our cross-sectional study limits our ability to discern causality although the use of retrospective data (in both focus groups and survey questionnaires) suggests temporality. More longitudinal work is needed to discern the causal order of collective efficacy and good exercise adherence. Notwithstanding these limitations, we found that shared support, motivation and responsibility comprised the collective efficacy beliefs of middle-aged and older couples living with diabetes.

Conclusions

Overall, our findings support a role for collective efficacy in promoting exercise adherence in couples living with diabetes. Collective efficacy may enhance a couple's shared capability to successfully maintain and adhere to an exercise program. Therefore, knowledge of collective efficacy beliefs is critical for understanding the influence of the spousal relationship on exercise adherence and, in turn, diabetes management. Additional research is needed to determine if higher levels of organizational support, such as clinicians, diabetes educators and nurse practitioners, relate to the emergence of collective efficacy. Because collective efficacy develops primarily at the interindividual level, it evolves from performance feedback and teamwork. Thus, we would expect that couples would be more likely to have a shared belief of collective efficacy when performance feedback is given at the couple or team level rather than the individual level. Accordingly, interventions designed to enhance individual capabilities as well as couple interdependencies may improve couples’ perceived collective efficacy in their diabetes management. Continued research efforts are needed to understand the types of social support and control, in addition to gender differences in the spouses’ provision of health-related support. Finally, clinical and research interventions should consider implementing dyadic educational (e.g. nutrition, exercise, medication adherence) and motivational and communication skills training (e.g. problem solving, emotional expressiveness training) to facilitate and optimize social support resources [78]. As the prevalence of diabetes burgeons among our population, we must fortify supportive networks to maximize successful management and, ultimately, improve both the length and quality of life experienced by couples in diabetes management.

Funding

National Institute on Aging (NIA) (T32 AG00048) to The Pennsylvania State University and NIA (P30 AG024395) for ‘Spousal Support & Diabetes-Related Behavior Change in Middle-Aged and Older Adults’ to L.A.W., C. K. Miller and S. L. Willis.

Conflict of Interest Statement

None declared.