Skip to main content
NCBI home page
Global Journal of Health Science logoLink to Global Journal of Health Science
. 2015 Feb 24;7(5):80–90. doi: 10.5539/gjhs.v7n5p80

Do Perceptions of Empowerment Affect Glycemic Control and Self-Care Among Adults with Type 2 Diabetes?

Melba Sheila D’Souza 1,✉, Subrahmanya Nairy Karkada 2, Nancy P Hanrahan 3, Ramesh Venkatesaperumal 1, Anandhi Amirtharaj 1
PMCID: PMC4803921  PMID: 26156908

Abstract

Background:

The Arab adult with T2DM is understudied with less known facts about the perception of empowerment and its relationship with self-care and glycemic control.

Purpose:

The purpose of this study was to determine the extent to which perception of empowerment by Arab adults living with Type 2 Diabetes Mellitus (T2DM) was associated with better glycemic control and self-care management.

Methods:

A cross-sectional descriptive study was led among 300 Arab adults living in Oman with T2DM in an outpatient diabetes clinic. The Diabetes Empowerment Scale (DES), glycosylated haemaglobin (HbA1c) and Body mass index was assessed. The DES was found to be valid and reliable for the population. ANOVA, Regression analysis, and Structural equation modeling was used for analysis.

Results:

The composite score and three subscales of DES were a significant and strong predictor of good glycemic control among Omani adults with T2DM (p<0.001). Age, education, duration of DM, prior DM education program and medications were significantly associated with DES.

Conclusion:

Diabetes nurse educators engaged in the care of adults with T2DM should assess self-empowerment and tailor interventions to increase empowerment for better glycemic control. Patient empowerment plays an essential role in maintaining self-care behaviours and HbA1c.

Keywords: diabetes empowerment, type 2 diabetes mellitus, nursing, self-efficacy, self-care management, glycosylated hemoglobin, patient education

1. Introduction

Diabetes mellitus (DM) is a public health problem affecting millions of individuals, families, and communities worldwide. The World Health Organization predicts that diabetes mellitus (DM) will be the 7th leading cause of death in 2030 (Alwan, 2011). Type 2 diabetes mellitus (T2DM) comprises 90-95% of all diabetes diagnoses among adults (Cox & Edelman, 2009) and is associated with high risk of complications, premature death, reduced quality of life (Williams, Walker, Smalls, Campbell, & Egede, 2014) and significant health care costs (Fowler 2008). T2DM incidence is predicted to grow along with the medical and economic burden of the disease indicating an urgent need for prevention of complications and novel interventions.

Since 1991, the prevalence of T2DM increased 15.4% among Arab Omani adults residing in Oman and over 20 years of age (Al-Lawati, Al Riyami, Mohammed, & Jousilahti, 2002; Ministry of Health, 2008). Improved living standards and socioeconomic conditions are thought to be associated with increased consumption of refined sugar, dried and evaporated whole milk, fast food, refined sugar, saturated fat, chicken, cheese, and chocolate products (Al-Lawati, Mabry, & Mohammed, 2008). Similar to other countries around the world, T2DM is growing at epidemic proportions among Omani adults (Aanstoot, 2009; Al-Lawati, Barakat, Al-Lawati, & Mohammed, 2008) with corresponding increases in complications associated with T2DM such as depression, loss of sight, limb amputations, infections, and early death (Williams, Walker, Smalls, Campbell, & Egede, 2014).

Although research is limited for Arab adults with T2DM, abundant research shows that educating individuals about diabetes treatment and self-care management—including drug therapy, appropriate risk factor control, and screening for diabetes-related complications—are cost-effective interventions that reduce the burden of diabetes and improve the quality of care on a large-scale basis. Empowerment perceptions are driven by culture and social norms. Research shows that patients who perceive they are empowered to self-manage their diabetes are more likely to be adherent with treatment and have better outcomes. The purpose of this study is to describe the Arab adult with T2DM and to understand the extent to which perceived empowerment and self-efficacy are related to better glycemic control.

The Diabetes Empowerment Conceptual (DEC) framework (Figure 1) suggests that perception of empowerment may underlie effective diabetes self-management and thus better glycemic control (Figure 1). The DEC includes three constructs 1) Managing the Psychosocial Aspects of Diabetes; 2) Assessing Dissatisfaction and Readiness to Change; and 3) Setting and Achieving Diabetes Goals. Individuals with T2DM are empowered to prepare for change, set appropriate goals and handle day-to-day psychosocial stressors. Individuals, for example, who perceived empowerment might manage calories and exercise because they felt empowered with the knowledge to choose to control glucose levels thereby improving their health. Studies have shown that a greater sense of empowerment and self-efficacy is an antecedent to motivation to self-care.

Figure 1.

Figure 1

Open in a new tab

Diabetes empowerment model among Omani adults with T2DM

1.1 Aim

Do perceptions of empowerment affect glycemic control and self-care management among adults living with Type 2 Diabetes Mellitus in Oman?

2. Method

2.1 Design

A cross-sectional descriptive design and structural equation modeling was used to determine relationships between perceived empowerment among Omani adults with T2DM and glycemic control.

2.2 Sampling Procedures

Starting June 2010, participants were selected from a clinic roster of patients with T2DM at an outpatient clinic that was located within a public hospital in Oman. Participants were included in the study if they were age 20 years or older, had a physician-determined diagnosis of type 2 diabetes, intact cognition, perceptual, sensory and communication ability.

2.3 Sample Size

For structural equation modeling (SEM), sample size was determined by power analysis based on root mean square error of approximation (RMSEA) (MacCallum, Browne, & Sugawara, 1996). The RMSEA was set at 0.05 and 0.08 for null and alternative models and 300 samples were found to be adequate for SEM (Steiger, 1990). A sample size of 330 was considered acceptable for this study to account for attrition.

2.4 Ethics

The study was approved by the Research and Ethics Committee at the Sultanate Qaboos University, College of Nursing. Participants were provided a written explanation of the purpose of the study and benefits and potential risks of participating. They were guaranteed confidentiality and were assured of voluntary withdrawal from the study at any time without any adverse consequences. Once consented, participants met with a diabetes nurse educator who administered the study survey. The completed study questionnaires were sealed in a closed envelope. Other data (lab value) was collected by the Diabetes Nurse Educator from the patient’s record. Of the 350 who met study criteria, 300 gave informed consent and provided complete data that were used in the analyses.

2.5 Measurements

Demographic Characteristics were collected by the Diabetic Nurse: age, gender, formal education, smoking, duration of T2DM diagnosis, and the presence of a formal diabetes education.

Diabetes Empowerment Scale (DES). The DES was administered twice with a 2-week interval to evaluate item reliability, stability, clarity and readability. The DES included 28 items that measure the psychosocial self-efficacy of people with diabetes and contains three subscales: Managing the Psychosocial Aspects of Diabetes subscale (α= 0.93) with 9 items; Assessing Dissatisfaction and Readiness to Change subscale (α = 0.81) with 9 items; and Setting and Achieving Diabetes Goals subscale (α=0.91) with 10 items. Participants responded to six items on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicated that participants more frequently used empowerment actions and perceived higher levels of empowerment (Robert M Anderson, Funnell, Fitzgerald, & Marrero, 2000). The tool was found to be reliable.

The Content Validity Index (CVI) of the scale was calculated by dividing the number of items rated 3 or 4 by the total number of items. The CVI for DES was 0.90, which indicated that it was acceptable for use.

Body Mass Index (BMI) was calculated using the World Health Organization calculation based on self-report of height and weight and calculated as weight in kilograms divided by the square of height in metres. BMI (kg/m2) = weight (kg)/[height (m2)]. and defined categories of BMI (World Health Organization, 2006). Overweight and obesity were defined as: underweight: BMI<18.5 kg/m2, normal weight: BMI 18.5–24.9 kg/m2, overweight (pre-obese): BMI 25–29.9 kg/m2 and Obese: BMI>30 kg/

Hemaglobin A1C. HbA1Cvalues were categorized into 1) good glycemic control if HbA1C values are <7% and 2) poor glycemic control, if HbA1C values are >7% (American Diabetes Association, 2007).

3. Results

3.1 Recruitment

There was a 90.9% response rate among 330 eligible participants and 300 participants agreed to participate in the study.

3.2 Data Analysis

Univariate and bivariate statistics showed demographic characteristics, calculated mean, median, and range of the items of the DEC, BMI, and HbA1C using the Statistical Program for the Social Sciences. A confidence value of 95% and probability of p <0.05 was considered significant.

3.2.1 Demographic and Clinical Characteristics (Table 1)

Table 1.

Sample characteristics, glycemic control and significance among adults with T2DM, N=300

Characteristics Categories Good control n % Poor control n % Total N % DES p value
Age (years) 30-39 24 51.1 23 48.9 47 16 0.000*
40-49 52 50.5 51 49.5 103 34
50-59 36 39.1 56 60.9 92 31
60 & above 26 44.8 32 55.2 58 19
Gender Male 54 37.8 89 62.2 143 48 0.396
Female 84 53.5 73 46.5 157 52
Education Until 8th grade 56 47.9 61 52.1 117 39 0.000*
High school 51 54.3 43 45.7 94 31
Diploma/Technical 31 10.3 58 67.4 89 30
Prevents activities of daily living Never 43 39.8 65 60.2 108 36 0.000*
Moderately 74 47.4 82 52.6 156 52
Mostly 21 58.3 15 41.7 36 12
Ability to manage positively Moderate ability 95 31.7 97 32.3 192 64 0.000*
Good ability 43 14.3 65 21.7 108 36
Duration of diabetes (years) 0-9 57 50.9 55 49.1 112 37 0.000*
10-19 68 47.2 76 52.8 144 48
20 & above 13 29.5 31 70.5 44 15
Diabetes education program No 54 47.0 61 53.0 115 38 0.000*
Yes 84 45.4 101 54.6 185 62
Medications Oral Hypoglycemics 109 48.7 107 51.3 216 75 0.000*
Oral Hypoglycemics and insulin 29 9.7 55 18.3 84 25
Body mass index < 18.5 - Underweight 3 37.5 5 62.5 8 3 0.118
18.5 - 24.9 - Healthy weight 87 43.1 115 56.9 202 67
25 - 29.9 - Overweight 48 53.3 42 46.7 90 30
Open in a new tab

Note.

*

p<0.001 level of significance using ANOVA. HbA1C (glycosylated haemaglobin) < 7% is good glycemic control, HbA1C > 7% is poor glycemic control. DM: Diabetes Mellitus, DES: Diabetes empowerment scale.

One-third of the adults with T2DM were aged 40-49 years (34%), of which half of the percentage had uncontrolled HbA1C>7% (49.5%); 46.5% of the females had uncontrolled HbA1C(>7%) compared to the men (62.2%); 45% of the adults with T2DM were tobacco users, of which 60.3% had uncontrolled HbA1C (Table 1). Nearly one-third of the adults had education until 8th grade (39%), high school (31%) and diploma (30%). Nearly half of the adults (48%) lived with T2DM for 10-19 years, of which 52.8% had uncontrolled HbA1c (Table 1). Nearly 52% expressed that diabetes prevented their activities of daily living, and 64% reported that they had positive attitude and ability to manage diabetes. More than half of the adults (62%) were exposed to diabetes education program, of which 45.4% had controlled HbA1C. Most of the adults (75%) were on oral hypoglycemic agents (OHA), of which 48.7% had controlled HbA1C. More adults (67%) with T2DM showed healthy body mass index (BMI), of which 43.1% showed controlled HbA1C. 53.3% of the adults who were overweight (30%) showed controlled HbA1C.

Age, education, duration of DM, prior DM education program, medications was significantly associated with DES (Table 1). The perception of DM prevents activities of daily living and ability to manage DM positively was also significantly associated with DES.

3.2.2 Global Diabetes Empowerment and Regression Analysis (Table 2)

Table 2.

Diabetes empowerment scale (DES) among T2DM and regression analysis, N = 300

Percentage of agreement with sub-dimensions of DES Regression analysis
Diabetes empowerment scale (DES) Strongly agree Agree Disagree Strongly disagree Mean B Coefficient Std. Error. p value
Sub-dimensions n % n % n % n %
Managing psychosocial aspects of diabetes 13 4.33 107 35.67 59 19.67 121 40.33 3.07 .630 .026 0.001*
Assessing dissatisfaction/readiness to change 3 1.00 33 11.00 228 76.00 36 12.00 3.00 .369 .015 0.001*
Setting/achieving diabetes goals 23 7.67 109 36.33 60 20.00 108 36.00 3.15 .614 .025 0.001*
Overall DES 4 1.33 82 27.33 149 49.67 65 21.67 3.07 .657 .027 0.001*
Open in a new tab

Note.

*

p<0.001 level of significance using regression analysis.

Nearly 7.67% of the adults with T2DM strongly agreed to Setting and achieving goals, e.g. choosing realistic diabetes goals (Table 2). One-third of the adults with T2DM were able to Set and achieve goals (36.33%) and Manage psychosocial aspects (35.67%), e.g. positive ways of coping with diabetes-related stressed. Most of the adults agreed that they were dissatisfied and not ready to change (76%), e.g. dissatisfied with areas of taking care of diabetes. Some of the adults strongly disagreed with ability to manage psychosocial aspects (40.33%) and Setting goals (36%). The highest mean score among the 3 DES sub-dimensions was Setting and Achieving Diabetes Goals subscale (mean=3.15+0.99). Global DES and the three sub-dimensions of DES (p<0.001) were highly significant among adults with T2DM.

3.2.3 Diabetes Empowerment Sub-Dimensions (Table 3)

Table 3.

Diabetes empowerment sub-dimensions among adults with T2DM, N = 300

Diabetes empowerment process Strongly agree Agree Disagree Strongly disagree Neutral
n % n % n % F % n %
Managing the Psychosocial Aspects of Diabetes
know the positive ways I cope with diabetes-related stress. 35 11.67 77 25.67 38 12.67 137 45.67 13 4.33
can cope well with diabetes-related stress. 33 11.00 101 33.67 39 13.00 119 39.67 8 2.67
know where I can get support for having and caring for my diabetes. 33 11.00 79 26.33 51 17.00 118 39.33 19 6.33
can ask for support for having and caring for my diabetes when I need it. 21 7.00 93 31.00 36 12.00 142 47.33 8 2.67
can support myself in dealing with my diabetes. 17 5.67 95 31.67 32 10.67 151 50.33 5 1.67
know what helps me stay motivated to care for my diabetes. 31 10.33 95 31.67 26 8.67 144 48.00 4 1.33
can motivate myself to care for my diabetes. 29 9.67 98 32.67 28 9.33 141 47.00 4 1.33
know enough about diabetes to make self-care choices that are right for me. 34 11.33 100 33.33 27 9.00 134 44.67 5 1.67
know enough about myself as a person to make diabetes care choices that are right for me. 21 7.00 105 35.00 31 10.33 135 45.00 8 2.67
Assessing Dissatisfaction and Readiness to Change
know what part(s) of taking care of my diabetes that I am satisfied with. 15 5.00 65 21.67 38 12.67 141 47.00 41 13.67
know what part(s) of taking care of my diabetes that I am dissatisfied with. 17 5.67 164 54.67 29 9.67 66 22.00 24 8.00
know what part(s) of taking care of my diabetes that I am ready to change. 22 7.33 65 21.67 29 9.67 174 58.00 10 3.33
know what part(s) of taking care of my diabetes that I am not ready to change. 5 1.67 182 60.67 27 9.00 61 20.33 25 8.33
can tell how I’m feeling about having diabetes. 37 12.33 76 25.33 57 19.00 114 38.00 16 5.33
can tell how I’m feeling about caring for my diabetes 34 11.33 68 22.67 37 12.33 135 45.00 26 8.67
know the ways that having diabetes causes stress in my life. 33 11.00 69 23.00 36 12.00 144 48.00 18 6.00
know the negative ways I cope with diabetes-related stress. 11 3.67 121 40.33 43 14.33 89 29.67 36 12.00
how care am able to figure out if it is worth my while to change how I take care of my diabetes. 26 8.67 97 32.33 32 10.67 136 45.33 9 3.00
Setting and Achieving Diabetes Goals n % n % n % F % n %
can choose realistic diabetes goals. 38 12.67 93 31.00 33 11.00 130 43.33 6 2.00
know which of my diabetes goals are most important to me. 34 11.33 113 37.67 27 9.00 123 41.00 3 1.00
know the things about myself that either help or prevent me from reaching my diabetes goals. 35 11.67 107 35.67 28 9.33 127 42.33 3 1.00
can come up with good ideas to help me reach my goals. 33 11.00 114 38.00 31 10.33 119 39.67 3 1.00
am able to turn my diabetes goals into a workable plan. 27 9.00 116 38.67 29 9.67 122 40.67 6 2.00
can reach my diabetes goals once I make up my mind. 20 6.67 110 36.67 37 12.33 123 41.00 10 3.33
know which barriers make reaching my diabetes goals more difficult. 46 15.33 89 29.67 39 13.00 121 40.33 5 1.67
can think of different ways to overcome barriers to my diabetes goals 28 9.33 69 23.00 79 26.33 123 41.00 1 0.33
can try out different ways of overcoming barriers to my diabetes goals. 60 20.00 62 20.67 49 16.33 126 42.00 3 1.00
am able to decide which way of overcoming barriers to my diabetes goals works best for me. 34 11.33 74 24.67 48 16.00 136 45.33 8 2.67
Open in a new tab

One-third to quarter percentage of the adults agreed that they were able to Manage their psychosocial aspects of DM (25.67%-35%) compared to those who strongly disagreed (39.33%-50.33%) (Table 3). Many adults with T2DM agreed they were able to Assess dissatisfaction and readiness to change (21.67%-60.67%) compared those who disagreed (20.33%-58%) with them. Some of the adults agreed that they were able to Set and achieve diabetes goals (20.67%-38.67%) compared to those who strongly disagreed (39.67%-45.33%). Hence perceptions of empowerment affected glycemic control.

3.3 Structural Equation Modelling

3.3.1 Testing of Hypotheses

H01: There is positive hypothetical relationship between Psychosocial factors, Readiness to change and Setting goals.

The results show that Chi-square = 17415.6, degrees of freedom = 6, and probability level = 0.0001 (Table 5)

Table 4.

Regression weights and lisrel maximim likelihood estimates

Latent Variable Measured Variables Estimates SE R2 CR P
OVERALL <--- PSY 3.152 .057 .75 54.968 0.001
OVERALL <--- RDN 3.004 .028 .67 108.049 0.001
OVERALL <--- GLS 3.068 .061 .41 50.369 0.001
Open in a new tab

p<0.001, significant at 1% level.

Table 5.

Model fit indices

Sl. No Model Fit Indices Calculated Value Acceptable Threshold Levels
1 Comparative Fit Index(CFI) 0.562 0-1
2 Normed Fit Index (NFI) 0.726 0-1
3 Relative Fit Index (RFI) 0.628 0-1
4 Incremental Fit Index (IFI) 0.825 0-1
5 Parsimonious Normed Fit Index (PNFI)) 0.682 0-1
6 Parsimony Comparative Fit Index (PCFI) 0.564 0-1
7 Tucker Lewis Index (TLI) 0.728 0-1
8 Root Mean Squared Error of Approximation (RMSEA) 0.03 0.05 or less would indicate a close fit of the model
Open in a new tab

3.3.2 Regression Weights and Lisrel Maximim Likelihood Estimates (Table 4)

All the manifest variables (Psychosocial, Readiness to change, and Setting goals) are influenced with the latent variable (Overall DES) of successful operation and also have positive relationship with the significance at 1% and 5 %. Table 4 indicates that the regression coefficient of the exogenous variables. The critical ratio of all the manifest variables is above the table value of 2.962 and it is significant at 1%.

3.3.3 Model Fit Indices (Table 5)

Table 5 conveys that the model fit indices of the variables. The entire test has the range of 0 to 1. The comparative fit index (CFI) scored 0.562, normed fit index (NFI) scored 0.726, relative fit index (RFI) scored 0.628, incremental fit index (IFI) scored 0.825, parsimonious normed fit Index (PNFI) scored 0.682, parsimony comparative fit index (PCFI) scored 0.564, Tucker Lewis index (TLI) scored 0.728, and the Root Mean Squared Error of Approximation (RMSEA) secured 0.03 that indicates a close fit of the model.

4. Discussion

Some adults with T2DM reported that they were able to manage their psychosocial aspects of DM related to making right diabetes care choices, coping with diabetes-related stress, and knew about diabetes to make self-care. Some adults perceived good ability to positively fit self-management in their daily life perceived lower HbA1c level. The dimension of the ‘setting and achieving diabetes goal’ was reported to be the most important empowerment domain (Tol et al., 2012). Adults who reported good health had high scores on the Swe-DES-23 scale (Leksell, et al., 2007) and Chinese version DES (Mei-Fang Chen et al., 2011). This study shows that empowerment is a crucial variable in the self-care management and glycemic control among adults with T2DM.

The conceptual framework was supported by the empowered adults who managed their diabetes and had better glycemic control than participants who had low scores on the DES. This means that participants who were empowered and actively managing their diabetes had better metabolic control. This study showed a significant relationship between the participants’ perceptions of Managing the Psychosocial Aspects of Diabetes, Readiness to change and Achieving goals and HbA1c. There a significant association between empowerment and positive metabolic control, self-efficacy and self-care behaviours (Peña-Purcell, Boggess, & Jimenez, 2011). This is similar to other studies related to self-care behaviours and psyschosocial factors that have influenced metabolic control compared to those with lower HbA1c (Cosansu & Erdogan, 2014; Mahjouri, Arzaghi, Qorbani, Nasli-Esfahani, & Larijani, 2011).

In contrast poor empowerment was due to inadequate management of psychosocial aspects related to knowledge of treatment and self-management, difficulty in readiness to change related to social (D’Souza et. al., 2013), self-care behaviours, and poor goal setting related to plan of action for achieving diabetes targets in the study. Increased empowerment was influenced by social support, exposure to education, self-efficacy in managing psychosocial aspects. Adults with T2DM felt empowered in their self-care ability (Sigurdardottir & Jonsdottir, 2008). Other studies showed that open communication (Funnell et al., 2009), mutual participation, sufficient knowledge and skills (Musacchio et al., 2011) and decisions related to goals is important in the diabetes empowerment process(Kettunen, Liimatainen, Villberg, & Perko, 2006; Skinner et al., 2006).

There was higher level of empowerment among adults in the middle age group (40-49 years), moderate duration of DM (10-19 years), prior DM education and use of oral medications. Adults with T2DM felt empowered in their self-care ability (Sigurdardottir & Jonsdottir, 2008). Education was associated with global DES among Turkish adults with T2DM (p < 0.01) indicating greater perception of empowerment among those with higher education (Tol et al., 2013). Empowerment is strongly influenced by religion, faith, cultural and spirituality (Redfield, 2011), and social, emotional and family support (Song et al., 2012). Patients who perceive higher empowerment have higher success with self-management and glycemic outcomes. The strength of the findings should spur diabetes nurse educators to assume that patients who perceive higher empowerment engage in the active involvement, thereby necessitating individualized tailored interventions to increase empowerment among Omani adults with T2DM.

Limitation included socio-cultural restrictions that may have hampered free responses in self-reports among Omani adults. A dyadic interaction between adults and the nurse educators limits an understanding of empowerment.

5. Conclusion

A significant percentage of the adults did not have a good sense of empowerment. Determinants of empowerment (ability to manage positively, education, patient-physician communication, activities of daily living) can improve the self-care beahviours for active participation in self-care management among adults with T2DM. This study showed that Omani adults with T2DM were not empowerment with their self-care management to make informed decisions or control their illness. They had moderate knowledge about their illness and problem solving ability to improve self-care management aspects. Only some adults perceive self-efficacy and readiness to change and ability to set and achieve goals, resulting in improved self-care. They have active participation to make informed decisions, have a sense of self-control and self-efficacy to improve HbA1c.

Adults with T2DM must have insight into their own needs, and they need to have knowledge about diabetes and its self-care. Empowerment strategies should address the determinants of empowerment for active participation in self-care activities. Achieving these tasks provide a sense of gain and mastery of glycemic control which enhances self-efficacy. Thus empowerment process leads to increase perceived self-efficacy and self-management among Omani adults with T2DM.

Empowering adults with T2DM is an intervention strategy that diabetes nurse educators should place in their diabetes resource toolkit including e-health and e-literacy. This mutual relationship can enable patient empowerment, a key component of self-care. Adults with T2DM who actively collaborate in the decision-making process are able to achieve glycemic control. Empowerment promotes better HbA1c and self-care through healthy self-care behaviors, life style modification, and social-cultural factors among Omani adults with T2MD. Empowered adults with T2DM are capable of making appropriate self-care decisions that requires managing diabetes.

Acknowledgments

The authors gratefully acknowledge the content experts for validation, Mrs Chandrani Isac for suggestions and Mr Reginald Roach for editing the manuscript. The source of funding was College of Nursing, Sultan Qaboos University DF/CN/06/10.

There are no organizations or communities with conflict of interest or coveting interests related to the study. The co-authors declare that they have no competing interests.

References

  1. ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575–1585. doi: 10.1056/NEJMoa1001286. http://dx.doi.org/10.1056/NEJMoa1001286 . [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Adolfsson E. T, Starrin B, Smide B, Wikblad K. Type 2 diabetic patients’ experiences of two different educational approaches--a qualitative study. Int J Nurs Stud. 2008;45(7):986–994. doi: 10.1016/j.ijnurstu.2007.07.007. http://dx.doi.org/10.1016/j.ijnurstu.2007.07.007 . [DOI] [PubMed] [Google Scholar]
  3. Al-Lawati J. A, Al Riyami A. M, Mohammed A. J, Jousilahti P. Increasing prevalence of diabetes mellitus in Oman. Diabet Med. 2002;19(11):954–957. doi: 10.1046/j.1464-5491.2002.00818.x. http://dx.doi.org/10.1046/j.1464-5491.2002.00818.x . [DOI] [PubMed] [Google Scholar]
  4. Al-Lawati J. A, Barakat N. M, Al-Lawati A. M, Mohammed A. J. Optimal cut-points for body mass index, waist circumference and waist-to-hip ratio using the Framingham coronary heart disease risk score in an Arab population of the Middle East. Diab Vasc Dis Res. 2008;5(4):304–309. doi: 10.3132/dvdr.2008.044. http://dx.doi.org/10.3132/dvdr.2008.044 . [DOI] [PubMed] [Google Scholar]
  5. Al-Lawati J. A. M, N. B, Al-Zakwani I, Elsayed M. K, Al-Maskari M, N, M. A.-L, Mohammed A. J. Control of risk factors for cardiovascular disease among adults with previously diagnosed type 2 diabetes mellitus: A descriptive study from a Middle Eastern Arab population. Open Cardiovasc Med J. 2012;6:133–140. doi: 10.2174/1874192401206010133. http://dx.doi.org/10.2174/1874192401206010133 . [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Al-Lawati J. A, Mabry R, Mohammed A. J. Addressing the threat of chronic diseases in Oman. Prev Chronic Dis. 2008;5(3):A99. [PMC free article] [PubMed] [Google Scholar]
  7. Alwan A. Global status report on noncommunicable diseases 2010. World Health Organization; 2011. [Google Scholar]
  8. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2007;30(Suppl 1):S42–47. doi: 10.2337/dc07-S042. http://dx.doi.org/10.2337/dc07-S042 . [DOI] [PubMed] [Google Scholar]
  9. American Diabetes Association. Economic costs of diabetes in the U.S. in 2007. Diabetes Care. 2008;31:596–615. doi: 10.2337/dc08-9017. [DOI] [PubMed] [Google Scholar]
  10. Anderson R. M, Funnell M. M. Patient empowerment: Myths and misconceptions. Patient Educ Couns. 2010;79(3):277–282. doi: 10.1016/j.pec.2009.07.025. http://dx.doi.org/10.1016/j.pec.2009.07.025 . [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Anderson R. M, Funnell M. M, Fitzgerald J. T, Marrero D. G. The Diabetes Empowerment Scale: A measure of psychosocial self-efficacy. Diabetes Care. 2000;23(6):739–743. doi: 10.2337/diacare.23.6.739. http://dx.doi.org/10.2337/diacare.23.6.739 . [DOI] [PubMed] [Google Scholar]
  12. Booker S, Morris M, Johnson A. Empowered to change: Evidence from a qualitative exploration of a user-informed psycho-educational programme for people with type 1 diabetes. Chronic Illn. 2008;4(1):41–53. doi: 10.1177/1742395307086695. http://dx.doi.org/10.1177/1742395307086695 . [DOI] [PubMed] [Google Scholar]
  13. Chen M. F, Wang R. H, Cheng C. P, Chin C. C, Stocker J, Tang S. M, Chen S. W. Diabetes Empowerment Process Scale: Development and psychometric testing of the Chinese version. J Adv Nurs. 2011;67(1):204–14. doi: 10.1111/j.1365-2648.2010.05486.x. http://dx.doi.org/10.1111/j.1365-2648.2010.05486.x . [DOI] [PubMed] [Google Scholar]
  14. Cooper H, Booth K, Gill G. A trial of empowerment-based education in type 2 diabetes--global rather than glycaemic benefits. Diabetes Res Clin Pract. 2008;82(2):165–171. doi: 10.1016/j.diabres.2008.07.013. http://dx.doi.org/10.1016/j.diabres.2008.07.013 . [DOI] [PubMed] [Google Scholar]
  15. Cosansu G, Erdogan S. Influence of Psychosocial Factors on Self-Care Behaviors and Glycemic Control in Turkish Patients with Type 2 Diabetes Mellitus. Journal of Transcultural Nursing. 2014;25(1):51–59. doi: 10.1177/1043659613504112. http://dx.doi.org/10.1177/1043659613504112 . [DOI] [PubMed] [Google Scholar]
  16. Cox M. E, Edelman D. Tests for screening and diagnosis of type 2 diabetes. Clinical diabetes. 2009;27(4):132–138. http://dx.doi.org/10.2337/diaclin.27.4.132 . [Google Scholar]
  17. D’Souza M. S, Venkatesaperumal R, Nairy K. S, Amirtharaj A. Determinants of glycosylated haemaglobin among adults with Type 2 Diabetes Mellitus in Muscat. Journal of Diabetes and Metabolism. 2013;4(5) http://dx.doi.org/10.4172/2155-6156.1000265 . [Google Scholar]
  18. Dirk T, Kreis H, Hildebrandt L. A Comparison of Current PLS Path Modeling Software - Features, Ease-of-Use, and Performance. In: Vinzi V. E, Chin W. W, Henseler J, Wang H, editors. Handbook of partial least squares: Concepts, methods and applications. Springer; 2010. [Google Scholar]
  19. Fowler M. J. Microvascularandmacrovascular complications of diabetes. Clin Diabetes. 2008;26:77–82. [Google Scholar]
  20. Funnell M. M, Brown T. L, Childs B. P, Haas L. B, Hosey G. M, Jensen B, Weiss M. A. National standards for diabetes self-management education. Diabetes Care. 2009;32(Suppl 1):S87–94. doi: 10.2337/dc08-S087. http://dx.doi.org/10.1177/0145721704273166 . [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Funnell M. M, Nwankwo R, Gillard M. L, Anderson R. M, Tang T. S. Implementing an empowerment-based diabetes self-management education program. Diabetes Educ. 2005;31(1):55–56. doi: 10.1177/0145721704273166. http://dx.doi.org/10.1177/0145721704273166 . [DOI] [PubMed] [Google Scholar]
  22. Hair J. F, Black W. C, Babin B. J, Anderson R. E. Structural Equation Modeling. In: Hair J. F, editor. Multivariate data analysis. 7th ed. Upper Saddle River, NJ: Prentice Hall; 2010. [Google Scholar]
  23. Herbert R. J, Gagnon A. J, Rennick J. E, O’Loughlin J. L. A systematic review of questionnaires measuring health-related empowerment. Res Theory Nurs Pract. 2009;23(2):107–132. doi: 10.1891/1541-6577.23.2.107. http://dx.doi.org/10.1891/1541-6577.23.2.107 . [DOI] [PubMed] [Google Scholar]
  24. Ho A. Y. K, Berggren I, Dahlborg-Lyckhage E. Diabetes empowerment related to Pender’s Health Promotion Model: A meta-synthesis. Nursing & Health Sciences. 2010;12(2):259–267. doi: 10.1111/j.1442-2018.2010.00517.x. http://dx.doi.org/10.1111/j.1442-2018.2010.00517.x . [DOI] [PubMed] [Google Scholar]
  25. Hood G. Patient empowerment in diabetes-past debates and new perceptions. European Diabetes Nursing. 2010;7(2):77–78. http://dx.doi.org/10.1002/edn.161 . [Google Scholar]
  26. Hu L. T, Bentler P. M. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal. 1999;6(1):1–55. http://dx.doi.org/10.1080/10705519909540118 . [Google Scholar]
  27. Kettunen T, Liimatainen L, Villberg J, Perko U. Developing empowering health counseling measurement. Preliminary results. Patient Educ Couns. 2006;64(1-3):159–166. doi: 10.1016/j.pec.2005.12.012. http://dx.doi.org/10.1016/j.pec.2005.12.012 . [DOI] [PubMed] [Google Scholar]
  28. Leksell J, Funnell M, Sandberg G, Smide B, Wiklund G, Wikblad K. Psychometric properties of the Swedish Diabetes Empowerment Scale. Scand J Caring Sci. 2007;21(2):247–252. doi: 10.1111/j.1471-6712.2007.00463.x. http://dx.doi.org/10.1111/j.1471-6712.2007.00463.x.4 . [DOI] [PubMed] [Google Scholar]
  29. Li R, Zhang P, Barker L. E, Chowdhury F. M, Zhang X. Cost-effectiveness of interventions to prevent and control diabetes mellitus: A systematic review. Diabetes Care. 2010;33:1872–1894. doi: 10.2337/dc10-0843. http://dx.doi.org/10.2337/dc10-0843 . [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. MacCallum R. C, Browne M. W, Sugawara H. M. Power analysis and determination of sample size for covariance structure modeling. Psychological methods. 1996;1(2):130. http://dx.doi.org/10.1037/1082-989X.1.2.130 . [Google Scholar]
  31. Mahjouri M. Y, Arzaghi S. M, Qorbani M, Nasli-Esfahani E, Larijani B. Evaluation of psychometric properties of the third version of the Iranian Diabetes Attitude Scale (IR-DAS-3) Iranian Journal of Diabetes and Lipid Disorders. 2011;10:1–6. [Google Scholar]
  32. Morgan C. L, Currie C. J, Peters J. R. Relationship between diabetes and mortality: A population study using record linkage. Diabetes Care. 2000;23:1103–1107. doi: 10.2337/diacare.23.8.1103. http://dx.doi.org/10.2337/diacare.23.8.1103 . [DOI] [PubMed] [Google Scholar]
  33. Ministry of Health. World Health Survey: Oman. D. G. o. P. Department of Research, Ministry of Health Publications; 2008. [Google Scholar]
  34. Mok E, Martinson I, Wong T. K. Individual empowerment among Chinese cancer patients in Hong Kong. West J Nurs Res. 2004;26(1):59–75. doi: 10.1177/0193945903259037. discussion 76-84. http://dx.doi.org/10.1177/0193945903259037 . [DOI] [PubMed] [Google Scholar]
  35. Musacchio N, Lovagnini Scher A, Giancaterini A, Pessina L, Salis G, Schivalocchi F, Rossi M. Impact of a chronic care model based on patient empowerment on the management of Type 2 diabetes: effects of the SINERGIA programme. Diabetic Medicine. 2011;28(6):724–730. doi: 10.1111/j.1464-5491.2011.03253.x. http://dx.doi.org/10.1111/j.1464-5491.2011.03253.x . [DOI] [PubMed] [Google Scholar]
  36. Peña-Purcell N. C, Boggess M. M, Jimenez N. An Empowerment-Based Diabetes Self-management Education Program for Hispanic/Latinos A Quasi-experimental Pilot Study. The Diabetes Educator. 2011;37(6):770–779. doi: 10.1177/0145721711423319. http://dx.doi.org/10.1177/0145721711423319 . [DOI] [PubMed] [Google Scholar]
  37. Redfield E. S. religion, faith and the empowerment process: stories of iranian people with diabetes. International Journal of Nursing Practice. 2011 doi: 10.1111/j.1440-172X.2011.01937.x. [DOI] [PubMed] [Google Scholar]
  38. Ringle C. M, Wende S, Will A. Vinzi V. E, Chin W. W, Henseler J, Wang H, editors. Finite Mixture Partial Least Squares Analysis: Methodology and Numerical Examples. Handbook of partial least squares: Concepts, methods and applications. 2010. http://dx.doi.org/10.1007/978-3-540-32827-8_9 .
  39. Shiu A. T, Thompson D. R, Wong R. Y. Quality of life and its predictors among Hong Kong Chinese patients with diabetes. J Clin Nurs. 2008;17(5A):125–132. doi: 10.1111/j.1365-2702.2007.02036.x. http://dx.doi.org/10.1111/j.1365-2702.2007.02036.x . [DOI] [PubMed] [Google Scholar]
  40. Shiu A. T, Wong R. Y, Thompson D. R. Development of a reliable and valid Chinese version of the diabetes empowerment scale. Diabetes Care. 2003;26(10):2817–2821. doi: 10.2337/diacare.26.10.2817. http://dx.doi.org/10.2337/diacare.26.10.2817 . [DOI] [PubMed] [Google Scholar]
  41. Sigurdardottir A. K. Self-care in diabetes: Model of factors affecting self-care. J Clin Nurs. 2005;14(3):301–314. doi: 10.1111/j.1365-2702.2004.01043.x. http://dx.doi.org/10.1111/j.1365-2702.2004.01043.x . [DOI] [PubMed] [Google Scholar]
  42. Sigurdardottir A. K, Jonsdottir H. Empowerment in diabetes care: Towards measuring empowerment. Scand J Caring Sci. 2008;22(2):284–291. doi: 10.1111/j.1471-6712.2007.00506.x. http://dx.doi.org/10.1111/j.1471-6712.2007.00506.x . [DOI] [PubMed] [Google Scholar]
  43. Skinner T. C, Carey M. E, Cradock S, Daly H, Davies M. J, Doherty Y, Oliver L. Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND): Process modelling of pilot study. Patient Educ Couns. 2006;64(1-3):369–377. doi: 10.1016/j.pec.2006.04.007. http://dx.doi.org/10.1016/j.pec.2006.04.007 . [DOI] [PubMed] [Google Scholar]
  44. Song Y, Song H.-J, Han H.-R, Park S.-Y, Nam S, Kim M. T. Unmet needs for social support and effects on diabetes self-care activities in Korean Americans with type 2 diabetes. The Diabetes Educator. 2012;38(1):77–85. doi: 10.1177/0145721711432456. http://dx.doi.org/10.1177/0145721711432456 . [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Steiger J. H. Understanding the limitations of global fit assessment in structural equation modeling. Personality and Individual Differences. 2007;42(5):893–898. http://dx.doi.org/10.1016/j.paid.2006.09.017 . [Google Scholar]
  46. Tabachnick B. G, Fidell L. S. Using Multivariate Statistics. Boston, MA: Pearson Education Inc; 2007. [Google Scholar]
  47. Tang T. S, Gillard M. L, Funnell M. M, Nwankwo R, Parker E, Spurlock D, Anderson R. M. Developing a new generation of ongoing: Diabetes self-management support interventions: A preliminary report. Diabetes Educ. 2005;31(1):91–97. doi: 10.1177/0145721704273231. http://dx.doi.org/10.1177/0145721704273231 . [DOI] [PubMed] [Google Scholar]
  48. Tol A, Baghbanian A, Mohebbi B, Shojaeizadeh D, Azam K, Shahmirzadi S. E, Asfia A. Empowerment assessment and influential factors among patients with type 2 diabetes. J Diabetes Metab Disord. 2013;12(1):6. doi: 10.1186/2251-6581-12-6. http://dx.doi.org/10.1186/2251-6581-12-6 . [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Tol A, Sharifirad G. R, Pourreza A. G, Rahimi A, Shojaeezadeh D, Mohajeritehrani M. R, Alhani F. Development of a valid and reliable diabetes empowerment scale: An Iranian version. Iran Red Crescent Med J. 2012;14(5):305–308. [PMC free article] [PubMed] [Google Scholar]
  50. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998;317:703–713. http://dx.doi.org/10.1136/bmj.317.7160.703 . [PMC free article] [PubMed] [Google Scholar]
  51. Williams J. L. S, Walker R. J, Smalls B. L, Campbell J. A, Egede L. E. Effective interventions to improve medication adherence in Type 2 diabetes: a systematic review. Diabetes Management. 2014;4(1):29–48. doi: 10.2217/dmt.13.62. http://dx.doi.org/10.2217/dmt.13.62 . [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. World Health Organization. What is the Evidence on Effectiveness of Empowerment to Improve Health. Copenhagen, Denmark: 2006. [Google Scholar]

Articles from Global Journal of Health Science are provided here courtesy of Canadian Center of Science and Education

RESOURCES