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. Author manuscript; available in PMC: 2018 Dec 1.
Published in final edited form as: Fam Syst Health. 2017 Dec;35(4):409–419. doi: 10.1037/fsh0000289

“Miscarried Helping” in Adults with Type 2 Diabetes: Helping for Health Inventory-Couples

Rika Tanaka a,b, Paula M Trief c, Kasandra Scales c, Ruth S Weinstock d
PMCID: PMC5751933  NIHMSID: NIHMS896701  PMID: 29283609

Abstract

INTRODUCTION

Family/partner support has been associated with better blood glucose control, self-care adherence, and quality of life in adult patients with type 2 diabetes (T2D). “Miscarried helping” has described interactions between youth with chronic diseases and their family members, in which a family member is helpful, but efforts are perceived as negative by the patient. “Miscarried helping” has not, however, been measured in adults with diabetes.

METHODS

Data from a randomized clinical trial (n=268) were analyzed to establish the psychometric properties and correlates of an adaptation of a measure of miscarried helping developed in pediatric populations, for use with adults with T2D.

RESULTS

The Helping for Health Inventory-Couples Version (HHI-C) was found to have 3 underlying factors and demonstrated adequate internal consistency across time (Cronbach’s α at baseline=.86, 4-months=.87, 8-months= .86, and 12-months=.83) and showed high test-retest reliability (p <.01) over a 12-month period. Convergent validity was partially supported, as baseline HHI-C was positively associated with maladaptive conflict resolution strategies (p=.03), and negatively associated with adaptive conflict resolution strategies (p=.04) and diabetes knowledge (p <.01). The HHI-C did not correlate with BMI or hemoglobin A1c, a measure of glycemic control. The HHI-C was positively associated with diabetes distress (p<.01) and depressive symptoms (p=.01).

DISCUSSION

This study is the first known reporting of the psychometric properties of a measure of miscarried helping for adults with T2D. This valid measure of miscarried helping could be useful in future studies evaluating novel, relationship-based approaches to assist adults with T2D in disease management.

Keywords: miscarried helping, type 2 diabetes, marital satisfaction

Global prevalence of Type 2 diabetes (T2D), a serious public health problem, is projected to increase from 8.8% to 10.4% by 2040 (International Diabetes Federation, 2016). Patients strive to achieve good glycemic control, as poor control increases risks of serious complications (e.g., eye disease, heart disease), mortality, and poor quality of life. (United Kingdom Prospective Diabetes Study Group, 1998; Yang et al., 2013).

Studies suggest that greater family/partner support relates to better glycemic control, self-care adherence, and quality of life (Garay-Sevilla, et al., 1995; Trief, Himes, Orendorff, & Weinstock, 2001; Trief, Ploutz-Snyder, Britton, & Weinstock, 2004; Trief, Wade, Britton, & Weinstock, 2002). Family interventions have been recommended to help partners and other family members learn how to best provide this support (Fisher, 2006; Fisher & Wiehs, 2000; Schmaling & Sher, 2000). However, partner involvement raises concern that they will become, what is colloquially called, the “diabetes police” (Polonsky, 1995), or more formally, “miscarried helping” (Anderson & Coyne, 1991). Miscarried helping describes interactions in which the family member tries to be helpful, but such help is perceived as negative by the patient. For example, miscarried helping may occur when a partner nags (e.g., “You really should watch your carbs”), or sees the patient’s self-care as his/her responsibility (e.g., “I’m doing everything I can to get your sugar down”). This type of interaction can lead to arguments, tension, patient resistance to help, and poorer self-care.

Miscarried helping has been studied within parent-child dyads. Harris and colleagues developed a miscarried helping measure, Helping for Health Inventory (HHI), and found it to be reliable and valid in adolescents with type 1 diabetes (T1D; Harris, et al., 2008). HHI was positively correlated with measures of parental non-support and child-parent conflict, and negatively correlated with adjustment and treatment adherence. Fales and colleagues (2014) used the HHI in a sample of youth with chronic pain, and found that higher perceived miscarried helping related to poorer family functioning.

For adults with diabetes, the concept of the diabetes police, or miscarried helpers, has been fully accepted in the popular literature. Several internet sites provide “tips” about how to “deal with” a miscarried helper, or avoid it (Davidson & Moreland, 2016; Roszler, 2016). For adults with T1D, there is evidence that having an engaged, but not overprotective, partner, relates to better glycemic control and adherence to some aspects of self-care (Trief, et al., 2015). Yet, no measure of miscarried helping has been validated in adults. The main goal was to assess the psychometric properties of an adaptation of the HHI for use with adults with T2D. A secondary goal was to assess its potential demographic, medical, and psychological correlates.

Methods

Participants and Procedures

The study was approved by the IRBs of SUNY Upstate Medical University and the University of California, San Francisco. Participants were compensated for their time completing questionnaires.

N=268 couples were recruited for a randomized clinical trial, the Diabetes Support Project (DSP), to compare the medical and psychosocial outcomes of three interventions: 1) couples-based behavior change intervention, 2) individual behavior change intervention, and 3) diabetes education, to improve glycemic control. The rationale, design, and implementation of the DSP (Trief et al, 2011) and primary results (Trief, et al., 2015) have been reported. Briefly, couples (one partner had T2D) were recruited (mail, advertisements) in Upstate NY and San Francisco Bay area. Inclusion criteria were that the partner diagnosed with T2D was in poor glycemic control (HbA1c > 7.5%), measured at blinded assessments at a central lab. All intervention contacts occurred on the phone; and medical, psychosocial, and behavioral outcomes were assessed at 4, 8, and 12 months.

Data examined for the current analyses are primarily baseline data from combined intervention groups. Because participants in the diabetes education group only received two diabetes education sessions, their data (N=82) were used to assess reliability across time.

Measures

Miscarried helping in couples

Helping for Health Inventory-Couples Version (HHI-C) is a 15-item questionnaire adapted from the Helping for Health Inventory (HHI, Harris et al., 2008), a measure of miscarried helping within parent-adolescent dyads (the youth has a chronic illness). The word “parent” on the HHI was changed to “partner” on the HHI-C. See Appendix for full measure.

Conflict resolution

Conflict Resolution Inventory (Kurdek, 1994), a 16-item self-report measure, assesses four conflict resolution styles exhibited by coupled adults: 1) Conflict Engagement (i.e., verbal aggression), 2) Positive Problem Solving (i.e., focusing on the problem itself), 3) Withdrawal (i.e., shutting down), and 4) Compliance (i.e., passivity or not asserting one’s view). It has been shown to be reliable (Cronbach’s α=.71, in current study) and valid (positive problem solving was significantly positively correlated with relationship satisfaction, r’s ranging from .19 to .37, and withdrawal was significantly negatively correlated with relationship satisfaction, r’s ranging from .26 to .47, p<.05, Kurdek, 1994).

Marital satisfaction/adjustment

Revised Dyadic Adjustment Scale (RDAS, Busby, Christensen, Crane, & Larson, 1995), is a 14-item self-report measure of relationship satisfaction. It has been significantly correlated with Locke-Wallace Marital Adjustment Test, a measure of factors thought to contribute to marital satisfaction, e.g., how conflicts are resolved, involvement in shared activities (r=.68, p<.01, Busby et al., 1995). It was also found to be reliable in the current study(Cronbach’s α=.82).

Diabetes-related distress

Diabetes Distress Scale (DDS, Polonsky, et al., 2005), a 17-item self-report questionnaire, assesses psychosocial adjustment related specifically to one’s diabetes, including diabetes-related emotional distress, physical-related distress, regimen-related distress, and interpersonal distress. The DDS has been found to have good internal reliability both for patients with T1D and T2D (Cronbach’s α >.87, Polonsky, et al., 2005). DDS was positively correlated with depressive symptoms (r =.56), and negatively correlated with adherence to meal-planning recommendations (r =−.30) and exercise levels (r = −.13).

Depressive symptoms

Patient Health Questionnaire (PHQ-8, Kroenke, et al., 2009), an 8-item measure of severity of depressive symptoms, found to be valid in large, epidemiological population-based studies. Patients with a PHQ-8 score > 10 are likely experiencing a current depressive disorder.

Diabetes knowledge

Diabetes Knowledge Test (Fitzgerald, et al., 1998), a 14-item measure, assesses degree to which patients are knowledgeable about diabetes and its management. It has been found to be reliable (Cronbach’s α >.70) and valid (adults with T1D and T2D who received diabetes education scored significantly higher than those who did not, mean differences ranged from 9.93 to 11.34, p <.01).

Blood glucose control

Glycated hemoglobin (HbA1c, Nathan, Singer, Hurxthal, & Goodson, 1984), a measure of average blood glucose in past 2–3 months, is widely accepted as a reliable and valid measure of blood glucose control. The AccuBase A1c Mail-in Test Kit, from Diabetes Technologies Inc. (DTI), can be used for home/community assessments, provides highly accurate HbA1c results (CV’s<1.0%, meaning that it is highly accurate when compared to a known laboratory HbA1c value) and has been used in numerous NIH-funded trials. Participants mailed finger-stick blood samples (5 ul) to a Clinical Laboratory Improvement Amendments (CLIA)-licensed, College of American Pathologist proficient participating lab. [CLIA is the regulatory vehicle for the Centers for Medicare and Medicaid Services to oversee quality of laboratory testing performed on U.S. humans.]

Body mass index

Measures of height (cm) and weight (kg) were taken to calculate body mass index (BMI, kg/m2, Deurenberg, Weststrate, & Seidell, 1991). A stadiometer was used to measure height. Weight was the average of two readings on a portable digital scale (Seca 884 Digital BMI scale).

Data Analysis Plan

Aim 1

Descriptive statistics (mean, standard deviation, range) of the HHI-C were examined to determine its psychometric properties in this sample of adults with T2D.

Aim 2

Principal components analysis (PCA) explored factors comprising the HHI-C in adults with T2D. Because the original HHI was developed with several theoretically overlapping themes posited (Harris et al, 2008), an oblique rotation was implemented using the oblimin command in SPSS. Consideration of the theoretical model of miscarried helping and an examination of scree plots were used to determine the optimal factor solution. Factors with eigenvalues >1 were considered to adequately fit the data. Each item indicator was assigned to a factor based on an examination of factor loadings. Items with factor loadings >.3 were considered for each factor. Items that loaded onto more than one factor were considered to best fit the factor for which they had the higher loading. Internal consistency of each subscale was measured using Cronbach’s α; and correlations between factors were examined.

Aim 3

Reliability of the HHI-C was measured with Cronbach’s α’s and correlations across time. Baseline measures of reliability included data from all participants. Analyses of reliability over time only included data from participants in the diabetes education arm. Cronbach’s α’s >.70 were considered to indicate adequate internal consistency (Nunnally, 1978).

Aim 4

Correlations of the HHI-C with concurrent baseline measures of relationship satisfaction (RDAS), conflict resolution (CRI), and diabetes knowledge were used to determine convergent and discriminant validity (all participants). We hypothesized that the HHI-C would correlate negatively with the RDAS and CRI-Positive Problem Solving; and positively with CRI-Conflict Engagement, CRI-Compliance, and CRI-Withdrawal. HHI-C was not expected to correlate with diabetes knowledge, as it does not assess relationship functioning. However, low patient diabetes knowledge might also increase miscarried helping.

Aim 5

Baseline associations between the HHI-C and demographic (i.e., age, gender, length of relationship, years since diagnosis), medical (i.e., BMI, HbA1c), and psychological (i.e., DDS, PHQ-8) measures were examined.

Results

Participants

See Table 1 for participant characteristics (N=268). Majority were male (61.6%), white (69.6%), married (86.2%), with some college education (70.5%). Participants were, on average, middle-aged (Mean=56.8 years, SD=10.9), had been living with T2D for an average of 12.4 years (SD=7.9), and had been in this committed relationship for an average of 25.5 years (SD=14.8). By study design, all participants were in poor glycemic control (mean HbA1c =9.11% (SD=1.5); and almost all (97%) were overweight/obese (mean BMI=35.9 kg /m2).

Table 1.

Baseline Descriptives and Sample Statistics

N (%) Mean S.D. Range Skew. Kurt.
Male 165 (61.6)
Age (years) 268 (100) 56.78 10.88 28–86 −.05 −.01
# years with diabetes 264 (98.5) 12.41 7.9 1–37 .79 .24
# years in committed relationship 266 (99.3) 25.49 14.83 1–67 .25 −.61
BMI (kg/m2) 268 (100) 35.88 7.51 19.90–77.72 1.12 3.45
HbA1c (%) 268 (100) 9.11 1.51 7.50–15.90 1.59 2.75
Miscarried Helping (Baseline) 268 (100) 33.57 10.74 15–75 .86 .95
Miscarried Helping (F1) 61 (78.2) 32.72 11.14 17–71 1.23 1.81
Miscarried Helping (F2) 59 (75.6) 30.32 10.01 15–59 .67 .58
Miscarried Helping (F3) 58 (74.4) 29.82 9.51 15–59 .80 .73
Dyadic Adjustment Scale 266 (99.3) 49.03 9.22 9–68 −.61 .70
CRI: Conflict Engagement 268 (100) 8.92 3.33 4–20 .52 .03
CRI: Positive 267 (99.6) 13.86 2.91 4–20 −.35 .68
CRI: Withdrawal 267 (99.6) 9.90 3.27 4–20 .27 −.03
CRI: Compliance 267 (99.6) 9.03 3.10 4–20 .47 .40
Diabetes Knowledge Test 267 (99.6) 0.74 .15 .31–1.00 −.49 −.30
Diabetes Distress Scale 268 (100) 2.27 .97 1–5.94 .96 .68
PHQ-8 268 (100) 5.81 5.33 0–24 1.09 .73
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Note. BMI= Body Mass Index, Base= Baseline, F1=4 month Follow-up, F2=8 month Follow-up, F3=12 month Follow-up.

Aim 1: Psychometric Properties of the HHI-C in Adults with T2D

Participants reported a range of miscarried helping scores from 15 (very little endorsement of miscarried helping) to 75 (high levels of reported miscarried helping). The mean baseline HHI-C score was 33.57 (SD=10.74). Lack of significant skewness (.86) or kurtosis (.95) indicated the measure was likely normally distributed and within limits of assumed normality for further analyses (See Table 1).

Aim 2: Exploratory Factor Analysis of the HHI-C in adults diagnosed with T2D

Examination of the scree plot and eigenvalues derived from the PCA, with consideration of theoretical underpinnings, revealed a 3-factor solution: 1) Conflict/Blame (8 items), 2) Partner Investment (4 items), and 3) Resistance (3 items). See Table 2. Together, these factors explained 59.6% of the overall variance in HHI-C: Conflict/Blame explained 36.6%, Partner Investment explained 14.4%, and Resistance explained 8.7%. Cronbach’s α’s revealed moderate to high internal consistency within each subscale (αConflict/Blame=.89, αPartner Investment=.68, and αResistance=.66). However, the removal of item #3, (“When my health does not improve, it seems like my partner thinks he/she has not been a good partner”) from Partner Investment resulted in improved subscale reliability (αwithout#3=.71). Removal of item #5 (“I think that my partner feels responsible for my having diabetes”) resulted in increased reliability (αwithout#5=.75) of the Resistance subscale. Moderate correlations between Conflict/Blame and Partner Investment (r=.22) and between Conflict/Blame and Partner Investment ( r=.36), but a very low correlation between Partner Investment and Resistance (r=−.04).

Table 2.

Principal Components Analysis of Miscarried Helping in Adults Diagnosed with T2D: Factor Loadings and Communalities

1. 2. 3.
HHI-C Item Conf. & Blame Partner Invest. Resist. Comm.
12. My partner gets upset with me when my health doesn’t improve. .89 .73
10. When I have health setbacks, my partner thinks that I am not trying hard enough. .89 .69
4. I feel my partner "nags" me about how I manage my diabetes. .74 .58
8. My partner gets upset when my health doesn’t improve. .73 .60
13. My partner argues with me about how he/she is trying to help me with managing my diabetes. .71 .61
11. When I don’t take my partner’s advice or direction in managing my health, he/she tries to do it him/herself. .65 .52
15. I tell my partner not to "nag" me about managing my diabetes. .61 .32 .59
14. I feel like the more my partner tries to help me with my diabetes, the worse things get between us. .53 −.34 .36 .59
1. I feel like my partner believes there are no limits to what he/she can do in helping me manage my diabetes. .85 .71
2. I believe that my partner wants to be a "good" helper when it comes to helping me manage my diabetes. .85 .70
9. My partner thinks that if he/she does the right thing, my health will improve. .43 .51 .52
3. When my health does not improve, it seems like my partner thinks he/she has not been a good partner. .31 .34 .33
6. I resist my partner’s involvement in my diabetes. .88 .69
7. The more my partner tries to involve him/herself in my diabetes, the more I resist their involvement. .85 .77
5. I think that my partner feels responsible for my having diabetes. .44 .33
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Rotation Method: Oblimin with Kaiser Normalization.

Aim 3: Reliability of HHI-C in Adults with T2D

At baseline, HHI-C showed adequate internal consistency (Cronbach’s α=.86). Within the diabetes education subsample, HHI-C was reliable across time (Cronbach’s α at 4-months=.87, at 8-months = .86, and at 12-months=.83). And the removal of any single item from the full scale had no significant impact on internal consistency at any time point. See Table 3.

Table 3.

Correlations and Cronbach's s of Miscarried Helping Across Time

1 2 3 4
1. Baseline 1
2. Follow-up 1 .77** 1
3. Follow-up 2 .72** .80** 1
4. Follow-up 3 .69** .75** .84** 1
Cronbach’s α .86 .87 .86 .83
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Note.

**

p<.01

Within the diabetes education group, the association of HHI-C across all four time points was high (r’s ranged from .69–.80). As expected within a longitudinal design, correlation between baseline and 12-month HHI-C was lowest (r=.69, p< .01), the highest correlation (r=.84, p<.01) was between 8- and 12-month assessments.

Aim 4: Validity of the HHI-C in Adults with T2D

As hypothesized, baseline HHI-C was positively associated with CRI-Conflict Engagement (r=.14, p=.03) and CRI-Compliance (r=.15, p=.02), and negatively associated with CRI-positive problem solving strategies (r=−.13, p=.04). See Table 4. However, overall HHI-C had no significant association with CRI-Withdrawal (r=.09, p=.14) or RDAS (r=−.04, p=.58). Further post-hoc analyses of the HHI-C subscales did find, however, that Resistance was the only HHI-C subscale to have a significant association with CRI- Withdrawal (r=.2, p=.001), that Conflict and Resistance were both negatively associated with RDAS (r=−.16, p=.004; r=−.15, p<.001, respectively), and that Partner Investment was positively associated with RDAS (r=.35, p<.001). Moreover, although we hypothesized that HHI-C would not relate to diabetes knowledge scores, we found a negative association (r=−.25, p<.01). We conclude that there was mixed support for the convergent and discriminant validity of the HHI-C.

Table 4.

Correlations of Miscarried Helping with Demographic, Physical, Psychological, and Relational Measures at Baseline

r df p
Demographic Age −.02 266 .72
# Years Since Diagnosis −.06 262 .32
# Years in Relationship −.03 264 .68
Physical Outcomes HbA1c −.07 266 .25
BMI .00 266 .96
Psychological Outcomes Diabetes Distress .27** 266 <.01
Depression (PHQ-8) .16** 266 <.01
Diabetes Knowledge Test −.25** 265 <.01
Relationship Satisfaction & Conflict Resolution Dyadic Adjustment Scale −.04 264 .58
CRI: Conflict Engagement .14* 266 .03
CRI: Positive Problem Solving −.13* 265 .04
CRI: Withdrawal .09 265 .14
CRI: Compliance .15* 265 .02
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Note. CRI= Conflict Resolution Inventory, BMI= Body Mass Index,

*

p<.05,

**

p<.01

Aim 5: Correlates of Miscarried Helping in Adults with T2D

HHI-C was not significantly correlated with age (r=−.02, p=.72), number of years with diabetes (r=−.06, p=.32), or length of relationship (r=−.03, p=.68). HHI-C did vary significantly by gender. On average, men (Mean=34.86, SD=10.41) reported significantly higher levels of miscarried helping than women (Mean=31.50, SD=11.00; t (1)=2.52, p=.01).

Baseline HHI-C was significantly positively associated with psychological distress (rDDS=.27, p<.01; rPHQ-8=.16, p=.01), but had no significant associations with medical measures (rBMI=−.07, p=.25) and HbA1c (rHbA1c =−.003, p=.96).

Discussion

We examined the psychometric properties (reliability, validity, underlying factor structure), and demographic, physical, and psychological correlates of a measure of miscarried helping that assessed the patient’s view of their partner’s behavior.

Underlying Structure of the HHI-C in Adults with T2D

We found three overlapping HHI-C factors: 1) Conflict/Blame, 2) Partner Investment, and 3) Resistance. “Conflict/Blame” refers to disagreements and blaming one individual or the other for negative health outcomes. Examples of Conflict/Blame are, “My partner gets upset with me when my health doesn’t improve,” and “When I have health setbacks, my partner thinks that I am not trying hard enough.” “Partner Investment” refers to patient beliefs that their partners are committed to helping them patients manage their health (e.g. “I feel like my partner believes there are no limits to what he/she can do in helping me manage my diabetes”). “Resistance” refers to patient non-compliance with the partner’s help (e.g. “I resist my partner’s involvement in my diabetes”). Miscarried helping theory within parent-child dyads suggested four stages: 1) parental investment helping, 2) evaluation of help using health outcomes, 3) conflict around help attempts, and 4) assigning blame to both parties for poor health outcomes (Anderson & Coyne, 1991). These stages show clear overlap with the three factors identified in this study. Similar models of the miscarried helping process may be useful when considering this process between adults with T2D and partners.

Although internal consistency was moderate to high within each factor, two items had somewhat lower factor loadings; and removing these items from their respective subscales resulted in improved internal reliability. Although there are likely overlapping processes that occur between parent-child and patient-partner relationships, there are also likely distinct differences. For example, there may be more emphasis on caregiving in being a “good parent,” compared to that for being a “good partner.” Similarly, because of the biological link between parent and child, parents may be more likely to “feel responsible” for their child’s illness than an adult partner would. Thus, these items may be less relevant to miscarried helping within adult couples and might be deleted from future versions of the HHI-C. Moreover, potential new items reflecting experiences unique to the coupled partner-patient relationship should also be considered.

Reliability and Validity of HHI-C in Adults with T2D

The HHI-C was adequately internally consistent across time points, with each item contributing meaningfully to the measure. For test-retest reliability, the HHI-C was relatively stable over 12 months. The stability of this measure is promising, pointing to the stability of this construct over time and suggesting that the measure will be useful in future longitudinal investigations of miscarried helping.

Overall, HHI-C was positively associated with conflict engagement and compliance conflict resolution strategies, and negatively associated with positive problem solving strategies, providing support for its construct validity. Although total HHI-C had no relationship to the use of withdrawal as a conflict resolution strategy, the Resistance subscale of HHI-C had a significant positive correlation with withdrawal strategies. A patient who resists partner help may also be likely to withdraw during conflict, thereby decreasing overall interactions, resulting in less of an opportunity for other aspects of conflict resolution or miscarried helping to occur.

We found that the commonly assumed pattern that miscarried helping is associated with lower relationship satisfaction, was true for the Conflict and Resistance subscales of the HHI-C. However, Partner Investment had the opposite association with relationships satisfaction, with more involvement being associated with higher satisfaction. These findings indicate that the subscales of the current measure likely capture the inherent complexity of interactions embedded within the concept of miscarried helping. For example, in a sample of adults with diabetes (T1D and insulin-using T2D), Schokker et al., (2010) found that more “protective buffering” of patients by partners (partners hide their concerns to avoid adding to patient stress) was associated with lower relationship satisfaction, but only for those who perceived a low level of overall partner engagement. Studies also suggest a positive effect of partner support, when such support is demonstrated by active engagement; and negative effects of over-protection (Coyne & Smith, 1991; Hagedoorn, et al., 2006; Hinnen, Hagedoorn, Ranchor, & Sanderman, 2008; Kuijer, et al., 2000; Trief et al., 2015). Clearly, the effects of partner support on relationship outcomes are complex and need further evaluation.

Correlates of Miscarried Helping in Adults with T2D

Miscarried helping was positively associated with both concurrent diabetes distress and depressive symptoms. This is consistent with the findings that miscarried helping was associated with poor adjustment to illness in adolescents with T1D (Harris et al., 2008), and more depressive symptoms in adolescents with chronic pain (Fales et al., 2014). Together, these findings highlight the potential negative impact of miscarried helping on the psychological well-being and adjustment of adults, as well as youth.

Contrary to the hypothesized null effect, patients who endorsed high levels of miscarried helping were more likely to score low on a test of diabetes knowledge. We had hypothesized that diabetes knowledge would have no significant association with miscarried helping, because the test of diabetes knowledge does not assess interpersonal factors. However, perhaps when patients are less informed, partners may perceive them as not being sufficiently knowledgeable, and thus in need of more direct help, even if this help is not appreciated.

On average, men reported greater miscarried helping from wives, than women from husbands. In many households, women are more responsible for activities related to diabetes self-care, e.g. grocery shopping, meal planning/preparation (Gonder-Frederick, Cox, & Ritterband, 2002), providing more opportunities for women to try to help their husband-patients, which may be perceived as miscarried. For T1D adolescents, mothers more than fathers, felt that their helping was perceived as miscarried, and the authors hypothesized this was due to their higher levels of involvement in the management of their child’s illness (Harris et al., 2008). Moreover, Rook, August, Stephens, & Franks (2011) found that high expectations for spousal involvement decreased resistance to help for women; but for men, expectations did not influence relation between spousal help and behavioral resistance, with higher frequency of helping behaviors associated with higher resistance. Combined, these studies suggest that the process of miscarried helping may vary by gender, perhaps based on differences in gender roles and expectations.

Miscarried helping did not correlate with BMI or HbA1c, which is consistent with prior work (Harris et al., 2008). Thus, it appears that miscarried helping likely does not have a direct negative association with weight or glycemic control of adults with T2D.

Limitations & Future Directions

Cross-sectional analyses limit any causal conclusions regarding the relations among variables. For example, miscarried helping may increase risk for poor adjustment to illness and depression; however, patients who are depressed or struggling with adjusting to illness may be more likely to perceive their partners’ efforts to help as “miscarried” or over-involved. These data are from middle-aged patients with poor glycemic control in long-term, committed relationships, and may not generalize to younger adults in shorter relationships, or those who have established better glycemic control. Also, we only include patient-reported experiences of miscarried helping. Given dynamic changes in interpersonal relationships over time, longitudinal studies of miscarried helping across multiple informants, including adult partners, would be valuable in future studies.

Conclusions

This is the first report of the psychometric properties and correlates of a measure of miscarried helping for adults with type 2 diabetes. This study was unique in that it used data from a large sample of both men and women with T2D in long-term committed relationships. We believe that these results identified miscarried helping, as measured by the HHI-C, as important to examine in future studies aimed at understanding the impact of partner support in predicting adult patient adjustment to diabetes, and the partner’s role in assisting in patient self-management.

Acknowledgments

This research was supported in part by NIH grant 1R18DK080867-01A2.

The authors would like to acknowledge our colleagues whose work on the DSP provided the data for this paper, including Dr. Lawrence Fisher and Dr. Danielle Hessler of University of California, San Francisco, Dr. Jonathan Sandberg of Brigham Young University, and Dr. Jacqueline Dimmock and Ms. Patricia Forken of SUNY Upstate Medical University. We would also like to thank Dr. Michael Harris, Oregon Health Sciences University, for graciously granting permission for us to adapt the HHI to use with couples. Finally, we thank the patients and partners who generously shared their time, thoughts, and feelings with us, and the diabetes educators who provided skilled interventions.

Appendix. The Helping for Health Inventory-Couples Version

Using the rating scale, indicate how often you experience each statement by circling one (1) number per line.

Rarely..........................Always
1. I feel like my partner believes there are no limits to what he/she can do in helping me manage my diabetes. 1 2 3 4 5
2. I believe that my partner wants to be a “good” helper when it comes to helping me manage my diabetes. 1 2 3 4 5
3. When my health does not improve, it seems like my partner thinks he/she has not been a good partner. 1 2 3 4 5
4. I feel my partner “nags” me about how to manage my diabetes. 1 2 3 4 5
5. I think that my partner feels responsible for my having diabetes. 1 2 3 4 5
6. I resist my partner’s involvement in my diabetes. 1 2 3 4 5
7. The more my partner tries to involve him/herself in my diabetes, the more I resist their involvement. 1 2 3 4 5
8. My partner gets upset when my health doesn’t improve. 1 2 3 4 5
9. My partner thinks that if he/she does the right thing, my health will improve. 1 2 3 4 5
10. When I have health setbacks, my partner thinks that I am not trying hard enough. 1 2 3 4 5
11. When I don’t take my partner’s advice or direction in managing my health, he/she tries to do it him/herself. 1 2 3 4 5
12. My partner gets upset with me when my health doesn’t improve. 1 2 3 4 5
13. My partner argues with me about how he/she is trying to help me with managing my diabetes. 1 2 3 4 5
14. I feel like the more my partner tries to help me with my diabetes, the worse things get between us. 1 2 3 4 5
15. I tell my partner not to “nag” me about managing my diabetes. 1 2 3 4 5
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