The impact of type D personality on self-care of patients with type 2 diabetes: the mediating role of coping strategies

Abstract

Purpose

As a chronic disease, Diabetes requires special self-care behaviors until the end of life. Psychological factors play an important role in following the self-care plans among patients with diabetes. The present study was designed to examine the relationship between type D personality and self-care with the mediating role of coping strategies in patients with type 2 diabetes.

Methods

This cross-sectional study was carried out on a sample of 361 patients with type 2 diabetes from Ale-Ebrahim Diabetes Charity Center in Isfahan, Iran. Type D personality, coping strategies and self-care were measured by validated questionnaires. The data were analyzed through Structural Equation Modeling (SEM).

Results

The results indicated that type D personality affects the self-care behaviors indirectly via emotion-oriented coping. Problem and avoidant oriented coping strategies did not significantly mediate the effect of type D personality on self-care.

Conclusion

In general, assessing psychological background (such as personality traits and coping strategies) can facilitate the treatment of patients with diabetes by means of self-care enhancement.

Introduction

Diabetes is one of the most common and costly chronic disease, which has been estimated to inflict suffering on people ranging from a population of 171 million in 2000 to 366 million in 2030 [1]. There are a variety of diabetes forms among which type 2 is the most prevalent kind in adults [2]. In type 2 diabetes, the pancreas produces insulin, yet its amount is insufficient or at times, the body is resistant to it [3]. Having escalated in the recent decades, type 2 diabetes is considered as a disease, which has brought about a great deal of health and socio-economic problems for human societies. Furthermore, it has been known as an impairing disease which may result in a wide range of disabilities [4]. Hence, recognition of the factors that can reduce such problems has been a concern to experts. One of these factors is self-care, which can improve the clinical outcomes according to the scientific research [5].

Self-care in diabetes is defined as a gradual process of maturation (knowledge or awareness acquisition), culminating strategies to deal with the complex nature of type 2 diabetes in a social context. The patient’s ability to take care of oneself and his/her perseverance to maintain care consistency in the long run are two essential factors to manage diabetes promptly [6]. Thus, psychological factors can have an impact on self-care behaviors, yet they are neglected very often.

Personality type is one of the most crucial psychological factors that has ever been studied as a risk factor for some groups of diseases [7]. The existing literature on self-care specifies that personality traits are the most effective psychological factors, playing a key role in the prediction of self-care behaviors as well as the management of diabetes [8]. In the recent years, a new personality trait, known as Type D (Distressed Personality Type), has been introduced, which was mentioned in a study by Denollet and his colleagues for the first time, with two components of negative affectivity (NA) and social inhibition (SI) [9]. NA is described as a consistent desire to experience negative emotions such as anger, hostility, depression, anxiety and inner conflict. In addition, SI refers to a tendency to refrain from revealing one’s feelings and beliefs in interactions so as to avoid social rejection [9].

It is noteworthy to mention that type D personality can exert influence on self-management [10]. Cao et al. [11] reported that there is a significant relationship between type D personality and behaviors such as smoking, following a sedentary lifestyle with no physical activity, being on an unhealthy diet and lacking compliance. In a report on Chinese patients with heart failure, Liu et al. [12] also mentioned a significant negative relationship between type D personality and adherence to self-care consistency. Moreover, Nefs et al. [13] noticed that individuals with type D personality, suffering from type 2 diabetes mellitus are likely to report poor mental health, minimal self-care activities (especially physical activities), unhealthy diet, as well as less consultation with health professionals. Nevertheless, Mols et al. [14] found out that type D personality had no effect on medication adherence after they had conducted a study on a sample of thyroid cancer survivors.

Diabetes is a complicated long-lasting disease whose nerve-wracking demands make patients use strategies to cope with them [15]. Furthermore, diabetes-related distress is one of the predictors of diabetes self-management behaviors [16]. The American Association of Diabetes Educators put an emphasis on the need to identify effective healthy coping styles so as to handle the tensions of the patients with diabetes [17]. Coping strategies, which can play a key role in the self-care behaviors of these patients, include choosing a healthy diet, working out, frequent monitoring of blood glucose, and compliance with the prescribed medication regimens [18].

Lazarus and Folkman [19] defined coping as a cognitive and behavioral effort in order to manage environmental conditions, whose effects are overestimated by the individual. Different coping strategies have been suggested by a large group of researchers, among whom Endler and Parker [20] suggest that coping strategies are categorized into three groups: problem-oriented, emotion-oriented and avoidance-oriented coping.

Problem-oriented coping is described as strategies through which individuals strive to reconceptualize or solve the issues at hand through cognition which would otherwise result in distress. Those individuals, utilizing emotion-oriented coping strategies make an attempt to reduce negative emotionality including rumination, suppression and self-blame. Ultimately, using avoidance-oriented coping is displayed by those actions and cognitions which aim to disengage people from stressful situations i.e. distraction and social diversion [21].

Samuel-Hodge et al. [22] examined 185 African Americans with type 2 diabetes. They stated that self-care behaviors were primarily affected by active forms of coping strategies (that is to say activities or any sort of schedule to act on). Another study was performed similarly, concerning a sample of adolescents with type 1 diabetes. In this regard, Jaser, et al. [23] came to the conclusion that those employing primary control engagement coping strategies (e.g., problem-solving) along with the secondary type (e.g., acceptance and distraction) experience a more successful self-management.

Personality traits are viewed as one of the chief personal factors in relation with coping strategies. In other words, personality traits can have an influence on the strategies, people choose to deal with stressful life situations [24]. Sogaro, et al. [25] investigated the relationship between type D personality and coping in patients attending an outpatient intensive program of cardiac rehabilitation. The results indicated that type D personality is associated with a significantly considerable use of maladaptive coping strategies. Besides, Williams and Wingate [26] substantiated that type D personality was positively correlated with avoidant coping in a non-cardiac population, however, its relation to problem-focused and emotion-focused coping was negative.

To sum up, diabetes is a disease that requires implementation of self-care behaviors. According to the results of studies conducted in this field, personality traits like type D personality have a significantly adverse effect on self-care [12, 13]. Given that diabetes can lead to a great deal of mental or emotional strain in one’s life (especially those patients with type D personality), coping strategies can be considered as one of the major mediators, facilitating the management of tension and anxiety in the long term. Therefore, the present study aims to investigate the relationship between type D personality and self-care behaviors with the mediating role of the coping strategies in patients with type 2 diabetes.

Methods

Design and Participants

The research design was a cross-sectional study. A convenience sampling method was employed to recruit participants. The data collection, lasting from May through July 2018 included 361 patients affected by type 2 diabetes (119 females and 142 males) from Ale-Ebrahim Diabetes Charity Center in Isfahan, Iran. The selection criteria of patients included passing at least 1 year from diagnosis for type 2 diabetes, start of treatment for a year before the beginning of the current study, being literate at least in order to understand and answer the questions as well as willingness to participate in the research. To observe ethical considerations, the research objectives were explained to the participants and they were assured about the confidentiality of the information. After that, informed consent was taken from all participants. Eventually, this study was approved by the Ethics Committee of Yazd University (Ethics Code: IR.YAZD.REC.1399.001).

Instruments

Type D scale (DS-14)

Type D personality was evaluated by type D Scale (DS14), which has 14 items and two subscales (negative affectivity and social inhibition) consisting of seven items each [9]. In addition, a five-point Likert scoring (0 = false to 4 = true) was put to use and the scores were calculated separately for these two subscales. A score of 10 or more in both of these two subscales categorizes an individual as type D personality. In this study, the Cronbach’s alpha coefficient of the negative affectivity subscale was 0.88 and the social inhibition subscale was 0.86 [9]. In a study, Bagherian and Ehsan [27] assessed the psychometric properties of the Persian version of DS-14 in myocardial infarction patients as well as healthy participants. The NA and the SI subscales of their study indicated good test–retest stability over a 2-month period (r = 0.86/0.77 respectively). They reported the Cronbach’s alpha coefficient for NA subscale was 0.84 in patients’ group and 0.87 in healthy group. Furthermore, the Cronbach’s alpha coefficient for SI subscale was 0.86 in patients’ group and 0.75 in healthy group. Moreover, in our study Cronbach’s alpha was 0.92 for negative affectivity and 0.78 for social inhibition.

Coping inventory for stressful situations- short form (CISS-21)

The Coping Inventory for Stressful Situations (CISS) was developed by Endler and Parker [20]. CISS-21 was obtained from the original CISS, which had 48 items. The short form contains 21 items and measures three coping styles: problem-oriented, emotion-oriented, and two types of avoidant-oriented coping (social diversion and distraction). In addition, each question is scored based on a five-point Likert Scale (1 = not at all to 5 = very much) [28]. Li et al. [28] reported Confirmatory factor analysis, approving the validity of the four-factor structure of CISS-21 in the Chinese sample. Also, the Cronbach’s α coefficients for the problem-oriented, emotion-oriented, social diversion and distraction coping strategies were 0.81, 0.74, 0.66, and 0.70, respectively. In Iran, Shokri et al. [29] studied factor Structure and psychometric properties of The Farsi Version of CISS. The results of Confirmatory Factor Analysis (CFA) revealed that the four-factor model demonstrated a good fit to the data. Cronbach’s α coefficients were 0.86, 0.84, 0.70 and 0.71 for problem-oriented, emotion-oriented, social diversion, and distraction coping strategies, respectively. Utilizing AMOS, CFA showed a good fit to the data for four-factor model in this study. Internal consistency of the subscales were 0.95 for the problem-oriented coping, 0.76 for the emotion-oriented coping, 0.67 for the social diversion, and 0.57 for distraction.

Summary of diabetes self-care activities (SDSCA)

The SDSCA is a well-known self-report questionnaire that assesses the self-care criteria of patients with type 2 diabetes over the past 7 days. This scale includes different aspects of diabetes treatment including diet, exercise, blood glucose testing, foot care, and smoking. It uses 12 questions in a Likert scale. With the exception of the smoking behavior, which has a score of 0 to 1, a score of 0 to 7 is given to the rest of the behaviors, and a score of total compliance is achieved by aggregating scores for each question. In general, higher scores indicate better diabetes self-care. Toobert, Hampson and Glasgow [30] have confirmed the reliability and validity of this scale. In the study of Reisi et al. [31] the reliability of SDSCA is evaluated in Iran, in which Cronbach’s α was 0.82. In our study Cronbach’s alpha for the self-care questionnaire was 0.83.

Data analysis

SPSS-22 (Statistical Package for the Social Sciences-version 22) and AMOS-22 (Analysis of moment structures-version 22) software programs were used for data analysis. Normality is assessed using skewness and kurtosis statistics [32] in SPSS. For normal distribution, kurtosis and skewness values should be between −1 and + 1 [33]. Likewise, the results verified normality of all variables (Table 2).

Table 2.

Skewness, Kurtosis, Mean, Standard deviation and Pearson correlation coefficients

Variable	Skewness	Kurtosis	Mean	Standard deviation	1	2	3	4	5	6
1. Self-care	−0.22	−0.98	43.20	16.46	–
2. Dimensional Type D	0.69	−0.80	188.59	159.93	0.73**	–
3. Problem-oriented	0.01	−0.90	22.07	8.87	0.73**	−0.76**	–
4. Emotion-oriented	0.16	−0.59	21.43	5.10	−0.07	0.23**	−0.27**	–
5. Distraction	0.14	−0.41	11.80	2.79	0.03	0.10*	−.10	0.71**	–
6. Social diversion	−0.15	−0.44	9.63	2.52	0.06	0.06	−.072	0.59**	0.46**	–

**p < 0.01, *p < 0.05

Before examining the mediating effect of coping strategies, the correlation between type D personality, self-care, and coping strategies were investigated using Pearson correlation test. Then, Structural Equation Modeling (SEM) using maximum-likelihood estimation procedures was applied to examine the mediating effect of coping strategies on the relationship between type D personality and self-care. The proposed fitness model was investigated based on the ratio of Chi-square statistics, the Comparative Fit Index (CFI), Normative Fitness Index (NFI), Goodness of Fit Index (GFI), the Root Mean Square Error of Approximation (RMSEA) and Standardized Root-Mean-Square Residual (SRMR). In order for the model to achieve a good fit to the data, CFI, NFI and GFI must be close to 0.95, RMSEA, 0.06 or less and SRMR, 0.08 or less [34]. In the present study, type D personality was used as a latent variable with two subscales of negative affectivity and social inhibition.

Results

The demographic, clinical and personality characteristics of the 361 participants are presented in Table 1. In this study, 60% of all subjects were female, 87% were married and 49% of participants had type D personality. Their age ranged from 30 to 88 years (M = 58.03, SD = 11.45).

Table 1.

Demographic, clinical and personality characteristics

Variables	Frequency	Percent
Gender
Woman	216	59.8
Man	145	40.2
Marital status
Married	314	87.0
Single/Divorced	47	13.0
Age
below 40	29	8.0
40–60	170	47.1
Above 60	162	44.9
Education
Middle schoolor less	206	57.1
Diploma	118	32.7
Bachelor degree	34	9.4
Master degree or higher	3	0.8
Duration of the disease (year)
1–5	118	32.7
6–10	102	28.3
11–15	71	19.7
16–20	43	11.9
21>	27	7.4
Current medication
Diabetes pill	228	63.2
Insulin	59	16.3
Pills and insulin	64	17.7
None	10	2.8
Fasting plasma glucose
Low (<90)	10	2.8
Normal (91–120)	90	24.9
Medium (120–160)	148	41
High (>160)	113	31.3
Personality Type
Type D personality	176	48.8
Non-type D personality	185	51.2

The relationship between demographic, clinical and personality characteristics with self-care behaviors was assessed. Among all these variables, there was only a relationship between type D personality and self-care. The results of the t-test revealed that the mean score of self-care in patients with type D personality was lower than non-type D personalities (t = 18.9, p < 0.05). Also, among the clinical variables, there was a negative relationship between fasting plasma glucose (was measured in the last laboratory sugar blood test) and self-care behaviors. Patients with more self-care behaviors had lower blood glucose scores (r = −0.19, p = 0.0001).

Pearson correlation test was utilized to investigate the correlation between main variables (Table 2), in which type D personality was analyzed as a dimensional construct (NA × SI). According to the results, there was a negative and significant relationship between type D personality and self-care (r = −0.73, p < 0.01), and a positive relationship between self-care and problem-oriented coping (r = 0.73, p < 0.01). Besides, there was a negative significant relationship between type D personality, problem-oriented and distraction coping (r = −0.77, p < 0.01), in addition to a positive relationship between type D personality and emotion-oriented coping (r = 0.23, p < 0.01).

Structural equation modeling was used to examine the mediating role of coping strategies between type D personality and self-care. The model 1 was used in order to determine whether coping strategies have a mediating role in the relationship between type D personality and self-care (Fig. 1).

Fig. 1.

The hypothesized model (NA Negative Affect, SI Social Inhibition, Co Coping Strategies, e error)

The initial results demonstrated that type D personality did not have a significant effect on social diversion. Also, problem-oriented coping, social diversion and distraction did not have a significant effect on self-care. After removing the non-significant paths, the fit of the model was assessed (χ²/df = 3.2, CFI = 0.92, IFI = 0.90, GFI = 0.88, RMSEA = 0.07, SRMR = 0.12, ECVI = 1.91). Since some of the indices were less than adequate, based on AMOS’s modification indices, the error terms of emotion-oriented and distraction coping were correlated since they are the two subscales of coping strategy. After the Modification, the model 2 (Fig. 2) showed an acceptable fit (χ ²/df = 1.9, CFI = 0.96, IFI = 0.96, GFI = 0.91, RMSEA = 0.05, SRMR = 0.07, ECVI = 1.23).

Fig. 2.

The path standardized coefficient of finalized model (NA Negative Affect, SI Social Inhibition, Co Coping Strategies, e error)

According to the proposed model, type D personality had direct (β = −0.89, p < 0.01) and indirect effect (β = 0.08, p < 0.01) on self-care. Therefore, the emotion-oriented coping strategy had a mediating role in the relationship between type D personality and self-care.

To test the significance of the mediation effects of emotion-oriented coping, bootstrapping procedures in AMOS were conducted. In the present study, 2000 bootstrapping samples were generated by random sampling. The Results with 95% confidence interval (CI:0.04–0.13) confirmed the mediating effect of emotion-oriented coping.

Discussion

In the present study, 48.8% of patients had type D personality. Although the previous studies reported the prevalence of type D personality in patients with diabetes, ranging from 17% in the Netherlands [13] to 51.6% in Bosnia and Herzegovina [35], this percentage was higher than most of them [36–38]. This result was consistent with the study conducted regarding the university students of Iran, where the prevalence of type D personality was higher than the other countries [39]. This result might be associated with cultural factors: For instance, Iranians experience more negative emotions [40] which increase the score of NA subscale. Moreover, their use of suppression and inhibition strategies to manage emotions [41] would raise the score of SI subscale. Given the high prevalence of type D personality among patients with diabetes in Iran, it is crucial to examine its effects with more precision.

It is evident that Type D Personality has an effect on self-care, however, the mechanism through which it can exert its influence is not investigated thoroughly. In the present study, the utmost attempt was made to address this limitation and expand what is known about this mechanism in patients with type 2 diabetes. Hence, the aim of this study was to investigate the relationship between type D personality and self-care with the mediating role of coping style (problem-oriented, emotion-oriented and avoidance-oriented coping) in patients with type 2 diabetes.

The final model showed type D personality has positive relationship with emotion-oriented and distraction coping strategies but has negative relationship with problem-oriented coping strategy. This result in accordance with prior research which indicated that type D personality was less associated with problem-oriented coping [26, 42, 43], yet more linked with emotion [42, 44] and avoidance [26, 43] oriented copings. Type D personalities consider stress agents far more extreme, therefore prefer to employ avoidance and emotion-focused coping, and have no interest in utilizing problem-focused coping strategy [42].

Among coping strategies only emotion-oriented strategy was correlated with self-care. Hence, our findings demonstrated that emotion-oriented coping played a mediating role in the relationship between type D personality and self-care. Consistent with the previous research on self-care in chronic heart failure patients [44], the findings of this study also showed that emotion-oriented coping has a positive relationship with type D personality and self-care. Other studies in this regard revealed that maladaptive coping in type D personalities has a side effect on perceived health among patients with coronary heart disease [45], physical symptoms in a non-cardiac population [26] and dietary intake in healthy participants [46].

Patients with type D personality experience high levels of negative emotions due to the chronic process of diabetes and they are not willing to convey their negative emotions to others. These individual characteristics would engender less social support [39]; therefore, patients with diabetes try to calm themselves down by emotion-oriented coping styles instead of seeking help from experts, friends and family to minimize their inner tensions [44]. These tensions and negative emotions are outcomes of drastic changes in lifestyle (such as compliance with the treatment plans, following a diet schedule, being physically active, monitoring of blood sugar) [47] and concern about complications of diabetes, including cardiovascular disorders, retinopathy, neuropathy, nephropathy, blindness, foot amputation and kidney loss [48], which would force patients with diabetes into employing more emotion-oriented coping.

Although it has been stated that emotion-oriented coping strategies may be less adaptive than problem-oriented strategies in the long term, the research has shown that each of the coping strategies is effective in a different situation. Problem-focused strategies are proper for the disease that can be cured directly. When the patients believe their illness is associated with manageable factors and they can have an impact on the state of their disease, they make use of problem-focused strategies to a greater extent. Nonetheless, for persons with chronic diseases like diabetes when there is no definite cure, emotion-focused strategies are more suitable [49].

On the other hand, the results of this study revealed that emotion-focused coping can positively predict self-care as a mediating variable. Use of emotion-oriented strategies can raise individuals’ awareness about distress, draws their attention to emotional processes and causes self-conscious emotions. Regret, guilt and self-blame may help patients to take charge of their treatment [50], hence emotion-oriented coping has a positive correlation with self-care. Eventually, it seems that patients with diabetes and type D personality experience highly negative emotions. Also, because of social inhibition and the nature of their disease; these patients use emotion-oriented coping to reduce their distress. This strategy could motivate them to change and practice self-care behavior.

There are several limitations to the present study. First, this study was a cross-sectional study which makes it impossible to establish a causal relationship over time. Second, all of the data had been collected with self-report measures. Respondents may respond to questionnaires, in particular, self-care with bias. The third limitation was that the patients were selected from one diabetes center which is not likely to be a representative of the whole population of patients with diabetes. Finally, the sample consists of patients with diabetes and the results may not be generalized to the other populations.

Conclusion

On a final point, according to the results of this study, diabetic patients with type D personality have a decreased self-care and emotion-oriented coping played a mediating role in this relationship. Therefore, negative affect and social inhibition components of type D personality have significant negative effects on the patients’ ability to employ self-care behaviors. However, emotion-oriented coping strategies can modify negative emotions and thus decrease the adverse effects of type D on self-care. This finding could have implications for the consideration of personality factors like type D personality when designing self-care plan for patients with type 2 diabetes.

Funding

The authors have no funding to report.

Compliance with ethical standards

Conflict of interest

The authors declare no conflicts of interest.

Ethics approval

This study was approved by Yazd University Ethics Committee (Ethics Code: IR.YAZD.REC.1399.001).