Qualitative Research Reports in Communication Vol. 6, No. 1, October 2005, pp. 69
/76 Diabetes Management: An Exploration into the Verbal Support Attempts of Relational Others Darlene K. Drummond This research employed a message-centered approach to explore how women managing diabetes through diet modification describe the support attempts of relational others including family, friends, co-workers and health professionals. In-depth interviews with 30 women diagnosed with non-insulin dependent diabetes were conducted. From this data, five speech acts that women with diabetes encounter when attempting to engage in healthy eating behaviors were identified and illustrated: deterrence, indifference, encouragement, compliment and temptation. The context and features of the acts are dissected to better understand when an act is perceived as supportive or nonsupportive. Keywords: Social support; Diabetes management; Diet Many diabetics do not exercise regularly nor maintain healthy diets to lose the weight necessary to acquire glycemic control (Glasgow et al., 1989; Wilson et al., 1986). This is particularly the case for overweight, middle-aged women living with diabetes (Wing, Marcus, Epstein, & Jawad, 1991). As a result, approximately 160,000 Americans die each year from diabetes and its related complications including heart disease, stroke, blindness, kidney failure, and gangrene (Shortridge-Baggett & van der Bijl, 1996). Nevertheless, several psychosocial factors like patient knowledge, previous levels of adherence, perceived confidence in one’s ability to perform a behavior and level of satisfaction with health care influence attempts to manage diabetes (Burke & Dunbar-Jacob, 1995). One of the most salient and positively influential factors is the availability of social support (Pham, Fortin, & Thibaudeau, 1996). Darlene K. Drummond, Ph.D., is an assistant professor in the School of Communication, P.O. Box 248127, University of Miami, Coral Gables, FL 33124-2105, USA (Email: dkdrummond@miami.edu). This paper is based on the author’s doctoral dissertation completed at The Ohio State University in August 2000 under the direction of Donald J. Cegala. An earlier version of the paper was presented at the November 2002 National Communication Association Convention in New Orleans, LA. ISSN 1745-9435 (print)/ISSN 1745-9443 (online) # 2005 National Communication Association DOI: 10.1080/17459430500262216 70 Darlene K. Drummond Social support is a complex process of individual interpretation and interpersonal negotiation of face guided by shared conventions for inferring messages about support, acceptance, and autonomy (Goldsmith, 1992, 1995). The effects of received or perceived support do not come about automatically through the mere issuance of a supportive message but rather through interactants’ interpretations of messages shaped by situational, conversational, and cultural contexts and their implications (Burleson, 1982, 1984; Burleson & Samter, 1985a, 1985b). Support acts to bolster selfesteem and a sense of personal control by assisting an individual in changing either the situation, or the meaning of the situation, or both (Thoits, 1986), and by reducing uncertainty (Albrecht, Adelman, & Associates, 1987) while functioning to inform, persuade, control, and instruct others (Samter & Burleson, 1984). Hence, successful interactants are those who deploy discursive resources in ways that ease respective and conflicting goals (Goldsmith, 1992, 1995; Goldsmith & Fitch, 1997). Even though communication scholars have explored the concept of social support in the context of health care since the 1980s, very few studies exist on the communicative aspects of this phenomenon in the context of chronic illness. None exist that take a message-centered approach in investigating diabetes management. Therefore, we are not informed about how social support is verbally enacted and with what outcome for people with diabetes. An exploration into the communicative aspects of social support in the context of diabetes management can benefit individuals living with diabetes and their supportive others. For these reasons, the following research question is posed: How do women living with and trying to manage their diabetes through diet describe the support attempts of relational others? Inquiry Procedures Through snowball sampling, 30 non-insulin dependent diabetic women, living in a major metropolitan area of the Southeastern United States, were identified. Participants included 17 African Americans and 13 European Americans between the ages of 36 and 75 (M47). Most were employed, single but not necessarily living alone, with household incomes above $20,000 per year. All were high school graduates who believed that a healthy diet is helpful in controlling diabetes and preventing long-term complications. However, most acknowledged that they did not follow the diet suggested by their physicians. Each signed a consent form and completed a personal information sheet. Then a semi-structured, 45
90 minute, tape-recorded interview fashioned on the work of Schlundt, Rea, Kline and Pichert (1994) was conducted (see Appendix). Participants were paid $20.00 each. Undergraduate research assistants transcribed the tapes and assisted in analyzing the accounts utilizing the immersion and crystallization approach of Crabtree and Miller (1999). All procedures were approved by a university institutional review board. / / Qualitative Research Reports in Communication 71 Thematic Revelations Acts of deterrence, indifference, encouragement, compliment, and temptation form the basis of perceived support or nonsupport for women living with diabetes who attempt to adhere to a self-care regimen that includes diet. The term, social support, refers to the diabetic woman’s perception of caring and assistance in achieving her goal through the reception of messages from relational others. Deterrence Routinely, women living with diabetes are discouraged from eating harmful foods by family members, friends, co-workers and health professionals. As these relational others speak, they use rule-like terminology like shouldn’t, don’t, can’t and not to command the diabetic to not eat at all, or to avoid or cease eating a diabetesinappropriate food. If I order something that I know I shouldn’t because I’m in a bad mood, my mother will say, ‘‘Do you really think you should have that? You really should eat some fruit, you know, get you some peaches or something.’’ If I say they got sugar in them, she says, ‘‘Well, get you some Jell-O or something. You don’t need that piece of pie. It’s not going to do you any good.’’ She always brings me back to reality. ‘‘You know what can happen . . . so stick with something good.’’ Study participants perceive these encounters as equally helpful or unhelpful. Deterrence is viewed as most helpful when diabetes-appropriate items are suggested, as in the above situation, or when healthy alternative ways for preparing foods are explained, or when family and friends advocate eating out in restaurants with a variety of foods that suit everyone in the group. Making suggestions and/or asking a question or a series of questions about what food items are appropriate, is interpreted as a caring endeavor that communicates an interest in the continued well being of the diabetic. However, supportiveness is rarely perceived in situations where deterrence is commanded and healthy alternatives are not offered or attainable. The command is seen as impolite, offensive, or insensitive. One woman spoke of a meeting she had with her dietician. She told me what I could eat and what I should not eat. She told me to drink water and eat rice. I told her that I don’t like this and she said, ‘‘Well, you need to change your eating habits. You need to eat to live instead of live to eat.’’ And I told her but I don’t like this stuff and I’m not going to eat it. I checked off all the stuff I didn’t like and it didn’t leave anything to eat. She said, ‘‘Stay on it and come back to see me.’’ I didn’t stay on it and I didn’t go back. Usually, as indicated in the above accounts, acts of deterrence focus on the prevention of negative behaviors like eating high caloric or sugar-dense foods. Nevertheless, relational others also discourage diabetics from engaging in positive health behaviors such as eating diabetes-appropriate foods and taking medication to control glucose levels. Such encounters are always seen as non-supportive. For example, one 72 Darlene K. Drummond participant talked about how excited she was to have a friend who also had diabetes. They had agreed to help each other with diet and exercise. After attending diabetes education classes and learning about the ways they could eliminate or limit sugar in their diet, they decided to shop for sugar-substituted items, but on their second or third outing the following happened. My diabetic girlfriend says, ‘‘I don’t even know . . . I don’t know why you buy that stuff. I mean that’s not good. I don’t like that.’’ Indifference Many times, relational others show a lack of interest in the health behaviors of diabetics. A lack of interest is most often interpreted as non-supportive when one holds back and fails to comment on the eating habits of the diabetic. Over and over again, in anger and frustration, study participants stated, ‘‘They [family, friends] don’t say anything.’’ Additionally, indifference occurs when relational others demonstrate a lack of attention to the needs of the diabetic. I used to find recipes without sugar for carrot cakes and chocolate cakes and make them for my [diabetic] father and I would try to find stuff that would replace the things that he used to eat all the time. I don’t feel like people do that for me. However, the indifference of others, especially in not commenting on eating behaviors, can be positive and supportive. This is a rare sign of support accomplished by family members and through long-standing friendships. The diabetic may interpret such silence as a recognition and endorsement of her judgment and as a validation of her self-efficacy. Self-efficacy refers to a dieter’s belief in her ability to ‘‘organize and execute the courses of action required to manage prospective situations’’ (Bandura, 1995, p. 2). Or, the supporter may simply be showing respect for the diabetics’ right to make her own food choices. They don’t say anything anymore after all these years. I think it is because they recognize that these comments make me angry and they have seen an improvement in the way that I make my own choices about diet. Encouragement Even though acts of deterrence and indifference are sometimes helpful as well as unhelpful, acts of encouragement are consistently perceived as supportive. When one has not yet accomplished her goals to lose weight, modify her eating habits, or successfully monitor her glucose levels, support in the form of encouragement comes primarily from health professionals. For example, one participant shared that she often felt compelled to confess any ‘‘wrong doings’’ to her doctor at each visit. She would sometimes treat herself to foods not included in her meal plan like her favorite cookies, potato chips or eggnog. How did her doctor respond? Qualitative Research Reports in Communication 73 She would say to me every time I went in practically, ‘‘You can’t be perfect. So if something happened this week that you know you shouldn’t have done
/it’s okay. Think of it as you rewarded yourself for your other good days.’’ And that is probably the one thing that keeps me going. Supporters, whether health professionals, family members or friends, express confidence in the diabetic’s ability to accomplish short-term goals (e.g., eating healthy at a specific meal) and/or long-term goals successfully (e.g., achieving one’s goal weight). They express understanding for the difficulty that the diabetic undoubtedly experiences in maintaining long-term lifestyle changes, while focusing on the rewards of adherence. In addition, some relational others who have also been forced to modify their lifestyles as a result of various illnesses such as diabetes and hypertension do not just ‘‘talk the talk’’ but consistently model appropriate dietary behaviors which the study participants find supportive. Compliment When I lost the 40 pounds, everyone would say, ‘‘Gosh, you look great!’’ They would tell me that my skin was even glowing because I was eating so healthy. The people I work with would say, ‘‘Wow, that diet plan is really great!’’ Like acts of encouragement, expressions of praise are perceived as helpful by women living with diabetes. Acts of encouragement generally occur during the process of change (e.g., learning healthy cooking techniques) but cease when long-term goals are achieved. However, compliments are perceived as helpful throughout the process of change as the diabetic achieves both short term (e.g., losing the first 10 pounds) and long term goals (e.g., reaching one’s goal weight). Once she has successfully controlled her weight, changed her diet, or controlled her glucose level, relational others notice and make statements acknowledging these accomplishments. These compliments function to boost the diabetic’s self-efficacy and thereby reinforce good self-care behaviors. Temptation Encouraging others in their efforts to change their lifestyle and complimenting small and large accomplishments is supportive. However, unhelpful are remarks made by relational others that entice or invite one to eat foods outside of a prescribed diet. My friend said, ‘‘But I can’t have a drink if you don’t have one. After all it is your birthday. Go ahead and have one. This is a special occasion. One little glass of wine won’t hurt you. One little sip of this drink isn’t going to hurt.’’ And it was difficult to argue back to that. Central to the act of temptation is a declaration by the relational other of no harm to the diabetic if she indulges just a little. Many of these encounters feature an outright accusation or implication that it is the relational other that will be harmed if the diabetic does not comply with the request. In the above account the friend is 74 Darlene K. Drummond implying that s/he will not be able to enjoy the pleasure of an alcoholic beverage if the diabetic does not participate in this social activity. Such acts may serve to undermine the diabetic’s self-efficacy, encourage unhealthy eating behaviors and result in negative health outcomes. Discussion Clearly, diabetics are bombarded with various types of messages that either support or undermine their efforts to lead a healthier lifestyle. While acts of encouragement and compliment are often perceived as supportive; acts of deterrence, temptation and indifference are potentially hazardous to the psychological well being of those struggling to improve their lives. Therefore, health communication scholars need to investigate further the contextual elements of these interpersonal communication encounters. The finding that health professionals compliment and encourage as a sign of support bolsters the conclusions of previous studies (Dunkel-Schetter, 1984; Dakof & Taylor, 1990) that physicians’ actions perceived as helpful are along the esteem/ emotional dimension. Because diabetics are susceptible to relapses in healthy dietary behaviors, they need feedback about how they are doing. Supportive messages like encouragement and compliments function to reinforce good self-care behaviors thereby enhancing self-efficacy. Plus, supportive acts of deterrence that question the diabetic’s food choices, engages the diabetic in a reasoning process while simultaneously making apparent the supporter’s and diabetic’s shared desire for positive health outcomes (Brown, Stewart, & Ryan, 2003). Thus, in adapting new health behaviors, the diabetic does not simply adopt ready-made habits, but acquires the cognitive and behavioral tools necessary to motivate long-term life-style changes through sustained effort. Additionally, non-supportive messages, whether acts of temptation, deterrence or indifference, lack person-centeredness. Person-centered messages ‘‘reflect an awareness of and adaptation to the subjective, affective, and relational aspects of communicative contexts’’ (Zimmermann & Applegate, 1992, p. 243). However, messages that lack person-centeredness deny individual perspectivity by condemning or ignoring the specific feelings that exist for the diabetic. Such messages attack the self-concept of the diabetic and fail to provide a rationale for adherence, an opening for further discussion, or a way out for her. In addition, these non-supportive messages function to undermine self-efficacy by negatively impacting the diabetic’s belief in her own ability to follow through with the medical prescriptions of her doctor. The result is ineffective coping strategies. Numerous factors can impact whether or not a message is perceived as supportive. Most of the participants in this study were single women living with female relatives. These family members expressed deterrence that was evaluated consistently as helpful by the diabetic; while acts of deterrence and temptation by non-friendly co-workers were consistently framed as least supportive. Such findings underscore those of previous studies that suggest support from immediate family members and caring Qualitative Research Reports in Communication 75 friends is most specifically associated with positive health outcomes (Albrecht & Goldsmith, 2003). These findings also suggest that the influence of relationship type on the effectiveness of support is an area worthy of continued study. In conclusion, relational others, including family, friends, co-workers, and health professionals can make a difference in the lives of diabetics by encouraging them, complimenting them, and deterring harmful eating behavior. Communication scholars can make a difference by continuing to examine the contextual and structural components of support attempts. References Albrecht, T. L., Adelman, M. B., & Associates (Eds.). (1987). Communicating social support . New bury Park, CA: Sage. Albrecht, T. L., & Goldsmith, D. J. (2003). Social support, social networks, and health. In T. L. Thompson, A. M. Dorsey, K. I. Miller, & R. Parrott (Eds.), Handbook of health communication (pp. 263
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/263. Appendix Interview Questions Scenario 1 : You get together with friends late one evening to play cards. One friend suggests calling out for pizza. You feel that you really should not snack because you have already had supper. However, you are tempted because pizza has always been one of your favorite foods, but because it is late, another friend suggests fruits, and vegetables with some dip. The others agree. You eat the fruit and vegetables and are content. Have you ever felt like that? Tell me what happened. What did ________ say to you that you feel helped in the situation? (Probes: Where did this happen? When? Were there other people around? Is this person a relative, friend, coworker or what? Anything else like this ever happen? If so, what? Why do you think the message affected you like it did? What else does this person do to support you?) Scenario 2: You try to follow your meal plan but you are sometimes discouraged because no one supports you in your efforts. For example, no one in your family seems to notice that you have lost weight. You feel that no one understands how you feel and how hard you try. Sometimes you feel like it’s not even worth all the trouble. It is a week after that huge Christmas dinner when you proudly ate only one small serving of everything. Today the family is having its New Year feast and you eat as much as you want. Your sister can not resist commenting on how much you are eating. You feel bad. Have you ever felt like that? Tell me what happened. What did __________ say to you that you feel was not helpful in the situation? (Probes: Where did this happen? When? Is this person a relative, friend, coworker or what? Were there other people around? Anything else like this ever happen? If so, what? Why do you think the message affected you like it did? What else does this person do that is not helpful to you?)
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