Elderly Development
Research and Theory for Nursing Practice: An International Journal, Vol. 28, No. 2, 2014
© 2014 Springer Publishing Company 113http://dx.doi.org/10.1891/1541-6577.28.2.113
Development of a Situation-Specific
Theory for Explaining Health-Related Quality of Life Among Older South
Korean Adults With Type 2 Diabetes
Sun Ju Chang, PhD
Department of Nursing Science, Chungbuk National University, South Korea
Eun-Ok Im, PhD
School of Nursing, University of Pennsylvania
The purpose of the study was to develop a situation-specific theory for explaining
health-related quality of life (QOL) among older South Korean adults with type 2
diabetes. To develop a situation-specific theory, three sources were considered:
(a) the conceptual model of health promotion and QOL for people with chronic\� and
disabling conditions (an existing theory related to the QOL in patients\� with chronic
diseases); (b) a literature review using multiple databases including Cumulative
Index for Nursing and Allied Health Literature (CINAHL), PubMed, PsycI\�NFO, and two
Korean databases; and (c) findings from our structural equation modelin\�g study on
health-related QOL in older South Korean adults with type 2 diabetes. The proposed
situation-specific theory is constructed with six major concepts includi\�ng barriers,
resources, perceptual factors, psychosocial factors, health-promoting behaviors, and
health-related QOL. The theory also provides the interrelationships among concepts.
Health care providers and nurses could incorporate the proposed situation-specific
theory into development of diabetes education programs for improving health-related
QOL in older South Korean adults with type 2 diabetes.
Keywords: situation-specific theory; older adults; type 2 diabetes;
health-related quality of life
Q
uality of life (QOL), which involves subjective perception of a wide range of
human experiences such as physical health, role/function, life satisfaction,
overall well-being, and interaction with the environment, is a universal
factor in both social and health sciences (Plummer & Molzahn, 2009). In particular, 114 Chang and Im
health care providers and health science researchers have an interest in evaluating
QOL and its relationship with health and health care. As a result, healt\�h-related
QOL and relevant investigations have evolved over several decades (Watkins &
Connell, 2004).
Health-related QOL focuses on the concepts of physical and mental health
along with relevant determinants from the patient’s perspective (Wandell, 2005). It
involves health perceptions and related factors from the individual to com\�munity
and national levels. Therefore, health-related QOL has been widely used in various
health-related fields such as patient care, health surveillance, and establishment of
health-related policies (Centers for Disease Control and Prevention, 20\�11). In par-
ticular, health-related QOL is a useful measurement for evaluating patient care\� at
the individual level among older adults with chronic diseases (Centers for Disease
Control and Prevention, 2011). This is because health-related QOL is a valid vari-
able for assessing the effectiveness of therapeutic interventions for ch\�ronic diseases
such as diabetes (Centers for Disease Control and Prevention, 2011). I\�n addition,
health-related QOL has been reported to be a strong predictor of mortality and
hospitalization among older adults (Dominick, Ahern, Gold, & Heller, 2002). For
these reasons, the impact of health-related QOL on the care of older adu\�lts with
chronic diseases has received significant attention. With a rapidly increasing older adult population and prevalence of chroni\�c diseases
in South Korea, health-related QOL in older adults with chronic diseases has emerg\�ed
as an important issue in the health care system (Chang, 2010). Type 2 diabetes, one
of the most common chronic diseases in older individuals, is believed to\� significantly
affect health-related QOL of older adults (Cho, 2004). For example, the results of a
Korea National Survey showed that health-related QOL in adults 65 years a\�nd older
with diabetes in South Korea was lower than that of individuals without diabetes
(Ministry of Health and Welfare, Korea Centers for Disease Control and Prevention,
2012). Hence, health care providers and researchers in South Korea are interested
in increasing the health-related QOL in older adults with type 2 diabetes. There has
been interest in developing theory-based approaches to promote health-re\�lated QOL
because assessments of health-related QOL conducted without a theoretica\�l basis
have failed to explain relationships between the determinants of health-related QOL
(Sousa & Kwok, 2006). Furthermore, theory-based approaches have been useful
for providing diabetes intervention and evaluating outcomes among patients with\�
type 2 diabetes (Osborn & Fisher, 2008).
BACKGROUND
There are several theories that could explain how health-related QOL is \�determined.
A conceptual model of health-related QOL devised by Wilson and Cleary (1995)
is the predominant health-related QOL theory. This model, which consists of five
levels including biological and physiological variables, symptoms, functional status,
general health perceptions, and QOL, has been adopted in health fields s\�uch as
ones involving major trauma care (Sleat, Ardolino, & Willett, 2011), heart failure A Situation-Specific Theory for Health-Related QOL 115
(Heo, Moser, Riegel, Hall, & Christman, 2005), and diabetes with complications
(Ribu, Hanestad, Moum, Birkeland, & Rustoen, 2007). However, some researchers
have argued that emotional and psychological variables (such as depress\�ion) that
are known to strongly influence health-related QOL are not included in the Wilson
and Cleary model and that few studies have examined the validity of this\� model
based on the simultaneous investigation of all five levels of the model (Sousa &
Kwok, 2006). Although other health-related QOL models and theories have\� been
introduced, the majority has focused on identifying the determinants of \�health-
related QOL rather than relationships between the determinants and their\� impact
on health-related QOL (Ferrans, 2005).
In diabetes care research, previous studies on health-related QOL have a\�dopted
existing theories such as self-determination theory (Williams et al., 2009) and self-
efficacy theory (Sturt, Hearnshaw, Farmer, Dale, & Eldridge, 2006). However, these
theories focus on behavior and behavioral changes. Thus, they do not inc\�orporate
health-related QOL-related determinants such as psychosocial factors inc\�luding
depression and social support (Rubin & Peyrot, 1999). From a nursing perspective, the concept of QOL has been embedded in existing
nursing theories such as Peplau’s theory of interpersonal relations, Roger’s science
of unitary human being, King’s interacting systems theory, Leininger’s transcultural
theory, and Parse’s human becoming theory (Plummer & Molzahn, 2009). However,
most existing nursing theories, which are influenced by Western cultural individualism,
are seldom suitable for South Korean populations because the cultural and socioeco-
nomic contexts of South Korea have been affected by collectivism and philosophical/
historical backgrounds that differ from Western experiences (Suh, 2011). In addition,
it was found that population-specific facilitators and barriers within c\�ultural contexts
need to be considered when developing effective diabetes interventions (\�Osborn &
Fisher, 2008). Thus, health care providers and researchers should consider theories that
reflect specific sociocultural, environmental, and demographical factors pertinent to
the population of interest. Given a limited population (older South Korean adults with
type 2 diabetes) and specific topic (health-related QOL), a situation\�-specific theory is
needed to develop because a situation-specific theory can comprehensivel\�y explain
care-related phenomena and promote nursing practice within a sociocultur\�al and
historical context unlike a midrange theory or a grand theory (Im, 2005\�). Here, we present a situation-specific theory for explaining the health-relat\�ed QOL in
older South Korean adults aged 65 years or older with type 2 diabetes that we named
the Health-related quality of life I n South Korean Older adults with type 2 D iabetes
(HIKOD) theory. By developing this theory, we have provided a framework that can
be used to identify factors influencing the health-related QOL in older \�South Korean
adults with type 2 diabetes and relationships between these factors and \�health-related
QOL. To develop the HIKOD theory, we adopted an integrative approach for devel-
oping situation-specific theories proposed by Im (2005). This integrat\�ive approach
consists of four steps: (a) verification of assumptions, (b) examina\�tion of the nursing
phenomenon using multiple sources, (c) theory construction, and (d) \�announcing/
sharing/testing the theory (Im, 2005). In this article, we describe the situation-specific
theory developmental process using the four-step integrative approach. 116 Chang and Im
METHODS
Assumptions
For the first step of the integrative approach, several assumptions were\� identified
and verified. First, we assumed that health-related QOL in patients with diabetes is
influenced by diverse and complex factors related to diabetes care. In a\�ddition, we
assumed that relationships between multiple factors and health-related QOL differ
among specific populations and according to sociocultural context. Final\�ly, from
a nursing perspective, we focused on well-being from the patient’s point of view
rather than on biological or pathological views. These assumptions may r\�esult in
potential limitations of the HIKOD theory. For example, the HIKOD theory may not
be applicable to other populations in different communities or social st\�ructures.
Also, the HIKOD theory does not include the objective variables such as glycated
hemoglobin (HbA1c) and blood glucose levels.
multiple sources
After verifying the assumptions for theory development, multiple sources were used
to develop the HIKOD theory. Three sources were used: (a) the conceptual model
of health promotion and QOL for people with chronic and disabling conditions (an
existing theory related to the QOL of patients with chronic diseases), (b) a litera-
ture review using multiple databases, and (c) findings from our struct\�ural equation
modeling (SEM) study on health-related QOL in older adults with type 2 diabetes.
The Conceptual Model of Health Promotion and QOL for People With Chronic
and Disabling Conditions. The conceptual model of health promotion and QOL for
people with chronic and disabling conditions devised by Stuifbergen (19\�95) was used
as a primary source for developing the HIKOD theory. This model was based on the
literature and research on patients with multiple sclerosis. It provides a framework
that explains the relationships between seven factors including demograp\�hics (e.g.,
age, gender, education, and employment), disease-related factors (e.g., severity and
duration of illness), barriers (e.g., financial problems and impairment), resources (e.g.,
income and social support), perceptual factors (e.g., self-efficacy an\�d demands of illness),
health-promoting behaviors, and QOL (Stuifbergen, 1995). The Stuifberg\�en (1995) con-
ceptual model suggests that five out of the seven factors (demographics, disease-related
factors, barriers, resources, and perceptual factors) directly influenc\�e health-promoting
behaviors and indirectly affect QOL via health-promoting behaviors. In a\�ddition, the
model suggests that health-promoting behaviors have a direct positive effect on QOL. Health care for older adults with chronic diseases such as diabetes involves
the improvement of health and QOL by promoting health and self-management
behaviors (Sabaté, 2003). In this regard, the Stuifbergen (1995) \�conceptual model
was suitable for developing the HIKOD theory because it adopts certain essential
concepts, such as health-promoting behaviors, QOL, and chronic diseases,\� that are
closely associated with the care of older adults with chronic diseases a\�nd provides
clear relationships between the concepts. Hence, development of the HIKOD theory
was guided by the Stuifbergen conceptual model. A Situation-Specific Theory for Health-Related QOL 117
Literature Review. To explore the current knowledge about health-related QOL
in older adults with type 2 diabetes, a literature review was conducted \�by searching
various databases including the Cumulative Index for Nursing and Allied \�Health
Literature (CINAHL), PubMed, PsycINFO, and two Korean databases (Research
Information Sharing Service and Korean Studies Information Service System).
Journal articles were included in the study when they were (a) written\� in English
or Korean, (b) published during the past 10 years, (c) published in nurs\�ing or clini-
cal journals, and (d) published using population-based data. Using the\� keywords
“diabetes,” “health-related QOL,” “Korean,” and “older adults or elderly,” six articles
were identified that met the inclusion criteria. Out of these six articl\�es, only two
concerned Korean older adults with type 2 diabetes. Hence, the studies on older
adults worldwide with type 2 diabetes were included in the literature re\�view. Using
the keywords diabetes, health-related QOL, and older adults or elderly, 33 articles
that met the inclusion criteria were retrieved. However, the number of retrieved
articles was too small to provide sufficient information about relationships between
factors that influence health-related QOL. Consequently, an extensive literature
search on QOL of adults with type 2 diabetes was conducted, and 231 arti\�cles that
met the inclusion criteria were obtained. The reference lists of all ret\�rieved articles
were also reviewed to identify additional articles. There were 270 artic\�les that were
ultimately retrieved by searching the databases, and all of the articles were critically
reviewed for this study. Based on the literature review findings, major concepts of the HIKOD theory
and their relationships were identified. Unlike the Stuifbergen (1995)\� model, we did
not include demographic or disease-related factors in the HIKOD theory. Instead,
depression, which is a factor that strongly influences the health-relate\�d QOL of older
adults with type 2 diabetes, was included in the HIKOD theory as a major concept.
Data from the literature review were integrated into the theory developm\�ent and
are described in the following sections according to each major concept \�including
barriers, social support, perceptual factors, depression, health-promoti\�ng behaviors,
and health-related QOL. Findings From the SEM Study. The results from the SEM study were used to
develop the HIKOD theory. The SEM study by Chang (2010) was performed to
identify predictors of health-related QOL in older South Korean adults with type 2
diabetes and explore paths to health-related QOL according to multiple f\�actors
such as barriers to self-management, social support, family support, sel\�f-efficacy,
depression, and diabetes self-management behaviors using an SEM analysis. In
this study, a convenience sample of 287 South Korean adults aged 65 years or older
with type 2 diabetes participated in face-to-face surveys. The data were\� collected
from February 8, 2010 to February 28, 2010 at one senior center in Seoul\�, South
Korea. The instruments used in the study included the Diabetes Self-Care Barriers
Assessment Scale for Older Adults to evaluate barriers, the Diabetes Sup\�port Scale
to measure social support, the Diabetes Family Behavior Checklist II to \�evaluate
family support, the Self-Efficacy for Diabetes scale to assess self-efficacy, the Center
for Epidemiological Studies Depression Scale to evaluate depression, the Summary
of Diabetes Self-Care Activities Questionnaires to assess diabetes self-\�management 118 Chang and Im
behaviors, and the Audit of Diabetes Dependent Quality of Life to measure health-
related QOL. Collected data were analyzed using descriptive analyses, Pe\�arson’s
correlation analyses, multiple regression analyses, and an SEM analysis. More
detailed information about this study was also found in a subsequent pub\�lication
(Chang, 2010). Findings from the SEM study were integrated into the HI\�KOD theory
development and are described in the following section.
DISCUSSION
HiKoD t Heory
Based on the assumptions made, the Stuifbergen (1995) conceptual model, and lit-
erature review findings, the HIKOD theory was constructed with six major concepts:
(a) barriers conceptualized as barriers to diabetes self-management be\�haviors,
(b) resources conceptualized as social support, (c) perceptual factors conceptualized
as self-efficacy, (d) psychosocial factors conceptualized as depression, (e) health-\�
promoting behaviors conceptualized as diabetes self-management behaviors\�, and
(f) health-related QOL. Relationships between these major concepts are\� illustrated
in Figure 1. Out of these six major concepts, three (barriers, resource\�s, and percep-
tual factors) directly affect health-related QOL and indirectly impact \�health-related
QOL via health-promoting behaviors and depression. Two of the six major concepts
(health-promoting behaviors and psychosocial factors) directly influen\�ce health-
related QOL, and mediate interactions between three major concepts (bar\�riers,
Figure 1. The HIKOD theory.
Health-promoting behaviors
• Diabetes self-management behaviors
Barriers
• Barriers to diabetes self-management behaviors
Resources
• Social support (family support)
Perceptual factors• Self-efficacy
Psychosocial factors• Depression Health-related quality of life A Situation-Specific Theory for Health-Related QOL 119
resources, and perceptual factors) and health-related QOL. A detailed description
of the major HIKOD theory concepts and their interrelationships are presented in
the following text with supporting evidence obtained from the literature\� review and
the SEM study (Chang, 2010).
Barriers. Barriers represent a major concept of the HIKOD theory adopted from the
Stuifbergen (1995) conceptual model. Barriers are defined as perceptio\�ns regarding
difficulties, discomfort, or inaccessibility that affect the selection a\�nd performance
of health-promoting behaviors. In this study, these could be interpreted as barriers
against the adoption of diabetes self-management behaviors. Patients with type 2 diabetes are confronted by barriers to diabetes sel\�f- management
behaviors because performing these activities requires a lot of time and\� can affect
every domain of a patient’s daily life (Clark & Hampson, 2001). Furthermore, these
barriers tend to be age-dependent among individuals with type 2 diabetes\�. For
example, older adults experience difficulties with exercise because of diminish\�ed
physical function and the presence of comorbidities such as arthritis. I\�n contrast,
younger adults view a busy life as a barrier to exercise (Song, Lee, & Shim, 2010). Interestingly, barriers to diabetes self-management behaviors in older South
Korean individuals are influenced by cultural and historical factors (Pa\�ik, 2008). For
example, older South Korean adults with type 2 diabetes are reluctant to observe
food intake requirements because most experienced the Korean War and economi-
cally harsh times. Consequently, these individuals did not take in enough food as
children and tend to consume more food to compensate for their difficult\� childhood
(Choi, Jang, & Nam, 2008; Paik, 2008). In addition, the permissive Korean attitude
toward alcohol consumption represents a barrier to diabetes self-managem\�ent
behaviors in older adults (Song et al., 2010). Barriers to diabetes self-management behaviors were found to be positive\�ly
associated with depression in older South Korean adults with type 2 diabetes (Jang,
2007) and negatively associated with diabetes self-management behaviors\� (Choi
et al., 2008). In addition, previous studies have shown that barriers to diabetes self-
management behaviors are strongly and negatively associated with QOL (Lee, 2008). The relationships between barriers to diabetes self-management, depressi\�on,
diabetes self-management behaviors, and health-related QOL are supported by the
SEM study (Chang, 2010). Barriers to diabetes self-management were fou\�nd to be
positively correlated with depression (r 5 .40, p , .01) and negatively correlated
with diabetes self-management behaviors (r 5 2.26, p , .01) and health-related
QOL (r 5 2.22, p , .01; Chang, 2010). Resources. Resources defined by Stuifbergen (1995) were also incorporated as
a concept into the HIKOD theory. Resources refer to personal and environmental
factors that facilitate the use of health-promoting behaviors (Stuifber\�gen, 1995). In
particular, social support has been identified as a core resource for patients wit\�h
chronic diseases (Stuifbergen, 1995). Social support in the context of diabetes care refers to emotional, info\�rmational,
appraisal, and tangible support received from family, significant others, or commu-
nities when a person plans to perform or is performing diabetes self-man\�agement
behaviors (Williams & Bond, 2002). Social support provides opportunities which 120 Chang and Im
allow patients with type 2 diabetes to express their diabetes-related co\�ncerns and
needs to family members, significant others, or communities (Williams & Bond,
2002). For these reasons, social support is a crucial factor that can reduce depres-
sion, promote diabetes self-management behaviors, and improve QOL (Jang, 2007).
In the HIKOD theory, focus was placed on social support provided by family
members (family support). South Korean society is traditionally based on the family
unit, and South Koreans, especially older adults, tend to attach great value to their
families (Chang, 2003). Thus, the family-centered attitudes of South Koreans impact
the lives of individuals in many different ways. For example, these attitudes affect
social, political, and economic philosophies as well as health and healt\�h-related
domains (Chang, 2003). A previous study also reported that diabetes ca\�re for older
South Korean adults with type 2 diabetes is strongly influenced by the attitudes of
family members toward diabetes and diabetes care (Choi et al., 2002). Findings of our literature review demonstrated the role of family suppor\�t in dia-
betes care for older South Korean adults with type 2 diabetes. South Korean older
adults lacking family support tend to be more depressed (Jang, 2007), \�whereas
those with high levels of family support are more likely to engage in di\�abetes self-
management behaviors (Cho, Jeon, Lee, & Lee, 2003). Furthermore, family support
has been reported to be positively associated with QOL in older South Korean adults
with type 2 diabetes (Choi et al., 2002; Lee, 2008) and have an indirect positive
effect on QOL by encouraging diabetes self-management behaviors (Cho, 2004). Results of the SEM study support the importance of relationships between\� family
support, depression, and health-related QOL. Older South Korean adults with type 2
diabetes who perceived that their families were not supportive of diabet\�es care are
more likely to be depressed (r 5 .15, p , .05). Furthermore, the perceived absence of
family support for diabetes care was found to be negatively correlated w\�ith health-
related QOL (r 5 2 .13, p , .05). However, no relationships between family support and
diabetes self-management behaviors were observed in the SEM study (Chan\�g, 2010). Perceptual Factors. Perceptual factors were derived from the Stuifbergen (1995)
conceptual model and incorporated into the HIKOD theory as a major concept. These
factors are defined as ones associated with the perceptions of individua\�ls with a
chronic disease that are related to health, health-promoting behaviors, \�and QOL
and include self-efficacy, perceived health, and demands of illness (Stuifbergen,
1995). Based on our literature review, the HIKOD theory was focused on self-efficacy
related to diabetes self-management behaviors. Self-efficacy, an individual’s belief in his or her capability to perform specific
behaviors in a specific context, is closely related to behavior and behavioral changes
(Bandura, 1986). In other words, a person with a higher degree self-efficacy is more
likely to more successfully fulfill specific behavioral requirements. This characteristic
has been demonstrated in health behavior–related studies of behaviora\�l changes
such as smoking cessation, regular performance of physical exercise, healthy eating,
and HIV prevention (Chang, 2010). Diabetes self-management behaviors involve
ones governing diet, regular physical activity, regular blood glucose monitoring,
and adherence to medication. Self-efficacy is thus a significant factor in terms of
facilitating and enhancing diabetes care (Cho et al., 2003). A Situation-Specific Theory for Health-Related QOL 121
Our literature review showed that self-efficacy plays a meaningful role \�in the
care of individuals with type 2 diabetes. It has been reported that pati\�ents who
have a high level of self-efficacy related to diabetes care tend to be l\�ess depressed
(Jun, Shin, Kim, & Kwon, 2007). In addition, data from previous studie\�s of older
South Korean have demonstrated positive relationships between self-efficacy and\�
diabetes self-management behaviors (Cho et al., 2003; Lee, 2005). Furthermore,
self-efficacy was found to be a significant predictor of QOL among patie\�nts with
type 2 diabetes (Choi, 2000). According to the SEM study (Chang, 2010), older South Koreans with type 2
diabetes and a high level of self-efficacy are less likely to be depress\�ed (r 5 2.13,
p , .05) and more likely to engage in diabetes self-management behaviors (r 5 .33,
p , .01). In addition, self-efficacy related to diabetes self-management b\�ehaviors is
positively correlated with increased health-related QOL ( r 5 .15, p , .05).
Psychosocial Factors. Based on our literature review, we selected psychosocial
factors, which refer to ones that psychologically and/or socially affect\� an individual
(Yale Medical Group, 2013), as a major concept. The HIKOD theory was focused on
depression, which is a well-recognized common comorbidity of diabetes (\�Blazer,
Moody-Ayers, Craft-Morgan, & Burchett, 2002). Depression is defined as an emot\�ional
state that may disrupt daily life (National Institute of Mental Health,\� 2011). Previous
studies have reported that approximately 24%–40% of those with type 2\� diabetes
experience significantly high levels of depression (Goldney, Phillips, Fisher, & Wilson,
2004). In addition, a meta-analysis demonstrated that people with diabe\�tes are twice
as likely to develop depression (Anderson, Freedland, Clouse, & Lustman, 2001). A
previous study also showed that depressive symptoms are more frequent am\�ong
older Korean Americans with diabetes (Jang, Park, Cho, Roh, & Chiriboga, 2012). Depression and the accompanying symptoms are prevalent health problems a\�mong
older adults (Yoo & Sung, 2009). In South Korea, approximately 30% of adults aged
65 years and older have experienced severe levels of depression; the pre\�valence
of these conditions among adults older than age 85 years is even higher \�(43%) and
increasing (Ministry of Health and Welfare, Korea Centers for Disease Control and
Prevention, 2012). In particular, rapidly increasing suicide rates among older adults
in South Korea have made depression among this population a significant social
issue (Park, 2011). Accordingly, we considered older South Korean adults with
diabetes vulnerable to depression. Findings of our literature review illustrate the critical role played by\� depression
in older adults with type 2 diabetes as well as the effects of depressio\�n on diabe-
tes self-management behaviors and health-related QOL. Previous studies o\�f older
South Korean community dwelling adults with type 2 diabetes have indicated that\�
depression is negatively correlated with diabetes self-management behavi\�ors (Kim
& Song, 2012). In fact, it has been reported that depression is the mos\�t important
factor that influences health-related QOL of older adults with type 2 diabetes. Kim
(2011) found that depression in older South Korean adults with type 2 diabetes has
a strong negative correlation with health-related QOL. Kim, Chae, and Cho (2009)
also discovered that older South Korean adults with type 2 diabetes who experienced
high levels of depression are less likely to be satisfied with life. 122 Chang and Im
The inverse relationships between depression, diabetes self-management behav-
iors, and health-related QOL are supported by the SEM study (Chang, 201\�0). It was
found that depression is negatively correlated with diabetes self-manage\�ment
behaviors (r 5 2.44, p , .01) and health-related QOL (r 5 2.43, p , .01). In addi-
tion, a structural equation model demonstrated that depression has a dir\�ect nega-
tive effect on health-related QOL and an indirect negative effect on hea\�lth-related
QOL by negatively influencing diabetes self-management behaviors (Chang\�, 2010). Health-Promoting Behaviors. Health-promoting behaviors as described in the
Stuifbergen (1995) conceptual model were also included in the HIKOD theory. In
Stuifbergen conceptual model, health-promoting behaviors are cooperative behaviors
that aid adaptation to lifestyle changes and provide adequate health maintenance
for patients with chronic illnesses. Health promoting behaviors can also directly
affect QOL and mediate paths between QOL and factors such as barriers, resources,
and perceptual factors (Stuifbergen, 1995). In the context of diabetes\� care, diabetes
self-management behaviors could be deemed health-promoting behaviors tha\�t
include “physical activity, healthy eating, taking medications, monitoring blood
glucose levels, diabetes self-care and related problem solving skills, r\�educing the
risks of acute and chronic complications, and psychosocial aspects of li\�ving with
diabetes” (Funnell et al., 2012). In addition, patients with diabet\�es can adapt to
lifestyle changes while achieving adequate health and functional status \�by adopting
a set of diabetes self-management behaviors (Cho, 2004). The findings of our literature review indicate that diabetes self-manage\�ment behaviors
confer considerable benefits in terms of improving the QOL in older adults with diabetes.
Older South Korean adults with type 2 diabetes that adopt diabetes self-management
behaviors are more likely to be satisfied with their QOL (Cho, 2004; Ki\�m et al., 2009).
The exact reason why diabetes self-management behavior results in better\� QOL is
still unclear, but Cochran and Conn (2008) suggested that achieving good glycemic
control by adhering to diabetes self-management behaviors helps patients\� feel better
and therefore affects health-related QOL. On the other hand, it was also\� suggested that
older adults who experience type 2 diabetes onset later in life find it more difficult to
change their lifestyle, and this may negatively impact health-related QOL (Chia, 2007). The SEM study revealed a strong positive correlation between diabetes se\�lf-
management behaviors and health-related QOL (r 5 .56, p , .01). In addition,
diabetes self-management behaviors in the structural equation model were found
to be the strongest influencing factor of health-related QOL. These behaviors also
mediate paths from self-efficacy and depression to health-related QOL (Chang, 2010). Health-Related QOL. Health-related QOL is the sixth and final major concept
incorporated into the HIKOD theory. Health-related QOL is a multidimensional fac-
tor that includes physical, functional, psychological, and social well-b\�eing resulting
from health-promoting behaviors in patients with chronic diseases (Rubin & Peyrot,
1999). In particular, type 2 diabetes has a marked effect on health-related QOL (Cho,
2004). In fact, overall QOL in patients with diabetes has been reported to be poorer
than that in general populations (Ministry of Health and Welfare, Korea Centers for
Disease Control and Prevention, 2012). QOL in older adults with type 2 \�diabetes
is also lower than that in other age groups because of physical and psychosocial A Situation-Specific Theory for Health-Related QOL 123
restrictions, decreased social support, the burden of behavioral changes such as
diet restriction, and increased medical expenses (Trief, Wade, Pine, & Weinstock,
2003). Furthermore, previous studies have concluded that older adults with type 2
diabetes feel significant pressure to perform diabetes self-management b\�ehaviors
in their daily lives and fear the risks posed by diabetes-related compli\�cations (Chia,
2007; Trief et al., 2003). For these reasons, optimizing QOL is regarded an important
goal of diabetes care for older adults (Suhl & Bonsignore, 2006).
Poorer health-related QOL in older adults with diabetes has been found in South
Korea. According to the Korean Ministry of Health and Welfare and Korea Centers
for Disease Control and Prevention (2012), South Korean adults aged 60 years or
older have poorer health-related QOL compared to all other age groups. I\�n addi-
tion, health-related QOL in older South Korean adults with diabetes is decreased
compared to individuals in the same age group who do not have chronic di\�seases
(Ministry of Health and Welfare, Korea Centers for Disease Control and Prevention,
2012). Hence, the importance of optimizing health-related QOL for older adults
with diabetes in South Korea has been realized, and health-related QOL has been
identified as a suitable outcome for evaluating the care of this population. According to the SEM study (Chang, 2010), the mean health-related QOL \�score
of older South Korean adults with a mean age of 75.2 years was 23.37 (29 5 the
poorest QOL, 1 3 5 the highest QOL). Results of the SEM study showed that barriers,
self-efficacy, depression, and diabetes self-management behaviors significantly affect
the health-related QOL of older South Korean adults with type 2 diabetes and that
these variables account for 38.8% of the total variance (Chang, 2010).
implicA tion for n ursing
Based on the HIKOD theory, we provide some implications for practice and research.
First, health care providers and nurses need to consider multiple factors influencing
health-related QOL in older South Korean adults with type 2 diabetes when they
take care of older patients with type 2 diabetes. Also, health care providers and
nurses could incorporate the HIKOD theory concepts and their interrelationships
into development of diabetes interventions for promoting diabetes self-m\�anagement
behaviors and improving health-related QOL in older South Korean adults with type
2 diabetes. For further theoretical development of the HIKOD theory, future studies
are needed to test and validate the HIKOD theory using a pilot/intervention tech-
nique. Furthermore, the theory must be validated in other age groups and different
settings to extend the theory to other patient populations because the t\�heory is
developed for a limited population in a defined cultural context and the\�refore may
not be applicable to other age groups, communities, or social structures.
CONCLUSION
The HIKOD theory provides a framework that explains how the health-related
QOL in older South Korean adults with type 2 diabetes is influenced by multiple
factors including barriers, resources, perceptual factors, psychosocial \�factors, and 124 Chang and Im
health-promoting behaviors. This theory is situation-specific and can be\� easily
applied in specific fields of nursing practice and research. We believe that the HIKOD
theory has great potential for promoting diabetes education and diabetes\�-related
research for older adults with type 2 diabetes in South Korea.
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Correspondence regarding this article should be directed to Sun Ju Chang, PhD, Department
of Nursing Science, Chungbuk National University, 52 Naesudong-ro, Chungju City, Chungbuk,
361-763, South Korea. E-mail: [email protected] R epro duce d w ith p erm is sio n o f th e c o pyrig ht o w ner. F urth er r e pro ductio n p ro hib ite d w ith out
p erm is sio n.
