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 Table of Contents  
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 88-93

Effectiveness of stress inoculation training on psychological well-being in women with diabetes mellitus type 2

1 Mental Health Unit, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Psychology, University of Isfahan, Isfahan, Iran

Date of Web Publication17-Mar-2016

Correspondence Address:
Farzaneh Dabbashi
Psychology Group, Educational Sciences and Psychology Faculty, University of Isfahan, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2395-2296.168504

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Aim: The purpose of the present research was to determine the effectiveness of stress inoculation training (SIT) method on psychological well-being in the women with diabetes mellitus type 2. Methods: In order to perform this study, 30 women with diabetes mellitus type 2 were randomly selected from women with diabetes mellitus type 2 population of Isfahan city via random cluster sampling method and were randomly assigned to experimental and control groups (each group consists of 15 women). It had of semi-experimental design with pretest-posttest and control group. The intervention was SIT method. Ryff”s psychological well-being and demographical information scales were used to gather the data. Data were analyzed using multivariate analysis of covariance. Results: The results showed that SIT had a significant effect on psychological wellbeing in women with diabetes mellitus type 2 in posttest (P ≤ 0. 02). Moreover, in the posttest SIT had a significant effect on positive relationships with others (P < 0.02), personal growth (P < 0.01). Discussion: In total, this study offers the use of intervention of SIT for improve wellbeing in the women with diabetes mellitus type 2.

Keywords: Psychological well-being, stress inoculation training, women with diabetes mellitus type 2

How to cite this article:
Esmaeili Z, Esmaeili L, Dabbashi F. Effectiveness of stress inoculation training on psychological well-being in women with diabetes mellitus type 2. Int J Educ Psychol Res 2016;2:88-93

How to cite this URL:
Esmaeili Z, Esmaeili L, Dabbashi F. Effectiveness of stress inoculation training on psychological well-being in women with diabetes mellitus type 2. Int J Educ Psychol Res [serial online] 2016 [cited 2020 May 30];2:88-93. Available from: http://www.ijeprjournal.org/text.asp?2016/2/2/88/168504

  Introduction Top

Diabetes is a nonhomogenous group of metabolic disease which is characterized by a chronic increase of blood sugar and carbohydrate, fat and protein mechanism impairment and it is caused by some deficiencies in insulin secretion and insulin act.[1] This disease is the center of behavioral problems, and psychological and social factors have a vital role in its creation and management.[2],[3] During past decades, psychological aspects of diabetes have drawn the attention of many specialists since it is considered one of the most annoying diseases emotionally and behaviorally.[4] After passing some years, the individuals suffering from diabetes, face strong performance drop, and their psychological wellbeing is endangered. By psychological wellbeing, we mean individual's affective and cognitive evaluation from his/her life.[5] The imposed burden on the governments because of treatment costs and damages resulting from people's function drop have drawn the attention of researchers to health and mental hygiene status of the society.[6] Psychological wellbeing includes experiencing adverse affections, low levels of negative mood and life satisfaction.[5] Ryff and Singer consider psychological wellbeing the cause of physical and emotional health promotion. They suggested evidence showing that living while considering spiritual aspect implying psychological wellbeing influences specific physiologic systems which are related to the function of immune system and health promotion.[7] The studies have proved that about 20 percent of diabetic diseases who refer to clinics suffer from mental disorders.[8] Diabetes causes mental complications besides physical ones for the patients. This effect can be as the result of diet change, food dependence, and persistent dependence on the drug, different short or long-term complications of the disease and its associated costs.[5] The highest prevalence of the disease is in 25–44-year-old and its prevalence in women is twice as men.[9] Taking high prevalence of diabetes in different countries besides psychological problems occurring for these patients,[10] the psychological society should start avoiding and controlling it through giving appropriate techniques besides medical treatment and taking steps to improve these people regarding their psychological wellbeing.

The research has shown that stress plays a major role in creating a psychosomatic disease, and diabetes is one of them. Behavioral-cognitive interventions have possessed a wide range during recent 20 years. These kinds of interventions are based on the important role of cognitive mediators in creating and continuing stress.[11] According to behavioral-cognitive theories, the stimulating situation, per se, would not lead to stress reactions, but the meanings which the person attributes to determines stressful reaction; that is, some environmental situations paves the way for a set of cognitions which creates stress and it causes affective arousal, behavioral disorder or avoidant behavior.[11] Most of the cognitive-behavioral therapists prefer to call the clients' beliefs deviated, or those possessing insufficient action thought patterns, instead of assuming them irrational.[11] These therapists believe that internal conversations or self-talk have primary and important role in clients' behavior.[11] Inconsistent behaviors and emotions are changed by modifying insufficient action beliefs. The therapist's action as a recognizer and trainer helps clients in expressing deviated cognition to develop new cognitive and behavioral patterns.[11]

Stress inoculation is one of the aspects of lifestyles that studies prove its relationship with physical health. Since stress states stay long, they can affect the body's physiologic system destructively and cause disorder in body health.[12] From the standpoint of stress inoculation training (SIT), stress is defined as a communicative concept between individual and the environment which reveals itself in the individual's cognition. In other words, stress is created in the relationship between the individual and the environment which the individual evaluates it as health and comfort intruder.[12] SIT is a cognitive-behavioral intervention the objective whereof is not completely removing stress from the life since this act is neither possible nor necessary, but the purpose is to overcome mental pressures by applying specific techniques.[12]

The study by Muris et al. and Fava, too, showed that inoculation against stress is effective on positive thoughts, psychological wellbeing and mental health of the people.[13],[14] Moreover, numerous studies imply efficiency of this method on decreasing the individual's stress;[15],[16] however, there was no study conducted on the efficiency of stress inoculation on psychological wellbeing of women suffering from diabetes.

Psychological wellbeing has been attended as one of the most basic positive psychological issues in different countries of the world, and there were many attempts to increase its indices. Now the psychologists are able to move from an attempt to remove the states which make the life hard to create and develop states of life worthiness and increase psychological wellbeing. Diabetic women, too, as a group facing the danger of decreasing psychological wellbeing should be greatly attended to and in order to improve their psychological wellbeing level, appropriate and useful strategies should be offered. Therefore, the objective of the present study is to investigate the effectiveness of stress inoculation on psychological wellbeing in type 2 diabetic women. According to the above purpose the following hypothesis was codified:

SIT is effective on psychological wellbeing of women suffering from diabetes mellitus type 2.

  Methods Top

Participants and research design

The design of research was semi-ex experimental with pretest-posttest and control group. The independent variable is SIT, which is merely applied in the experimental group and its effect on posttest scores has been investigated on the experimental group participants and compared with control group. The statistical population of the study was all 45–65-year-old women suffering from diabetes mellitus (by the physician's diagnosis) in Isfahan from March to May in 2012. The research samples were 30 clients referring to Isfahan hygiene-therapeutic centers who had the criteria to enter the study. The sampling method was through clustered random sampling which were selected from a center of the city (Shahid Rezaian hygiene center), 30 people selected from these. The criteria to inter the study included: Being a woman and suffering from diabetes according to physician's diagnosis and using the drug to control diabetes. Then the individuals were put into two experimental and control groups (15 in each group). The age mean of the participants was 53-year-old.

The format of the sessions of SIT made up according to Michen instruction in 1974 was administered along with assignments of each session by the researcher in eight 90-minute sessions on the experimental group in such a way that from 30 subjects of the sample group, 15 were replaced in the experimental group and so were 15 others in the control group. The experimental group was put under inoculation training in one of Isfahan hygiene centers. In the first sessions both groups were asked to fill out Ryff's psychological wellbeing and demographic scale; after taking the agreement from the experimental group, the intervention models were held. In every session, the content and points of the previous sessions were discussed briefly. Then, the content of the new session was trained, and the assignments of group members to be exercised at home were reminded. Besides the mutual relationship between people and the researcher, necessary training was offered in all sessions. Finally, after finishing training, the posttest was administered on both groups. Excluding the first session of group training which was spent on members making familiar and describing the objectives of participating in the group and general duties of group members up to the end of sessions, in other sessions, at first the assignments of previous sessions were reviewed, and the intended topic for that session was suggested and the members were asked to take part in group discussion. Then the assignments the next session were specified and the members were committed to do the assignment in the next session. At the end of the sessions, all the material offered was summed up. The trainer was a 30-year-old expert woman (who had MA) in clinical psychology.

Ryff's revised psychological wellbeing scale (1980)

Psychological wellbeing scale was designed by Ryff in 1980, the original form was composed of 120 questions, but in later investigations, 18, 54, and 84-question shorter forms were also suggested. In this study, 84-question form was applied according to Ryff [17] suggestion to the researchers. Psychological wellbeing scale included six subscales of self-acceptance, positive communication with others, authority, purposeful life, personality growth, and dominance on the environment. In 84-question form, each factor has 14 questions, and while administering, the participants are asked to read the questions and choose 1 of 6 alternatives from totally disagree to totally agree. For each question, the scores 1–6 was given to them. The higher score indicates better psychological wellbeing. Bayani et al.[18] normalized the scale. The internal consistency equals 0.890 through bi-section method, and the test reliability was reported 0.82.

Method of executive and data analysis

Stress inoculation intervention method based on teaching package of “SIT” which was made by Michenbaum in 1986 was administered in groups in eight 90-minute training sessions for the participants of the experimental group. The summary of sessions is as follows:

  • First session: Familiarity, describing group objectives and rules, conceptualization and describing its symptoms and consequences in diabetes
  • Second session: Receiving feedback from previous session, reviewing group member assignments, training relaxation along with stating the importance and advantages and the necessary conditions to do it by training tapes, explaining the relationship of body and mind and the effect of physical and mental states and vice versa, practical administration of relaxation assignment in the group, giving assignments
  • Third and fourth sessions: Receiving feedback from the previous session, familiarity with cognitive concepts, the role of thoughts in creating stress and relating thoughts to feelings and behaviors, negative automatic thoughts and introducing cognitive errors, reviewing group members' assignments and comparing their degree of stress before and after relaxation exercise, training the manner of coping with negative thoughts including awareness of thoughts, responding to the thoughts and practical measures to test the thoughts with members participation, giving assignments
  • Fifth session: Receiving feedback from previous session, reviewing group members' assignments, and making familiar with self-talks and the role of negative self-talks in making stress, training guided self-talk and its stages, giving assignment
  • Sixth session:Receiving feedback from previous session, reviewing group members' assignments, training thought concentration and techniques of attention return, exercising what have been trained, giving assignment
  • Seventh session: Receiving feedback from previous session, reviewing group members' assignments, problem-solving training through mentioning some examples, giving assignment
  • Eighth session: Receiving feedback from previous session, reviewing group members' assignments, exercising what has been trained in sessions and the necessity of these skills application while facing stressful situations to decrease disease symptoms and increase general recovery, discussing about symptoms and stress severity, giving a summary of trained techniques in sessions.

Data were analyzed using multivariate analysis of covariance (MANCOVA) using Statistical Package for the Social Sciences (SPSS) software - Version 19.

Research ethics

All the participants were taken written agreement to take part in the study, and they were told that they could leave the study whenever they wanted.

  Results Top

Mean and standard deviation of pretest scores, psychological wellbeing posttest and it is constituents in experimental and control groups are given in [Table 1].
Table 1: Descriptive statistics of the scores of subscales of psychological wellbeing test in experimental and control groups

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The results of [Table 1] show that the score means of positive relationship, authority, dominance on the environment, self-acceptance and personal growth in the posttest stage have been increased comparing to that of pretest and the score of purposeful life was decreased and in the control group the mean of the scores in dominance on the environment and purposeful life have been increased and the scores of positive relationship, authority, self-acceptance, and personal growth have been decreased comparing to pretest stage.

In order to determine the effect of SIT on psychological wellbeing, MANCOVA has been used. The results are reported in [Table 2].
Table 2: MANCOVA analysis of the effect of group membership on the difference between experimental and control groups regarding total score of psychological wellbeing in the posttest stage

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[Table 2] shows that there is a significant difference between posttest adjusted means of experimental and control groups (P < 0.02). Stress inoculation intervention was effective in the posttest stage in experimental and control groups. The effect size was 0.63; that is, 63 percent of the variance of adjusted mean scores was related to intervention effect. The statistical power equaled 78; that is, the amount of accuracy in this analysis was 78 percent in exploring significant differences. High statistical power indicates sample size adequacy. Therefore, group training of SIT is effective on psychological wellbeing of the women suffering from diabetes mellitus type 2 at the posttest stage.

As it is indicated in [Table 3], there is a significant difference between experimental and control group in subscales of positive relation with others (P < 0.05) and personal growth (P < 0.05); that is, SIT could increase the degree of psychological wellbeing in women suffering from diabetes mellitus type 2 at posttest stage in subscales of positive relationship with others and personal growth.
Table 3: Covariance analysis of the scores of subscales of psychological wellbeing in groups under study at posttest stage

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  Discussion and Conclusions Top

The purpose of the present research was to determine the effectiveness of SIT method on psychological well-being in the women with diabetes mellitus type 2. The results showed that SIT can be effective in some components of psychological wellbeing in women suffering from diabetes mellitus type 2 [Table 3]. These components include positive relationship with others and personal growth [Table 3]. These findings regarding effectiveness of SIT are along with the findings of the research by Muris et al., Fava, Mazloom et al.(2012), Hasanzade(2012);[13],[14],[15],[16] however, there was no study about the effectiveness of stress inoculation on psychological wellbeing of diabetic patients. But, the effectiveness of these methods has been confirmed in decreasing the blood pressure of women suffering from blood pressure (2011).[19] In explaining these findings, it can be stated that people are taught life stress coping methods to some extent through teachings and educational methods. They model from parents' behaviors through observing their way of coping with stress from the childhood and apply them in their life. Recent studies have shown that stress has an adverse effect on creation and procedure of diseases through aggravating cognitive immunization dysfunction and exacerbates disease activity. Moreover, physical disease with psychological origin which diabetes is one of them can decrease life quality, happiness, mirth and generally psychological wellbeing in these patients; therefore, psychological interventions increases the sense of self-efficacy in them, so it improves their capacity in coping with stress and controlling their turmoil and helps strengthening the sense of self-management in patients. In addition, in explaining the manner of the effect of this training method on patients' psychological wellbeing, investigating the content of offered material in these sessions seems necessary. Training cognitive skills such as problem solving, positive self-talks, struggling with negative thoughts, rational thinking, and attention return techniques cause the increase of mental health and training behavioral skills such as relaxation and enjoyable activities cause increase in physical health; all in all, the increase of mental and physical health includes the increase of psychological wellbeing. One of the results of the study was the fact that group stress inoculation intervention can be effective on a positive relationship with women suffering from diabetes mellitus type 2. It can be pointed out that the nature of group training has more extensive and stable effects on people due to special dynamics which are beyond training sessions and individual treatment. Because of their interactive nature, these effects make it possible to make a support group in situ ations, wherein there are common problems and difficulties, create a sense of group solidarity, reinforce sympathy and mutual understanding on the part of group members, participate in group activities such as feeling worthwhile, increase self-confidence and suggest solution from other people reciprocally due to common condition and offer personal experiences for other group members. In the procedure of these interactions, the individual shows improvement in his/her other positive existential aspects in addition to concentrating on his/her ability in facing the problems. On these findings, SIT could increase positive emotions in people suffering from diabetes mellitus type 2 in the experimental group. A positive relationship with others causes the person to behave socially and wisely and empower social support networks by applying it and be able to solve the problems creatively in daily life through creativity. Increasing social support is a rather stable outcome of happiness which can help personal evolution and growth, and it leads to positive emotions. These findings showed that psychology can address physical and mental health besides psychological wellbeing in addition to mental diseases and empower them in facing daily life stresses.

According to these findings, it is suggested that SIT be used as an effective method to improve the psychological wellbeing of people with diabetes. Further, it is advised to future researchers to apply this method for those who suffer from another psychosomatic disease. In addition, it should be repeated on men. This study, like other studies, has its own limitations; first, the number of the participant was 30 individuals, and it is better to recruit more people in future studies. Second, the present study was conducted on women and generalization of the conclusions to men society should be avoided. Third, the effect of familial and economic conditions has not been taken into account which should be controlled in future studies and kept fixed. Generalizing and interpreting the study results should be done cautiously taking these limitations.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

American Diabetes Association (ADA). National standards for diabetes self-management education. Diabetes Care 2005;28:72-9.  Back to cited text no. 1
Snoek FJ. Management of diabetes: Psychological aspects of diabetes management.Kidlington: The Medicine Publishing Company, Ltd.; 2002.  Back to cited text no. 2
Denollet J. DS14: Standard assessment of negative affectivity, social inhibition, and Type D personality. Psychosom Med 2005;67:89-97.  Back to cited text no. 3
Adili F, Larijani B, Haghighatpanah M. Diabetic patients: Psychological aspects. Ann N Y Acad Sci 2006;1084:329-49.  Back to cited text no. 4
Clarke D, Goosen T. The mediating effects of coping strategies in the relationship between automatic negative thouyhs and depression in a clinical sample of diabetes pat ions. Pers Individ Dif 2009;46:460-4.  Back to cited text no. 5
World Health Organization (WHO) Report. Promoting mental health: Concepts, emerging evidence, practice: Summary report. Geneve: World Health Organization; 2005.  Back to cited text no. 6
Ryff CD, Singer B. The contours of positive human health. Psychol Inq 1998;9:1-28.  Back to cited text no. 7
Braunwald E, Fauci AS, Kasper DL, Harrison S. Principles of International Medicine. 15th ed. New York: McGraw-Hill; 2001.  Back to cited text no. 8
Harold IM, Benjamin IM. Comprehensive Text Book of Psychiatry. 7th ed. Philadelphia: Lippincott Williams and Wilkins; 1999.  Back to cited text no. 9
Neamatpour S, Shahbazian HB, Gholampour A. Evaluation of psychological problems in diabetic patients. Scientific Medical Journal 2011;9:345-52.  Back to cited text no. 10
Jabalameli SH. Investigation the Effectiveness of Stress Management Training in Method of Cognitive-Behavioral on Quality of Life in Patients with Blood Pressure. Unpublished M. S. Thesis. University of Isfahan; 2011.  Back to cited text no. 11
Meichenbaum D. Stress Inoculation Training. New York: Pergamon Press; 1986.  Back to cited text no. 12
Muris P, Vermeer E, Horselenberg R. Cognitive development and the interpretation of anxiety-related physical symptoms in 4-13-year-old non-clinical children. J Behav Ther Exp Psychiatry 2008;39:73-86.  Back to cited text no. 13
Fava GA. The decline of pharmaceutical psychiatry and the increasing role of psychological medicine. Psychother Psychosom 2009;78:220-7.  Back to cited text no. 14
Mazloom SR, Darban F, Vaghei S, Modarres Gharavi M, Kashani Lotfabadi M, Shad M. The effect of stress inoculation program (SIP) on nurses' perceived stress in psychiatric wards. JMSNM 2012;2:35-43.  Back to cited text no. 15
Hasanzade M, Tarkhan M, Taghizade ME. Effectiveness of stress inoculation training on perceived stress in pregnant women with infertility. Holist Nurse Midwifery 2014;23:27-34.  Back to cited text no. 16
Ryff CD, Keyes CL. The structure of psychological well-being revisited. J Pers Soc Psychol 1995;69:719-27.  Back to cited text no. 17
Bayani AA, Koocheky AM, Bayani A. Reliability and validity of Ryff's psychology wellbeing scales. Iran J Psychiatry Clin Psychol 2008;14:146-51.  Back to cited text no. 18
Esmaeili Z. Effect of Stress Inoculation Training on Psychological Wellbeing and Blood Pressure on Women with Essential Blood Pressure in City of Isfahan. Unpublished M. S. Thesis. Islamic Azad University of Isfahan (Khorasgan); 2013.  Back to cited text no. 19


  [Table 1], [Table 2], [Table 3]


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