Journal of Behavioral Medicine, Vol. 27, No.

5, October 2004 (©2004)

Assessment of Problem-Solving: A Key to Successful

Diabetes Self-Management
Russel] E. Glasgow,''"* Deborah J. Toobert,^ Manuel Barrera, Jr.,'
and Lisa A. Strycker^
Accepted for publication: March 12, 2004

Problem-solving skill is important for chronic illness self-management. This

projectprospectively evaluated a measure of diabetes problem-solving skill for
its reliability, convergent validity, sensitivity to intervention, and relationship
to change in behavior. Postmenopausal women with type 2 diabetes (N — 279)
participated in a RCTto evaluate a lifestyle modification program. The 9-item
Diabetes Problem-Solving Inventory (DPSI) was used to assess how patients
cope with challenges to diabetes self-care. The DPSI was found to have good
inter-rater reliability and internal consistency for a brief scale, be moderately
stable over time, and relate significantly to hypothesized variables. DPSI scores
improved significantly more in the lifestyle change condition than in controls
and were related to improved outcomes. Mediation analyses indicated that
the increase in problem-solving was a partial mediator of outcomes. Results
support the reliability, predictive ability, and sensitivity to change of the DPSI.
Directions for future research on problem-solving and chronic illness are
discussed.
KEY WORDS: diabetes; self-care; problem-solving; assessment; measures; chronic illness.

Problem-solving is emerging as a central component of chronic illness self-

management (Bodenheimer et ai, 2002; Center for the Advancement of
Health, 2001, 2002; Hill-Briggs, 2003). It is a key component of almost all
successful diabetes management programs, be they individually or group
'Kaiser Permanente Colorado, Penrose, Colorado.
^Oregon Research Institute, Eugene, Oregon.
^Arizona State University, Tempe, Arizona.
''To whom correspondence should be addressed at Kaiser Permanente Colorado, 335 Road
Runner Road, Penrose, Colorado 81240; e-mail: russg@ris.net.

477

016()-7715/()4/l(XX>-0477/0 © 2(K)4 Springer Science+Business Media, Inc.

478 Assessment of Problem-Solving: A Key to Successfnl Diabetes Self-Management

focused (Anderson et al, 1999; Delamater et ai, 1991; Grey et aL, 1998;
Wysocki era/,, 2001).
There has also been increased attention to process measures and medi-
ators of change to help determine how interventions work (Baranowski and
Stables, 2000; MacKinnon and Dwyer, 1993). Most authors see problem-
solving as consisting of a sequence of activities, including problem orien-
tation, generation of alternatives, selection of strategies, and evaluation of
outcomes (D'Zurilla and Maydeu-Olivares, 1995; Hill-Briggs, 2003; Perri
etal, 2001; Toobert and Glasgow, 1991).
The purpose of this article is to describe the adaptation and validation
of a problem-solving instrument (the Diabetes Problem-Solving Inventory;
DPSI) for adult type 2 diabetes patients. The DPSI was updated and mod-
ified from an earlier more time-consuming and more expensive procedure
we have described previously (Toobert and Glasgow, 1991). We describe the
content, assessment process, scoring criteria, and results, and report prelim-
inary data on the reliability, validity, sensitivity to change, and mediational
effects of the DPSI.

METHODS

Participants

Participants were 279 women who participated in a randomized evalua-

tion of a multiple lifestyle behavior change program (Mediterranean
Lifestyle Program [MLP]) (Toobert et al., 2002a) designed to reduce risk
of coronary heart disease (CHD) among postmenopausal women with type
2 diabetes. Inclusion criteria were: female sex, diagnosis of type 2 diabetes for
at least 6 months, postmenopausal, living independently, having a telephone,
ability to read English, not being developmentally disabled, and living within
30 miles of the intervention site. Recruitment procedures, a participant flow
diagram, and participation rates are presented elsewhere (Toobert et aL,
2002b). Participants were representative of patients of the 59 participating
primary care providers and the diabetes population of the state.
The mean age was 61 years (range: 39-75) with 15% of participants
older than 70 years of age. The average income was $27,739 with large vari-
ability (range: <10,000 to >80,000) and 90% had completed high school.
The mean body mass index was 35.3 kg/m^ (range: 20-67). Most women
had lived with diabetes for a number of years (mean: 8 years; range: 0-48
years), were taking diabetes medications, were Caucasian (94%), were mar-
ried (57%), and had other chronic diseases, most commonly arthritis and
hypertension.
Glasgow, Toobert, Barrera, and Strycker 479

Procedures

After cotnpleting baseline assessment, 116 participants were random-

ized to usual care (UC) and 163 to the MLP. The UC condition participated
in all assessments and received ongoing diabetes care from their physicians.
TTie MLP intervention lasted 6 months and addressed the primary behavioral
risk factors affecting CHD in postmenopausal women (i.e., diet, physical ac-
tivity, stress management, and social support). The program began with a
22-day nonresidential retreat. Retreats were followed by weekly meetings
consisting of 1 h each of physical activity, stress management, Mediterranean
potluck, and support groups (Toobert et a/., 2002a,b).

Measures

Problem-solving related to diabetes self-management was assessed us-

ing a modification of our previously validated procedure (Toobert and Glas-
gow, 1991) except that in this trial the instrument was administered via survey
rather than as an interview. The current DPSI is divided into three sections,
one for each of three diabetes regimen areas: healthful eating, physical ac-
tivity, and stress management. Each section begins with a description of a
hypothetical barrier or problematic event. One such scenario is: "You've
recently started a walking or jogging program with your neighbor in the
mid-afternoon. You had a difficult day, you feel tired, and you don't feel
like exercising. In your own words, describe how you have dealt (or would
deal) with such a situation. Be specific." Respondents were asked to provide
a written summary of how they would react to each scenario. Spaces were
provided for up to three coping strategies for each situation.
Following the initial hypothetical situation within each regimen area,
participants were asked to provide a personally relevant situation that made
it difficult for them to engage in that lifestyle practice (i.e., eating a healthful
diet, engaging in physical activity, or practicing stress-management tech-
niques). Then they were asked to describe how they would respond to each
problematic situation described with up to three strategies. Prompts were
provided to encourage participants to list multiple strategies. Each section
concluded by asking respondents to describe the strategies they generally
use to help them adhere to that aspect of their regimen.
Coders provided an overall problem-solving rating for each situation
on a 5-point scale (from 1 = very poor strategy to 5 = excellent strategy). A
rating of 1 or 2 was assigned if nothing was done to improve the problem
situation or if a strategy would produce a detrimental effect (for instance, "I
just take a little extra insulin when I have eaten inappropriately."). A score
480 Assessment of Problem-Solving: A Key to Successful Diabetes Self-Management

of 4 or 5 was assigned if strategies included planning ahead and flexibility in

carrying out the regimen activity (for instance, "in case my first strategy did
not work, I would then ..."; "I would either walk before work if the weather
was good, or meet my neighbor at the mall if the weather was bad."). Coders
read and discussed a detailed coding manual and coded practice responses
prior to the actual study. The surveys were coded by independent raters who
received 10 h of training and held regular discussions of coding disparities.
Ratings from coders, blinded to treatment condition, are summed across
items to produce two scores: an average overall rating of problem-solving
skill and the number of different solutions proposed.
Table I contains the DPSI. This inventory is now in the public domain,
researchers are free to use the instrument without charge, and permission is
not required from the authors.

Other Measures

Dietary Outcomes

To measure behaviors related to low-fat and high-fiber eating patterns,

the following validated and widely used instruments, were included: the Fat
and Fiber Behavior Questionnaire (FFB); two National Cancer Institute
(NCI) "screeners"—one for dietary fat intake and one for fiber, fruit, and
vegetables; and the Women's Health Initiative Food Frequency Question-
naire (FFQ). The FFB measures low-fat eating behaviors, namely, replacing
high-fat foods with low-fat foods, modifying meat choices, increasing fruit
and vegetable intake, and avoiding fats as flavoring. A mean across all four
dimensions was computed for the present analysis. The NCI fat screener
(Thompson et ai, 1998) measures dietary fat intake and produces an es-
timate of percent of calories from fat. The NCI fiber, fruit, and vegetable
screener (Thompson etal., 2002) assesses the frequency and portion size for
intake of fruits and vegetables, and produces daily servings of fruit and veg-
etables. Finally, the Summary of Diabetes Self-Care (Toobert et al, 2000)
assessed patient report of following a healthy eating plan.

Physical Activity

The CHAMPS Activities Questionnaire for Qlder Adults (Stewart et al.,

1997) provided an estimate of total kilocalories expended. The Summary
of Diabetes Self-Care Scale also includes a score for the extent to which
participants regularly exercise. Participants also recorded their exercise for
Glasgow, Toobert, Barrera, and Strycker 481

Table 1. Diabetes Problem-Solving Inventory

Instructions
Here are a variety of situations that eould be stressful. Please read each situation carefully,
then describe in your own words what, if anything, you have done to cope with such situa-
tions. "Cope" just means what you have done to try to improve the situation. If you haven't
experienced a particular situation, describe how you think you would have handled it. Try
to list two or three different strategies, if you can, that you would be likely to use. There are
no right or wrong answers.
Situation I
At 4:30 this afternoon, you are going to either (pick one): (a) make a presentation in front
of other people or (b) discuss a problem with someone who is angry with you. You have
been extra nervous all day. You have butterflies in your stomach and you are really sweaty.
It's now 3 p.m. and you have an hour and a half left to go. In your own words, describe how
you have dealt (or would deal) with such a situation. Be specific.
Strategies:
1.
2.
3.
Situation 2
Think of a situation you've recently experienced that was stressful.
What happened?
In your own words, describe how you dealt with this situation. Be specific.
Strategies:
1.
2.
3.
Sittiation 3
In general, how would you say that you go about trying to make sure that you manage your
stress? Be specific.
Strategies:
1.
2.
3.
Situation 4
You're going to spend a holiday with your relatives. In the past, this has always been a
problem for you because the group never eats until extremely late in the day, hardly any of
the foods are healthful, and you always end up eating too much. You're worried about the
same thing happening again. In your own words, describe how you have dealt (or would
deal) with such a situation. Be specific.
Strategies:
1.
2.
3.
Situation 5
Think of another recent situation in which it's been difficult to stick to your eating plan.
What happened?
In your own words, describe how you dealt with this situation. Be specific.
Strategies:
1.
2.
3.

(Continued on next page).

482 Assessment of Problem-Solving: A Key to Successful Diabetes Self-Management

Table I. (Continued)
Situation 6
In general, how would you say that you go about trying to make sure that you follow your
eating plan? Be specific.
Strategies:
1.
2.
3.
Situation 7
You've recently started a walking or jogging program with your neighbor in the mid-
afternoon. You had a difficult day, you feel tired, and you don't feel like exercising. In
your own words, describe how you have dealt (or would deal) with such a situation. Be
specific.
Strategies:
1.
2.
3.
Situation 8
Think of another recent situation in which it's been hard to be as physically active as you'd
like.
What happened?
In your own words, describe how you dealt with this situation. Be specific.
Strategies:
1.
2.
3.
Situation 9
In general, how would you say that you go about trying to make sure that you engage in
physical activity? Be specific.
Strategies:
1.
2.
3.

Note. Global ratings: 1 = very poor strategy; 2 = poor strategy; 3 = adequate strategy; 4 = good
strategy; 5 = excellent strategy.

a 7-day period and wore an Actigraph activity monitor for this time period
to provide an objective measure of physical activity.

Self-Efficacy

Self-efficacy was assessed by the Sallis Self-Efficacy for Diet and Ex-
ercise Behaviors instrument (Sallis et ai, 1988). Participants rated their
confidence in performing exercise and diet behaviors for at least 6 months.
Confidence in Overcoming Challenges to Illness Management (Glasgow
et ai, 2001), assessed confidence in overcoming obstacles to exercise, diet,
and stress self-management.
Glasgow, Toobert, Barrera, and Strycker 483

Analyses

Analyses consisted of preliminary descriptive analyses, reliability analy-

ses, and validity analyses. Descriptive statistics included means and standard
deviations, as well as distributional measures. Reliability analyses included
inter-rater (Pearson product-moment correlation coefficients), internal con-
sistency (Cronbach's alpha), and test-retest reliability over 6 months (Pear-
son product-moment correlation coefficients). Validity analyses included
correlations of problem-solving summary scores with other key measures,
both unadjusted and adjusting for potential confounding variables (i.e., age,
income), as well as sensitivity to change as indexed by a multivariate analysis
of covariance (MANCOVA) comparing postintervention problem-solving
scores between treatment conditions, adjusting for pretest scores, income,
age, and socially desirable responding (Hebert et al, 1997). Hierarchical,
multiple regression analyses were conducted to determine if changes in
problem-solving were related to changes in validity indicators (e.g., dietary
and exercise behaviors, self-efficacy), and if changes in problem-solving me-
diated the effects of the intervention.

RESULTS

There was reasonable variability on both measures of diabetes problem-

solving skill (Table II). Analyses of relationships between problem-solving
measures and patient demographic and medical history variables revealed
that, of the various characteristics analyzed, only age and income were sig-
nificantly related to either of the PSS scores. Neither of these correlations
exceeded 0.20, but they were each controlled for (income and age partialled
out) in the predictive analyses below. Of particular note, neither problem-
solving score was related to social desirability.
As listed in Table II, the most commonly used strategies were "compro-
mise" and to rely on an established routine or to create situational prompts.
By far the most common obstacles reported were "stress" and having phys-
ical symptoms that interfered with self-management.

Reliability

Three measures of reliability were calculated: inter-rater consistency,

test-retest reliability, and internal consistency. Inter-rater reliability for a ran-
domly selected subset of surveys (A' = 114) coded by two different coders
in this study was r = 0.60 {p < 0.001) for the global rating and r = 0.86
484 Assessment of Problem-Solving: A Key to Successful Diabetes Self-Management

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{p < 0.001) for number of strategies. The 6-month test-retest stability (con-
trol condition only) was also good (r = 0.59 and 0.50 for the two coding
measures), given the brevity of the scale and that one would expect some
change over time. Internal consistency for the overall problem-solving rat-
ing, as assessed by Cronbach's alpha, was 0.77.

Validity

Two tests of validity were employed: (1) correlations between base-

line problem-solving constructs and various outcomes (e.g., healthful eating,
physical activity, self-efficacy) and (2) a MANCOVA evaluating the sensi-
tivity of the DPSI to intervention effects. As shown in Table III, 15 of 20
correlations between problem-solving and key outcome measures showed
significant but modest relationships (median r = 0.16,p < 0.01). In particular,
both problem-solving measures were significantly related to all self-efficacy
measures (r = 0.16-0.34, all p < 0.01). Most relationships remained signifi-
cant after adjusting for age, income, and treatment condition. For example,
the partial correlations between the problem-solving rating and number of
strategy scores with fruit and vegetable intake were 0.17 and 0.14, p < 0.01;
with self-efficacy measures, partial correlations ranged from 0.17-0.36, all
p < 0.01. The DPSI was sensitive to intervention effects: Problem-solving
Table III. Unadjusted and Partial Correlations Between Baseline Problem-Solving Summary
Scores and Various Outcome Measures
Problem-solving Problem-solving
global rating number of strategies
Unadjusted r Partial" r Unadjusted r Partial" r

Physical activity measures

CHAMPS scale 0.11 0.09 0.09 0.08
Activity monitor counts 0.21*** 0.18** 0.18** 0.16**
Self-monitoring of physical activity 0.16** 0.18** 0.14* 0.16**
Summary diabetes self-care activity 0.12* 0.16** 0.12* 0.1.5*
Dietary behavior measures
Fruit and vegetable 0.18** 0.17** 0.15** 0.14*
Behavioral measure fat intake (Kristal) -0.16 -0.22*** -0.09 -0.13*
Summary diabetes self-care—Diet 0.23*** 0.29*** 0.14* 0.18**
Fat intake (NCI fat screener) -0.04 -0.06 -0.03 -0.06
Self-efficacy
Sallis total score 0.21*** 0.21*** 0.16** 0.17**
Challenges efficacy score 0.34*** 0.36*** 0 22*** 0.24***

"Partial correlations control for effects of age and income.

*p< 0.05;
**p <0.01;
*'*p < 0.001.
486 Assessment of Problem-Solving: A Key to Successful Diabetes Self-Management

scores improved significantly more in the intervention than the control con-
dition, as indicated by the highly significant MANCOVA (Wilks' X = 0,95,
F(2,222) = 5.9,p < 0,004), which also included age and income as covariates.

Mediational Analyses

One aspect of the construct validity of the problem-solving measure

is that changes in problem-solving should be related to changes in validity
indicators such as diabetes management behaviors (diet and exercise) and
self-efficacy. Because this study was conducted as part of an intervention trial,
we conducted these analyses according to established procedures for evalu-
ating mediation (Baron and Kenny, 1986; MacKinnon and Dwyer, 1993) with
problem-solving as the hypothesized mediator of the intervention's effects
on outcome variables. These procedures call for the demonstration that:

i. The intervention affects problem-solving (the mediator)

ii. The intervention affects outcomes
iii. Problem-solving accounts for a significant amount of the interven-
tion's effects on outcomes.
The first of these steps was demonstrated by the MANCOVA reported
above, showing a significant intervention effect on the problem-solving mea-
sure. The results of the other two steps are shown in Table IV, To limit the
number of analyses, one well-known and widely used measure was selected
from the area of dietary behavior (percent calories from fat, from the FFQ)
and one from exercise (calories expended, from the CHAMPS), The final
outcome measure used was the Sallis self-efficacy scale.
Showing that the treatment variable is related to the outcome is the
second requirement of demonstrating mediation. Results showed that there
were significant intervention effects for all outcomes (including CHAMPS,
which is not shown in Table IV), In addition, there were significant effects
for change in problem-solving for all outcomes except for the CHAMPS,
In the second step, the pretest and posttest measures of problem-solving
are added to the regression model. Mediation is demonstrated if posttest
problem-solving is significantly related to the outcome and the intervention
effect drops to nonsignificance (complete mediation) or a substantial amount
(partial mediation). The significance of the mediated effect can be tested
with a procedure that uses a z distribution. Results indicated that pre to post
changes in problem-solving partially mediated the effects of the intervention
on fat consumption {z = 3,01, p < 0,01) and self-efficacy (z = 2,54, p < 0,02),
A consistent finding was that changes in problem-solving exerted significant
effects on outcomes that were independent of the intervention effects.
Glasgow, Toobert, Barrera, and Strycker 487

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488 Assessment of Problem-Solving: A Key to Successful Diabetes Self-Management

DISCUSSION

Type 2 diabetes calls for the self-management of multiple behaviors that

influence the course of the disease and its consequences. People who live with
type 2 diabetes are presented routinely with many challenges to healthful
living. Their ability to solve problems connected to the self-management of
type 2 diabetes is an important skill to assess and to strengthen as part of dia-
betes self-management education (Baquet and Hammond, 2002; Hill-Briggs,
2003; Toobert and Glasgow, 1991).
This research demonstrated that a revised and more practical version of
the DPSI was reliable, valid, and sensitive to intervention effects. Our origi-
nal version of the DPSI was an interview in which participants verbalized re-
sponses that were tape-recorded and later coded by trained assistants. In the
present study, participants wrote descriptions of problem-solving strategies
to situations involving obstacles to diabetes management. Results showed
that responses could be rated reliably by coders, responses across nine situ-
ations were internally consistent, the DPSI reflected changes following the
intervention, and it demonstrated validity on several criteria. Taken together,
thosefindingssupport the construct validity (Cronbach and Meehl, 1955) of
the DPSI. This version of the DPSI should be much easier for other programs
to use than the previous, more expensive, and labor-intensive procedure.
Problem-solving is a key skill for managing the course of diabetes and
its consequences. From theory, people who can solve problems would be
expected to feel effective in enacting self-management behaviors (D'Zurilla
and Maydeu-Olivares, 1995; Hill-Briggs, 2003). Good problem-solvers should
report fewer problems associated with type 2 diabetes. Over the course
of a multifaceted intervention, those who are good problem-solvers would
likely experience some success in incorporating healthy behaviors into their
lifestyles. Our results offered some support for each of those theory-based
hypotheses.
This research included a comprehensive lifestyle change intervention
that included active instruction in nutrition, physical activity, stress manage-
ment, and smoking cessation in addition to skills such as problem-solving.
TTie intervention was successful in improving problem-solving as assessed
by the DPSI. Mediational analyses showed that intervention effects on diet
and self-efficacy were partially mediated by problem-solving. In addition,
the intervention and changes in problem-solving over the first 6 months of
the project each showed independent effects on the outcomes. In retrospect,
it was unrealistic to expect complete mediation effects on diet and exer-
cise because the multifaceted intervention procedures included those that
were designed to change dietary and exercise behaviors directly (e.g., spe-
cific dietary and exercise instructions). Nevertheless, the independent effects
Glasgow, Tooberl, Barrera, and Strycker 489

for problem-solving indicate that problem-solving can add incrementally to

healthy lifestyle changes beyond those that are achieved through a compre-
hensive diabetes education intervention.
The DPSI differs from many other problem-solving scales in that it
is specific to diabetes and calls for free-form responses rather than fixed
responses. A multiple-choice format would be easier to score, but our pre-
liminary attempts with such a format failed to adequately differentiate partic-
ipants, possibly because the important step of generating possible solutions
(D'Zurilla and Maydeu-Olivares, 1995) is not captured by multiple-choice
questions. Scenarios used on the DPSI can be adapted or changed to suit
other populations, illnesses, and settings based upon commonly reported
barriers in such situations.
This study has both strengths and limitations. Its strengths include the
prospective, experimental design, the focus on multiple psychometric issues
such as sensitivity to change and mediation in addition to the more standard
measures, the good reliability of the DPSI, and the moderately large sample
size. Limitations include the largely Caucasian population and inclusion of
only adult women. Future research is needed to replicate these findings
and determine if they extend to other populations, and to compare this
instrument to more generic problem-solving or coping measures.

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