Socioeconomic Status and Psychosocial Mechanisms of Lifestyle Change in a Type 2 Diabetes Prevention Trial

  • Nelli HankonenEmail author
  • Pilvikki Absetz
  • Ari Haukkala
  • Antti Uutela
Rapid Communication



Little is known about psychosocial mechanisms that may underlie differences in lifestyle change between socioeconomic groups.


The purpose of this study is to examine how educational level influences middle-aged participants’ (N = 385) psychosocial responses to the GOAL Lifestyle Implementation Trial.


The measurements of self-efficacy and planning for healthy lifestyle were conducted pre-intervention (T1) and post-intervention (T2, 3 months), and measurements of exercise and healthy eating as outcomes at T1 and at 12 months (T3).


Psychosocial determinants at T1 and their T1–T2 changes were mostly similar, irrespective of educational levels. Exercise barriers self-efficacy was enhanced slightly less (p = 0.08) among the low-SES. T2 levels as well as pre–post-intervention changes in exercise self-efficacy predicted 12-month changes in exercise, and T2 diet coping planning predicted changes in dietary fat intake. The associations were similar across all SES groups.


Enhancing self-efficacy and planning is similarly effective among intervention participants regardless of education level.


Socioeconomic status Health behavior change Self-efficacy Planning Health promotion 


  1. 1.
    Adler NE, Boyce WT, Chesney MA, et al. Socioeconomic status and health: The challenge of the gradient. Am Psychol. 1994; 41: 15-24.CrossRefGoogle Scholar
  2. 2.
    Laaksonen M, Talala K, Martelin T, et al. Health behaviours as explanations for educational level differences in cardiovascular and all-cause mortality: A follow-up of 60,000 men and women over 23 years. Eur J Public Health. 2007; 18: 38-43.CrossRefPubMedGoogle Scholar
  3. 3.
    Huisman M, Kunst AE, Bopp M, et al. Educational inequalities in cause-specific mortality in middle-aged and older men and women in eight western European populations. Lancet. 2005; 365: 493-500.PubMedGoogle Scholar
  4. 4.
    Meara ER, Richards S, Cutler DM. The gap gets bigger: Changes in mortality and life expectancy, by education, 1981–2000. Health Aff (Millwood). 2008; 27: 350-360.CrossRefGoogle Scholar
  5. 5.
    Cavelaars AE, Kunst AE, Geurts JJ, et al. Differences in self reported morbidity by educational level: A comparison of 11 western European countries. J Epidemiol Community Health. 1998; 52: 219-227.CrossRefPubMedGoogle Scholar
  6. 6.
    Acheson D. Independent inquiry into inequalities in health: Report. London: HMSO; 1998.Google Scholar
  7. 7.
    Victora CG, Vaughan JP, Barros FC, Silva AC, Tomasi E. Explaining trends in inequities: Evidence from Brazilian child health studies. Lancet. 2000; 356: 1093-1098.CrossRefPubMedGoogle Scholar
  8. 8.
    Bandura A. Self-efficacy: The exercise of control. New York: Freeman; 1997.Google Scholar
  9. 9.
    Sniehotta FF, Schwarzer R, Scholz U, Schüz B. Action planning and coping planning for long-term lifestyle change: Theory and assessment. Eur J Soc Psychol. 2005; 35: 565-576.CrossRefGoogle Scholar
  10. 10.
    Schwarzer R, Schüz B, Ziegelmann JP, Lippke S, Luszczynska A, Scholz U. Adoption and maintenance of four health behaviors: Theory-guided longitudinal studies on dental flossing, seat belt use, dietary behavior, and physical activity. Ann Behav Med. 2007; 33: 156-166.CrossRefPubMedGoogle Scholar
  11. 11.
    Taylor SE, Seeman TE. Psychosocial resources and the SES-health relationship. In: Adler NE, Marmot M, McEwen BS, Stewart J, eds. Socioeconomic status and health in industrial nations: Social, psychological, and biological pathways. New York: New York Academy of Sciences; 1999: 210-225.Google Scholar
  12. 12.
    Gurin P, Gurin G, Morrison BM. Personal and ideological aspects of internal and external control. Soc Psychol. 1978; 41: 275-296.CrossRefGoogle Scholar
  13. 13.
    Ross CE, Wu C-l. The links between education and health. Am Sociol Rev. 1995; 60: 719-745.CrossRefGoogle Scholar
  14. 14.
    Clark DO, Patrick DL, Grembowski D, Durham ML. Socioeconomic status and exercise self-efficacy in late life. J Behav Med. 1995; 18: 355-376.CrossRefPubMedGoogle Scholar
  15. 15.
    Goldman DP, Smith JP. Can patient self-management help explain the SES health gradient? Proc Natl Acad Sci USA. 2002; 99: 10929-10934.CrossRefPubMedGoogle Scholar
  16. 16.
    Absetz P, Valve R, Oldenburg B, et al. Type 2 diabetes prevention in the "real world": One-year results of the GOAL Implementation Trial. Diabetes Care. 2007; 30: 2465-2470.CrossRefPubMedGoogle Scholar
  17. 17.
    Uutela A, Valve R, Talja M, Absetz P, Nissinen A, Fogelholm M. Health psychological theory in promoting population health in Päijät-Häme, Finland: First steps toward a type 2 diabetes prevention study. J Health Psychol. 2004; 9: 73-84.CrossRefPubMedGoogle Scholar
  18. 18.
    Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001; 344: 1343-1350.CrossRefPubMedGoogle Scholar
  19. 19.
    Schwarzer R, Fuchs R. Self-efficacy and health behaviours. In: Conner M, Norman P, eds. Predicting health behaviour. Buckingham: Open University Press; 1996: 163-196.Google Scholar
  20. 20.
    Oettingen G, Honig G, Gollwitzer PM. Effective self-regulation of goal attainment. Int J of Educ Res. 2000; 33: 705-732.CrossRefGoogle Scholar
  21. 21.
    Lindström J, Peltonen M, Eriksson JG, Louheranta A, Fogelholm M, Uusitupa M. High-fibre, low-fat diet predicts long-term weight loss and decreased type 2 diabetes risk: The Finnish Diabetes Prevention Study. Diabetologia. 2006; 49: 912-920.CrossRefPubMedGoogle Scholar
  22. 22.
    McArdle JJ. Latent variable modeling of differences and changes with longitudinal data. Annu Rev Psychol. 2009; 60: 577-605.CrossRefPubMedGoogle Scholar
  23. 23.
    McArdle JJ, Nesselroade JR. Using multivariate data to structure developmental change. In: Cohen SH, Reese HW, eds. Life-span developmental psychology: methodological contributions. Hillsdale, NJ: Erlbaum; 1994: 223-267.Google Scholar
  24. 24.
    Adams J, White M. Are the stages of change socioeconomically distributed? A scoping review. Am J Health Promot. 2007; 21: 237-247.PubMedGoogle Scholar
  25. 25.
    MacIntyre S, Hunt K. Socio-economic position, gender and health: How do they interact? J Health Psychol. 1997; 2: 315-334.CrossRefGoogle Scholar
  26. 26.
    Fogelholm M, Valve R, Absetz P, et al. Rural–urban differences in health and health behaviour: A baseline description of a community health-promotion programme for the elderly. Scand J Public Health. 2006; 34: 632-640.CrossRefPubMedGoogle Scholar

Copyright information

© The Society of Behavioral Medicine 2009

Authors and Affiliations

  • Nelli Hankonen
    • 1
    Email author
  • Pilvikki Absetz
    • 1
  • Ari Haukkala
    • 2
  • Antti Uutela
    • 1
  1. 1.Department of Lifestyle and ParticipationNational Institute for Health and WelfareHelsinkiFinland
  2. 2.Department of Social PsychologyUniversity of HelsinkiHelsinkiFinland

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