Diabetes Research and Clinical Practice, 8 (1990)
31-44
37
Elsevier DIABET
00333
Importance
of attitude evaluation in diabetes patient education Yoshitugu
Masaki,
Third Department of Internal Medicine,
Soji Okada and Zensuke
Ota
Okayama University Medical School. Okayama
700, Japan
(Received 23 May 1988) (Revision received 25 April 1989) (Accepted 11 July 1989)
Summary
Attitudes were evaluated according to the ‘Personal Responsibility Attitude Assessment System’ (PRAS), which allows grading of patients’ attitudes into five levels of perception of responsibility toward their disease. In 59 diabetics evaluated in this study, no sex difference was observed in attitude level, but more of those aged less than 40 years showed lower attitude levels (levels l-4) than those aged 40 years or over (P -C 0.01). Of those aged 40 or over, more patients with a high attitude level (level 5) had had diabetes for 10 years or longer than those with low attitude levels (levels l-4) (P -C 0.05). Among those not treated with insulin, patients with a low attitude level showed higher hemoglobin A, (HbA,) levels (P < 0.01) and more frequently had retinopathy (P -C 0.05) than patients with high attitude levels. As for women, low attitude level patients consumed less fruit, meat or fish, and vegetables (P < 0.05) but more fat and sweetening agents (P -C 0.05) than high attitude level patients. These results suggest an association between the attitude level of diabetic patients evaluated by PRAS and the degree of their self-care. Evaluation of patients’ attitudes is important in predicting the response to educational intervention in diabetes. Key words: Attitude;
Patient compliance;
Patient education;
Introduction
The primary aim of the treatment of diabetes mellitus is not cure but control of the disease, which continues throughout the patient’s life. Treatment consists mainly of dietary and exercise Address for correspondence: Y. Ma&i, M.D., Department of Internal Medicine, Matuyama Shimin Hospital, 2-6-5 Ote-cho, Matuyama 790, Japan. 0168-8227/90/%03.50 0 1990 Elsevier Science Publishers
Self-care
therapies, which require a detailed alteration of a patient’s life-style. Dietary therapy, in particular, is complicated, it demands abstinence, and must be maintained during ordinary social activities, which are all factors that make compliance difficult [l-3]. The necessity of diabetes patient education is, therefore, vital The management of diabetes must be undertaken, in principle, by the patients themselves in their individual lives, and medical staff must provide appropriate support
B.V. (Biomedical
Division)
38
for them. However, patients cannot be sufficiently motivated to strict compliance to the regimen simply by a perception of the disease and its potential problems; perception is necessary but may not be sufficient to make the necessary changes [4-81. Compliance to a regimen is achieved by motivation sufficient to overcome the inconvenience and discomfort it involves [ 91. Motivation is determined generally by desire, as the source of energy, and attitude, which gives appropriate direction to the energy. Attitude, which mediates between perception and action, must be changed in order to properly motivate patients [ 91. With increasing recognition of the importance of a patient’s attitude toward the disease in diabetes education, a number of studies were carried out [3,13-171, including those using health belief models [ 10-121, but few of the findings of these studies have, as yet, been applied in clinical practice. This is considered to be due to the lack of practical and effective means for the assessment of patients’ attitudes. We previously examined [20] the validity of the Personal Responsibility Assessment System (PRAS) [ 191, a modification for diabetes education of the attitude assessment procedure developed by Genthner [ 181. This system is designed to evaluate the attitude of patients according to the degree of their perception of responsibility for their disease, and it is considered to allow practical and quantitative evaluation of patients’ attitudes toward their daily self-care and, further, to enable educational intervention that would be optimal for the patients’ individual attitude levels. In this study the relationships between patients’ attitude levels, evaluated by PRAS, biological factors, the degree of control of blood sugar level, complications, and the compliance to a regimen were studied to clarify the importance of attitude assessment for more effective educational intervention with diabetic patients. Materials and methods This study involved 59 patients with diabetes mellitus who were treated at the diabetic outpatient
TABLE I Relationship Sex
Male Female Total
of age to level of perception Age
under 39 over 40 under 39 over 40 under 39 over 40
of responsibility
Level l-3
4
5
2 1 0 3 2 4
2 7 5 8 I 15
0* 19 0 12 0** 31
*P < 0.05; **P < 0.01.
clinic of our Internal Department, and who had had the disease for 1 year or longer. The patients consisted of 31 men and 28 women, with a mean age of 54.9 years (25-75 years) and a mean duration of the disease of 10.2 years (l-30 years) (Table 1). Twenty-three of these patients were treated by insulin injection, 23 by oral medication, and 13 by dietary therapy alone. Fifty of the patients (27 men and 23 women) were aged 40 years or over; they had a mean age of 58.9 & 9.3 years and a mean duration of the disease of 10.2 k 6.6 years; 16 received insulin injections, 22 oral medication, and 12 a dietary regimen alone. Laboratory studies HbA,.
Hemoglobin A, (HbA,) was evaluated as an index of the state of diabetes control. Measurement was made at least three times with intervals of 1 month or longer, and the mean value was compared with a normal value of 5.0-8.0%. Retinopathy.
The patients were evaluated for retinopathy with cooperation from the Ophthalmology department of our hospital. Retinopathy was considered to be positive when any diabetic changes were observed in the eyegrounds (over the first stage of Scott’s classification). Clinicopsychological examinations. Subjective psychological symptoms and the intensity of psychological experience were evaluated according to
39
the Cornell Medical Index (CMI) and Taylor’s Manifest Anxiety Scale (MAS). The CMI, formulated at Cornell University [21] and adjusted to Japanese patients [ 221, consists of questions concerning subjective psychological and physical symptoms. By this method neurotic tendency was classified into: I, normal; II, subnormal; III, neurotic; IV, neurosis. We, however, divided our patients into normal (I-II) and neurotic (III-IV). The MAS [23], modified for Japanese patients [ 241, was designed to evaluate a series of manifestations of anxiety by a scoring system, with the maximum score being 50. Since women are considered to have higher scores than men, men and women were evaluated separately.
TABLE 2 Summary of levels of personal responsibility” Level of personal responsibility
Characteristics
Level I
No responsibility Hopelessness, helplessness, and despair. ‘It’s no use trying.’
Having diabetes is a disaster Level 2
Having diabetes is a burden Level 3
Having diabetes is a problem Level 4
Examination of dietary intake Compliance to dietary therapy was examined as being representative of compliance to the entire regimen. In Japan, the dietary therapy for diabetic patients is prescribed according to the Nutritional Conversion Table of the Japan Diabetic Society, in which foods are classified into seven groups: the staple food (source of carbohydrate), fruit, fish or meat, dairy products, oil and fat, vegetables, and others. Patients are allowed to consume foods of their choice up to the allowance imposed for each food group. Instructions concerning this method were provided by a dietitian on an outpatient basis. The patients’ understanding of the method was evaluated by a perception test, and education was continued until the patients attained a sufficient level of understanding. The patients recorded the items and amount of different foods consumed on 3 consecutive days at home, and brought the record sheets on visits to the clinic for a check by a dietitian. The table was completed at this stage. The mean daily consumption of each food group was expressed as a percentage of the indicated allowance. Attitude assessment The attitude level of the patients was evaluated PRAS [ 191, a modification for education diabetic patients of the method of Genthner et [ 181. This system allows grading of a series
by of al. of
Having diabetes is a challenge Level 5
Having diabetes is an opportunity a From Anderson
Little responsibility Anger, complainig, denial, blaming, and depersonalizing. ‘If it weren’t for diabetes, I’d be OK.’ Partial responsibility ‘I know it’s up to me, but circumstances are holding me back.’ Full verbal responsibility ‘I know it’s up to me. I’m going to do it.’ Total responsibility ‘I’m doing it.’
et al. [IY].
adaptation responses of patients to the diagnosis of diabetes, a crisis in their lives. Responses are graded into five levels on the basis of the degree of perception of their responsibility for the disease (Table 2). We performed this assessment according to a questionnaire filled in by the patients themselves. Statistical analyses Statistical analyses were made by Student’s t-test and the chi-square test (Yates’ correction included).
Results The attitude was level 1 in one patient, level 2 in one patient, level 3 in four patients, level 4 in 22 patients, and level 5 in 31 patients; it was level 4 or above in 53 out of 59 patients. Attitude level and biological factors As shown in Table 1, no sex difference was ob-
40 TABLE 3 Relationship of mode of therapy and duration of diabetes to level of perception of responsibility Level
Treatment Insulin Tablet Diet only Duration (years) l-4 5-9 lo-
l-3 (%)
4 (%)
5 (%)
2 (12.5) 2 (9.1) 0 (0.0)
6 (37.5) 4 (18.2) 5 (41.7)
8 (50.0) 16 (72.7) 7 (58.3)
0 (0.0) 1 (5.9) 3 (12.0)
2 (25.0) 2 (11.8) 11 (44.0)
6 (75.0) 14 (82.4) 11 (44.0)*
Subjects were aged over 40 years. *P < 0.05.
served in the attitude level. The effect of age on attitude was compared between those aged less than 40 years and those aged 40 years or over. The attitude level was 4 or less in all patients aged less than 40 years, but was 5 in the majority of both men and women aged 40 years or over. The attitude level was 4 or less more frequently (P < 0.01) in those aged less than 40 years than in those aged 40 years or over, suggesting that patients’ attitudes are affected by their age. For this reason, and since there were few patients aged less than 40 years in this study, the following evaluations were made only in those aged 40 years or over.
The patients were classified according to the duration of the disease, estimated from the time when the diagnosis of diabetes was first made: 1 year or longer and less than 5 years, 5 years or longer and less than 10 years, and 10 years or longer. As shown in Table 3, the attitude level was more frequently 4 or less in those who had had diabetes for 10 years or more than in those who had had the disease for less than 10 years (P < 0.05). The mean duration of the disease was 11.5 k 5.7 years for level l-4 patients and 9.5 2 6.9 years for level 5 patients. Attitude level, the state of blood sugar control and the presence of diabetic retinopathy The attitude level was compared between patients aged 40 years or over treated with insulin (insulin group) and not treated with insulin (non-insulin group). The HbA, level was significantly higher (P-C 0.001) in the insulin group (9.7 + 2.4%) than in the non-insulin group (7.6 k 1.3%) (Table 4). Also, more patients of the insulin group had retinopathy (P < 0.05) (Table 5). In the insulin group, the HbA, level was not significantly different according to attitude level. In the noninsulin group, however, the HbA, level was significantly higher (P < O.Ol), and retinopathy was more frequently observed (P < 0.05), in level l-4 patients (8.4 k 1.9%) than in level 5 patients (7.2 2 0.6%).
TABLE 4 Relationship Insulin therapy
of HbA, score to level of perception HbA, score (% ) Level 1-4
With Without Total
of responsibility
Level 5
Total
n
Mean + SD
n
Mean k SD
n
Mean k SD
8 11 19
10.2 + 2.6 8.4 f 1.9** 9.1 f 2.4*
8 23 31
9.2 + 2.0 7.2 + 0.6 7.7 + 1.4
16 34 50
9.7 k 2.4 7.6 f 1.3 8.3 + 2.0
a Normal range 5-8%. Subjects were aged over 40 years. *P < 0.05; **p < 0.01.
41
Attitude level and diet
TABLE 5 Relationship of diabetic retinopathy responsibility Insulin therapy
With Without
to level of perception
Retinopathy
of
Level
With Without With Without
l-3
4
5
1 1 1 1
4 2 5 4
5 3 3* 20
Subjects were aged over 40 years. *P < 0.05.
Attitude level and clinicopsychological projle No significant associations were observed
Discussion
between attitude level and psychological characteristics of the patients (Tables 6 and 7).
The therapeutic regimen for diabetes is complicated, encompasses details of many aspects of the life of each patient, and demands alterations in life-style. For strict compliance to such a regimen, the patients must accept their disease and take full responsibility for their own condition. Patients are considered to undergo psychological damage when they are informed that they have diabetes. They may become apathetic and helpless and may react to it with anger and fear, but, through compromise and bargaining, they gradually learn to accept their disease. The degree of perception of responsibility for their own disease is considered to be correlated with these stages of mental and psychological self-
TABLE 6 Relationship of Cornell Medical Index to level of perception of responsibility Sex
Male Female
Grade
I-II III-IV I-II III-IV
Level 1-3
4
5
1 0 2 1
6 1 4 4
15 4 8 4
Sex differences were noted in the actual food intake compared to the prescribed allowance for each food group. Since attitude level was significantly correlated with diet, particularly in women aged 40 years or over, only the results in this group are presented (Table 8). Both the total caloric intake and the intake of each food group generally conformed to the regimen in level 5 patients. In contrast, the intake of fruit, meat and fish, and vegetables was significantly lower, and the intake of oil and fat and sweetening agents was significantly higher (PC 0.05 for both) in level 1-4 patients compared with level 5 patients.
Subjects were aged over 40 years. TABLE 7 Relationship Sex
of Taylor’s Manifest Anxiety Scale (MAS) to level of perception MAS score Level l-4
Male Female Total
of responsibility
Level 5
Total
n
mean f SD
n
mean + SD
It
mean & SD
8 11 19
19.5 * 10.1 21.5 * 7.1 20.6 f 8.5
19 12 31
16.6 * 1.7 19.3 + 8.5 17.7 f 8.1
21 23 50
17.5 f 8.6 20.3 f 1.9 18.8 f 8.4
Subjects were aged over 40 years.
42 TABLE 8 Relationship
of dietary intake to level of perception
Food
Total calories Staple foods Fruit Meat and fish Milk Fat Vegetables Condiment
of responsibility
Actual intake against recommended
quantity (%)
Level l-4
Level 5
Total
Mean f SD (n = 11)
Mean rt: SD (n = 12)
Mean + SD (n = 23)
96.1 102.1 68.2 86.7 80.5 137.1 76.6 114.6
98.7 96.7 104.2 97.0 102.7 93.8 94.1 101.6
97.6 99.3 87.0 92.1 92.0 114.5 85.7 107.5
f 13.0 + 16.7 f 44.1* & 20.8 + 30.3* f 59.0* f 22.1* f 19.1*
f + + + f f f f
3.4 12.0 28.9 8.8 17.6 18.4 9.2 3.7
+ f f + f f f f
9.2 14.7 41.1 16.5 26.8 48.0 18.8 14.6
Subjects were female patients *P < 0.05.
aged over 40 years.
adjustment. The PRAS used in this study is designed for the evaluation of the process of mental and psychological adjustment of the patients to the problem that they have come to encounter [ 18,191. Patients require educational intervention at each stage of this adjustment, and this intervention will be made more efficiently if we can accurately determine the current position of the patient in his or her adjustment. Etzwiler divided the adjustment period of diabetic patients into acute, in-depth and continuing phases, and emphasized the importance of the implementation of educational intervention suited for each of these phases [25]. Compliance to a regimen is achieved by motivation sufficient to overcome the inconvenience and discomfort it involves. Motivation is determined generally by desire as the source of energy and attitude giving an appropriate direction to the energy [ 91. The age of the patients is considered to be related to their emotion, social status, and life-style [6,14]. In this study, the attitude level was 4 or less in all patients aged less than 40 years, with a significant difference in frequency in comparison with patients aged 40 years or over. Patients may understand the necessity of conforming to the regimen, but a change in the atti-
tude level may be hindered by factors related to age so that it may as yet be insufficient to cause total responsibility in younger patients. Although the relationship between degree of compliance and age could not be evaluated because of the smallness of our patient population, compliance was found to be related to attitude level in patients aged 40 years or over. This finding may be consistent with the report that compliant patients are older and consider their disease to be more serious than non-compliant patients [ 141. In the present study, the attitude level was 4 or higher in most patients and 5 in many of them, probably because they had had the disease for more than 1 year and had already passed through levels l-3. In patients aged 40 years or over, attitude levels 4 or less were observed significantly more frequently in those who had been ill for 10 years or longer than in those who had been ill for less than 10 years. A report shows that the level of recognition of the severity of disease is related to the compliance level: the non-compliance state increases with the duration of disease [ 141. According to PRAS, the non-compliant state is attributable to a decrease in the sense of responsibility for the patient’s own disease. This may suggest that the attitude is changeable, and the enthu-
43
siasm towards the therapy is likely to diminish over time, even when the patients had once been adequately motivated. Therefore, re-education to enhance the willingness to compliance to the therapy through refreshment of their perception of their status is considered to be necessary for patients who have undergone a prolonged period of therapy. If carried out after an appropriate interval PRAS is considered to be an effective means for maintaining patient compliance at an optimal level. The results of the present study, although it was cross-sectional, may support the above speculation. Its proof requires a long-term prospective study to follow up patients from the time when the diagnosis of diabetes mellitus was first established. Lane et al. [6] state that the patient’s emotional condition seems to affect his/her attitude toward the disease. Patients on a dietary regimen alone or those receiving oral hypoglycemics do not seem to be motivated towards self-management until they reach the state of insulin therapy [ 61. The present study detected no significant association between either one of the two psychological tests and attitude level and therapy. We do not know whether it is due to the small number of cases or to our method. Examination of the actual dietary intake as an index of compliance showed that level 5 patients conformed more frequently to their allowance, in terms of intake of each food group, compared with level l-4 patients. In the patients treated without insulin, the former had better control of blood sugar level, as indicated by the HbA, test results, than the latter. Therefore, diabetes was more adequately controlled in those who answered that they took total responsibility for their, own disease and were actually following the dietary regimen than in those who did not. The attitude level was also associated with the incidence of retinopathy. This observation, although cross-sectional, suggests that, if a patient becomes more responsible for his/her own disease, carries out the regimen more faithfully, and controls the blood sugar level more adequately, complications may be prevented more effectively. As for the relationship between attitude and blood
sugar control or retinopathy, we do not know which is the cause and which is the result. Our survey was cross-sectional and involved only a small number of patients. Since a number of factors are thought to be involved in blood sugar control and retinopathy, the relationship between the patient’s attitude toward his/her disease and each of these factors remains to be investigated in more detail. The health belief model [ lo-121 may give a theoretical framework for compliance behavior. This theory assumes that a patient would: (a) think that attainment of his social or individual goals will become difficult if the disease becomes more advanced; (b) believe that faithful compliance to the therapeutic regimen will yield good results ; and (c) be more compliant to the regimen if he/she believes that he/she can practice it. The theoretical validity of the method has been indicated by a number of reports [ 3,14,17]. However, little improvement has been made in the scales for evaluation of the concepts that make up this model, so that the model has hardly been used in daily clinical practice. On the other hand, PRAS is designed to allow a practical and quantitative evaluation of a patient’s attitudes in clinical settings [ 191. To follow a therapeutic regimen one must overcome the difficulties that it presents [ 91. Non-compliance with the regimen is a result of failure to adjust one’s attitude and behavior to the new environment rather than of lack of knowledge or understanding of the disease [ 61. Dietary therapy, a principal remedy for diabetes, requires restriction of eating habits but it must be practiced in the face of these biological burdens as well as social burdens derived from the necessity to practice it amid ordinary social activities. Psychological adjustment to the disease is a key to a successful therapeutic regimen, and the more adjusted the patient becomes the greater responsibility he/she can assume for self-management of the disease. Assessing the patient’s psychological adjustment to, and his/her sense of responsibility for, the disease, we are able to provide for his/her needs at the stage of each parameter.
44
References 1 Davis, M.S. (1968) Variations in patients’ compliance with doctor’s advice: an empirical analysis of patterns of communication. Am. J. Public Health 58, 274-289. 2 Francis, V., Korsch, B.M. and Morris, M.J. (1969) Gaps in doctor-patient communication. Patients’ response to medical advice. N. Engl. J. Med. 280, 535-540. 3 Bloom Cerkoney, K.A. and Hart, L.A. (1980) The relationship between the health belief model and compliance of persons with diabetes mellitus. Diabetes Care 3, 594-598. 4 Williams, T.F., Martin, D.A., Hogan, M.D., Watkins, J.D. and Ellis, E.V. (1967) The clinical picture of diabetic control studies in four settings. Am. J. Public Health 57, 441-451. 5 Watkins, J.D., Williams, T.F., Martin, D.A., Hogan, M.D. and Anderson, E. (1967) A study of diabetic patients at home. Am. J. Public Health 57, 452-459. 6 Lane, D.S. and Evans, D. (1979) Measures and methods in evaluating patient education programs for chronic illness. Med. Care 17, 30-42. I Sulway, M., Tupling, H., Webb, K. and Harris, G. (1980) New techniques for changing compliance in diabetes. Diabetes Care 3, 108-l Il. model for diabetic 8 Jenny, J. (1983) A compliance instruction. Rehabil. Liter. 44, 258-263, 299. 9 Munakata, T. (1982) Psycho-social influence on self-care ofthe hemodialysis patient. Sot. Sci. Med 16,1253-1264. I.M. (1966) Why people use the health 10 Rosenstock, service. Milbank Mem. Fund Q. 44, 94-124. J.P., Haefner, D.P., Kegeles, S.S. and 11 Kirscht, Rosenstock, I.M. (1966) A national study of health beliefs. J. Health Hum. Behav. 7, 248-254. 12 Becker, M.H., Drachman, R.H. and Kirscht, J.P. (1974) A new approach to explaining sick-role behavior in lowincome populations. Am. J. Public Health 64, 205-216. 13 Linn, M.W., Linn, B.S., Skyler, J.S. and Harris, R. (1980)
14
15
16
17
18
19
20
21
22
23 24 25
The importance of self-assessed health in patients with diabetes. Diabetes Care 3, 599-606. Alogna, M. (1980) Perception of severity of disease and health locus of control in compliant and noncompliant diabetic patients. Diabetes Care 3, 533-534. Davis, W.K., Hull, A.L. and Boutaugh, M.L. (1981) Factors affecting the educational diagnosis of diabetic patients. Diabetes Care 4, 275-278. Boutaugh, M.L., Hull, A.L. and Davis, W.K. (1982) An examination of diabetes educational assessment forms. Diabetes Educ. 7, 29-34. Given, C.W., Given, B.A., Gallin, R.S. and Condon, J.W. (1983) Development of scales to measure belief of diabetic patients. Res. Nurs. Health 6, 127-141. Genthner, R.W. and Jones, D.E. (1976) A system for assessing personal responsibility, validity, reliability, and rater trainability. J. Personality Assess. 40, 269-275. Anderson, R.M., Genthner, R.W. and Alogna, M. (1982) Diabetes patient education: from philosophy to delivery. Diabetes Educ. 8, 265-275. Masaki, Y., Okada, S. and Ota, Z. (1985) Factors which influence the attitude of diabetic patients without insulin therapy. Jap. J. Prim. Care 8, 25-30 (in Japanese). Brodman, K., Erdmann, A.J. Jr., Lorge, I., Gershenson, C.P. and Wolff H.G. (1952) The Cornell Medical IndexHealth Questionnaire, III. The evaluation of emotional disturbances. J. Clin. Psychol. 8, 119-124. Fukamachi, K. (1959)The study on the Cornell Medical Index (1). The characteristic of complaints of neurotic patients shown on the CMI. Fukuoka Med. J. 50, 2988-3000. Taylor, J.A. (1953) A personality scale of manifest anxiety. J. Abnorm. Sot. Psychol. 48, 285-290. Taylor, J.A., Abe, M. and Takaishi, N. (1968) The Guide Book of MAS. Sankyobo, Kyoto. Etzwiler, D.D. (1980) Teaching allied health professionals about self-management. Diabetes Care 3, 121-123.
31-44
37
Elsevier DIABET
00333
Importance
of attitude evaluation in diabetes patient education Yoshitugu
Masaki,
Third Department of Internal Medicine,
Soji Okada and Zensuke
Ota
Okayama University Medical School. Okayama
700, Japan
(Received 23 May 1988) (Revision received 25 April 1989) (Accepted 11 July 1989)
Summary
Attitudes were evaluated according to the ‘Personal Responsibility Attitude Assessment System’ (PRAS), which allows grading of patients’ attitudes into five levels of perception of responsibility toward their disease. In 59 diabetics evaluated in this study, no sex difference was observed in attitude level, but more of those aged less than 40 years showed lower attitude levels (levels l-4) than those aged 40 years or over (P -C 0.01). Of those aged 40 or over, more patients with a high attitude level (level 5) had had diabetes for 10 years or longer than those with low attitude levels (levels l-4) (P -C 0.05). Among those not treated with insulin, patients with a low attitude level showed higher hemoglobin A, (HbA,) levels (P < 0.01) and more frequently had retinopathy (P -C 0.05) than patients with high attitude levels. As for women, low attitude level patients consumed less fruit, meat or fish, and vegetables (P < 0.05) but more fat and sweetening agents (P -C 0.05) than high attitude level patients. These results suggest an association between the attitude level of diabetic patients evaluated by PRAS and the degree of their self-care. Evaluation of patients’ attitudes is important in predicting the response to educational intervention in diabetes. Key words: Attitude;
Patient compliance;
Patient education;
Introduction
The primary aim of the treatment of diabetes mellitus is not cure but control of the disease, which continues throughout the patient’s life. Treatment consists mainly of dietary and exercise Address for correspondence: Y. Ma&i, M.D., Department of Internal Medicine, Matuyama Shimin Hospital, 2-6-5 Ote-cho, Matuyama 790, Japan. 0168-8227/90/%03.50 0 1990 Elsevier Science Publishers
Self-care
therapies, which require a detailed alteration of a patient’s life-style. Dietary therapy, in particular, is complicated, it demands abstinence, and must be maintained during ordinary social activities, which are all factors that make compliance difficult [l-3]. The necessity of diabetes patient education is, therefore, vital The management of diabetes must be undertaken, in principle, by the patients themselves in their individual lives, and medical staff must provide appropriate support
B.V. (Biomedical
Division)
38
for them. However, patients cannot be sufficiently motivated to strict compliance to the regimen simply by a perception of the disease and its potential problems; perception is necessary but may not be sufficient to make the necessary changes [4-81. Compliance to a regimen is achieved by motivation sufficient to overcome the inconvenience and discomfort it involves [ 91. Motivation is determined generally by desire, as the source of energy, and attitude, which gives appropriate direction to the energy. Attitude, which mediates between perception and action, must be changed in order to properly motivate patients [ 91. With increasing recognition of the importance of a patient’s attitude toward the disease in diabetes education, a number of studies were carried out [3,13-171, including those using health belief models [ 10-121, but few of the findings of these studies have, as yet, been applied in clinical practice. This is considered to be due to the lack of practical and effective means for the assessment of patients’ attitudes. We previously examined [20] the validity of the Personal Responsibility Assessment System (PRAS) [ 191, a modification for diabetes education of the attitude assessment procedure developed by Genthner [ 181. This system is designed to evaluate the attitude of patients according to the degree of their perception of responsibility for their disease, and it is considered to allow practical and quantitative evaluation of patients’ attitudes toward their daily self-care and, further, to enable educational intervention that would be optimal for the patients’ individual attitude levels. In this study the relationships between patients’ attitude levels, evaluated by PRAS, biological factors, the degree of control of blood sugar level, complications, and the compliance to a regimen were studied to clarify the importance of attitude assessment for more effective educational intervention with diabetic patients. Materials and methods This study involved 59 patients with diabetes mellitus who were treated at the diabetic outpatient
TABLE I Relationship Sex
Male Female Total
of age to level of perception Age
under 39 over 40 under 39 over 40 under 39 over 40
of responsibility
Level l-3
4
5
2 1 0 3 2 4
2 7 5 8 I 15
0* 19 0 12 0** 31
*P < 0.05; **P < 0.01.
clinic of our Internal Department, and who had had the disease for 1 year or longer. The patients consisted of 31 men and 28 women, with a mean age of 54.9 years (25-75 years) and a mean duration of the disease of 10.2 years (l-30 years) (Table 1). Twenty-three of these patients were treated by insulin injection, 23 by oral medication, and 13 by dietary therapy alone. Fifty of the patients (27 men and 23 women) were aged 40 years or over; they had a mean age of 58.9 & 9.3 years and a mean duration of the disease of 10.2 k 6.6 years; 16 received insulin injections, 22 oral medication, and 12 a dietary regimen alone. Laboratory studies HbA,.
Hemoglobin A, (HbA,) was evaluated as an index of the state of diabetes control. Measurement was made at least three times with intervals of 1 month or longer, and the mean value was compared with a normal value of 5.0-8.0%. Retinopathy.
The patients were evaluated for retinopathy with cooperation from the Ophthalmology department of our hospital. Retinopathy was considered to be positive when any diabetic changes were observed in the eyegrounds (over the first stage of Scott’s classification). Clinicopsychological examinations. Subjective psychological symptoms and the intensity of psychological experience were evaluated according to
39
the Cornell Medical Index (CMI) and Taylor’s Manifest Anxiety Scale (MAS). The CMI, formulated at Cornell University [21] and adjusted to Japanese patients [ 221, consists of questions concerning subjective psychological and physical symptoms. By this method neurotic tendency was classified into: I, normal; II, subnormal; III, neurotic; IV, neurosis. We, however, divided our patients into normal (I-II) and neurotic (III-IV). The MAS [23], modified for Japanese patients [ 241, was designed to evaluate a series of manifestations of anxiety by a scoring system, with the maximum score being 50. Since women are considered to have higher scores than men, men and women were evaluated separately.
TABLE 2 Summary of levels of personal responsibility” Level of personal responsibility
Characteristics
Level I
No responsibility Hopelessness, helplessness, and despair. ‘It’s no use trying.’
Having diabetes is a disaster Level 2
Having diabetes is a burden Level 3
Having diabetes is a problem Level 4
Examination of dietary intake Compliance to dietary therapy was examined as being representative of compliance to the entire regimen. In Japan, the dietary therapy for diabetic patients is prescribed according to the Nutritional Conversion Table of the Japan Diabetic Society, in which foods are classified into seven groups: the staple food (source of carbohydrate), fruit, fish or meat, dairy products, oil and fat, vegetables, and others. Patients are allowed to consume foods of their choice up to the allowance imposed for each food group. Instructions concerning this method were provided by a dietitian on an outpatient basis. The patients’ understanding of the method was evaluated by a perception test, and education was continued until the patients attained a sufficient level of understanding. The patients recorded the items and amount of different foods consumed on 3 consecutive days at home, and brought the record sheets on visits to the clinic for a check by a dietitian. The table was completed at this stage. The mean daily consumption of each food group was expressed as a percentage of the indicated allowance. Attitude assessment The attitude level of the patients was evaluated PRAS [ 191, a modification for education diabetic patients of the method of Genthner et [ 181. This system allows grading of a series
by of al. of
Having diabetes is a challenge Level 5
Having diabetes is an opportunity a From Anderson
Little responsibility Anger, complainig, denial, blaming, and depersonalizing. ‘If it weren’t for diabetes, I’d be OK.’ Partial responsibility ‘I know it’s up to me, but circumstances are holding me back.’ Full verbal responsibility ‘I know it’s up to me. I’m going to do it.’ Total responsibility ‘I’m doing it.’
et al. [IY].
adaptation responses of patients to the diagnosis of diabetes, a crisis in their lives. Responses are graded into five levels on the basis of the degree of perception of their responsibility for the disease (Table 2). We performed this assessment according to a questionnaire filled in by the patients themselves. Statistical analyses Statistical analyses were made by Student’s t-test and the chi-square test (Yates’ correction included).
Results The attitude was level 1 in one patient, level 2 in one patient, level 3 in four patients, level 4 in 22 patients, and level 5 in 31 patients; it was level 4 or above in 53 out of 59 patients. Attitude level and biological factors As shown in Table 1, no sex difference was ob-
40 TABLE 3 Relationship of mode of therapy and duration of diabetes to level of perception of responsibility Level
Treatment Insulin Tablet Diet only Duration (years) l-4 5-9 lo-
l-3 (%)
4 (%)
5 (%)
2 (12.5) 2 (9.1) 0 (0.0)
6 (37.5) 4 (18.2) 5 (41.7)
8 (50.0) 16 (72.7) 7 (58.3)
0 (0.0) 1 (5.9) 3 (12.0)
2 (25.0) 2 (11.8) 11 (44.0)
6 (75.0) 14 (82.4) 11 (44.0)*
Subjects were aged over 40 years. *P < 0.05.
served in the attitude level. The effect of age on attitude was compared between those aged less than 40 years and those aged 40 years or over. The attitude level was 4 or less in all patients aged less than 40 years, but was 5 in the majority of both men and women aged 40 years or over. The attitude level was 4 or less more frequently (P < 0.01) in those aged less than 40 years than in those aged 40 years or over, suggesting that patients’ attitudes are affected by their age. For this reason, and since there were few patients aged less than 40 years in this study, the following evaluations were made only in those aged 40 years or over.
The patients were classified according to the duration of the disease, estimated from the time when the diagnosis of diabetes was first made: 1 year or longer and less than 5 years, 5 years or longer and less than 10 years, and 10 years or longer. As shown in Table 3, the attitude level was more frequently 4 or less in those who had had diabetes for 10 years or more than in those who had had the disease for less than 10 years (P < 0.05). The mean duration of the disease was 11.5 k 5.7 years for level l-4 patients and 9.5 2 6.9 years for level 5 patients. Attitude level, the state of blood sugar control and the presence of diabetic retinopathy The attitude level was compared between patients aged 40 years or over treated with insulin (insulin group) and not treated with insulin (non-insulin group). The HbA, level was significantly higher (P-C 0.001) in the insulin group (9.7 + 2.4%) than in the non-insulin group (7.6 k 1.3%) (Table 4). Also, more patients of the insulin group had retinopathy (P < 0.05) (Table 5). In the insulin group, the HbA, level was not significantly different according to attitude level. In the noninsulin group, however, the HbA, level was significantly higher (P < O.Ol), and retinopathy was more frequently observed (P < 0.05), in level l-4 patients (8.4 k 1.9%) than in level 5 patients (7.2 2 0.6%).
TABLE 4 Relationship Insulin therapy
of HbA, score to level of perception HbA, score (% ) Level 1-4
With Without Total
of responsibility
Level 5
Total
n
Mean + SD
n
Mean k SD
n
Mean k SD
8 11 19
10.2 + 2.6 8.4 f 1.9** 9.1 f 2.4*
8 23 31
9.2 + 2.0 7.2 + 0.6 7.7 + 1.4
16 34 50
9.7 k 2.4 7.6 f 1.3 8.3 + 2.0
a Normal range 5-8%. Subjects were aged over 40 years. *P < 0.05; **p < 0.01.
41
Attitude level and diet
TABLE 5 Relationship of diabetic retinopathy responsibility Insulin therapy
With Without
to level of perception
Retinopathy
of
Level
With Without With Without
l-3
4
5
1 1 1 1
4 2 5 4
5 3 3* 20
Subjects were aged over 40 years. *P < 0.05.
Attitude level and clinicopsychological projle No significant associations were observed
Discussion
between attitude level and psychological characteristics of the patients (Tables 6 and 7).
The therapeutic regimen for diabetes is complicated, encompasses details of many aspects of the life of each patient, and demands alterations in life-style. For strict compliance to such a regimen, the patients must accept their disease and take full responsibility for their own condition. Patients are considered to undergo psychological damage when they are informed that they have diabetes. They may become apathetic and helpless and may react to it with anger and fear, but, through compromise and bargaining, they gradually learn to accept their disease. The degree of perception of responsibility for their own disease is considered to be correlated with these stages of mental and psychological self-
TABLE 6 Relationship of Cornell Medical Index to level of perception of responsibility Sex
Male Female
Grade
I-II III-IV I-II III-IV
Level 1-3
4
5
1 0 2 1
6 1 4 4
15 4 8 4
Sex differences were noted in the actual food intake compared to the prescribed allowance for each food group. Since attitude level was significantly correlated with diet, particularly in women aged 40 years or over, only the results in this group are presented (Table 8). Both the total caloric intake and the intake of each food group generally conformed to the regimen in level 5 patients. In contrast, the intake of fruit, meat and fish, and vegetables was significantly lower, and the intake of oil and fat and sweetening agents was significantly higher (PC 0.05 for both) in level 1-4 patients compared with level 5 patients.
Subjects were aged over 40 years. TABLE 7 Relationship Sex
of Taylor’s Manifest Anxiety Scale (MAS) to level of perception MAS score Level l-4
Male Female Total
of responsibility
Level 5
Total
n
mean f SD
n
mean + SD
It
mean & SD
8 11 19
19.5 * 10.1 21.5 * 7.1 20.6 f 8.5
19 12 31
16.6 * 1.7 19.3 + 8.5 17.7 f 8.1
21 23 50
17.5 f 8.6 20.3 f 1.9 18.8 f 8.4
Subjects were aged over 40 years.
42 TABLE 8 Relationship
of dietary intake to level of perception
Food
Total calories Staple foods Fruit Meat and fish Milk Fat Vegetables Condiment
of responsibility
Actual intake against recommended
quantity (%)
Level l-4
Level 5
Total
Mean f SD (n = 11)
Mean rt: SD (n = 12)
Mean + SD (n = 23)
96.1 102.1 68.2 86.7 80.5 137.1 76.6 114.6
98.7 96.7 104.2 97.0 102.7 93.8 94.1 101.6
97.6 99.3 87.0 92.1 92.0 114.5 85.7 107.5
f 13.0 + 16.7 f 44.1* & 20.8 + 30.3* f 59.0* f 22.1* f 19.1*
f + + + f f f f
3.4 12.0 28.9 8.8 17.6 18.4 9.2 3.7
+ f f + f f f f
9.2 14.7 41.1 16.5 26.8 48.0 18.8 14.6
Subjects were female patients *P < 0.05.
aged over 40 years.
adjustment. The PRAS used in this study is designed for the evaluation of the process of mental and psychological adjustment of the patients to the problem that they have come to encounter [ 18,191. Patients require educational intervention at each stage of this adjustment, and this intervention will be made more efficiently if we can accurately determine the current position of the patient in his or her adjustment. Etzwiler divided the adjustment period of diabetic patients into acute, in-depth and continuing phases, and emphasized the importance of the implementation of educational intervention suited for each of these phases [25]. Compliance to a regimen is achieved by motivation sufficient to overcome the inconvenience and discomfort it involves. Motivation is determined generally by desire as the source of energy and attitude giving an appropriate direction to the energy [ 91. The age of the patients is considered to be related to their emotion, social status, and life-style [6,14]. In this study, the attitude level was 4 or less in all patients aged less than 40 years, with a significant difference in frequency in comparison with patients aged 40 years or over. Patients may understand the necessity of conforming to the regimen, but a change in the atti-
tude level may be hindered by factors related to age so that it may as yet be insufficient to cause total responsibility in younger patients. Although the relationship between degree of compliance and age could not be evaluated because of the smallness of our patient population, compliance was found to be related to attitude level in patients aged 40 years or over. This finding may be consistent with the report that compliant patients are older and consider their disease to be more serious than non-compliant patients [ 141. In the present study, the attitude level was 4 or higher in most patients and 5 in many of them, probably because they had had the disease for more than 1 year and had already passed through levels l-3. In patients aged 40 years or over, attitude levels 4 or less were observed significantly more frequently in those who had been ill for 10 years or longer than in those who had been ill for less than 10 years. A report shows that the level of recognition of the severity of disease is related to the compliance level: the non-compliance state increases with the duration of disease [ 141. According to PRAS, the non-compliant state is attributable to a decrease in the sense of responsibility for the patient’s own disease. This may suggest that the attitude is changeable, and the enthu-
43
siasm towards the therapy is likely to diminish over time, even when the patients had once been adequately motivated. Therefore, re-education to enhance the willingness to compliance to the therapy through refreshment of their perception of their status is considered to be necessary for patients who have undergone a prolonged period of therapy. If carried out after an appropriate interval PRAS is considered to be an effective means for maintaining patient compliance at an optimal level. The results of the present study, although it was cross-sectional, may support the above speculation. Its proof requires a long-term prospective study to follow up patients from the time when the diagnosis of diabetes mellitus was first established. Lane et al. [6] state that the patient’s emotional condition seems to affect his/her attitude toward the disease. Patients on a dietary regimen alone or those receiving oral hypoglycemics do not seem to be motivated towards self-management until they reach the state of insulin therapy [ 61. The present study detected no significant association between either one of the two psychological tests and attitude level and therapy. We do not know whether it is due to the small number of cases or to our method. Examination of the actual dietary intake as an index of compliance showed that level 5 patients conformed more frequently to their allowance, in terms of intake of each food group, compared with level l-4 patients. In the patients treated without insulin, the former had better control of blood sugar level, as indicated by the HbA, test results, than the latter. Therefore, diabetes was more adequately controlled in those who answered that they took total responsibility for their, own disease and were actually following the dietary regimen than in those who did not. The attitude level was also associated with the incidence of retinopathy. This observation, although cross-sectional, suggests that, if a patient becomes more responsible for his/her own disease, carries out the regimen more faithfully, and controls the blood sugar level more adequately, complications may be prevented more effectively. As for the relationship between attitude and blood
sugar control or retinopathy, we do not know which is the cause and which is the result. Our survey was cross-sectional and involved only a small number of patients. Since a number of factors are thought to be involved in blood sugar control and retinopathy, the relationship between the patient’s attitude toward his/her disease and each of these factors remains to be investigated in more detail. The health belief model [ lo-121 may give a theoretical framework for compliance behavior. This theory assumes that a patient would: (a) think that attainment of his social or individual goals will become difficult if the disease becomes more advanced; (b) believe that faithful compliance to the therapeutic regimen will yield good results ; and (c) be more compliant to the regimen if he/she believes that he/she can practice it. The theoretical validity of the method has been indicated by a number of reports [ 3,14,17]. However, little improvement has been made in the scales for evaluation of the concepts that make up this model, so that the model has hardly been used in daily clinical practice. On the other hand, PRAS is designed to allow a practical and quantitative evaluation of a patient’s attitudes in clinical settings [ 191. To follow a therapeutic regimen one must overcome the difficulties that it presents [ 91. Non-compliance with the regimen is a result of failure to adjust one’s attitude and behavior to the new environment rather than of lack of knowledge or understanding of the disease [ 61. Dietary therapy, a principal remedy for diabetes, requires restriction of eating habits but it must be practiced in the face of these biological burdens as well as social burdens derived from the necessity to practice it amid ordinary social activities. Psychological adjustment to the disease is a key to a successful therapeutic regimen, and the more adjusted the patient becomes the greater responsibility he/she can assume for self-management of the disease. Assessing the patient’s psychological adjustment to, and his/her sense of responsibility for, the disease, we are able to provide for his/her needs at the stage of each parameter.
44
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