bs_bs_banner
Japan Journal of Nursing Science (2015) 12, 367–376
doi:10.1111/jjns.12076
ORIGINAL ARTICLE
Relationship between social support and fatigue in patients with type 2 diabetes mellitus in the east of turkey ˘ ,2 Kevser IS¸IK1 and Melek YILDIRIM3 Rukuye AYLAZ,1* Ezgi KARADAG Departments of 1Public Health Nursing, School of Health, Inonu University, 3Internal Medicine Nursing, Malatya State Hospital, Malatya, 2Internal Medicine Nursing, Tunceli University Health High School, Tunceli, Turkey
Abstract Aim: This study was planned to assess the levels of fatigue and social support in patients with diabetes and to determine the relationship between fatigue and social support in these patients. Methods: A descriptive design was used in this research. The study was conducted between March and June 2013 with 300 sampled patients from 1657 studied participants with type 2 diabetes who presented to the diabetes polyclinics of Malatya State Hospital and Inonu University, Turgut Ozal Medical Center. The Multidimensional Scale of Perceived Social Support and the Fatigue Severity Scale were used in the study. Results: When the correlation analysis carried out between fatigue severity and social support in patients with diabetes was examined, a significant relationship was found in the negative direction between fatigue severity and family support (r = −0.145, P < 0.05) as well as overall support (r = −0.132, P < 0.05). A statistically significant difference was found between the Fatigue Severity Scale score and sex, education status, occupation, cohabitation, presence of complications, and hemoglobin A1c (P < 0.05). Family support was significant only with respect to marital status, occupation, and being employed (P < 0.05). Conclusion: It was seen at the end of this research that social support reduced the level of fatigue in a number of patients with type 2 diabetes. Nurses of diabetes patients should carry out fatigue assessments routinely and reflect these in nursing care plans by also associating them with the social support sources of the patient. Key words: fatigue, nursing, patients, social support, type 2 diabetes.
INTRODUCTION Diabetes mellitus is a chronic illness that requires continuing medical care and ongoing patient selfmanagement, education, and support to prevent acute complications and to reduce the risk of long-term complications (American Diabetes Association, 2013). According to the most recent estimates from the International Diabetes Federation (IDF), 8.3% of adults – 382 million people – have diabetes, and the number of Correspondence: Rukuye Aylaz, Department of Public Health Nursing, Malatya School of Health, Inonu University, Malatya 44280, Turkey. Email: [email protected] * Present address: Department of Oncology Nursing, Dokuz Eylül University Faculty of Nursing, I˙zmir 35100, Turkey. Received 19 March 2014; accepted 28 January 2015.
people with the disease is set to rise beyond 592 million in less than 25 years (IDF-International Diabetes Federation, 2013). According to the results of the Turkish Diabetes Epidemiology Study (TURDEP) that was carried out at 540 sites in 15 provinces in Turkey, the prevalence of diabetes in the Turkish adult population has reached 13.7% (TURDEP II, 2010). The same study revealed that the regional diabetes prevalence was the highest in the east of Turkey with 18.2% (Satman et al., 2013). The region where this study was carried out was found to come first in Turkey with 20% of T2DM patients in the diabetes statistics performed by TURDEP in 2010. Fatigue is a general, frequently seen complaint experienced by everyone in daily life. Although it is a universal symptom that occurs in all physical and mental diseases in varying degrees, it is quite difficult to define
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
R. Aylaz et al.
Japan Journal of Nursing Science (2015) 12, 367–376
it and it has been defined differently by many healthcare disciplines. Fatigue is used in the same sense as weakness, lassitude, lack of energy, and debility; it can be defined as a state of physical and mental exhaustion to include, in a sense, all of these (Azak, Altundag˘, Sert, & Çinar, 2008; Yönt, Akin Korhan, & Gündüzog˘lu, 2012). According to another definition, fatigue is an unpreventable feeling of exhaustion that occurs in situations such as muscular weakness, accumulation of waste material, and inflammatory processes (Azak & Çinar, 2005). When it is not put under control, it becomes an important symptom that adversely affects the individual’s daily life activities and quality of life (Fritschi et al., 2012). Fatigue is a widespread clinical complaint among adults with type 2 diabetes (T2DM), has been directly related to poor self-reported health, and is likely a key barrier to successful self-management of diabetes (Fritschi et al., 2012). In these patients, various physiological, psychological, and social factors lead to fatigue. These factors include physiological factors such as diabetes-related hypo/hyperglycemia attacks, drug side-effects due to polypharmacy and presence of comorbid conditions, psychological factors such as intensity of self-management regimens in diabetes, sleep disturbances, and diagnosis-related emotional distress or depression, and lifestyle changes such as being overweight/reduced physical activity (Fritschi & Quinn, 2010; Fritschi et al., 2012; Lasselin et al., 2012). The presence of short- and long-term complications of diabetes and their symptoms, including symptoms of hypoor hyperglycemia, cardiac disease, neuropathy, or retinopathy, has also been associated with increased fatigue (Singh & Kluding, 2013). It is seen in many studies that the prevalence of fatigue is high in patients with T2DM (Azak et al., 2008; Lasselin et al., 2012). In an epidemiological study of 1137 subjects with T2DM, the prevalence of fatigue was found to reach 61% (Drivsholm, Olivarius, Nielsen, & Siersma, 2005). In a study by Singh and Kluding (2013) of individuals with T2DM, the mean score of the Fatigue Severity Scale (FSS) was found to be as high as 4.28 ± 1.49. The level of fatigue has also been found to be high in other studies of individuals with T2DM (Fritschi et al., 2012; Lasselin et al., 2012). Coping with fatigue in chronic diseases requires effective social support. A significant relationship was found between social support and fatigue in the study of Prins et al. (2004). Social support can be defined as the assistance supplied to an individual by the people around him/her.
368
Studies carried out in recent years state that the term “social support” is divided into two groups: perceived social support and received social support. The former is support the individual believes is available to him/her in times of need; the latter is the support actually received by the individual in real life (Eker et al., 2001; Karakurt, Hacihasanog˘lu, & Yildirim, 2013). Social support means satisfying an individual’s basic needs such as belongingness, affection, appreciation, and selfrealization as a result of the interaction he/she establishes with other individuals such as friends, family, or professional advisors (Eker et al., 2001; Karakurt et al., 2013). According to another definition, social support is an aid provided to the individual under stress or in difficult situations by the people around him/her; a support conveyed from his/her social connections with other people, groups, and community; and a special concept showing that he/she is loved and appreciated and is in communication based on mutual cooperation (Altintoprak, Cos¸kunol, Kesebir, Yildiz, & Yüncü, 2005). Social support has been demonstrated to be an important psychosocial factor linked to healthy diet behaviors, physical activity, and adherence to medication among those with T2DM (Boas, Foss, Freitas, & Pace, 2012; Brouwer et al., 2012; Schiøtz et al., 2012). The International Diabetes Federation confirms that poor social support is a predictor of poor adherence to prescribed therapy (IDF-International Diabetes Federation, 2005). Additionally, studies carried out among patients with T2DM show that as social support increases, patients feel better physically and psychologically, cope more easily with stress and fatigue, and display improved diabetic self-management (Schiøtz et al., 2012; Tang, Brown, Funnell, & Anderson, 2008). Social support involves not only family support but also persons with whom the individual interacts outside the family (friends) and social facilities (e.g. financial support, services). Social support from family and friends has been demonstrated to reduce stress related to performing self-care behaviors, facilitate adjustment to and coping with a diabetes diagnosis, and provide resources for frequent engagement in self-care behaviors (Boas et al., 2012; Brouwer et al., 2012). In patients with a chronic disease, as the level of social support increases, physical and psychological welfare as well as coping with stress and fatigue improve. Because fatigue occurs in association with psychophysiological reasons in patients with T2DM, the hypothesis comes up that the level of fatigue in patients may be affected positively as social support increases.
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 367–376
If nurses deal with fatigue symptoms and the factors affecting fatigue in patients with T2DM and activate the social support systems of the patient, this may be effective in improving the patient’s well-being. Assessing social support and fatigue is important to help nurses plan appropriate interventions that can enhance people’s adaptation to their disease and, consequently, improve treatment adherence. However, there are no study results that explain the relationship between social support and fatigue in patients with diabetes. This study will provide new data for the published work on this subject. The Turkish nation has a traditional structure. Due to this social structure, the responsibility of daily housework and child care is assumed by women (Tezcan, 2013). Women participate in the workforce at a rate of one third that of men. The rate at which women participate in the workforce in Turkey is the lowest among the member and candidate countries of the European Union. The 8 year compulsory education came into force in Turkey in 1997; as the majority of survey participants were aged 56 years and over, a number were illiterate. The illiterate male population in Turkey was 1.4% in 2012, whereas this rate was 7% in women and even higher in the region where the present study was carried out (Turkey Statistical Institution, 2013). The aim of this study is to assess the levels of fatigue and social support, to examine the demographic and disease-related factors associated with fatigue and social support, and to determine the relationship between fatigue and social support.
METHODS Study design and sample In an average year, 1657 patients with T2DM are treated at Malatya State Hospital and Inonu University Turgut Ozal Medical Center. Between March and June 2013, the sample size was defined as 312 patients according to the sample calculation method where the number of the population is known. However, patients who did not wish to participate in the study (n = 8) and those who had speech problems (n = 4) were excluded from the study. Therefore, the sample consisted of 300 patients with T2DM who met the study criteria and who agreed to take part in the study. The criteria for inclusion were: (i) having been diagnosed at least 1 year ago; (ii) not having any hearing or speech problem; and (iii) the absence of depression from medical record.
Social support and fatigue in patients
Data collection A questionnaire consisting of 18 questions for sociodemographic and disease data as well as the Multidimensional Scale of Perceived Social Support and the Fatigue Severity Scale were used in the study. The questionnaire, the Multidimensional Scale of Perceived Social Support (MSPSS), and Fatigue Severity Scale (FSS) were administered to the patients in the diabetes outpatient clinic.
Procedure The questionnaire and the scale were administered by way of face-to-face interviews after the written and verbal consent of the subjects was obtained. The investigators read the questions for those who were illiterate and marked the answers after making certain that the questions were understood. The questionnaire took approximately 15–20 min to complete.
Instruments Questionnaire for sociodemographic and disease characteristics The sociodemographic data were collected through 10 questions about age, sex, marital status, education, occupation, employment status, economic status, residence, number of children, cohabitation, and the disease-related data through eight questions about duration of diabetes disease, treatment of diabetes, presence of any chronic disease other than diabetes, duration of insulin use, frequency of daily insulin use, compliance with the treatment, and diabetes education in the past.
MSPSS This scale, which was developed by Zimet et al. (1988) and whose validity and reliability in Turkish were assessed by Eker and Arkar (1995), subjectively assesses the adequacy of social support received from three different sources. Three different support sources – family, friends, and a significant other – can be assessed using this scale with 12 expressions. This scale shows the level of social and psychological support the individual received from the people around them. These social supports include individuals’ being liked and loved by others (emotional support); being respected (respect support); getting financial aid (instrumental support); helping an individual to understand, define, and cope with the problem (informational support); and social friendship support. The total score of the scale can also be found by adding the subscale scores. Each item is rated by using a 7 point measure with a Likert-type scoring. The scores of the subdimensions in the scale
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
369
R. Aylaz et al.
Japan Journal of Nursing Science (2015) 12, 367–376
range between 4 and 28 and the total score of the scale between 12 and 84. Obtaining a high score means a high level of perceived social support (Eker & Arkar, 1995). Cronbach’s coefficient alphas of subscales were found to be between 0.77 and 0.92 (Eker & Arkar, 1995). The overall internal consistency coefficient was found to be 0.84 in this study.
FSS Perceived fatigue was measured with the FSS (Krupp, LaRocca, Muir-Nash, & Steinberg, 1989). The 9 item scale measures the severity of fatigue and its effect on a person’s activities and lifestyle in patients with a variety of disorders. It assesses the physical fatigue of the patients. This scale has good evidence of internal consistency, test–retest reliability and score validity (Krupp et al., 1989). The FSS has high reliability with a Cronbach’s alpha coefficient of 0.88. The Turkish version of the scale was administered to multiple sclerosis subjects by Armutlu et al. (2007). Cronbach’s alpha value of the study was found to be 0.95.
Permission and ethics Written permissions were obtained from the Scientific Ethics Committee of Malatya Inonu University Turgut Ozal Medical Center and from the Chief Physician of Malatya State Hospital. Before administering the forms, the purpose of the study was explained to the patients and their verbal approvals were obtained; their privacy was respected.
Statistical analyses In evaluating the data, the descriptive characteristics of patients and the information on the illness were taken as the independent variables and the scores obtained from the MSPSS and the FSS as the dependent variables. The statistical analyses to evaluate the data were carried out using the program Statistical Package for the Social Sciences version 16.0 (SPSS, Chicago, IL, USA). After using the Kolmogorov–Smirnov test to determine whether the data variance was standard, the variance analysis, independent Student’s t-test, and Pearson’s correlation analysis were used for the parametric data. Kruskal– Wallis was used for the non-parametric data. The level of significance was accepted to be P < 0.05 in the study.
RESULTS Of those who took part in the research, 61.3% were female, 38.7% were male, most of them (60.7%) were 56 years of age and older, 75% were married, 35%
370
were graduates of primary school, and 54% were housewives. More than half of the participants (64.0%) had a medium level of economic status, 47% lived with their spouses and children, 40.3% had had diabetes for 1–6 years, 36.7% used oral diabetes drugs for treatment, 65.7% of those who used insulin had used it for 1–5 years, and the hemoglobin A1c (HbA1c) levels of 56.0% of the patients were 9% and above (Table 1). Of the results of the patients who participated in the study, which are not shown in the table, 61.3% had four and more children, 91.7% had social security, 76.7% of them resided in provincial centers, 38.2% of them used insulin four times a day, 68% complied with their treatment on a regular basis, and 56.7% received training on diabetes. Fifty-nine percent had other members of their patients with T2DM, and 50% of the participants felt tired all the time due to the medication they used (p.o. diabetes drugs and insulin). While the proportion of patients stating that they administrated insulin themselves was 70.6%, the remaining 29.4% said that others and mostly their children (12.9%) administrated it. The most frequently seen complications that developed due to T2DM were visual problems with 25.3% and kidney problems with 11.0%. The mean fasting blood glucose of research participants was 217.25 ± 96.47, their mean postprandial blood glucose was 311.15 ± 111.99, and their mean HbA1c was 9.20 ± 4.47%.
Comparison of the scores of MSPSS and FSS with the sociodemographic data of patients The overall mean scores obtained by the patients from the social support scale revealed that they received support mostly from their families (5.89 ± 1.70), this was followed by support from friends (5.52 ± 1.51), and support from significant other (5.35 ± 1.46). The overall mean score obtained by the patients from the FSS was 5.69 ± 1.61 (range, 1.0–7.0). A comparison of the sociodemographic characteristics of the patients and their mean FSS scores revealed that the statistical difference between age and FSS score was not significant; those who were 56 years of age and older had higher FSS scores than other age groups (P > 0.05). The difference between sex and the patients’ overall mean score of the FSS showed that female patients had a higher mean score of fatigue severity (5.76 ± 1.40) than that of male patients (4.89 ± 1.78) and the difference was statistically significant (P < 0.05). Education status of patients also created a significant difference on fatigue severity and those who were not literate had higher fatigue scores (P < 0.05). The statistical difference between occupation, cohabitation, and the FSS
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science 39.3 60.7 61.3 38.7 75.0 25.0 33.0 11.0 35.0 6.7 9.3 5.0 17.7 6.3 54.0 14.7 7.3 16.7 64.0 19.3 9.7 25.0 13.0 47.0 5.3 11.7 88.3 40.3 28.0 18.0 13.7 36.7 35.7 21.7 6.0 65.7 20.9 13.4 46.3 53.7 44.0 56.0
184 116 225 75 99 33 105 20 28 15 53 19 162 44 22 50 192 58 29 75 39 141 16 35 265 121 84 54 41 110 107 65 18 113 36 23 139 161 132 168
%
118 182
N
0.561 P = 0.575†
5.46 ± 1.59 5.33 ± 1.69
−1.65 P = 0.099† 2.103 P = 0.100§
1.91 P = 0.590‡
0.221 P = 0.896‡ 4.16 P = 0.001 2.99 P = 0.003†
5.16 ± 1.67 5.67 ± 1.45 5.43 ± 1.79 5.69 ± 1.43 5.46 ± 1.44 5.46 ± 1.66 5.45 ± 1.72 4.97 ± 1.98 5.42 ± 1.69 5.58 ± 1.57 5.32 ± 1.87 5.83 ± 1.31 5.07 ± 1.76 5.18 ± 1.28 5.74 ± 1.80
9.55 P = 0.049‡
2.716 P = 0.068§
25.54 P = 0.001‡
5.00 ± 1.83 5.48 ± 1.58
5.90 ± 1.13 5.20 ± 1.80 5.53 ± 1.70 5.54 ± 1.48 4.35 ± 1.1.87
5.88 ± 1.41 5.29 ± 1.64 5.49 ± 1.64
4.75 ± 1.71 4.62 ± 2.01 5.80 ± 1.40 5.39 ± 1.60 5.43 ± 1.61
14.01 P = 0.016‡
4.68 P = 0.001†
5.76 ± 1.40 4.89 ± 1.78
5.85 ± 1.28 5.46 ± 1.38 5.38 ± 1.73 5.05 ± 1.73 4.64 ± 2.08 4.85 ± 1.42
0.249 P = 0.804†
5.40 ± 1.56 5.44 ± 1.65
P
5.89 ± 1.73 5.89 ± 1.69
5.81 ± 1.50 5.96 ± 1.86
5.82 ± 1.65 5.45 ± 1.33 5.82 ± 1.46
6.00 ± 1.74 5.75 ± 1.66 5.73 ± 1.42 6.61 ± 2.42
5.86 ± 1.67 6.14 ± 1.88 5.64 ± 1.51 5.80 ± 1.63
6.54 ± 2.14 5.81 ± 1.62
6.08 ± 1.97 5.97 ± 1.93 5.93 ± 1.49 5.50 ± 2.16
6.28 ± 1.91 5.78 ± 1.62 5.93 ± 1.74 5.34 ± 1.23
5.73 ± 1.82 6.31 ± 2.28 5.87 ± 1.63 6.36 ± 164 5.13 ± 1.16
5.80 ± 1.52 5.56 ± 1.72 5.97 ± 1.67 6.00 ± 2.00 5.60 ± 1.77 6.93 ± 2.25
5.94 ± 1.66 5.74 ± 1.82
5.88 ± 1.65 5.91 ± 1.79
6.13 ± 1.75 5.74 ± 1.65
Family, mean ± SD
−0.025 P = 0.980†
.789 P = 430†
1.18 P = 0.552‡
3.47 P = 0.325‡
1.01 P = 0.385§
2.40 P = 0.017†
6.03 P = 0.199‡
1.68 P = 0.188§
10.33 P = 0.035‡
6.77 P = 0.238‡
2.07 P = 0.039†
−0.138 P = 0.890†
1.96 P = 0.051†
5.51 ± 1.42 5.52 ± 1.58
5.48 ± 1.38 5.55 ± 1.62
5.28 ± 1.35 5.62 ± 1.37 5.21 ± 1.08
5.75 ± 1.53 5.24 ± 1.26 5.77 ± 2.62 5.52 ± 1.51
5.47 ± 1.45 5.58 ± 172 5.55 ± 138 5.46 ± 1.45
6.05 ± 1.96 5.44 ± 1.43
5.68 ± 1.91 5.35 ± 1.40 5.58 ± 1.30 4.87 ± 1.66
5.48 ± 1.87 5.53 ± 1.48 5.93 ± 1.74 5.34 ± 1.31
5.84 ± 1.91 5.57 ± 1.64 5.41 ± 1.31 5.81 ± 1.7 44.86 ± 0.94
5.27 ± 1.26 5.39 ± 1.47 5.78 ± 1.72 5.70 ± 1.34 5.17 ± 1.46 6.00 ± 1.69
5.56 ± 1.52 5.38 ± 1.47
5.46 ± 1.33 5.61 ± 1.76
5.63 ± 1.52 5.44 ± 1.50
Friend, mean ± SD
−0.049 P = 0.961†
403 P = 0.687†
2.07 P = 0.355‡
5.22 P = 0.156
0.106 P = 0.957§
2.24 P = 0.025†
7.55 P = 0.110‡
0.034 P = 0.967§
7.24 P = 0.123‡
8.76 P = 0.119‡
0.879 P = 0.380†
−0.835 P = 0.404†
1.06 P = 0.288†
5.44 ± 1.42 5.28 ± 1.50
5.23 ± 1.24 5.46 ± 1.63
5.18 ± 1.45 5.34 ± 1.28 4.91 ± 1.04
5.55 ± 1.41 5.23 ± 1.47 5.10 ± 1.20 5.77 ± 2.31
5.44 ± 1.49 5.42 ± 1.62 5.18 ± 1.37 5.17 ± 1.13
5.60 ± 2.15 5.32 ± 1.35
5.70 ± 1.95 5.10 ± 1.33 5.34 ± 1.24 5.00 ± 1.41
5.60 ± 1.77 5.29 ± 1.39 5.36 ± 1.42 5.06 ± 1.09
5.54 ± 1.63 5.84 ± 2.21 5.32 ± 1.29 5.25 ± 1.6 34.90 ± 1.01
5.20 ± 1.10 5.24 ± 1.47 5.40 ± 1.57 5.75 ± 1.51 5.10 ± 1.44 6.20 ± 2.36
5.45 ± 1.52 5.05 ± 1.25
5.29 ± 1.28 5.45 ± 1.71
5.44 ± 1.53 5.30 ± 1.42
Special person, mean ± SD
Scores of MSPSS
.94 P = 0.346†
1.38 P = 0.166†
1.77 P = 0.412
7.14 P = 0.068‡
0.68 P = 0.565
1.04 P = 0.298†
5.68 P = 0.224‡
0.874 P = 0.418§
4.07 P = 0.396‡
5.12 P = 0.400‡
0.879 P = 0.380†
−0.938 P = 0.349
0.797 P = 0.426†
16.85 ± 3.60 16.70 ± 4.09
16.52 ± 3.16 16.98 ± 4.40
16.29 ± 3.56 16.42 ± 2.63 15.95 ± 2.97
17.31 ± 3.98 16.39 ± 3.55 16.09 ± 2.90 18.16 ± 6.78
16.79 ± 3.88 17.15 ± 4.36 16.38 ± 3.48 16.43 ± 3.35
18.20 ± 5.66 16.58 ± 3.55
17.46 ± 5.20 16.43 ± 3.55 16.86 ± 3.03 15.37 ± 5.01
17.36 ± 4.78 16.61 ± 3.66 16.79 ± 3.74 15.75 ± 2.99
17.13 ± 4.58 17.73 ± 5.58 16.61 ± 3.26 17.43 ± 4.40 14.90 ± 2.87
16.28 ± 2.66 16.27 ± 3.87 17.16 ± 4.37 17.45 ± 4.11 15.89 ± 3.98 19.13 ± 5.54
16.96 ± 3.92 16.18 ± 3.71
16.64 ± 3.36 16.98 ± 4.59
17.21 ± 4.06 16.48 ± 3.74
Total, mean ± SD
0.32 P = 0.74†
1.02 P = 0.305†
0.42 P = 0.808‡
6.24 P = 0.100
0.546 P = 0.651§
2.33 P = 0.020†
7.26 P = 0.123‡
0.731 P = 0.483§
5.86 P = 0.210‡
6.62 P = 0.250‡
1.514 P = 0.131†
−0.741 P = 0.459†
1.57 P = 0.115†
P
*Actively working in own occupation. †Independent Student’s t-test. ‡Kruskal–Wallis. §One-way anova. FSS, Fatigue Severity Scale; HbA1c, hemoglobin A1c; MSPSS, Multidimensional Scale of Perceived Social Support; SD, standard deviation.
Age groups (years) 18–55 ≥56 Sex Female Male Marital status Married Single/widowed Level of education Illiterate Literate Primary school Secondary school High school Faculty/college Occupation Retired Officer Housewife Employee Unemployed Economic status Poor Moderate Good Status of cohabitation Alone With spouse With children With spouse and children With parents Still working* Yes No Duration of diabetes (years) 1–6 7–12 13–19 ≥20 Treatment received Oral diabetes drugs Insulin Diabetes drugs and insulin None Duration of insulin (years) 1–5 6–10 ≥11 Presence of complications Yes No Levels of HbA1c 5–8% ≥9%
Features
Scores of FSS, mean ± SD
Table 1 Comparison of sociodemographic and disease-related characteristics of patients with their mean MSPSS and FSS scores
Japan Journal of Nursing Science (2015) 12, 367–376 Social support and fatigue in patients
371
R. Aylaz et al.
Japan Journal of Nursing Science (2015) 12, 367–376
score was significant, and housewives and those living alone had higher FSS scores than the others. No significant relationship was found between the FSS score and marital or economic status (P > 0.05) (Table 1). When the present authors examined the comparison of the patients’ sociodemographic characteristics with their mean MSPSS and subdomain scores, while there were no statistically significant differences between overall MSPSS score and marital status or occupation, the difference between the scores of support from family was statistically significant and those who were married and who were workers received more support. There were no statistically significant differences between the MSPSS scores and age, sex, education, economic status, or cohabitation (P > 0.05) (Table 1).
Comparison of MSPSS scores and FSS scores with disease-related data of patients The difference between the FSS score and the presence of diabetes-related complications in the patients and HbA1c was statistically significant, and the fatigue scores of the patients who had HbA1c levels of above 9% were found to be higher (P < 0.05). No significant relationship was found between the FSS score and duration of diabetes, treatment received, and duration of insulin use (P > 0.05) (Table 1). There were no statistically significant differences between the MSPSS scores and duration of diabetes, the presence of complications, HbA1c levels, treatment received, and duration of insulin use (P > 0.05) (Table 1).
Comparison of the relationship between the mean scores of MSPSS and FSS The overall mean MSPSS score of the patients was 16.77 ± 3.88 (range, 12.0–42.0) and the overall mean score they obtained from the FSS was 5.69 ± 1.61 (range, 1.0–7.0). A correlation analysis between fatigue severity and social support in patients with T2DM showed that there was a significant negative correlation between fatigue severity and support from family (r = −0.145, P < 0.05) and overall support (r = −0.132, P < 0.05). The patients whose fatigue was less severe had higher mean scores of family and overall support. No significant relationship was found between fatigue severity and support from friends (r = −0.101, P > 0.05) or support from significant other (r = −0.86, P > 0.05) (Table 2).
372
Table 2 Comparison of the relationship between the mean scores of Multidimensional Scale of Perceived Social Support and the Fatigue Severity Scale (MSPSS) of perceived social support and Fatigue Severity Scale (FAS) (n = 300) Scores of MSPSS Scales Scores of FSS
Special person
Family
Friend
Total
−0.86 P = 0.137
−0.145 P = 0.012
−0.101 P = 0.80
−0.132 P = 0.22
DISCUSSION In this study, the present authors tried to determine the relationship between social support and fatigue in patients with T2DM and to reveal the levels of social support and fatigue and the variables that affected these. The importance of this study increases when it is considered that it was conducted in the east of Turkey where relatively less service is provided although T2DM is more common and that this subject has not been dealt with sufficiently. It was found that the patients who were included in the study had support mostly from their families and they received less support from their friends and significant others. The support these patients receive from their families is a strong source for preventing and solving their social and psychological problems and for coping with the situations where they struggle during their treatment. They received social support mostly from their children during insulin administration. Similar studies have also shown that the major source of support for patients with diabetes is their families (Brouwer et al., 2012; Karakurt et al., 2013; Schiøtz et al., 2012; Tol et al., 2011). The Turkish community has strong family ties and the “family comes first” ideal motivates Turkish family members to protect the health of other family members (Asti, Kara, Ipek, & Erci, 2006). The support received from the family, where one receives unconditional love, is very important for the individual in coping with problems. Positive family relationships strengthen the individual and facilitate their adaptation to the disease. Studies on patients with T2DM have reported that increased support received from the family produced better glycemic index results, compliance with the treatment, and self-management (Boas et al., 2012; Brouwer et al., 2012; Schiøtz, Bøgelund, Almdal, Jensen, & Willaing, 2012; Tol et al., 2011). The mean scores of family support of those who were married were found to be higher in the study. This may
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 367–376
be due to the support married patients received from their family members such as their spouses or children. It was stressed in similar studies of with various sample groups with other chronic diseases that families and spouses played a major role as a source of coping, that the family was very important in providing emotional support to the person, and that they also provided support by sharing the responsibilities inflicted on the individual by the disease process and the problems such as the life and the changes in roles the patients experienced due to a chronic disease (Karadag, Kilic, & Metin, 2013; Karakoç & Yurtsever, 2010). The family support, friend support and overall support scores of those who were employed were found to be higher in the present study. It was also found in the study of Kahraman, Çinar, and Pinar (2006) that family, friends, and overall support was higher in individuals who were employed than in those who were unemployed or retired. It is possible to say that being employed in a job makes many contributions in a social sense such that it brings respect to the individual and enables him/her to have social interaction and to earn a reputation in society. When an individual works, this brings social status to him/herself and their families and this status regulates the individual’s life. No statistically significant difference was found in this study between the presence of complications that developed in the patients due to diabetes and HbA1c, and the family support, friend support, and total support scores. Moreover, because 59.0% of the patients in this study had other patients with T2DM in their families, they could have had inabilities to provide social support to each other. The fatigue level of the patients with T2DM who participated in this research was found to be high. In a study by Singh and Kluding (2013) with individuals with T2DM, the mean score of the Fatigue Assessment Scale was found to be as high as 25.10 ± 7.62. A study conducted in Turkey also reported that 40.3% of patients with T2DM experienced fatigue (Azak et al., 2008). The level of fatigue was found to be high also in other studies of patients with T2DM (Fritschi et al., 2012; Lasselin et al., 2012). In the present study, female patients were found to be significantly more tired than male patients. This result suggests that female patients may be more tired because they assume more responsibility at home (e.g. child care, housework) due to the traditional social structure in the east of Turkey. Moreover, in Turkish society, which accommodates patriarchal characteristics, it is a family
Social support and fatigue in patients
doctrine that men should look strong and it can be observed that men try more to avoid talking about their diseases. Azak et al. (2008) also found in their study of individuals with T2DM that female patients were more tired. In a study by Karakoç and Yurtsever (2010) of cancer patients, female patients had more fatigue than males. In the present study, illiterate patients were found to be more tired than patients who had higher levels of education. A low level of education might have caused individuals to comprehend less of the training given on management of diabetes and to develop inadequate management of the condition, leading to an increase in physical fatigue. Economic status may also be poorer in parallel with a lower level of education and these patients might have experienced more fatigue due to reasons such as circumstances creating physical and emotional stress on individuals and benefiting less from healthcare services. It is stated in the study by Lerdal, Celius, and Moum (2003) of patients with multiple sclerosis and similarly in the study of Karakoç and Yurtsever (2010) that as the level of education goes down, the level of fatigue goes up. In this study, the FSS scores of the patients living alone were higher than those living with their spouses and children. When the responsibilities inflicted on the individual by the disease process as well as their personal responsibilities can be shared by the spouse and children in patients who live with their spouses and children, this can be effective in decreasing the fatigue being experienced. This may not be possible in individuals who live alone. De Jong, Candel, Schouten, Abu-Saad, and Courtens (2005) found in their study of cancer patients that individuals living with their spouses and children experienced less fatigue. The difference between the FSS score and the presence of diabetes-related complications that developed in the patients and HbA1c was statistically significant in this study and the level of fatigue was found to be higher in the patients who had HbA1c levels above 9%. The other studies also indicate that there is a significant difference between HbA1c levels and fatigue (Azak et al., 2008; Lasselin et al., 2012). In a parallel study, Singh and Kluding (2013) also reveal that there is significant difference between the presence of diabetes-related complications and fatigue (Singh & Kluding, 2013). HbA1c is a clinically useful index of the average glycemia in the past 120 days and an indicator of the risk of developing diabetic complications (Altunog˘lu et al., 2012; Çitil, Öztürk, & Günay, 2010; Tekes¸in, Dog˘an, Yag˘iz, & Polat, 2014). The observed complications may
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
373
R. Aylaz et al.
Japan Journal of Nursing Science (2015) 12, 367–376
negatively impact the patient’s quality of life and this leads to over-fatigue (Altunog˘lu et al., 2012; Azak et al., 2008; Singh & Kluding, 2013). When the correlation analysis carried out between fatigue severity and social support in patients with diabetes was examined, a significant correlation was found in the negative direction between fatigue severity and family support as well as overall support. The mean family and overall support scores were higher in patients with low fatigue severity. Although no study has been carried out with patients with T2DM exploring a relationship between fatigue severity and social support, there are a limited number of similar studies with different patient groups. It has been found in studies of various disease groups that these two factors affected each other in the negative direction. Fatigue may cause social relationships to weaken by decreasing physical and social mobility. Inadequacy of social support components may also be shown as a cause of emergence of fatigue (Karakoç & Yurtsever, 2010). It has been found in studies of patients with chronic fatigue syndrome that inadequate social support increased fatigue severity (Jason et al., 2010; Prins et al., 2004). Karakoç and Yurtsever (2010) stated in their study with patients receiving chemotherapy that as the levels of social support increased in patients, the severity of fatigue experienced by them decreased. In their study of hemodialysis patients, Karadag et al. (2013) found a significant relationship in the negative direction between fatigue severity and social support. Mancuso, Rincon, Sayles, and Paget (2006) also found in their study that patients with rheumatoid arthritis who had less social support experienced more fatigue.
Practical implications In light of the results of the present authors’ study, it is clear that social support is vital for patients who have to cope with the debilitating symptom of fatigue. Assuming a holistic approach and activating the social support resources for diabetes patients will help to manage this symptom. Optimal utilization of the social support resources will help activate resources, manage fatigue, maintain functional sufficiency, and improve quality of life for diabetes patients. Patients should be provided with support resources such as friends and family members, and also support groups for patients should be increased. Training programs can be prepared for patient families about the effectiveness of social support in controlling symptoms of fatigue. Informative, supportive
374
consultation services can be provided to develop the social support skills of families.
Limitations Because only patients with T2DM were included in the study, it can be generalized only to these patients. This study collected data from only two hospitals in Turkey; thus, its generalizability is limited. Another limitation of this study was that most of the patients participating in the study had poor glycemic control.
CONCLUSION It was found in the study that the patients with T2DM had a high severity of fatigue and the patients received support mostly from their families, which was followed by support from friends and from special persons, respectively. It was also observed that there was a significant relationship in the negative direction between fatigue severity and social support, and the level of social support provided to the patients had an effect on their fatigue. Nurses tending patients with T2DM should carry out fatigue assessments routinely and reflect these in nursing care plans by also associating them with the social support sources of the patient. Future research should include interventional studies that will enable patients with T2DM to cope with fatigue and to strengthen their social support systems.
ACKNOWLEDGMENTS The present authors would like to thank all those who participated in this study. They would also like to thank Malatya State Hospital and Inonu University Turgut Ozal Medical Center health personnel for their help and cooperation.
CONFLICT OF INTEREST The authors of this paper have no conflicts of interest to report. All authors have materially participated in the research and/or article preparation. All authors have approved the final article.
AUTHOR CONTRIBUTION All authors were involved in study design, data collection, and manuscript development. R. A. and E. K.
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 367–376
wrote the paper. K. I. and M. Y. performed the statistical analysis. All authors read and approved the final manuscript.
REFERENCES Altintoprak, E., Cos¸kunol, H., Kesebir, S., Yildiz, U. & Yüncü, Z. (2005). Assessment of social support systems of patients, those have the alcohol use problem. Journal of Dependence, 6, 129–135. Altunog˘lu, E. G., Sari, Z., Erdenen, F., Müderrisog˘lu, C., Ülgen, E. & Sari, M. (2012). The relationship of depression, anxiety and disability with hba1c and the duration of diabetes in patients with type 2 diabetes mellitus. Journal of Istanbul Medicine, 13, 115–119. American Diabetes Association. (2013). Standards of medical care in diabetes. Diabetes Care, 36, 11–66. Armutlu, K., Korkmaz, N. C., Keser, I., Sumbuloglu, V., Akbiyik, D. I., Guney, Z. et al. (2007). The validity and reliability of the Fatigue Severity Scale in Turkish multiple sclerosis patients. International Journal of Rehabilitation Research, 30, 81–85. Asti, T., Kara, M., Ipek, G. & Erci, B. (2006). The experiences of loneliness, depression, and social support of Turkish patients with continuous ambulatory peritoneal dialysis and their caregivers. Journal of Clinical Nursing, 15, 490– 497. Azak, A., Altundag˘, S., Sert, H. & Çinar, S. (2008). Acute fatigue syndrome in patients with type II diabetes mellitus and influencing factors. Journal of Health Sciences Firat University, 22, 73–76. Azak, A. & Çinar, S. (2005). Fatigue Syndrome in Patients with Lymphoma (Hodgkin and Non-Hodgkin) and Influencing Factors. The Turkish Journal of Hematology and Oncology, 2, 78–85. Boas, L. C., Foss, M. C., Freitas, M. F. & Pace, A. E. (2012). Relationship among social support, treatment adherence and metabolic control of diabetes mellitus patients. Enfermagem, 20, 52–58. Brouwer, A. M., Salamon, K. S., Olson, K. A., Fox, M. M., Yelich-Koth, S. L., Fleischman, K. M. et al. (2012). Adolescents and type 2 diabetes mellitus: A qualitative analysis of the experience of social support. Clinical Pediatrics, 51, 1130–1139. Çitil, R., Öztürk, Y. & Günay, O. (2010). Metabolic regulation and related factors in diabetic patients referred to a primary health center in provincial center of kayseri. Erciyes Medical Journal, 32, 111–122. De Jong, N., Candel, M. J. J., Schouten, H. C., Abu-Saad, H. H. & Courtens, A. M. (2005). Course of mental fatigue and motivation in breast cancer patients receiving adjuvant chemotherapy. Annals of Oncology, 16, 372–382. Drivsholm, T., Olivarius, N., Nielsen, A. B. & Siersma, V. (2005). Symptoms, signs and complications in newly
Social support and fatigue in patients
diagnosed type 2 diabetic patients, and their relationship to glycaemia, blood pressure and weight. Diabetologia, 48, 210–214. Eker, D. & Arkar, H. (1995). Factorial structure, validity, and reliability of the Multidimensional Scale of Perceived Social Support. Journal of Turkish Psycholog, 34, 45–55. (in Turkish). Eker, D., Arkar, H. & Yaldiz, H. (2001). Factorial structure, validity, and reliability of revised form of the Multidimensional Scale of Perceived Social Support. Journal of Turkish Psychiatry, 12, 17–25. (in Turkish). Fritschi, C. & Quinn, L. (2010). Fatigue in patients with diabetes: A review. Journal of Psychosomatic Research, 69, 33–41. Fritschi, C., Quinn, L., Hacker, E. D., Penckofer, S. M., Wang, E., Foreman, M. et al. (2012). Fatigue in women with type 2 diabetes. The Diabetes Educator, 38, 662–672. IDF-International Diabetes Federation. (2013). IDF diabetes atlas. [Cited 2 May 2014.] Available from URL: http:// www.idf.org/diabetesatlas IDF-International Diabetes Federation. (2005). Global guideline for type 2 diabetes. [Cited 15 April 2013.] Available from URL: http://www.idf.org Jason, L. A., Roesner, N., Porter, N., Parenti, B., Mortensen, J. & Till, L. (2010). Provision of social support to individuals with chronic fatigue syndrome. Journal of Clinical Psychology, 66, 249–258. Kahraman, A., Çinar, S. & Pinar, R. (2006). Relationship between depression and perceived social support levels in hemodialysis patients. Journal of Turkish Nephrology Dialysis and Transplantation, 15, 130–133. (in Turkish). Karadag, E., Kilic, S. P. & Metin, O. (2013). Relationship between fatigue and social support in hemodialysis patients. Nursing and Health Sciences, 15, 164–171. Karakoç, T. & Yurtsever, S. (2010). Relationship between social support and fatigue in geriatric patients receiving outpatient chemotherapy. European Journal of Oncology Nursing, 14, 61–67. Karakurt, P., Hacihasanog˘lu, R. & Yildirim, A. (2013). Evaluation of the self-care agency and perceived social support in patients with diabetes mellitus. Journal of Faculty Medicine Adnan Menderes University, 14, 1–9. (in Turkish). Krupp, L. B., LaRocca, N. G., Muir-Nash, J. & Steinberg, A. D. (1989). The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Archives of Neurology, 46, 1121–1123. Lasselin, J., Layé, S., Barreau, J. B., Rivet, A., Dulucq, M. J., Gin, H. et al. (2012). Fatigue and cognitive symptoms in patients with diabetes: Relationship with disease phenotype and insulin treatment. Psychoneuroendocrinology, 37, 1468–1478. Lerdal, A., Celius, E. G. & Moum, T. (2003). Fatigue and its association with sociodemographic variables among multiple sclerosis patients. Multiple Sclerosis, 9, 509–514.
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
375
R. Aylaz et al.
Japan Journal of Nursing Science (2015) 12, 367–376
Mancuso, C. A., Rincon, M., Sayles, W. & Paget, S. A. (2006). Psychosocial variables and fatigue: A longitudinal study comparing individuals with rheumatoid arthritis and healthy controls. The Journal of Rheumatology, 33, 1496–1502. Prins, J. B., Bos, E., Huibers, M. J., Servaes, P., van der Werf, S. P., van der Meer, J. W. et al. (2004). Social support and the persistence of complaints in chronic fatigue syndrome. Psychotherapy and Psychosomatics, 73, 174–182. Satman, I., Omer, B., Tutuncu, Y., Kalaca, S., Gedik, S., Dinccag, N. et al. (2013). Twelve-year trends in the prevalence and risk factors of diabetes and prediabetes in Turkish adults. European Journal of Epidemiology, 28, 169–180. Schiøtz, M. L., Bøgelund, M., Almdal, T., Jensen, B. B. & Willaing, I. (2012). Article: Education and psychological aspects. Social support and self-management behaviour among patients with type 2 diabetes. Diabetic Medicine, 29, 654–661. Singh, R. & Kluding, P. M. (2013). Fatigue and related factors in people with type 2 diabetes. The Diabetes Educator, 39, 320–326. Tang, T. S., Brown, M. B., Funnell, M. M. & Anderson, R. M. (2008). Social support, quality of life and self-care behaviors among african americans with diabetes. The Diabetes Educator, 34, 266–276.
376
Tekes¸in, A., Dog˘an, B., Yag˘iz, O. & Polat, H. (2014). The correlation between cerebrovascular disease and HBA1C levels in patients with type 2 diabetes mellitus. Journal of Istanbul Medicine, 15, 40–42. (in Turkish). Tezcan, M. (2013). Since the republic turkish family past, present, future. [Cited 7 May2014.] AvailablefromURL: http://www.turkoloji.cu.edu.tr/GENEL/tezcan_aie.pdf Tol, A., Baghbanian, A., Rahimi, A., Shojaeizadeh, D., Mohebbi, B. & Majless, F. (2011). The Relationship between perceived social support from family and diabetes control among patients with diabetes type 1 and type 2. Journal of Diabetes and Metabolic Disorders, 10, 1–8. TURDEP II. (2010). Diabetes, Hypertension, Obesity and Endocrinology Diseases Prevalence Study II in Turkey. [Cited 2 June 2014.] Available from URL: http://www .turkendokrin.org Turkey Statistical Institution. (2013). Education Statistics in Turkey, Turkey Statistical Institution 2013. [Cited 5 June 2014.] Available from URL: http://www.tuik.gov.tr Yönt, H., Akin Korhan, E. & Çiray Gündüzog˘lu, N. (2012). Fatigue after stroke and quality of life. Journal of Health Sciences Firat University, 26, 115–120. (in Turkish). Zimet, G. D., Dahlem, N. W., Zimet, S. G. & Farley, G. K. (1988). The multidimensional scale of perceived social support. Journal of Personality Assessment, 52, 30–41.
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 367–376
doi:10.1111/jjns.12076
ORIGINAL ARTICLE
Relationship between social support and fatigue in patients with type 2 diabetes mellitus in the east of turkey ˘ ,2 Kevser IS¸IK1 and Melek YILDIRIM3 Rukuye AYLAZ,1* Ezgi KARADAG Departments of 1Public Health Nursing, School of Health, Inonu University, 3Internal Medicine Nursing, Malatya State Hospital, Malatya, 2Internal Medicine Nursing, Tunceli University Health High School, Tunceli, Turkey
Abstract Aim: This study was planned to assess the levels of fatigue and social support in patients with diabetes and to determine the relationship between fatigue and social support in these patients. Methods: A descriptive design was used in this research. The study was conducted between March and June 2013 with 300 sampled patients from 1657 studied participants with type 2 diabetes who presented to the diabetes polyclinics of Malatya State Hospital and Inonu University, Turgut Ozal Medical Center. The Multidimensional Scale of Perceived Social Support and the Fatigue Severity Scale were used in the study. Results: When the correlation analysis carried out between fatigue severity and social support in patients with diabetes was examined, a significant relationship was found in the negative direction between fatigue severity and family support (r = −0.145, P < 0.05) as well as overall support (r = −0.132, P < 0.05). A statistically significant difference was found between the Fatigue Severity Scale score and sex, education status, occupation, cohabitation, presence of complications, and hemoglobin A1c (P < 0.05). Family support was significant only with respect to marital status, occupation, and being employed (P < 0.05). Conclusion: It was seen at the end of this research that social support reduced the level of fatigue in a number of patients with type 2 diabetes. Nurses of diabetes patients should carry out fatigue assessments routinely and reflect these in nursing care plans by also associating them with the social support sources of the patient. Key words: fatigue, nursing, patients, social support, type 2 diabetes.
INTRODUCTION Diabetes mellitus is a chronic illness that requires continuing medical care and ongoing patient selfmanagement, education, and support to prevent acute complications and to reduce the risk of long-term complications (American Diabetes Association, 2013). According to the most recent estimates from the International Diabetes Federation (IDF), 8.3% of adults – 382 million people – have diabetes, and the number of Correspondence: Rukuye Aylaz, Department of Public Health Nursing, Malatya School of Health, Inonu University, Malatya 44280, Turkey. Email: [email protected] * Present address: Department of Oncology Nursing, Dokuz Eylül University Faculty of Nursing, I˙zmir 35100, Turkey. Received 19 March 2014; accepted 28 January 2015.
people with the disease is set to rise beyond 592 million in less than 25 years (IDF-International Diabetes Federation, 2013). According to the results of the Turkish Diabetes Epidemiology Study (TURDEP) that was carried out at 540 sites in 15 provinces in Turkey, the prevalence of diabetes in the Turkish adult population has reached 13.7% (TURDEP II, 2010). The same study revealed that the regional diabetes prevalence was the highest in the east of Turkey with 18.2% (Satman et al., 2013). The region where this study was carried out was found to come first in Turkey with 20% of T2DM patients in the diabetes statistics performed by TURDEP in 2010. Fatigue is a general, frequently seen complaint experienced by everyone in daily life. Although it is a universal symptom that occurs in all physical and mental diseases in varying degrees, it is quite difficult to define
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
R. Aylaz et al.
Japan Journal of Nursing Science (2015) 12, 367–376
it and it has been defined differently by many healthcare disciplines. Fatigue is used in the same sense as weakness, lassitude, lack of energy, and debility; it can be defined as a state of physical and mental exhaustion to include, in a sense, all of these (Azak, Altundag˘, Sert, & Çinar, 2008; Yönt, Akin Korhan, & Gündüzog˘lu, 2012). According to another definition, fatigue is an unpreventable feeling of exhaustion that occurs in situations such as muscular weakness, accumulation of waste material, and inflammatory processes (Azak & Çinar, 2005). When it is not put under control, it becomes an important symptom that adversely affects the individual’s daily life activities and quality of life (Fritschi et al., 2012). Fatigue is a widespread clinical complaint among adults with type 2 diabetes (T2DM), has been directly related to poor self-reported health, and is likely a key barrier to successful self-management of diabetes (Fritschi et al., 2012). In these patients, various physiological, psychological, and social factors lead to fatigue. These factors include physiological factors such as diabetes-related hypo/hyperglycemia attacks, drug side-effects due to polypharmacy and presence of comorbid conditions, psychological factors such as intensity of self-management regimens in diabetes, sleep disturbances, and diagnosis-related emotional distress or depression, and lifestyle changes such as being overweight/reduced physical activity (Fritschi & Quinn, 2010; Fritschi et al., 2012; Lasselin et al., 2012). The presence of short- and long-term complications of diabetes and their symptoms, including symptoms of hypoor hyperglycemia, cardiac disease, neuropathy, or retinopathy, has also been associated with increased fatigue (Singh & Kluding, 2013). It is seen in many studies that the prevalence of fatigue is high in patients with T2DM (Azak et al., 2008; Lasselin et al., 2012). In an epidemiological study of 1137 subjects with T2DM, the prevalence of fatigue was found to reach 61% (Drivsholm, Olivarius, Nielsen, & Siersma, 2005). In a study by Singh and Kluding (2013) of individuals with T2DM, the mean score of the Fatigue Severity Scale (FSS) was found to be as high as 4.28 ± 1.49. The level of fatigue has also been found to be high in other studies of individuals with T2DM (Fritschi et al., 2012; Lasselin et al., 2012). Coping with fatigue in chronic diseases requires effective social support. A significant relationship was found between social support and fatigue in the study of Prins et al. (2004). Social support can be defined as the assistance supplied to an individual by the people around him/her.
368
Studies carried out in recent years state that the term “social support” is divided into two groups: perceived social support and received social support. The former is support the individual believes is available to him/her in times of need; the latter is the support actually received by the individual in real life (Eker et al., 2001; Karakurt, Hacihasanog˘lu, & Yildirim, 2013). Social support means satisfying an individual’s basic needs such as belongingness, affection, appreciation, and selfrealization as a result of the interaction he/she establishes with other individuals such as friends, family, or professional advisors (Eker et al., 2001; Karakurt et al., 2013). According to another definition, social support is an aid provided to the individual under stress or in difficult situations by the people around him/her; a support conveyed from his/her social connections with other people, groups, and community; and a special concept showing that he/she is loved and appreciated and is in communication based on mutual cooperation (Altintoprak, Cos¸kunol, Kesebir, Yildiz, & Yüncü, 2005). Social support has been demonstrated to be an important psychosocial factor linked to healthy diet behaviors, physical activity, and adherence to medication among those with T2DM (Boas, Foss, Freitas, & Pace, 2012; Brouwer et al., 2012; Schiøtz et al., 2012). The International Diabetes Federation confirms that poor social support is a predictor of poor adherence to prescribed therapy (IDF-International Diabetes Federation, 2005). Additionally, studies carried out among patients with T2DM show that as social support increases, patients feel better physically and psychologically, cope more easily with stress and fatigue, and display improved diabetic self-management (Schiøtz et al., 2012; Tang, Brown, Funnell, & Anderson, 2008). Social support involves not only family support but also persons with whom the individual interacts outside the family (friends) and social facilities (e.g. financial support, services). Social support from family and friends has been demonstrated to reduce stress related to performing self-care behaviors, facilitate adjustment to and coping with a diabetes diagnosis, and provide resources for frequent engagement in self-care behaviors (Boas et al., 2012; Brouwer et al., 2012). In patients with a chronic disease, as the level of social support increases, physical and psychological welfare as well as coping with stress and fatigue improve. Because fatigue occurs in association with psychophysiological reasons in patients with T2DM, the hypothesis comes up that the level of fatigue in patients may be affected positively as social support increases.
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 367–376
If nurses deal with fatigue symptoms and the factors affecting fatigue in patients with T2DM and activate the social support systems of the patient, this may be effective in improving the patient’s well-being. Assessing social support and fatigue is important to help nurses plan appropriate interventions that can enhance people’s adaptation to their disease and, consequently, improve treatment adherence. However, there are no study results that explain the relationship between social support and fatigue in patients with diabetes. This study will provide new data for the published work on this subject. The Turkish nation has a traditional structure. Due to this social structure, the responsibility of daily housework and child care is assumed by women (Tezcan, 2013). Women participate in the workforce at a rate of one third that of men. The rate at which women participate in the workforce in Turkey is the lowest among the member and candidate countries of the European Union. The 8 year compulsory education came into force in Turkey in 1997; as the majority of survey participants were aged 56 years and over, a number were illiterate. The illiterate male population in Turkey was 1.4% in 2012, whereas this rate was 7% in women and even higher in the region where the present study was carried out (Turkey Statistical Institution, 2013). The aim of this study is to assess the levels of fatigue and social support, to examine the demographic and disease-related factors associated with fatigue and social support, and to determine the relationship between fatigue and social support.
METHODS Study design and sample In an average year, 1657 patients with T2DM are treated at Malatya State Hospital and Inonu University Turgut Ozal Medical Center. Between March and June 2013, the sample size was defined as 312 patients according to the sample calculation method where the number of the population is known. However, patients who did not wish to participate in the study (n = 8) and those who had speech problems (n = 4) were excluded from the study. Therefore, the sample consisted of 300 patients with T2DM who met the study criteria and who agreed to take part in the study. The criteria for inclusion were: (i) having been diagnosed at least 1 year ago; (ii) not having any hearing or speech problem; and (iii) the absence of depression from medical record.
Social support and fatigue in patients
Data collection A questionnaire consisting of 18 questions for sociodemographic and disease data as well as the Multidimensional Scale of Perceived Social Support and the Fatigue Severity Scale were used in the study. The questionnaire, the Multidimensional Scale of Perceived Social Support (MSPSS), and Fatigue Severity Scale (FSS) were administered to the patients in the diabetes outpatient clinic.
Procedure The questionnaire and the scale were administered by way of face-to-face interviews after the written and verbal consent of the subjects was obtained. The investigators read the questions for those who were illiterate and marked the answers after making certain that the questions were understood. The questionnaire took approximately 15–20 min to complete.
Instruments Questionnaire for sociodemographic and disease characteristics The sociodemographic data were collected through 10 questions about age, sex, marital status, education, occupation, employment status, economic status, residence, number of children, cohabitation, and the disease-related data through eight questions about duration of diabetes disease, treatment of diabetes, presence of any chronic disease other than diabetes, duration of insulin use, frequency of daily insulin use, compliance with the treatment, and diabetes education in the past.
MSPSS This scale, which was developed by Zimet et al. (1988) and whose validity and reliability in Turkish were assessed by Eker and Arkar (1995), subjectively assesses the adequacy of social support received from three different sources. Three different support sources – family, friends, and a significant other – can be assessed using this scale with 12 expressions. This scale shows the level of social and psychological support the individual received from the people around them. These social supports include individuals’ being liked and loved by others (emotional support); being respected (respect support); getting financial aid (instrumental support); helping an individual to understand, define, and cope with the problem (informational support); and social friendship support. The total score of the scale can also be found by adding the subscale scores. Each item is rated by using a 7 point measure with a Likert-type scoring. The scores of the subdimensions in the scale
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
369
R. Aylaz et al.
Japan Journal of Nursing Science (2015) 12, 367–376
range between 4 and 28 and the total score of the scale between 12 and 84. Obtaining a high score means a high level of perceived social support (Eker & Arkar, 1995). Cronbach’s coefficient alphas of subscales were found to be between 0.77 and 0.92 (Eker & Arkar, 1995). The overall internal consistency coefficient was found to be 0.84 in this study.
FSS Perceived fatigue was measured with the FSS (Krupp, LaRocca, Muir-Nash, & Steinberg, 1989). The 9 item scale measures the severity of fatigue and its effect on a person’s activities and lifestyle in patients with a variety of disorders. It assesses the physical fatigue of the patients. This scale has good evidence of internal consistency, test–retest reliability and score validity (Krupp et al., 1989). The FSS has high reliability with a Cronbach’s alpha coefficient of 0.88. The Turkish version of the scale was administered to multiple sclerosis subjects by Armutlu et al. (2007). Cronbach’s alpha value of the study was found to be 0.95.
Permission and ethics Written permissions were obtained from the Scientific Ethics Committee of Malatya Inonu University Turgut Ozal Medical Center and from the Chief Physician of Malatya State Hospital. Before administering the forms, the purpose of the study was explained to the patients and their verbal approvals were obtained; their privacy was respected.
Statistical analyses In evaluating the data, the descriptive characteristics of patients and the information on the illness were taken as the independent variables and the scores obtained from the MSPSS and the FSS as the dependent variables. The statistical analyses to evaluate the data were carried out using the program Statistical Package for the Social Sciences version 16.0 (SPSS, Chicago, IL, USA). After using the Kolmogorov–Smirnov test to determine whether the data variance was standard, the variance analysis, independent Student’s t-test, and Pearson’s correlation analysis were used for the parametric data. Kruskal– Wallis was used for the non-parametric data. The level of significance was accepted to be P < 0.05 in the study.
RESULTS Of those who took part in the research, 61.3% were female, 38.7% were male, most of them (60.7%) were 56 years of age and older, 75% were married, 35%
370
were graduates of primary school, and 54% were housewives. More than half of the participants (64.0%) had a medium level of economic status, 47% lived with their spouses and children, 40.3% had had diabetes for 1–6 years, 36.7% used oral diabetes drugs for treatment, 65.7% of those who used insulin had used it for 1–5 years, and the hemoglobin A1c (HbA1c) levels of 56.0% of the patients were 9% and above (Table 1). Of the results of the patients who participated in the study, which are not shown in the table, 61.3% had four and more children, 91.7% had social security, 76.7% of them resided in provincial centers, 38.2% of them used insulin four times a day, 68% complied with their treatment on a regular basis, and 56.7% received training on diabetes. Fifty-nine percent had other members of their patients with T2DM, and 50% of the participants felt tired all the time due to the medication they used (p.o. diabetes drugs and insulin). While the proportion of patients stating that they administrated insulin themselves was 70.6%, the remaining 29.4% said that others and mostly their children (12.9%) administrated it. The most frequently seen complications that developed due to T2DM were visual problems with 25.3% and kidney problems with 11.0%. The mean fasting blood glucose of research participants was 217.25 ± 96.47, their mean postprandial blood glucose was 311.15 ± 111.99, and their mean HbA1c was 9.20 ± 4.47%.
Comparison of the scores of MSPSS and FSS with the sociodemographic data of patients The overall mean scores obtained by the patients from the social support scale revealed that they received support mostly from their families (5.89 ± 1.70), this was followed by support from friends (5.52 ± 1.51), and support from significant other (5.35 ± 1.46). The overall mean score obtained by the patients from the FSS was 5.69 ± 1.61 (range, 1.0–7.0). A comparison of the sociodemographic characteristics of the patients and their mean FSS scores revealed that the statistical difference between age and FSS score was not significant; those who were 56 years of age and older had higher FSS scores than other age groups (P > 0.05). The difference between sex and the patients’ overall mean score of the FSS showed that female patients had a higher mean score of fatigue severity (5.76 ± 1.40) than that of male patients (4.89 ± 1.78) and the difference was statistically significant (P < 0.05). Education status of patients also created a significant difference on fatigue severity and those who were not literate had higher fatigue scores (P < 0.05). The statistical difference between occupation, cohabitation, and the FSS
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science 39.3 60.7 61.3 38.7 75.0 25.0 33.0 11.0 35.0 6.7 9.3 5.0 17.7 6.3 54.0 14.7 7.3 16.7 64.0 19.3 9.7 25.0 13.0 47.0 5.3 11.7 88.3 40.3 28.0 18.0 13.7 36.7 35.7 21.7 6.0 65.7 20.9 13.4 46.3 53.7 44.0 56.0
184 116 225 75 99 33 105 20 28 15 53 19 162 44 22 50 192 58 29 75 39 141 16 35 265 121 84 54 41 110 107 65 18 113 36 23 139 161 132 168
%
118 182
N
0.561 P = 0.575†
5.46 ± 1.59 5.33 ± 1.69
−1.65 P = 0.099† 2.103 P = 0.100§
1.91 P = 0.590‡
0.221 P = 0.896‡ 4.16 P = 0.001 2.99 P = 0.003†
5.16 ± 1.67 5.67 ± 1.45 5.43 ± 1.79 5.69 ± 1.43 5.46 ± 1.44 5.46 ± 1.66 5.45 ± 1.72 4.97 ± 1.98 5.42 ± 1.69 5.58 ± 1.57 5.32 ± 1.87 5.83 ± 1.31 5.07 ± 1.76 5.18 ± 1.28 5.74 ± 1.80
9.55 P = 0.049‡
2.716 P = 0.068§
25.54 P = 0.001‡
5.00 ± 1.83 5.48 ± 1.58
5.90 ± 1.13 5.20 ± 1.80 5.53 ± 1.70 5.54 ± 1.48 4.35 ± 1.1.87
5.88 ± 1.41 5.29 ± 1.64 5.49 ± 1.64
4.75 ± 1.71 4.62 ± 2.01 5.80 ± 1.40 5.39 ± 1.60 5.43 ± 1.61
14.01 P = 0.016‡
4.68 P = 0.001†
5.76 ± 1.40 4.89 ± 1.78
5.85 ± 1.28 5.46 ± 1.38 5.38 ± 1.73 5.05 ± 1.73 4.64 ± 2.08 4.85 ± 1.42
0.249 P = 0.804†
5.40 ± 1.56 5.44 ± 1.65
P
5.89 ± 1.73 5.89 ± 1.69
5.81 ± 1.50 5.96 ± 1.86
5.82 ± 1.65 5.45 ± 1.33 5.82 ± 1.46
6.00 ± 1.74 5.75 ± 1.66 5.73 ± 1.42 6.61 ± 2.42
5.86 ± 1.67 6.14 ± 1.88 5.64 ± 1.51 5.80 ± 1.63
6.54 ± 2.14 5.81 ± 1.62
6.08 ± 1.97 5.97 ± 1.93 5.93 ± 1.49 5.50 ± 2.16
6.28 ± 1.91 5.78 ± 1.62 5.93 ± 1.74 5.34 ± 1.23
5.73 ± 1.82 6.31 ± 2.28 5.87 ± 1.63 6.36 ± 164 5.13 ± 1.16
5.80 ± 1.52 5.56 ± 1.72 5.97 ± 1.67 6.00 ± 2.00 5.60 ± 1.77 6.93 ± 2.25
5.94 ± 1.66 5.74 ± 1.82
5.88 ± 1.65 5.91 ± 1.79
6.13 ± 1.75 5.74 ± 1.65
Family, mean ± SD
−0.025 P = 0.980†
.789 P = 430†
1.18 P = 0.552‡
3.47 P = 0.325‡
1.01 P = 0.385§
2.40 P = 0.017†
6.03 P = 0.199‡
1.68 P = 0.188§
10.33 P = 0.035‡
6.77 P = 0.238‡
2.07 P = 0.039†
−0.138 P = 0.890†
1.96 P = 0.051†
5.51 ± 1.42 5.52 ± 1.58
5.48 ± 1.38 5.55 ± 1.62
5.28 ± 1.35 5.62 ± 1.37 5.21 ± 1.08
5.75 ± 1.53 5.24 ± 1.26 5.77 ± 2.62 5.52 ± 1.51
5.47 ± 1.45 5.58 ± 172 5.55 ± 138 5.46 ± 1.45
6.05 ± 1.96 5.44 ± 1.43
5.68 ± 1.91 5.35 ± 1.40 5.58 ± 1.30 4.87 ± 1.66
5.48 ± 1.87 5.53 ± 1.48 5.93 ± 1.74 5.34 ± 1.31
5.84 ± 1.91 5.57 ± 1.64 5.41 ± 1.31 5.81 ± 1.7 44.86 ± 0.94
5.27 ± 1.26 5.39 ± 1.47 5.78 ± 1.72 5.70 ± 1.34 5.17 ± 1.46 6.00 ± 1.69
5.56 ± 1.52 5.38 ± 1.47
5.46 ± 1.33 5.61 ± 1.76
5.63 ± 1.52 5.44 ± 1.50
Friend, mean ± SD
−0.049 P = 0.961†
403 P = 0.687†
2.07 P = 0.355‡
5.22 P = 0.156
0.106 P = 0.957§
2.24 P = 0.025†
7.55 P = 0.110‡
0.034 P = 0.967§
7.24 P = 0.123‡
8.76 P = 0.119‡
0.879 P = 0.380†
−0.835 P = 0.404†
1.06 P = 0.288†
5.44 ± 1.42 5.28 ± 1.50
5.23 ± 1.24 5.46 ± 1.63
5.18 ± 1.45 5.34 ± 1.28 4.91 ± 1.04
5.55 ± 1.41 5.23 ± 1.47 5.10 ± 1.20 5.77 ± 2.31
5.44 ± 1.49 5.42 ± 1.62 5.18 ± 1.37 5.17 ± 1.13
5.60 ± 2.15 5.32 ± 1.35
5.70 ± 1.95 5.10 ± 1.33 5.34 ± 1.24 5.00 ± 1.41
5.60 ± 1.77 5.29 ± 1.39 5.36 ± 1.42 5.06 ± 1.09
5.54 ± 1.63 5.84 ± 2.21 5.32 ± 1.29 5.25 ± 1.6 34.90 ± 1.01
5.20 ± 1.10 5.24 ± 1.47 5.40 ± 1.57 5.75 ± 1.51 5.10 ± 1.44 6.20 ± 2.36
5.45 ± 1.52 5.05 ± 1.25
5.29 ± 1.28 5.45 ± 1.71
5.44 ± 1.53 5.30 ± 1.42
Special person, mean ± SD
Scores of MSPSS
.94 P = 0.346†
1.38 P = 0.166†
1.77 P = 0.412
7.14 P = 0.068‡
0.68 P = 0.565
1.04 P = 0.298†
5.68 P = 0.224‡
0.874 P = 0.418§
4.07 P = 0.396‡
5.12 P = 0.400‡
0.879 P = 0.380†
−0.938 P = 0.349
0.797 P = 0.426†
16.85 ± 3.60 16.70 ± 4.09
16.52 ± 3.16 16.98 ± 4.40
16.29 ± 3.56 16.42 ± 2.63 15.95 ± 2.97
17.31 ± 3.98 16.39 ± 3.55 16.09 ± 2.90 18.16 ± 6.78
16.79 ± 3.88 17.15 ± 4.36 16.38 ± 3.48 16.43 ± 3.35
18.20 ± 5.66 16.58 ± 3.55
17.46 ± 5.20 16.43 ± 3.55 16.86 ± 3.03 15.37 ± 5.01
17.36 ± 4.78 16.61 ± 3.66 16.79 ± 3.74 15.75 ± 2.99
17.13 ± 4.58 17.73 ± 5.58 16.61 ± 3.26 17.43 ± 4.40 14.90 ± 2.87
16.28 ± 2.66 16.27 ± 3.87 17.16 ± 4.37 17.45 ± 4.11 15.89 ± 3.98 19.13 ± 5.54
16.96 ± 3.92 16.18 ± 3.71
16.64 ± 3.36 16.98 ± 4.59
17.21 ± 4.06 16.48 ± 3.74
Total, mean ± SD
0.32 P = 0.74†
1.02 P = 0.305†
0.42 P = 0.808‡
6.24 P = 0.100
0.546 P = 0.651§
2.33 P = 0.020†
7.26 P = 0.123‡
0.731 P = 0.483§
5.86 P = 0.210‡
6.62 P = 0.250‡
1.514 P = 0.131†
−0.741 P = 0.459†
1.57 P = 0.115†
P
*Actively working in own occupation. †Independent Student’s t-test. ‡Kruskal–Wallis. §One-way anova. FSS, Fatigue Severity Scale; HbA1c, hemoglobin A1c; MSPSS, Multidimensional Scale of Perceived Social Support; SD, standard deviation.
Age groups (years) 18–55 ≥56 Sex Female Male Marital status Married Single/widowed Level of education Illiterate Literate Primary school Secondary school High school Faculty/college Occupation Retired Officer Housewife Employee Unemployed Economic status Poor Moderate Good Status of cohabitation Alone With spouse With children With spouse and children With parents Still working* Yes No Duration of diabetes (years) 1–6 7–12 13–19 ≥20 Treatment received Oral diabetes drugs Insulin Diabetes drugs and insulin None Duration of insulin (years) 1–5 6–10 ≥11 Presence of complications Yes No Levels of HbA1c 5–8% ≥9%
Features
Scores of FSS, mean ± SD
Table 1 Comparison of sociodemographic and disease-related characteristics of patients with their mean MSPSS and FSS scores
Japan Journal of Nursing Science (2015) 12, 367–376 Social support and fatigue in patients
371
R. Aylaz et al.
Japan Journal of Nursing Science (2015) 12, 367–376
score was significant, and housewives and those living alone had higher FSS scores than the others. No significant relationship was found between the FSS score and marital or economic status (P > 0.05) (Table 1). When the present authors examined the comparison of the patients’ sociodemographic characteristics with their mean MSPSS and subdomain scores, while there were no statistically significant differences between overall MSPSS score and marital status or occupation, the difference between the scores of support from family was statistically significant and those who were married and who were workers received more support. There were no statistically significant differences between the MSPSS scores and age, sex, education, economic status, or cohabitation (P > 0.05) (Table 1).
Comparison of MSPSS scores and FSS scores with disease-related data of patients The difference between the FSS score and the presence of diabetes-related complications in the patients and HbA1c was statistically significant, and the fatigue scores of the patients who had HbA1c levels of above 9% were found to be higher (P < 0.05). No significant relationship was found between the FSS score and duration of diabetes, treatment received, and duration of insulin use (P > 0.05) (Table 1). There were no statistically significant differences between the MSPSS scores and duration of diabetes, the presence of complications, HbA1c levels, treatment received, and duration of insulin use (P > 0.05) (Table 1).
Comparison of the relationship between the mean scores of MSPSS and FSS The overall mean MSPSS score of the patients was 16.77 ± 3.88 (range, 12.0–42.0) and the overall mean score they obtained from the FSS was 5.69 ± 1.61 (range, 1.0–7.0). A correlation analysis between fatigue severity and social support in patients with T2DM showed that there was a significant negative correlation between fatigue severity and support from family (r = −0.145, P < 0.05) and overall support (r = −0.132, P < 0.05). The patients whose fatigue was less severe had higher mean scores of family and overall support. No significant relationship was found between fatigue severity and support from friends (r = −0.101, P > 0.05) or support from significant other (r = −0.86, P > 0.05) (Table 2).
372
Table 2 Comparison of the relationship between the mean scores of Multidimensional Scale of Perceived Social Support and the Fatigue Severity Scale (MSPSS) of perceived social support and Fatigue Severity Scale (FAS) (n = 300) Scores of MSPSS Scales Scores of FSS
Special person
Family
Friend
Total
−0.86 P = 0.137
−0.145 P = 0.012
−0.101 P = 0.80
−0.132 P = 0.22
DISCUSSION In this study, the present authors tried to determine the relationship between social support and fatigue in patients with T2DM and to reveal the levels of social support and fatigue and the variables that affected these. The importance of this study increases when it is considered that it was conducted in the east of Turkey where relatively less service is provided although T2DM is more common and that this subject has not been dealt with sufficiently. It was found that the patients who were included in the study had support mostly from their families and they received less support from their friends and significant others. The support these patients receive from their families is a strong source for preventing and solving their social and psychological problems and for coping with the situations where they struggle during their treatment. They received social support mostly from their children during insulin administration. Similar studies have also shown that the major source of support for patients with diabetes is their families (Brouwer et al., 2012; Karakurt et al., 2013; Schiøtz et al., 2012; Tol et al., 2011). The Turkish community has strong family ties and the “family comes first” ideal motivates Turkish family members to protect the health of other family members (Asti, Kara, Ipek, & Erci, 2006). The support received from the family, where one receives unconditional love, is very important for the individual in coping with problems. Positive family relationships strengthen the individual and facilitate their adaptation to the disease. Studies on patients with T2DM have reported that increased support received from the family produced better glycemic index results, compliance with the treatment, and self-management (Boas et al., 2012; Brouwer et al., 2012; Schiøtz, Bøgelund, Almdal, Jensen, & Willaing, 2012; Tol et al., 2011). The mean scores of family support of those who were married were found to be higher in the study. This may
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 367–376
be due to the support married patients received from their family members such as their spouses or children. It was stressed in similar studies of with various sample groups with other chronic diseases that families and spouses played a major role as a source of coping, that the family was very important in providing emotional support to the person, and that they also provided support by sharing the responsibilities inflicted on the individual by the disease process and the problems such as the life and the changes in roles the patients experienced due to a chronic disease (Karadag, Kilic, & Metin, 2013; Karakoç & Yurtsever, 2010). The family support, friend support and overall support scores of those who were employed were found to be higher in the present study. It was also found in the study of Kahraman, Çinar, and Pinar (2006) that family, friends, and overall support was higher in individuals who were employed than in those who were unemployed or retired. It is possible to say that being employed in a job makes many contributions in a social sense such that it brings respect to the individual and enables him/her to have social interaction and to earn a reputation in society. When an individual works, this brings social status to him/herself and their families and this status regulates the individual’s life. No statistically significant difference was found in this study between the presence of complications that developed in the patients due to diabetes and HbA1c, and the family support, friend support, and total support scores. Moreover, because 59.0% of the patients in this study had other patients with T2DM in their families, they could have had inabilities to provide social support to each other. The fatigue level of the patients with T2DM who participated in this research was found to be high. In a study by Singh and Kluding (2013) with individuals with T2DM, the mean score of the Fatigue Assessment Scale was found to be as high as 25.10 ± 7.62. A study conducted in Turkey also reported that 40.3% of patients with T2DM experienced fatigue (Azak et al., 2008). The level of fatigue was found to be high also in other studies of patients with T2DM (Fritschi et al., 2012; Lasselin et al., 2012). In the present study, female patients were found to be significantly more tired than male patients. This result suggests that female patients may be more tired because they assume more responsibility at home (e.g. child care, housework) due to the traditional social structure in the east of Turkey. Moreover, in Turkish society, which accommodates patriarchal characteristics, it is a family
Social support and fatigue in patients
doctrine that men should look strong and it can be observed that men try more to avoid talking about their diseases. Azak et al. (2008) also found in their study of individuals with T2DM that female patients were more tired. In a study by Karakoç and Yurtsever (2010) of cancer patients, female patients had more fatigue than males. In the present study, illiterate patients were found to be more tired than patients who had higher levels of education. A low level of education might have caused individuals to comprehend less of the training given on management of diabetes and to develop inadequate management of the condition, leading to an increase in physical fatigue. Economic status may also be poorer in parallel with a lower level of education and these patients might have experienced more fatigue due to reasons such as circumstances creating physical and emotional stress on individuals and benefiting less from healthcare services. It is stated in the study by Lerdal, Celius, and Moum (2003) of patients with multiple sclerosis and similarly in the study of Karakoç and Yurtsever (2010) that as the level of education goes down, the level of fatigue goes up. In this study, the FSS scores of the patients living alone were higher than those living with their spouses and children. When the responsibilities inflicted on the individual by the disease process as well as their personal responsibilities can be shared by the spouse and children in patients who live with their spouses and children, this can be effective in decreasing the fatigue being experienced. This may not be possible in individuals who live alone. De Jong, Candel, Schouten, Abu-Saad, and Courtens (2005) found in their study of cancer patients that individuals living with their spouses and children experienced less fatigue. The difference between the FSS score and the presence of diabetes-related complications that developed in the patients and HbA1c was statistically significant in this study and the level of fatigue was found to be higher in the patients who had HbA1c levels above 9%. The other studies also indicate that there is a significant difference between HbA1c levels and fatigue (Azak et al., 2008; Lasselin et al., 2012). In a parallel study, Singh and Kluding (2013) also reveal that there is significant difference between the presence of diabetes-related complications and fatigue (Singh & Kluding, 2013). HbA1c is a clinically useful index of the average glycemia in the past 120 days and an indicator of the risk of developing diabetic complications (Altunog˘lu et al., 2012; Çitil, Öztürk, & Günay, 2010; Tekes¸in, Dog˘an, Yag˘iz, & Polat, 2014). The observed complications may
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
373
R. Aylaz et al.
Japan Journal of Nursing Science (2015) 12, 367–376
negatively impact the patient’s quality of life and this leads to over-fatigue (Altunog˘lu et al., 2012; Azak et al., 2008; Singh & Kluding, 2013). When the correlation analysis carried out between fatigue severity and social support in patients with diabetes was examined, a significant correlation was found in the negative direction between fatigue severity and family support as well as overall support. The mean family and overall support scores were higher in patients with low fatigue severity. Although no study has been carried out with patients with T2DM exploring a relationship between fatigue severity and social support, there are a limited number of similar studies with different patient groups. It has been found in studies of various disease groups that these two factors affected each other in the negative direction. Fatigue may cause social relationships to weaken by decreasing physical and social mobility. Inadequacy of social support components may also be shown as a cause of emergence of fatigue (Karakoç & Yurtsever, 2010). It has been found in studies of patients with chronic fatigue syndrome that inadequate social support increased fatigue severity (Jason et al., 2010; Prins et al., 2004). Karakoç and Yurtsever (2010) stated in their study with patients receiving chemotherapy that as the levels of social support increased in patients, the severity of fatigue experienced by them decreased. In their study of hemodialysis patients, Karadag et al. (2013) found a significant relationship in the negative direction between fatigue severity and social support. Mancuso, Rincon, Sayles, and Paget (2006) also found in their study that patients with rheumatoid arthritis who had less social support experienced more fatigue.
Practical implications In light of the results of the present authors’ study, it is clear that social support is vital for patients who have to cope with the debilitating symptom of fatigue. Assuming a holistic approach and activating the social support resources for diabetes patients will help to manage this symptom. Optimal utilization of the social support resources will help activate resources, manage fatigue, maintain functional sufficiency, and improve quality of life for diabetes patients. Patients should be provided with support resources such as friends and family members, and also support groups for patients should be increased. Training programs can be prepared for patient families about the effectiveness of social support in controlling symptoms of fatigue. Informative, supportive
374
consultation services can be provided to develop the social support skills of families.
Limitations Because only patients with T2DM were included in the study, it can be generalized only to these patients. This study collected data from only two hospitals in Turkey; thus, its generalizability is limited. Another limitation of this study was that most of the patients participating in the study had poor glycemic control.
CONCLUSION It was found in the study that the patients with T2DM had a high severity of fatigue and the patients received support mostly from their families, which was followed by support from friends and from special persons, respectively. It was also observed that there was a significant relationship in the negative direction between fatigue severity and social support, and the level of social support provided to the patients had an effect on their fatigue. Nurses tending patients with T2DM should carry out fatigue assessments routinely and reflect these in nursing care plans by also associating them with the social support sources of the patient. Future research should include interventional studies that will enable patients with T2DM to cope with fatigue and to strengthen their social support systems.
ACKNOWLEDGMENTS The present authors would like to thank all those who participated in this study. They would also like to thank Malatya State Hospital and Inonu University Turgut Ozal Medical Center health personnel for their help and cooperation.
CONFLICT OF INTEREST The authors of this paper have no conflicts of interest to report. All authors have materially participated in the research and/or article preparation. All authors have approved the final article.
AUTHOR CONTRIBUTION All authors were involved in study design, data collection, and manuscript development. R. A. and E. K.
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 367–376
wrote the paper. K. I. and M. Y. performed the statistical analysis. All authors read and approved the final manuscript.
REFERENCES Altintoprak, E., Cos¸kunol, H., Kesebir, S., Yildiz, U. & Yüncü, Z. (2005). Assessment of social support systems of patients, those have the alcohol use problem. Journal of Dependence, 6, 129–135. Altunog˘lu, E. G., Sari, Z., Erdenen, F., Müderrisog˘lu, C., Ülgen, E. & Sari, M. (2012). The relationship of depression, anxiety and disability with hba1c and the duration of diabetes in patients with type 2 diabetes mellitus. Journal of Istanbul Medicine, 13, 115–119. American Diabetes Association. (2013). Standards of medical care in diabetes. Diabetes Care, 36, 11–66. Armutlu, K., Korkmaz, N. C., Keser, I., Sumbuloglu, V., Akbiyik, D. I., Guney, Z. et al. (2007). The validity and reliability of the Fatigue Severity Scale in Turkish multiple sclerosis patients. International Journal of Rehabilitation Research, 30, 81–85. Asti, T., Kara, M., Ipek, G. & Erci, B. (2006). The experiences of loneliness, depression, and social support of Turkish patients with continuous ambulatory peritoneal dialysis and their caregivers. Journal of Clinical Nursing, 15, 490– 497. Azak, A., Altundag˘, S., Sert, H. & Çinar, S. (2008). Acute fatigue syndrome in patients with type II diabetes mellitus and influencing factors. Journal of Health Sciences Firat University, 22, 73–76. Azak, A. & Çinar, S. (2005). Fatigue Syndrome in Patients with Lymphoma (Hodgkin and Non-Hodgkin) and Influencing Factors. The Turkish Journal of Hematology and Oncology, 2, 78–85. Boas, L. C., Foss, M. C., Freitas, M. F. & Pace, A. E. (2012). Relationship among social support, treatment adherence and metabolic control of diabetes mellitus patients. Enfermagem, 20, 52–58. Brouwer, A. M., Salamon, K. S., Olson, K. A., Fox, M. M., Yelich-Koth, S. L., Fleischman, K. M. et al. (2012). Adolescents and type 2 diabetes mellitus: A qualitative analysis of the experience of social support. Clinical Pediatrics, 51, 1130–1139. Çitil, R., Öztürk, Y. & Günay, O. (2010). Metabolic regulation and related factors in diabetic patients referred to a primary health center in provincial center of kayseri. Erciyes Medical Journal, 32, 111–122. De Jong, N., Candel, M. J. J., Schouten, H. C., Abu-Saad, H. H. & Courtens, A. M. (2005). Course of mental fatigue and motivation in breast cancer patients receiving adjuvant chemotherapy. Annals of Oncology, 16, 372–382. Drivsholm, T., Olivarius, N., Nielsen, A. B. & Siersma, V. (2005). Symptoms, signs and complications in newly
Social support and fatigue in patients
diagnosed type 2 diabetic patients, and their relationship to glycaemia, blood pressure and weight. Diabetologia, 48, 210–214. Eker, D. & Arkar, H. (1995). Factorial structure, validity, and reliability of the Multidimensional Scale of Perceived Social Support. Journal of Turkish Psycholog, 34, 45–55. (in Turkish). Eker, D., Arkar, H. & Yaldiz, H. (2001). Factorial structure, validity, and reliability of revised form of the Multidimensional Scale of Perceived Social Support. Journal of Turkish Psychiatry, 12, 17–25. (in Turkish). Fritschi, C. & Quinn, L. (2010). Fatigue in patients with diabetes: A review. Journal of Psychosomatic Research, 69, 33–41. Fritschi, C., Quinn, L., Hacker, E. D., Penckofer, S. M., Wang, E., Foreman, M. et al. (2012). Fatigue in women with type 2 diabetes. The Diabetes Educator, 38, 662–672. IDF-International Diabetes Federation. (2013). IDF diabetes atlas. [Cited 2 May 2014.] Available from URL: http:// www.idf.org/diabetesatlas IDF-International Diabetes Federation. (2005). Global guideline for type 2 diabetes. [Cited 15 April 2013.] Available from URL: http://www.idf.org Jason, L. A., Roesner, N., Porter, N., Parenti, B., Mortensen, J. & Till, L. (2010). Provision of social support to individuals with chronic fatigue syndrome. Journal of Clinical Psychology, 66, 249–258. Kahraman, A., Çinar, S. & Pinar, R. (2006). Relationship between depression and perceived social support levels in hemodialysis patients. Journal of Turkish Nephrology Dialysis and Transplantation, 15, 130–133. (in Turkish). Karadag, E., Kilic, S. P. & Metin, O. (2013). Relationship between fatigue and social support in hemodialysis patients. Nursing and Health Sciences, 15, 164–171. Karakoç, T. & Yurtsever, S. (2010). Relationship between social support and fatigue in geriatric patients receiving outpatient chemotherapy. European Journal of Oncology Nursing, 14, 61–67. Karakurt, P., Hacihasanog˘lu, R. & Yildirim, A. (2013). Evaluation of the self-care agency and perceived social support in patients with diabetes mellitus. Journal of Faculty Medicine Adnan Menderes University, 14, 1–9. (in Turkish). Krupp, L. B., LaRocca, N. G., Muir-Nash, J. & Steinberg, A. D. (1989). The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Archives of Neurology, 46, 1121–1123. Lasselin, J., Layé, S., Barreau, J. B., Rivet, A., Dulucq, M. J., Gin, H. et al. (2012). Fatigue and cognitive symptoms in patients with diabetes: Relationship with disease phenotype and insulin treatment. Psychoneuroendocrinology, 37, 1468–1478. Lerdal, A., Celius, E. G. & Moum, T. (2003). Fatigue and its association with sociodemographic variables among multiple sclerosis patients. Multiple Sclerosis, 9, 509–514.
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
375
R. Aylaz et al.
Japan Journal of Nursing Science (2015) 12, 367–376
Mancuso, C. A., Rincon, M., Sayles, W. & Paget, S. A. (2006). Psychosocial variables and fatigue: A longitudinal study comparing individuals with rheumatoid arthritis and healthy controls. The Journal of Rheumatology, 33, 1496–1502. Prins, J. B., Bos, E., Huibers, M. J., Servaes, P., van der Werf, S. P., van der Meer, J. W. et al. (2004). Social support and the persistence of complaints in chronic fatigue syndrome. Psychotherapy and Psychosomatics, 73, 174–182. Satman, I., Omer, B., Tutuncu, Y., Kalaca, S., Gedik, S., Dinccag, N. et al. (2013). Twelve-year trends in the prevalence and risk factors of diabetes and prediabetes in Turkish adults. European Journal of Epidemiology, 28, 169–180. Schiøtz, M. L., Bøgelund, M., Almdal, T., Jensen, B. B. & Willaing, I. (2012). Article: Education and psychological aspects. Social support and self-management behaviour among patients with type 2 diabetes. Diabetic Medicine, 29, 654–661. Singh, R. & Kluding, P. M. (2013). Fatigue and related factors in people with type 2 diabetes. The Diabetes Educator, 39, 320–326. Tang, T. S., Brown, M. B., Funnell, M. M. & Anderson, R. M. (2008). Social support, quality of life and self-care behaviors among african americans with diabetes. The Diabetes Educator, 34, 266–276.
376
Tekes¸in, A., Dog˘an, B., Yag˘iz, O. & Polat, H. (2014). The correlation between cerebrovascular disease and HBA1C levels in patients with type 2 diabetes mellitus. Journal of Istanbul Medicine, 15, 40–42. (in Turkish). Tezcan, M. (2013). Since the republic turkish family past, present, future. [Cited 7 May2014.] AvailablefromURL: http://www.turkoloji.cu.edu.tr/GENEL/tezcan_aie.pdf Tol, A., Baghbanian, A., Rahimi, A., Shojaeizadeh, D., Mohebbi, B. & Majless, F. (2011). The Relationship between perceived social support from family and diabetes control among patients with diabetes type 1 and type 2. Journal of Diabetes and Metabolic Disorders, 10, 1–8. TURDEP II. (2010). Diabetes, Hypertension, Obesity and Endocrinology Diseases Prevalence Study II in Turkey. [Cited 2 June 2014.] Available from URL: http://www .turkendokrin.org Turkey Statistical Institution. (2013). Education Statistics in Turkey, Turkey Statistical Institution 2013. [Cited 5 June 2014.] Available from URL: http://www.tuik.gov.tr Yönt, H., Akin Korhan, E. & Çiray Gündüzog˘lu, N. (2012). Fatigue after stroke and quality of life. Journal of Health Sciences Firat University, 26, 115–120. (in Turkish). Zimet, G. D., Dahlem, N. W., Zimet, S. G. & Farley, G. K. (1988). The multidimensional scale of perceived social support. Journal of Personality Assessment, 52, 30–41.
© 2015 The Authors Japan Journal of Nursing Science © 2015 Japan Academy of Nursing Science
