A family based intervention to manage type 2 Diabetes in patients from lower socio-economic background
Date
2013-01-24
Authors
Mshunqane, Nombeko
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Abstract
Background
The quality of care in the management of type 2 diabetes has a significant impact on glycaemic control and quality of life of patients. Recent research in developing countries aiming to establish the factors that influence the quality of care of patients with type 2 diabetes has shown that poor adherence to medication and resistance to behavior change is associated with poor glycaemic control, development of complications and increased health care utilization in patients with type 2 diabetes. Factors contributing to quality of care have been thus far stated as the willingness of a patient to take control of the disease, good communication between the clinician and the patient to improve the patient‟s understanding and environmental factors. Environmental factors include the socioeconomic status and health system which determine health care utilization. There has been an improvement in the models of care for type 2 diabetes in which the use of diabetes self-management education strategies as described by the National Standards of Diabetes Management is the most recommended worldwide. South Africa has also adopted some of these strategies and drew guidelines for the management of type 2 diabetes in South Africa which are contained in National Health Policy document published in 2007. This study aimed to establish the effects a family based intervention which used diabetes self management education strategies in the management of type 2 diabetes in patients from poor socioeconomic backgrounds.
Objectives
The objectives of this thesis were:
1. to determine the demographic background (including socio-economic status (SES)) of patients with type 2 diabetes from lower socio-economic at Dr George Mukhari hospital.
2. to determine the availability of diabetes education programmes at Dr George Mukhari hospital.
3. to assess the appropriateness of the existing diabetic education programmes at Dr George Mukhari hospital.
4. to determine the level of knowledge of patients from lower socio-economic backgrounds with type 2 diabetes at Dr George Mukhari hospital about the management of the disease.
5. to determine the effects of a family based education and exercise intervention on the control of the levels of random blood results on the following parameters:
i. HbA1c
ii. Blood glucose
iii. Lipogram
6. to determine the impact of a family based education and exercise intervention on the health related quality of life of patients with type 2 diabetes at Dr George Mukhari hospital. 7. to determine the factors that affect the management of diabetes in patients with type 2 diabetes at Dr George Mukhari hospital.
Four studies were conducted to address the above seven objectives. The steps below were followed in sequence to answer the specified objectives as described below:
Methods
Two preliminary studies were conducted to develop a knowledge questionnaire and to test the validity and reliability of a developed knowledge questionnaire and an internationally validated health related quality of life tool, (DIMS). To answer objectives 1 and 2, stated above, a qualitative approach where data were collected using focus groups and in-depth interviews was used. This approach was explored to establish the opinions of both patients and the management team regarding the medical management and services provided to treat patients with type 2 diabetes. A total of 10 patients and 13 members of the management team took part in the study. Qualitative survey methodology was followed to interpret the data. Five themes emerged from the qualitative data and these were used to develop a quantitative tool, a diabetes knowledge questionnaire which was used in the study population. Following this approach, a quantitative approach was used to determine the validity and reliability of a developed diabetes knowledge questionnaire and an internationally standardised Diabetes Impact Measurement Scale (DIMS). A total of 25 participants with type 2 diabetes took part in this study. Participants were selected from the clinic using a sample of convenience and they answered both questionnaires one after another. Cronbach‟s α coefficient was used to test the internal consistency that is the homogeneity of the questionnaire items. The test-retest reliability of the questionnaires was assessed by calculating the intraclass correlation coefficient (ICC). The two valid and reliable questionnaires were used to gather demographic characteristics of patients with type 2 diabetes consulting at Dr George Mukhari Hospital.
To answer objectives 3 and 4, as stated above, a cross sectional descriptive study, where a total of 135 black participants with type 2 diabetes, aged between 28 to 70 years were recruited from a population with type 2 diabetes consulting at Dr George Mukhari hospital. Participants were selected using simple random sampling. Both the knowledge questionnaire and DIMS were administered to all participants at the same time to establish the demographic characteristics. Descriptive statistics were used to interpret data. Findings of this study were used as needs analysis for interventions that are needed to address the problems of this population. To answer objectives 5, 6 and 7, as stated above, a prospective single blinded randomized controlled trial was used. A total of 135 patients with type 2 diabetes were randomized into three groups after determining their demographic data. The family supported group which selected a family member who was called once a month also engaged in a home walking and education programme plus the usual care given at the hospital; the no family supported group, only had education and home walking plus the usual care given at the hospital; and the control group, only got the usual care given at the hospital. Patients‟ baseline characteristics and health status were determined using a diabetes knowledge questionnaire and the Diabetes Impact Measurement Scale (DIMS). The intervention lasted for six months and there was a further six months follow up during which time there was no intervention. All outcome measures were evaluated at baseline, after six months of intervention and after 12 months (six months of no intervention).Data were collected from August 2008 – February 2010. Groups were compared using an ANOVA. A multivariate logistic regression analysis was done to establish the effects of the intervention.
Results
Five themes emerged from the patients‟ and the professionals‟ focus groups. These were knowledge through health communication, education, behaviour change, support and patient-centered approach. These themes guided the domains of the developed knowledge questionnaire.
Cronbach‟s α coefficient for all standardized items for the knowledge questionnaire, ranged between 55% and 69%, (95% Ci, 0.54 ; 0.69), indicating good validity. Intraclass correlation coefficient ranged between 69 % and 71%, indicating good reliability.
The total score for DIMS ranged from 0. 62 to 0.71 for Cronbach‟s α coefficient and 0.63 to 0.70 for intraclass correlation coefficient also indicating good validity and reliability. The results of the cross sectional study to determine demographic backgrounds showed that there were more females than males diagnosed with type 2 diabetes. Female patients with type 2 diabetes consulting at Dr George Mukhari hospital were obese and male patients are overweight. All participants came from lower socioeconomic backgrounds and were sedentary. Education levels showed that participants had low schooling levels, (the majority of patients had a grade 11). The knowledge scores showed that there were diabetes education programmes, however these programmes were not appropriately conducted when comparing them to the guidelines recommended by the National Standards of Diabetes Self-Management Education Strategies and the South African National Health Policy. All participants had poor glycaemic and poor health related quality of life. These results showed poor quality of care at Dr George Mukhari hospital. A randomized control trial showed that groups were similar at baselines, (p>0.05). Following the six months intervention, the knowledge scores improved significantly in all groups but better in the family supported group. Health related quality of life also improved compared to baseline. Blood pressure and resting pulse did not change. The distance walked improved significantly at six months and 12 months compared to baseline, (p<0.05) but there were no significant differences between groups. There were significant improvements in total cholesterol, and LDL-C, after 6 months and again after 12 months in all groups, but better in the family supported group,(p<0.05). Health related quality of life; HDL-C and triglycerides not significant statistically even though the results on symptoms of the health related quality of life improved after the six months intervention compared to baseline. The findings of the multivariate logistic regression showed that group1 (family support) had a reduced risk of poor glycaemic control (OR= 0.58), whilst group 2 (no family group) showed a higher risk of poor glycaemic control (OR=1.1). Again for random blood glucose, similar effect was also confirmed, group 1 showed a reduced risk of poor glycaemic control (OR=0.64) and group 2 showed a higher risk of poor glycaemic control (OR=1.5). These results were not significant statistically.
Conclusion
The results from the qualitative approach showed that despite the psychosocial problems that were raised by patients when diagnosed with type 2 diabetes, participants did not think of diabetes as a lifelong disease that needs understanding and control. Therefore it is important to reinforce the understanding of these patients through health communication, encourage behaviour change by encouraging physical activity and adherence to recommended diet. Individual patient‟s environmental backgrounds should be considered because patients are unique. These results were used to design a diabetes knowledge questionnaire that was used to gather demographic data.
Reliability study showed that the developed knowledge questionnaire and DIMS were good and reliable questionnaires to use in patients with type 2 diabetes consulting at Dr George Mukhari hospital. The demographic study suggested that patients with type 2 diabetes consulting at Dr George Mukhari hospital had poor glycaemic control and poor health related quality of life; this indicated poor quality of care. The randomised control trial showed that a 12 months family based intervention improved knowledge, distance walked and lipids except HDL-C and triglycerides in patients with family support. This intervention showed that this intervention can improve self-care behaviours and its effects can be sustained for 12 months.