| Research Article |
Open Access |
|
| Impact of Quality of Life Education on Self-Concept among Type 2
Diabetes Patients |
| Nasrin Samadi1*, Mahboubeh Safavi2 and Mahmood Mahmoodi3 |
| 1MSC of Nursing, Faculty of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran |
| 2Assistant Professor, PhD of Management of Education, Islamic Azad University, Tehran Medical Branch, Tehran, Iran |
| 3Professor, PhD of Biostatistics, Department of Biostatistics, Faculty of Health, Tehran Medical University, Tehran, Iran |
| *Corresponding author: |
Dr. Nasrin Samadi, MSC of Nursing
Faculty of Nursing
and Midwifery
Ardabil University of Medical Sciences, Ardabil, Iran
E-mail: na.samadi@arums.ac.ir |
|
| |
| Received June 01, 2011; Accepted August 05, 2011; Published August 10, 2011 |
| |
| Citation: Samadi N, Safavi M, Mahmoodi M (2011) Impact of Quality of Life
Education on Self-Concept among Type 2 Diabetes Patients. J Diabetes Metab
2:132. doi:10.4172/2155-6156.1000132 |
| |
| Copyright: © 2011 Samadi N, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited. |
| |
| Abstract |
| |
| Background: Type 2 diabetes mellitus is a chronic disease with severe late complications and a chronic illness
such as diabetes has effect on self concept. The aim of this study was to determine the effect of quality of life education
on self concept of patients with type 2 diabetes. |
| |
| Methods: This investigation was a random controlled clinical trial study on 123 type 2 diabetes patients admitted
to clinic of diabetes in Imam Khomeini Hospital at Ardebil. They diagnosed that 30 up to 70 years old participants are
afflicted with type 2 diabetes; randomly divided them in 61 people of case group and 62 people of control group. The
questionnaires were composed of socio-demographic status, Beck’s self concept test, Rosenberg’s Self-esteem and
Body image questionnaires and quality of life education plan was codified to educate and evaluate them. P<0.05 is
acceptable for all of these tests. |
| |
| Results: The study showed that participants in case group had low self concept (29.6%), low self esteem(13%) and
moderate body image (34.8%) before QOL education and after the intervention increased their self concept (49.2%),
self esteem(39%) and decreased their body image (28.6%) , but control group had moderate self concept (43.6%),
moderate self esteem (62.5%) and low body image (14.9%) in pre-test and changed to low self concept (20.9%), low
self esteem (12.9%) and low body image (29%) in post-test, and there was significant difference in before and after the
intervention(P<0.05). |
| |
| Conclusion: Patients with type 2diabetes often have negative self-concepts, feel hopeless and, therefore, become
lax about following their regimen. This study shows that quality of life education can have positive effect on diabetes
self concept, and prevent physical and side effects of type 2 diabetes. |
| |
| Keywords |
| |
| Education; Quality of life; Self-concept; Type 2 diabetes |
| |
| Background |
| |
| Type 2 diabetes mellitus is a chronic disease with severe late
complications and high mortality. The increasing prevalence of Type
2 diabetes is mainly due to reduced physical activity and consumption
of unhealthy food and larger portion sizes in genetic susceptible
individuals [1], and present in every country regardless of their stage of
development, and afflicts people in all socio-economic classes [2]. Longterm
complications of diabetes include effects on the eyes, kidneys,
nerves, and blood vessels that can lead to blindness, neuropathy, and
kidney failure [3]. The prevalence of type 2 diabetes in Iran is 4-4.5%
and in population aged above 30 years is greater than 14% [4]. |
| |
| Further, although glycemic control, the development of
complications and mortality represent critical outcomes in people with
type 2 diabetes, quality of life (QOL) outcomes are also important. The
value of optimizing QOL has increasingly been recognized not only
because it represents an important goal for health care in its own right
but also because of the associations between poor QOL and adverse
outcomes in people with type2 diabetes, including poor response
to therapy, disease progression and even mortality [5]. Quality of
life represents a broad, multi-dimensional concept that reflects an
individual’s sense of well-being or satisfaction with life circumstances
[5]. |
| |
| Furthermore, self concept is one’s image of oneself, and involves
all of the self-perceptions appearance, value, and beliefs that influence
behavior and are referred to when using the words I or me. There are
four components of self concept: personal identity, body image, role
performance, and self esteem [6]. A positive self concept is essential
to a person’s mental and physical health. Individuals with a positive self concept are better able to develop and maintain inter personal
relationship and resist psychological and physical illness. |
| |
| Research has shown an association between self concept and health
practice across the life span, Also some studies show that education
program alone improve glycemic control [7], and promote Quality of
life in patients with type 2 diabetes. Also research has shown that quality
of life and self esteem decreased in clients with chronic obstructive
pulmonary disease and arthritis [8]. |
| |
| The aim of this study was to determine the effect of quality of
life education on self concept of patients with type 2 diabetes. We
hypothesize that patients participating in the case group who receive
Quality of life education program will improve their quality of life and
will promote their level of self concept. |
| |
| Methods |
| |
| This was a random controlled clinical trial study and the subjects
were 30 up to 70 years old known type 2 diabetes. 180 individuals were selected randomly among admitted patients to clinic of diabetes in
Imam Khomeini hospital at Ardebil. The participants became aware
on aim of study and then filled a written consent form. Subjects were
neglected for dissatisfaction and uncompleted study form. Then, the
subjects were randomly classified in two case and control groups. 14
sick subjects and 22 unattended subjects in training sessions were
neglected. Totally there were 123 subjects, 61 subjects of control group
and 62 subjects of case one. |
| |
| The Beck self concept test, Rosenberg’s self esteem questionnaire
and Body image questionnaire were used to measure participant’s
current self concept, self esteem and body image as a baseline. The
quality of life education as an intervention factor was performed by
face-to-face, group teaching methods, and handout to case group. The
quality of life education (QOLE) program included a weekly group
session of 90 minutes for 8 incessant weeks, limited to 8 patients per
group. A nurse, a physiotherapist, a nutritionist, an orthopedist, and
a psychologist ran the sessions. The education program was originally
developed at the diabetes outpatient that referred to clinic of diabetes
in Emam Khomeini Hospital of Ardebil University of medical science.
The quality of life education program contents of the sessions included
information on the path physiology of diabetes, education in self blood
glucose monitoring, the importance of physical activity, healthy diet,
weight loss, medication, and smoking cessation if required, the late
complications of type 2 diabetes, hypertension and cardiovascular
disease, and foot care (as a physical dimension of QOL), and Social
support included the resources provided by others that enable the
person to feel valued and part of a reliable network of support; this could
be family, friends, neighbors, government agencies, and organizations
that are available to provide support if needed (as a Social dimension
of QOL) , and the importance of control of stress and anxiety (as a
Emotional/Spiritual dimension of QOL). |
| |
| Then, the patients were evaluated 1 month after the final
intervention program by follow-up telephone contacts, and again
participants filled the same questionnaires (Beck self concept test, Rosenberg’s self esteem questionnaire and Body image questionnaire)
as a follow up. After the follow up, control group received handout,
and the same quality of life (QOL) education program (see Figure 1). |
| |
|
Figure 1: The Quality Of Life Education program outline. |
|
| |
| In this study, the inclusion criteria were composed of: to be 30
years of age or older, to have cognitive ability to answer the questions
with the research instruments and agreement to take part in the study,
Known type 2 diabetes, Both genders. However the exclusion criteria
were included of: prior quality of life intervention during the last year,
Severe heart, liver, or kidney disease or any incurable cancer, Chronic
mental disorder background [17]. |
| |
| I need to mention that study was conducted according to the
principles of the Helsinki declaration, Azad-University of Medical
science-Tehran branch Committee of Biomedical Research Ethics and
the Iranian registry of clinical trials approved the study protocol. |
| |
| Instruments |
| |
| The questionnaire composed of four parts |
| |
| Sociodemographic questionnaire: This questionnaire was
prepared to elicit information on demographic and clinical variables
such as age, sex, marital status, level of education, family history of
diabetes, and drugs [18]. |
| |
| Beck’s self concept test (BSCT): 25 questions self concept test
is a tool for measuring the negative attitudes towards self. Beck’s self
concept test differs from other self concept and self-esteem tests in
this respect that it asks the subject (responder) to compare her/himself
with others rather than using unspecific criteria. Scoring is performed
reversely for questions number 2, 3, 6, 8, 13, 21, 23 and directly for
other questions [19]. The internal consistency (Cronbach’s alpha) of
this instrument in previous researches was reported (r=0.80) [20], and
in the present study was calculated (r=0.74). |
| |
| A test-retest method was used for reliability as well, and Pearson’s
correlation coefficient of this instrument was calculated 0.80. |
| |
| Rosenberg’s Self-Esteem questionnaire: To evaluate self-esteem,
Rosenberg’s Self-Esteem Instrument was used, adapted and validated
for the Brazilian culture [21-23]. This instrument consists of ten
statements, which can either be agreed or disagreed with. The individual
has four answer choices varying from” totally agree to totally disagree”.
In items 1, 3, 4, 7 and 10, the answer choice “totally agree” refers to the
highest self -esteem, while this option points to the lowest self -esteem
in items 2, 5, 6, 8 and 9. The internal consistency (Cronbach’s alpha) of
this instrument was reported (r=0.88) (2) for previous researches but
it was (r=0.73) for current study. We used test-retest for reliability too. |
| |
| Body image questionnaire: To evaluate body image, this
Instrument was used. Body image questionnaire is the result of
assessing several articles, and consists of thirty statements. The
individual has four answer choices varying from” totally positive to
totally negative”. Scoring is performed reversely for questions number
4, 5, 6,7,9,12,17,18,19,20 and directly for other questions. The internal
consistency (Cronbach’s alpha) of this instrument in present study
was calculated (r=0.88). We used test-re test for reliability too, and
Pearson’s correlation coefficient of this instrument was calculated 0.93. |
| |
| Statistical analysis |
| |
| The data were analyzed using SPSS/PC software (version 11).
Descriptive analysis, Chi-square, and Fisher’s tests were used to
determine the relationship among demographics in case and control
group. As already was said that participants were divided to groups
randomly, Group I was the case, and group II was the control group.
Wilcox and pair t test were used for comparing before and after
intervention in case and control group. Furthermore, Independent t test
was used to compare two groups (case and control) after intervention.
The results of statistical tests were considered significant when p<0.05. |
| |
| Results |
| |
| The characteristics of 123 subjects (61 cases and 62 controls)
are described in Table 1. The socio-demographic characteristics
were similar between 2 groups and showed no significant difference
(P>0.05). Also according to scoring BMI (<25 kg/m2 normal, 25-29.9
kg/m2 Overweight, and over 30kg/m2 Obesity) show that most of case
(39%) and control (45.5%) group subjects had Overweight before the
quality of life (QOL) education (see Table 1), but after the intervention,
the most of case group subject’s BMI changed to normal (47.5%) and
participants in control group had not any change to BMI. Finally,
according to the result of Wilcox test, there was significant difference
in before and after the intervention (P=0.004). |
| |
|
Table 1: Characteristics of respondents (n=123). |
|
| |
| Data in Table 2 according to scoring self concept (0-33.3% low, 33.3%-66.6% moderate, and over 66.6% high self concept) show
that case group subjects had low self concept (29.6%) before the
quality of life (QOL) education, and after the intervention increased
their self concept (49.2%). But participants in the control group had
moderate self concept (43.6%) before QOL education and after time of
intervention changed to low self concept (20.9%), and according to the
result of Wilcox test, there was significant difference in before and after
the intervention (P =0.002). |
|
| |
|
Table 2: Level of self-concept in case and control group. |
|
| |
| Subjects in case group according to scoring self esteem (0-33.3%
low, 33.3%-66.6% moderate, and over 66.6% high self esteem) had low
self esteem(13%) before QOL education and after the intervention they
had moderate self esteem(39%), but control group had moderate self
esteem (62.5%) in baseline and changed to low self esteem (12.9%)
in follow up, and according to the result of Wilcox test, there was a
significant difference in before and after the intervention (P <0.05) (see
Table 3). |
| |
|
Table 3: Level of self-esteem in case and control group. |
|
| |
| Finally Table 4 according to scoring body image (0-33.3% low,
33.3%-66.6% moderate, and over 66.6% high body image) shows that
participants before QOL education had moderate body image (34.8%)
and changed to low body image (28.6%) after the intervention, in case
group. In control group, before QOL education, participants had low
body image (14.9%) and after time of QOL education had low body
image (29%), too. But to compare before and after the intervention,
in both groups (case and control) with Independent t test, there was
a statistically significant difference between case and control group
(P=0.000). |
| |
|
Table 4: Level of Body-image in case and control group. |
|
| |
| Pair t test was calculated to assess the effect of QOL education on
self concept and its dimensions (self esteem and body image) in each
group (see table 5). Subjects’ self concept, self esteem, body image and
BMI in study group were higher and better than those in the control
group, and there was a statically significant difference (P=0.000)
between previous and next intervention. |
| |
|
Table 5: Compare of case and control group. |
|
| |
| Also, Table 5 shows the result of Independent t test to compare
two groups (case and control), and a statically significant difference
was indicated (P=0.000) between case and control group, after the
intervention. |
| |
| Discussion |
| |
| Diabetes mellitus (DM) is a chronic disease (2), health and illness
affect self concept. Adaptation with burden of chronic disease affects
the self concept. Also, due to the duration and severity of chronic
diseases such as diabetes, physical function, psychological, social and
economic quality of life is undergoing enormous changes. In addition,
health problems, negative effects on their self concept, and the patient
may need help to accept the changes in the status and quality of life [8]. |
| |
| In this study, Beck’s self concept test shows that participants in case
group, before intervention had low self concept that according to above
studies, and it increased their self concept after intervention that was
due to the positive effects of quality of life education on participants’
level of self concept. But control group’s participants had moderate
self concept before intervention and changed to low self concept after
time of intervention. Diabetic patients are at high risk of psychiatric
symptoms and psychological symptoms have negative effects on
quality of life of patients with diabetes [9]. Furthermore metabolic
control is related to level of self-concept [24]. Increased plasma
glucose in men and central obesity in women is associated with low
self concept [25]. Therefore factors such as hypoglycemia, diabetic foot
ulcer, hospitalization for control blood sugar in period of before and
after time of intervention was due to descent of self concept in control
group, while participates in case group hadn’t any diabetic foot ulcer
and hospitalization in period of before and after intervention. |
| |
| The self-esteem and quality of life concepts were related, i.e. , the
higher the self-esteem, the better the quality of life in patient with
diabetes [2]. The subjects in case group before intervention had low
self esteem and after the intervention increased their self esteem that is
matched to Swann WB Jr et al. [26] & Taylor TL [27] and Tatiana de Sá
Novato et al. [2] studies. But control group, before time of intervention
had moderate self esteem and after time of intervention change to low
self esteem. Audrey barman et al. [6] showed that full stress related
to chronic disease can significantly decrease person’s self esteem.
Therefore we attached this decrease in self esteem to inability in control
of blood sugar, and creation diabetic foot ulcer, stress and anxiety in
some of control group’s subjects. The presence of depression in diabetic
patients has been associated with a high rate of complications [3], and
persons with diabetes are at higher risk for depression than the general
population [28]. |
| |
| In addition, type II diabetes is extremely common among obese
and over 30 years age [29], and showed that obese people are unhappy
with their body and obesity is the source of stress related to negative
body image [30]. |
| |
| In this study, most of the subjects in case group had BMI=25-29.9
and BMI=30 or over, it means were overweight or obese. What is
more, obesity is a chronic disorder that cannot obviate it speedily and
it should be treated with correct planning for weight loss over time. But
comparing case and control, before and after intervention showed little
decrease in body image in case group that is due to positive effects of
quality of life education on participants’ level of body image. |
| |
| Gardner et al. [31] has done first research entitled “Quality of
Life Program”. Also researches stated that concepts of quality of life
and self concept are interrelated [2]. Indeed self concept is root of all behavior is shown in persons [10]. People with positive self concept,
can be better developed, interpersonal relationships protect against
disease and resistance to physical and mental. Someone who has a
positive self concept is quite strong and can accept the changes that
occur throughout life better [6]. Diabetic patients are subject to various
stresses that can lead to potential losses and changes in lifestyle.
Subjective symptoms and medical complications can lead to functional
limitations and changes in quality of life [3].Furthermore training of
health care has a very profound influence on factors affecting quality of
life and satisfaction of treatment in diabetic patients [32]. |
| |
| In the present study, quality of life education can improve diabetes’
self concept, self esteem and body image. The intervention also
improved their knowledge of diabetes and their emotional status. |
| |
| Conclusion |
| |
| Patients with type 2 diabetes often have negative self-concepts, feel
hopeless and, therefore, become lax about following their regimen. This
study shows that quality of life education can have positive effect on
diabetes self concept, and prevent physical and side effects of type 2
diabetes. |
| |
| Acknowledgements |
| |
| I would like to extend my sincere gratitude to the Manager of Emam Khomeini
Hospital and the entire instructor who cooperated with me in this paper. |
| |
|
| References |
| |
- Vadstrup E, Frolich A, Perrild H, Borg E, Roder M (2009) Lifestyle intervention
for type 2 diabetes patients - trial protocol of The Copenhagen Type 2 Diabetes
Rehabilitation Project. BMC Public Health 9: 166.
- De Sá Novato T, Aurora S, Grossi A, Kimura M (2007) Quality of life and selfesteem
of adolescents with diabetes mellitus. Acta paul Enferm 21: 562-567.
- Coelho R, Amorim I, Prata J (2003) Coping Styles and Quality of Life in Patients
With Non-Insulin-Dependent Diabetes Mellitus. Psychosomatics 44: 312-318.
- Baghianimoghadam MH, Afkhami Ardekani M (2007) The effect of education
intervention on quality of life of diabetic patients type 2 referee to diabetic
research center of Yazd. Journal of Gonabad Faculty of Health and Medicine.
13: 21-29.
- Ali S, Stone M, Chas-Skinner T, Robertson N, Davies M, et al. (2010) The
association between depression and health-related quality of life in people with
type 2 diabetes: A systematic literature review. Diabetes Metab Res Rev 26:
75-89.
- Berman Audrey (2008) Fundamentals of Nursing: Concepts, Process and
Practice. 8th edition, "Pearson Education International".
- Trento M, Passera P, Bajardi M, Tomalino M, Grassi G, et al. (2002) Lifestyle
intervention by group care prevents deterioration of Type II diabetes: a 4-year
randomized controlled clinical trial. Diabetologia 45: 1231-1239.
- Harkreader H (2007) "Fundamentals of nursing: caring and clinical judgment".
3rd edition, Philadelphia, Lippincott.
- Centers for Disease Control and Prevention (2005) Social support and healthrelated
quality of life among older adults - Missouri, 2000. Morbidity and
Mortality Weekly Report 54: 433-437.
- Kurtus, Eleanor M (2002) Lifestyle Factors Affecting Quality of Life in Late
Adulthood. http://www.schoolfor-champions.com/health/lifestyle_elderly.htm
(accessed June 2, 2008).
- Legacy Caregiver Services (2006) The caregiver helpbook: powerful tools for
caregivers. Legacy Health System: Portland, Oregon.
- National Family Caregivers Association. Accessing Resources: Telephone
Tips and Techniques That Can Help.
- National Senior Corps Association.
- Samaritan Health Services (2004) Ten Reasons to Keep Fit as you Age.
- U.S. National Institutes of Health, National Institute on Aging. 2001. Dramatic
decline in disability continues for older Americans.
- Volz, Joe (2000) Successful aging: the second 50. Monitor on Psychology, Vol.
31: No. 1.
- Vadstrup ES, Frølich A, Perrild H, Borq E, Røder M (2009) Lifestyle intervention
for type 2 diabetes patients - trial protocol of The Copenhagen Type 2 Diabetes
Rehabilitation Project. BMC Public Health 9:166.
- Mosaku K, Kolawole B, Mume C, Ikem R (2008) Depression, Anxiety and
Quality of life among Diabetic Patients: A comparative study. J Natl Med Assoc
100: 73-78.
- Narimani M, Mousazadeh T (2010) Comparing self-esteem and self-concept of
handicapped and normal students. Procedia Social and Behavioral Sciences
2: 1554-1557.
- Beck AT, Steer Robert, Epstein Norman, Browngary (1990) Beck self-concept
test; psychological assessment. Journal of conculting and clinical psychology
2: 191-197.
- Rosenberg M (1965) Society and the adolescent self-image. Princeton, NJ:
Princeton University Press.Satorra, A., & Bentler, P. (1994). Corrections to test
statistics and standard errors in covariance structure analysis. In A. von Eye,
& C. Clogg (Eds.), Latent variables analysis (pp. 399-441). Thousand Oaks,
CA: Sage.
- Greenberger E, Chen CH, Dmitrieva J, Farruggia SP (2003) Item-wording and
the dimensionality of the Rosenberg Self-Esteem Scale: do they matter?. Personality and Individual Differences 35: 1241-1254.
- Dini GM. Adaptação cultural, validade e reprodutibilidade da versão brasileira
da escala de auto-estima de Rosenberg [tese]. São Paulo: Universidade
Federal de São Paulo; 2001.
- Maharaj SH, Daneman D, Olmsted M, Rodin G (2004) Metabollic Control in
Adolescent girls. Diabetes Care 27: P709-715.
- Miettola J, Leo K, Niskanen H, Viinamak , Sintonen H, et al. (2008) Metabolic
syndrome is associated with self-perceived depression. Scand J Prim Health
Care 26: 203-210.
- Swann WB Jr, Chang-Schneider C, Larsen MKClarty K (2007) Do people's
self-views matter? Self-concept and self-esteem in everyday life. Am Psychol
62: 84-94.
- Taylor TL, Montgomery P (2007) Can cognitive - behavoral therapy increase
self - esteem among depressed adolescents? A systematic review. Children
and Youth Services Review 29: 823-839.
- Osborn CY, Trott HW, Buchowski MS, Patel KA, Kirby LD, et al. (2010) Racial
Disparities in the treatment of Depression in low, Incame Patients with diabetes. Diabetes Care 33: 1050-1054.
- Braunwald Eugene, et al. (2008) Harrison's Principle of Internal Medicine.17th
edition.
- Makara-Stuxzinsk M, Zaborska A (2009) Obesity and body Image. Psychiatri
pol. 43: 109-114.
- Gardner R (1977) Quality of life education program. Journal of visual impairment
and blindness. 71: 435-437.
- Gurkova E, Cáp J, Ziaková K (2009) Quality of life and treatment satisfaction
in the context of diabetes self-management education. Int J Nurs Pract 15: 91-98.
|
| |
| |
|
|
|
This article |
DOWNLOAD |
|
CONTRIBUTE |
|
SHARE |
|
EXPLORE |
|
 |
 |
| |
|
| |
| |
| |
|
Untitled Document
|
|
|
|
|
