The Family Knowledge about the Disease and Complications Risk among Diabetic Patients-in Poland

Department of Nursing, Faculty of Medicine, University of Warmia and Mazury in Olsztyn, Poland Taking care of diabetic patients involves a family which is perceived as an environment, whose support is a factor that best forecasts implementation of required recommendations for diabetes care. The ability of family to support patients’ effort can improve diabetes care results. The aim of this work is to indicate how family knowledge about the disease diversifies a medical condition and complications risk among diabetic patients. Research has been carried out within the scope of NCSR grant no. 6P05D02320, under the leadership of the work’s author, among 1366 families/ caregivers of diabetic patients randomly chosen from 61 primary healthcare centres in Poland. For the purpose of this work, the research has been carried out based on: anonymous questionnaires among patients’ families/caregivers, analysis of medical records. Results: The majority of families supporting the patient have no knowledge about the disease (56.2%). Among families with higher (moderate) knowledge level a statistical analysis demonstrated that the patient takes more care about oral hygiene (p<0.00001), participates in self-control (p<0.00001) and self-monitoring (p<0.05), is more efficient and independent (p<0.00001), have no somatic (p<0.005) or psycho-emotional health complains (p<0.005) or additional medical conditions (p<0.005) and his/her weight (p<0.0005) blood pressure (p<0.005) and triglycerides level (p<0.05) are in the normal range. Conclusions: 1. Family knowledge about the disease is a significant factor that diversifies a medical condition of diabetic patients. 2. Higher knowledge level of the family about the disease improves patients’ medical condition and reduces the risk of diabetes complications. *Corresponding author: Anna Abramczyk, Department of Nursing, Faculty of Medicine, University of Warmia and Mazury in Olsztyn, Poland, Tel: +48 89 524 61 01; Fax: +48 89 524 61 14; E-mail: wesola2000@2com.pl Journal of Data Mining in Genomics & Proteomics J o u r n a l of D ata Mi ning in Gmics & rot e o m i c s ISSN: 2153-0602 Citation: Abramczyk A (2013) The Family Knowledge about the Disease and Complications Risk among Diabetic Patients-in Poland. J Data Mining Genomics Proteomics 4: 142. doi:10.4172/2153-0602.1000142


Introduction
Diabetes is an issue of people around the globe [1]. Research shows that 8.3% of adults (over 170 million people) suffer from diabetes around the world [2,3], and every 4 out of 5 patients live in the countries of low or average level of salary [4]. According to estimates, there are 8.4% adults (over 55 million people) [4] suffering from diabetes in the region of Europe, including over 3 millions in Poland (10.64% of the adult population). Diabetes that lasts for years can lead to many complications in the cardiovascular system [5], retinopathy [6], neuropathy [6,7], renal insufficiency and even death [7,8]. Ischemic heart disease is the most frequent case of macroangiopathy and cause of death among people suffering from diabetes [9,10]. The risk of death due to heart diseases is 2-4 times higher in diabetes patients than in non-diabetes adults [10], with heath diseases causing around 65% of all deaths of people who suffer from diabetes [9,11]. Diabetes increases the risk of stroke by 2-8 times [12,13], and even 12 times if a patient suffers from arterial hypertension and diabetes at the same time [14]. On top of that, in Poland the mortality related to stroke is higher than in the USA and some countries of Western Europe [15]. Patients with a long history of diabetes make 8-10% of the group of people with poor vision or blind people [16]. Also, nephropathy is more frequent in diabetes patients than in the overall population [17]. Diabetes is the main cause of end-stage renal insufficiency in the USA, Japan and Europe [18][19][20]. The diabetes foot is another serious issue for the diabetics and leads to a greater risk of recurring ulcers, amputations and even death [21,22]. The rising mortality rate is also caused by diabetic neuropathy [23] which co-exists with other complications and is one of their preceding symptoms [24]. Studies show that over 80% of deaths related to diabetes occur in countries where salaries are low or average [25], with the risk of death being two or more times higher among people with diabetes [26]. According to WHO, in 2030 diabetes will become the seventh most frequent cause of death worldwide [7]. The serious complications which increase the costs of health care, incidence of disabilities and early death among people suffering from diabetes make this disease one of the greatest challenges for the public health of the 21st century [3,4,27].
The relationship between the treatment of a chronic disease and the family situation requires that the provisioning of patient care is combined with involvement of the patient's family [28]. Patients and their families are the main parties burdened with and rendering care for chronic disease patients [28]. The care is more effective when the social environment of a patient (i.e. the family) supports his/her treatment [28,29].
By rendering care the family provides emotional support, ensures the appropriate conditions of treatment, motivates the patient to stay healthy, performs nursing activities for the patient and helps him/her in the everyday duties [29,30]. In the case of diabetes patients, the family is a crucial factor impacting the regular implementation of medical recommendations for treatment of diabetes [29,31].
If prepared and trained properly, the patients, their families and friends could provide the right environment for administration of hypoglycaemic drugs and ensure the right time of administration (drugs vs. meals) in order to avoid errors in patient care [32].
If the family is not prepared appropriately to support the chronically ill patient, many adverse implications, including health risks for the patient could occur. Negative consequences of errors in drug administration, such as intensified risk of complications, increased incidence of diseases, physical disability and even death [33][34][35][36], put special focus on education and collaboration of health care professionals with respect to patients and their caregivers alike, because it will improve the competences in the area of chronic disease management [33,37,38].
The aim of this work is to indicate how family knowledge about the disease diversifies a medical condition and complications risk among diabetic patients.

Materials and Methods
The 2001-2004 research project was aimed at identifying the condition of the primary health care in Poland related to diabetes patients.
One of the objectives was to verify the connection between the knowledge of diabetes among families and the risk of complications among people suffering from diabetes.
The study method, population sampling and the study toolkit (original questionnaires tested in prior pilot runs) were approved by the Committee for Scientific Research (KBN) in Warsaw and the Commission of Bioethics of Medical University (UM) in Wrocław.
The study uses a random sample to ensure that conclusions apply to the overall population of diabetics in terms of the primary health care [39]. As the population is very diversified in terms of the studies variables, such as the place of residence (cities, villages), and because there is no reliable sampling frame, the sample was selected using the stratified sampling method. The stratified sampling was chosen also because of the financial cost of the study [40]. The population of diabetics was divided into certain groups from which a certain number of elements were sampled. Every subject in the population belonged to one group only [39]. Based on the register of diabetes-related PHC and outpatient service providers and the administrative structure of Poland (16 provinces), the following were sampled in every province: 1 district with a diabetes clinic; 1 district with no diabetes clinic; Next, the following was sampled 1 PHC facility in the capital of every province (16 facilities in total); 1 PHC facility in the district-level town in a district with a diabetes clinic, and 1 PHC facility in a rural area of that district (Tables 1 and 2).
Because of certain choice of services contracted by diabetes outpatient clinics and due to the nature of the administrative structure of Poland, in the provinces of Pomorskie, Śląskie there were less than 5 PHC facilities that qualified to the sample in line with the sampling criteria (Table 1). There were teams consisting of one family doctor and one family nurse deployed in 77 PHC facilities in Poland. If one team resigned, another team was prepared in the next PHC facility selected randomly. Since not all the facilities which declared to co-operate submitted study materials, the subsequent analysis covered the data from 61 facilities (Tables 1 and 2). The patient sample is mixed and derived from a closed population which was selected in a complex, multi-stage, stratified/cluster sampling [40,41]. The study covered all the patients who were registered with a given family doctor and a given family nurse in the respective PHC facility. The doctors, nurses, patients and their families participated in the study on a voluntary basis. For the *) no rural area in the district with no diabetes clinic **) no district without a diabetes clinic   purpose of this study, research was carried out among 1,366 families and care providers and among 1,986 patients with diabetes from 61 randomly chosen national primary health care service units, within the scope of NCSR grant no 6P05D02320, managed by the author of this work.
In the respective facilities, the study took up to 6 months but not less than 3 months. For the purpose of this work, the research was carried out on the basis of [37,[42][43][44]: 1. Nurse anamnesis (carried in the diabetes patient environment) including the following: patients knowledge on (questionnaire in Table 3): selected indices concerned with diabetes treatment (body mass, blood pressure, glycaemia, glucosuria, total blood cholesterol, hypoglycaemia), basic issues of diabetes treatment (causes of the disease, prevention of acute and chronic diabetes complications, diet, physical activity, feet hygiene, self-control, and diabetes pharmacotherapy) patients behavior, including: physical activity, alcohol, cigarettes, diet, feet care, whole body hygiene, mouth and teeth hygiene, treatment modifications within limits stated by the physician, taking drugs, contacting the GP, participation in laboratory examinations, feet and mouth observations, somatic complaints, and psycho-emotional disorders lasting over 2 weeks, factors that hinder fulfillment of the recommendations of diabetes treatment, care and nursing possibilities of the whole family of the patient, patient's social functioning (participation in family, marital, professional, and social life, as well as in social organizations), supply in agents and devices, that help in participation in the treatment and health care social situation of diabetes patients, social care, (family, neighbors), data based on the information concerning: ability of conversation, difficulties to gain help, sufficiency of help received, conformity of achieved help to the expectations, satisfaction of care level, living place, living conditions, marital status, education, sources of income, use of counselling and help: general practitioner, family, neighbors, social worker, specialist in outpatient diabetes clinic, patient's expectations as far as education and care: by general physician, health nurse, family, and social worker.
2. Nurse's assessment of diabetes patients abilities and selfdependence (relative assessment of fitness and independence of the patients); 3. Anonymous questionnaire, focused on obtaining patients' opinions on: access to medical services, satisfaction from health care, life, care; 4. Anonymous questionnaire among families giving support in the process of taking care of the patient, by which information upon knowledge about the disease, expectations and satisfaction from the care was obtained; 5. Analysis of the medical documentation. This included information provided by the GP (family doctor) as to: age, sex, type of diabetes, duration of illness, treatment methods, self-control, results from tests carried out within the previous 12 months (total cholesterol, cholesterol HDL, fasting glycaemia, glycosuria, microalbuminuria or proteinuria, creatinine, glycated haemoglobin, body mass, height, BP, waist circumference, trochanters), accompanying diseases which require treatment. The answers were evaluated by the project manager and the author of this document. Characteristics of interest were described as frequencies and percentages and compared using the chi-square test [41]. All the tested hypotheses were verified at the level of significance Results of α=0.05. Precise values of the significance level p were calculated.
Research materials were obtained from patients aged above 16 years, living in the area of work of a social and family nurse, and registered on the list of a local GP. The youngest patient was 17 and the oldest was 96. The majority of the tested population consisted of women (63.4%), persons aged above 65 (59%) and patients living in urban areas (57.7%).
The most numerous group of tested patients consisted of pensioners (49.5%). Slightly more than one in three patients indicated disability pension as their source of income (37.2%) and 9.3% of patients indicated a job on a farm as their source of income. The majority of persons interviewed were married (61.3%). Almost every third patient was a widow or widower (30.3%). Most of the patients took only oral drugs (56.8%), every fifth patient took only insulin (20%), and almost every fifth patient took insulin and oral drugs (18.5%); only 4.7% of the patients were on a diet. Analysis of the medical documentation shows that diabetes type 1 was found in 11,6% of the patients and diabetes type 2 was found in 51.4%, while 32.9% of the patients were treated without defining the type of diabetes. No information about diabetes type was found in the case of 4.1% of the patients. A pronounced majority of the patients were characterised by elementary or incomplete elementary education (56.2%). Vocational education was found in 15.1% of the patients, secondary school education was found in 2.8%, and higher education was found in 4% of the patients. No information about education was found in 0.9% of the patients.

Discussion
A comprehensive summary is prevented due to the variety of tests, methods of assessing the knowledge, the type of the population and its size, and the studied areas [45,46]. Our results are hardly comparable with other studies which covered small populations of families of hospitalised patients, diabetic caregivers of children or patients suffering from a specific disease only [45][46][47]. Unlike results of other studies which show better knowledge among patients than their caregivers, in our study both patients and their caregivers had a similar level of knowledge about diabetes, however insufficient to ensure effective care. In our study, the level of the knowledge did not depend on the duration of the disease, unlike in the other studies [47].
The results confirmed the other studies in that the patients with better social status had families with higher knowledge of the disease [46]. Own studies revealed that families which have better knowledge of the disease promote various patient behaviours which are recommended for treatment of diabetes and help to keep the required indicators of health, such as: body mass, blood pressure, triglycerides, full physical   Tables 6 and 7.
According to statistics, the patients whose care giving families show moderate or minimum level of knowledge about the disease more often have: the right body mass (p<0.0005), acceptable blood pressure (p<0.005), level of triglycerides (p<0.05), are physically fit (p<0.00001) and independent (p<0.00001), and lack other somatic (p<0.005) and mental symptoms (p<0.005) or other diseases which often accompany diabetes (p<0.005). The data is shown in Table 8.
Furthermore, the patients who have families with good level of knowledge about the disease experience less problems with following the medical recommendations for treatment of diabetes (p<0.005), Also, they are more often have better social and living situation (p<0.00001), and better access to medical services (p<0.05), while demonstrating less (moderate) demand for professional health care (p<0.00001) unlike patients who have families lacking the knowledge about diabetes. The data is shown in Table 9.
shows that a great majority of the families (96.1%) which support diabetes patients does not have the sufficient knowledge about diabetes in order to support the patients effectively. The data is shown in Table 5.
According to statistics, the patients whose care giving families show moderate or minimum level of knowledge about the disease: have a higher (moderate) level of knowledge about the disease (p<0.00001), are familiar with indicators of one's health (p<0.00001), care for one's body (p<0.00001), mouth and teeth more (p<0.00001), exercise the expected measures of self-control (p<0.00001), monitor one's feet and   fitness and independency, no emotional or somatic problems and no accompanying diseases which require treatment.
The deficit of the recommended behaviours, excessively low indicators of health, incidence of accompanying diseases, higher risk of complications and the high demand for professional health care, as observed in patients whose families lack the knowledge about diabetes, confirm the opinion that the sole fact of having a family is not enough to ensure better care for diabetes patients and that families not always support patients [29]. Such results could be demonstrating that the high deficit of the knowledge about diabetes among both patients and their supporting families could lead to negative clinical effects [33]. Own studies confirmed the correlation of the level of knowledge in the patient's family with the health and the risk of complications [29,45,48].
The studies demonstrated that professional and comprehensive education of families and caregivers who support diabetes patients at home is a measure preventing the risk of errors in patient care [49] and promoting better implementation of medical recommendations [50]. The education of patient families helps to improve their competences, effective care and nursing and involvement in the basic and secondary prevention of diabetes. It also leads to better results in patient care, followed by the reduction of costs of such care [36,47]. In our study, those patients who had families with better knowledge of diabetes more frequently behaved as recommended in the treatment of diabetes and had the indicators of personal health closer to the standard levels, including body mass, blood pressure, triglycerides, full physical fitness and self-reliance, no emotional or somatic problems and no accompanying diseases which require treatment. Such situation could result from more effective procedures which the families with better knowledge apply, and provides grounds for including family training as the permanent component of high-quality health care rather than just a solution dedicated to families of old-age patients or patients with serious deficits (as is the case in the Polish health care system) [27]. The incidence of diabetes is rising and the costs of health care are high but the Polish system still lacks a diabetes-dedicated register or incentives to commit the state to diabetes prevention and related training [27].
The conducted studies are a frontier research. Many positive results of patient care which is rendered by patient families with better knowledge about diabetes, and the great deficit of such knowledge among many families, as demonstrated by the studies, are a crucial but underestimated factor in the care of diabetes patients, while such care provided by supportive families could lead to reduced incidence of complications and lower costs of treatment.

Study reservations
1. Study results cover patients and families from those PHC facilities only where the doctors and nurses agreed to participate in the study.
2. The study cannot be completed, if the doctor, the nurse and the patient do not cooperate.
3. The study does not involve a longer observation. 4. n their medical history, some patients lack results of biomechanical tests (triglycerides), anthropometrics and body mass information. 5. he missing results could explain why there is no connection between the knowledge of diabetes among families and the medical indicators of treatment (such as HbA1c).

Conclusions
1. Family knowledge about the disease is a significant factor that diversifies a medical condition of diabetic patients.
2. Higher knowledge level of the family about the disease improves patients' medical condition and reduces the risk of diabetes complications.
3. The process of preventing diabetes complications in this group of patients should reflect the impact from the level of knowledge about diabetes among supporting families.

Acknowledgement
This study was carried out within the scope of SCSR grant no 6P05D02320, directed by the author of this paper.  In your opinion, diabetes is a illness where: 1-there is too much insulin 2-there is too little insulin 3-I don't know What leads to high blood sugar?
What leads to low blood sugar?
What is hypoglycemia?
What are the symptoms of low blood sugar (hypoglycemia)?
What are the symptoms of high blood sugar (hyperglycemia)?
What are the symptoms of ketotic coma?
What are the complications in diabetes?
What supports normal glucose level in blood?
What reduces the risk of complications in diabetes?
How to perform foot care in diabetes?
What the diabetes patient should control himself/herself?
What are the rules of nutrition in diabetes?
What are the physical activity recommendations in diabetes?
What are the effects using drugs for diabetes? 1-lower blood sugar level 2-higher blood sugar level 3-no effect on the blood sugar level

4-I don't know their role or effects
What is the objective of the diet (nutrition) in diabetes?
What are the effects of physical activity in diabetes? 1-lower blood sugar level 2-higher blood sugar level 3-no effect on the blood sugar level 4-I don't know its role or effects What are the effects of Glucagon? 1-higher blood sugar level 2-lower blood sugar level 3-no effect on the blood sugar level 4-I don't know its role or effects What is the recommended procedure with low blood sugar (hypoglycemia)?
1-eat an extra meal 2-wait until the condition passes 3-skip one meal 4-take an extra dose of the drug

5-I don't know
What is the recommended procedure with high blood sugar (hyperglycemia)?
When to perform urine tests for acetone?
How to prevent hypoglycaemia? How to prevent hyperglycaemia? Table 9: Questions evaluating the knowledge of the disease.