SATI SFACTI ON OF DI ABETES PATI ENTS UNDER FOLLOW -UP I N A
DI ABETES EDUCATI ON PROGRAM
Mar ia Lúcia Zanet t i1 Liudm ila Miy ar Ot er o2 Mar ília Volt olini Biaggi3 Manoel Ant ônio dos Sant os4 Denise Siqueir a Pér es5 Fer nanda Pont in de Mat t os Guim ar ães6
Zanet t i ML, Ot ero LM, Biaggi MV, Sant os MA, Péres DS, Guim arães FPM. Sat isfact ion of diabet es pat ient s under follow - up in a diabet es educat ion pr ogr am . Rev Lat ino- am Enfer m agem 2007 j ulho- agost o; 15( 4) : 583- 9.
This st udy aim ed t o descr ibe t he sat isfact ion of diabet es pat ient s, using t he infor m at ion r eceiv ed and t he care offered aft er t he im plem ent at ion of t he healt h educat ional program called St aged Diabet es Managem ent ( SDM) , in April 2005, at a Universit y Research and Ext ension Cent er in Ribeirão Pret o - SP. Pat ient sat isfact ion w as assessed t h r ou gh a sat isf act ion qu est ion n air e, applied t o 5 4 diabet es pat ien t s w h o par t icipat ed in t h e pr ogr am dur ing 12 m ont hs. The pat ient s r epor t ed t hat t he infor m at ion r eceiv ed dur ing t he pr ogr am at t ended t heir needs; of t he 54 pat ient s, 59.3% m ent ioned inform at ion relat ed t o nut rit ion; 33.3% m ent ioned m edicines and 31.5% glucose cont r ol. Relat ed t o t he assessm ent of car e, 81.5% of t he pat ient s consider ed it ex cellent . We con clu d ed t h at t h e p at ien t sat isf act ion ev alu at ion w as a v alu ab le f eed b ack t o ev alu at e t h e p r og r am im plem ent ed by t he m ult ipr ofessional t eam .
DESCRI PTORS: diabet es m ellit us; pat ient sat isfact ion; healt h educat ion
SATI SFACCI ÓN DEL PACI ENTE DI ABÉTI CO EN SEGUI MI ENTO EN UN
PROGRAMA DE EDUCACI ÓN EN DI ABETES
La finalidad de est e est udio fue describir la sat isfacción de los pacient es diabét icos con las inform aciones r ecibidas y la at en ción of r ecida despu és de la im plem en t ación del pr ogr am a edu cat iv o den om in ado St aged Diabet es Managem ent ( SDM) , en abr il de 2005, en un cent r o de invest igación y ext ensión en Ribeir ão Pr et o -SP. Par a est o, fue aplicado un cuest ionar io de sat isfacción a 54 diabét icos que par t icipar on del pr ogr am a por un período de 12 m eses. Con relación a las inform aciones recibidas durant e la at ención, los pacient es refirieron que ellas at endieron a sus necesidades, siendo que el 59,3% de ellos m encionó las inform aciones relacionadas con la alim ent ación, el 33,3% los m edicam ent os, el 31,5% el cont rol glicém ico. Respect o a la evaluación de la at ención, el 81,5% de los usuarios lo consideró excelent e. Se concluye que la sat isfacción del pacient e const it uyó un v alioso feedback par a que el equipo m ult ipr ofesional pudiese ev aluar el pr ogr am a im plem ent ado.
DESCRI PTORES: diabet es m ellit us; sat isfacción del pacient e; educación en salud
SATI SFAÇÃO DO PACI ENTE DI ABÉTI CO EM SEGUI MENTO EM UM
PROGRAMA DE EDUCAÇÃO EM DI ABETES
Est e est udo t ev e com o obj et iv o descr ev er a sat isfação dos pacient es diabét icos com as infor m ações recebidas e a assist ência oferecida após a im plem ent ação do program a educat ivo, denom inado St aged Diabet es Managem ent – SDM, em abril de 2005, em um cent ro de pesquisa e ext ensão universit ária em Ribeirão Pret o, SP. Par a t an t o, f oi ap licad o q u est ion ár io d e sat isf ação a 5 4 d iab ét icos q u e p ar t icip ar am d o p r ogr am a p or período de 12 m eses. Em relação às inform ações recebidas durant e o at endim ent o, os pacient es referiram que elas at en der am as su as n ecessidades, sen do qu e 5 9 , 3 % deles m en cion ar am as in for m ações r elacion adas à al i m en t ação , 3 3 , 3 % ao s m ed i cam en t o s, 3 1 , 5 % ao co n t r o l e g l i cêm i co . No q u e co n cer n e à av al i ação d o at endim ent o, 81,5% dos usuários o consideraram excelent e. Conclui- se que a sat isfação do pacient e const it uiu v alioso feedback par a a equipe m ult ipr ofissional av aliar o pr ogr am a im plem ent ado.
DESCRI TORES: diabet es m ellit us; sat isfação do pacient e; educação em saúde
1 Associat e Professor,e- m ail: zanet t [email protected]; 2 Doct oral st udent ; 3 Undergraduat e Nursing st udent . Universit y of São Paulo at Ribeirão Pret o College of Nursing, WHO Collaborat ing Cent re for Nursing Research Developm ent , Brazil; 4 PhD, Professor, Universit y of São Paulo at Ribeirão Pret o School of Philosophy, Sciences and Languages; 5 Psychologist . MSc in Medical Sciences; 6 Nut rit ionist , MSc in Public Healt h
I NTRODUCTI ON
V
a r i o u s r e se a r ch e r s h av e r e co m m e n d e d educat ion of diabet es pat ient s by a m ult ipr ofessionalt eam( 1 ). I n t h is sen se, sev er al edu cat ion pr ogr am s
and care services for diabet es pat ient s wit h t his focus
hav e been im plem ent ed in differ ent count r ies( 1- 2).
I n line w it h t he Declar at ion of t he Am er icas
o n D i a b e t e s , s i n c e D e c e m b e r 2 0 0 0 , t h e
m u l t i p r o f e ssi o n a l t e a m a t t h e Nu r si n g Ed u ca t i o n
Ce n t e r f o r A d u l t s a n d El d e r l y ( N ECA E) o f t h e
Univ er sit y of São Paulo at Ribeir ão Pr et o College of
N u r si n g h a s co n t i n u o u sl y f o l l o w e d t h e d i a b e t e s
pat ient s r egist er ed at t he ser v ice.
As fr om 2003, due t o t he need t o or ganize
car e for diabet ics at t his Cent er, a sy st em ized car e
program w as im plem ent ed, based on a care prot ocol
called St aged Diabet es Managem ent - SDM( 2 ).
Th e SDM is a sy st em ized car e pr ogr am for
d i a b et es p a t i en t s d ev el o p ed b y t h e I n t er n a t i o n a l
Diabet es Cent er - I DC, Minneapolis, Minnesot a - USA.
I t cont ains a pract ical guide for t he m ult iprofessional
t eam t o deliv er pat ient car e, w it h specific cr it er ia t o
est ablish t he t reat m ent and follow- up, wit h a view t o
im pr ov ing t he pat ient s’ m et abolic cont r ol and enable
t he t eam for clinical pract ice. This program has already
been im plem ent ed in different count ries, leading t o a
pr ov ed r educt ion in gly cat ed hem oglobin lev els and
a d ecr ease in ch r on ic com p licat ion s r esu lt in g f r om
diabet es( 2- 3).
I n t he syst em ized care program for diabet es
pat ient s im plem ent ed at t his Cent er, we use research
inst r um ent s r ecom m ended by t he I DC. One of t hem
refers t o t he pat ient s’ sat isfact ion wit h t he care t hey
r eceiv e( 2 ).
The sat isfact ion concept pr iv ileges t he user
in t he assessm ent of healt h qualit y. There are various
m easu r em en t m odels, bu t all of t h em depar t f r om
t he pr em ise of addr essing t he pat ient s’ per cept ions
in relat ion t o t heir expect at ions, values and desires( 4).
I n a general way, user sat isfact ion can be defined as
each indiv idual’s assessm ent of t he differ ent healt h
car e dim en sion s.
Lit er at ur e displays a br oad discussion of t he
c o n c e p t o f u s e r s a t i s f a c t i o n( 4 ). Th e r e s e a r c h
m et hodologies used in t his ar ea cont ain sim ilar it ies,
conv er gences and super posit ions of som e t er m s and
concept s t hat em phasize, in a way t hat is not always
clear, users’ place in t he assessm ent of healt h services
an d sy st em s.
Sat isfact ion st udies in Br azil st ood out fr om
1990 onw ar ds, w it h t he com m unit y ’s par t icipat ion in car e p lan n in g an d assessm en t . Th ese st u d ies ar e r e l e v a n t b e ca u se t h e y a l l o w f o r e n r i ch m e n t a n d f eed b ack of t h e in t er v en t ion s m ad e b y t h e h ealt h
t eam , pr ov iding for healt h ser v ice im pr ov em ent s. I n p u b l i c se r v i ce s, u se r s h a v e l i t t l e p o w e r t o e x e r t pressure, as t here is no need t o capt ure client s like in t h e pr iv at e sect or. I n t h is con t ex t , t h e sat isf act ion
assessm en t s of p u b lic ser v ice u ser s con t r ib u t e t o out line t his quest ion, funct ioning as an inst rum ent t o “ giv e v oice” t o t he user s, allow ing t hem t o ex pr ess t heir needs, per cept ions and ex pect at ions about t he
h ealt h ser v ices an d sy st em . Th u s, it is a r elev an t resource for t he receivers of healt h act ions t o m onit or t he qualit y of t he care t hey receive( 5).
Th e q u a l i t y o f t h e d e l i v e r e d s e r v i c e s i s
influenced by t he user ’s subj ect iv e per cept ion of t he services. Sat isfact ion is assessed on t he basis of t he user s’ opinion of t he ser vice qualit y offer ed in t er m s of problem solving in service delivery, am ong ot hers. I n g e n e r a l , t h e s e a s p e c t s a s s e s s t h e e f f i c a c y,
effect iveness, efficiency, conform it y, equit y, adequacy and legit im acy( 6).
I n Brazil, t he qualit y im plant at ion process in h o sp i t al s h as st i m u l at ed r esear ch t o i d en t i f y an d m easur e sat isfact ion as a par t of r esult assessm ent . Th i s assessm en t h as m o t i v at ed h eal t h m an ag er s’ d eci si o n s. Heal t h ser v i ce assessm en t st u d i es u se u s e r s ’ o p i n i o n t o c e r t i f y t h e q u a l i t y o f s e r v i c e delivery( 7). Different inst rum ent s are used t o m easure
sat isfact ion. These include opinion quest ionnaires, wit h closed alt er n at iv es t o an sw er t h e qu est ion s ask ed, Likert - t ype scales, and quest ionnaires wit h a m ixt ure of closed and open answ er alt er nat iv es( 8).
St u d i e s a sse ssi n g t h e r e su l t s o f cl i n i ca l in t er v en t ion s in d iab et es ed u cat ion p r og r am s h av e al so b een r ecom m en d ed( 2 , 9 ). Am o n g t h e av ai l ab l e assessm ent inst rum ent s, quest ionnaires are frequent ly u se d( 9 ). Th e se i n st r u m e n t s i n p a r t i cu l a r m a k e i t possible t o address aspect s relat ed t o t reat m ent and
t o t he under st anding of em ot ional and social fact or s o f ca r e d e l i v e r y t o p a t i e n t s w i t h ch r o n i c h e a l t h condit ions( 10- 11). I n t his st udy, t he diabet es pat ient s’ sat isfact ion refers t o t he inform at ion received and t he care offered aft er t he im plem ent at ion of t he educat ion program called St aged Diabet es Managem ent - SDM.
The St aged Diabet es Managem ent - SDM Pr ot ocol
The St aged Diabet es Managem ent - SDM is
con t ain s a t ex t b ook an d t w o Qu ick Gu id es f or t h e
m u lt ip r of ession al t eam t o d eliv er car e t o d iab et es pat ient s. The Quick Guides ar e docum ent s based on scient ific knowledge and define t he bases of t reat m ent an d t h e m et h od s f or p r of ession al d ecision - m ak in g
about t reat m ent , and also guide t he m ult iprofessional t eam in order t o offer t he m eans for diabet es pat ient s t o cope w it h t he disease. This guide is st r uct ur ed t o classify and diagnose t he disease, define t r eat m ent
o p t i o n s a n d m e t a b o l i c o b j e c t i v e s , m o n i t o r t h e m e t a b o l i c a n d l i p i d p a r a m e t e r s a n d t o f o l l o w - u p diabet es pat ient s. These docum ent s were adapt ed by differ ent inst it ut ions at global lev el, in w hich healt h
car e pr ov ider s cou ld u se t h e r esou r ces av ailable in t h e co m m u n i t y. Th e Qu i ck Gu i d es f r o m t h e SD M pr ot ocol ar e based on t he r ecom m endat ions by t he Am er ican Diabet es Associat ion - ADA, t h e Nat ion al
D i a b e t es D a t a Gr o u p , t h e I n t er n a t i o n a l D i a b e t es Federat ion - I DF, t he World Healt h Organizat ion - WHO and on various organizat ions from different count ries. Th ese Gu ides ar e u sed f or clin ical decision
m a k i n g , u si n g a n a l g o r i t h m t h a t e st a b l i sh e s t h e m axim um t im e for each int ervent ion t ype in t he st art , ad j u st m en t an d m ain t en an ce p h ase of t r eat m en t , using st eps and phases.
Th e st eps r ef er t o t h e t r eat m en t t y pe, ar e called t herapeut ic st eps and are adj ust ed t o each t ype o f d i ab et es. Th ey can b e i n t r o d u ced , ad j u st ed o r
subst it ut e t hroughout t he t reat m ent and are t herefore d y n am ic.
The t herapeut ic st eps are const it ut ed by t he n u t r it ion al st ep, by t h e or al m edicat ion agen t st ep an d b y t h e in su lin st ep . I n t h e SDM p r ot ocol, t h e n u t r i t i o n a l s t e p , k n o w n a s d i e t a n d e x e r c i s e , const it ut es food or ient at ion and t he im plem ent at ion of an ex er cise pr ogr am t o help pat ient s r each t heir m et abolic obj ect iv es. Th e or al agen t st ep r ef er s t o t h e pat ien t ’s u se of oral an t idiabet ic dr u gs. Fin ally, t he st ep called insulin refers t o t he adm inist rat ion of
fast , int er m ediar y or long- act ing insulin.
The t herapeut ic st eps indicat ed what t ype of t r e a t m e n t i s se l e ct e d f o r t h e p a t i e n t . Fo r e a ch t herapeut ic st ep nut rit ional, oral agent and insulin -t he pa-t ien-t goes -t hrough -t hree -t rea-t m en-t phases, which are: init ial phase, adj ust m ent phase and m aint enance phase. This is j ust ified as care for diabet es pat ient s is a cont inuum , w hich st art s w it h t he diagnosis - init ial phase - and m oves t o t he adj ust m ent phase, unt il t he
obj ect iv es ar e r eached. At t his point , t he t her apy is m a i n t a i n e d - m a i n t e n a n ce p h a se . Th u s, ca r e f o r diabet es pat ient s is defined by t he t her apeut ic st eps t hat indicat e t he ex pect ed pr ogr ess.
For each t herapeut ic st ep, t hat is, nut rit ional st ep, or al m edicat ion agent and insulin, t he pat ient
goes t hr ough t he follow ing phases:
I n t he init ial phase, t he m ult iprofessional t eam
obt ains t he pat ient ’s dat a t o r each a diagnosis and st ar t t r eat m ent . I t should be em phasized t hat each
t y pe of diabet es or com plicat ion dem an ds dif f er en t inform at ion and dat a for diagnosis and clinical decision
m ak in g .
I n t he t reat m ent adj ust m ent phase, changes occur in t he t reat m ent , t hat is, in t he insulin dose, in
f o o d , e x e r ci se o r o r a l a n t i d i a b e t i c d r u g s. Th e se adj u st m en t s h elp t o opt im ize diabet es con t r ol. Th is
phase can t ak e day s or m ont hs and is char act er ized by t he pat ient ’s consider able par t icipat ion, as it ar e
t he dat a ( s) he provides t hat will direct t he changes in t r eat m en t .
Th e m a i n t e n a n ce p h a se st a r t s w h e n t h e
pat ient reaches t he expect ed t reat m ent obj ect ives and is act iv ely inv olv ed in it s m aint enance. Pat ient s ar e
expect ed t o ent er and leave t his phase independent ly of t h e t r eat m en t st ep . Th e f act or s in f lu en cin g t h e
pat ient ’s exit from t his phase are changes in lifest yle, adher ence t o t he food plan, social and psy chological
adj ust m ent s t o t he disease, t he desire t o reach a good cont r ol and t he nat ur al pr ogr ession of diabet es.
Th e SD M p r o t o co l r e co m m e n d s t h a t t h e im p lem en t at ion of t h e st ep s an d t h eir su b seq u en t
phases should occur t hr ough t he dev elopm ent of an educat ion program direct ed at t he at t ended pat ient s’
act ual needs.
The im plem ent at ion of t he Sy st em ized Car e Pr oj ect
for Diabet es Pat ient s at t he NECAE, using t he SDM p r ot ocol
To p u t t h e Sy s t e m i z e d Ca r e Pr o j e c t f o r
Diabet es Pat ient s in pract ice at t he NECAE, using t he
SDM prot ocol, we m oved t hrough five st eps, described n ex t .
I n t he first st ep, from August 2003 t o March 2 0 0 4 , w e p e r f o r m e d t h e f o l l o w i n g a c t i v i t i e s :
a s s e s s m e n t o f t h e N ECA E; t r a i n i n g o f t h e m u l t i p r o f essi o n a l t ea m ; r ecr u i t m en t o f t h e st u d y
populat ion; const ruct ion of dat a collect ion inst rum ent s and or ganizat ion of pat ient files.
I n t he second st ep, from March t o April 2004, w e c l a r i f i e d t h e r e s e a r c h o b j e c t i v e s a n d s t e p s ,
regist ered t he pat ient s ( n= 59) . The first consult at ion
b y t h e m u lt ip r of ession al t eam t ook p lace an d t h e
Lab t est s w er e don e, or gan ized an d an aly zed as a cr it er ion f or t h e pat ien t ’s en t r y in t h e st ar t an d/ or
adj ust m ent phase of t r eat m ent .
I n t he t hird st ep, bet ween April and Oct ober
2 0 0 4 , t h e follow in g act iv it ies occu r r ed: st ar t of t h e i m p l em en t a t i o n o f t h e SD M p r o t o co l , sy st em i zed
nursing act ivit y in group, syst em ized individual nursing consult at ion, m edical and nursing consult at ion, nursing
an d m ed ical p ost - con su lt at ion - self - m on it or in g of
ca p i l l a r y g l u co se a t h o m e , sy st e m i ze d i n d i v i d u a l or ient at ion, nut r it ional consult at ion and psychological
su ppor t .
I n t he fourt h st ep, from Oct ober 2004 t o April
2005, t he im plem ent at ion of t he SDM prot ocol cont inue, wit h t he assessm ent of t he result s obt ained in t he t hird
phase, lab t est s, eye t est , syst em ized nursing act ivit y in gr oup, sy st em ized indiv idual nur sing consult at ion,
m edical and nursing consult at ion, nursing and m edical
post - consult at ion - self- m onit oring of capillary glucose at hom e, syst em ized individual orient at ion, nut rit ional
consult at ion and psychological suppor t .
I n t h e f if t h st ep, w h ich t ook place in Apr il
2 0 0 5 , t h e follow in g act iv it ies occu r r ed: assessm en t o f t h e i m p l e m e n t a t i o n o f t h e S D M p r o t o c o l ,
assessm ent of t he r esult s obt ained in t he t hir d and fourt h phase, lab t est s, final assessm ent of knowledge
a b o u t t h e d i s e a s e a n d a s s e s s m e n t o f t h e hy pogly cem ia episodes t he pat ient s pr esent ed.
Considering t hat , aft er t he im plem ent at ion of t h e pr oj ect , t h e m u lt ipr of ession al t eam ’s w or k also
needs t o be evaluat ed from t he pat ient ’s perspect ive,
w e felt t he need t o assess pat ient sat isfact ion aft er t he im plem ent at ion of t he SDM pr ot ocol.
OBJECTI VE
To charact erize t he diabet es pat ient s at t ended
at t he Nursing Educat ion Cent er for Adult s and Elderly, a c c o r d i n g t o d e m o g r a p h i c a n d d i s e a s e - r e l a t e d
v ar iab les.
To describe t he diabet es pat ient s’ sat isfact ion
w it h t he inform at ion t hey received and t he care t hat was offered aft er t he im plem ent at ion of an educat ion
p r og r am .
METHODOLOGY
A descr ipt iv e and cr oss- sect ional st udy w as car r ied ou t at t h e NECAE of t h e Un iv er sit y of São
Paulo at Ribeirão Pret o College of Nursing ( EERP- USP) in April 2005. t his Cent er was chosen as t he place of
st udy because it offers care t o diabet es pat ient s by a m u l t i p r o f e s s i o n a l t e a m , t h r o u g h a n Ed u c a t i o n
Pr ogr am , as r ecom m ended by t he SDM pr ot ocol.
Mult ipr ofessional t eam
To develop t he SDM care prot ocol for diabet es
pat ient s, t he following professionals collaborat ed: four nur ses, t w o endocr inologist s, one nut r it ionist , t hr ee
psychologist s, one physical educat ion professional and t hr ee scient ific init iat ion st udent s.
Un iv er se
The universe consist ed of t he 240 t ype 1 and
t y p e 2 d iab et es p at ien t s r eg ist er ed at t h e Nu r sin g
Ed u ca t i o n Cen t er f o r Ad u l t s a n d El d er l y b et w een Sept em ber 17t h 2000 and March 2nd 2004, as show n
in Table 1.
Table 1 - Pat ient dist ribut ion according t o year of ent ry
in t he NECAE. Ribeir ão Pr et o/ SP, 2004- 2005
E A C E N n i y r t n e f o r a e
Y Simplefrequency Accumulated y c n e u q e r f
0 0 0
2 30 30
1 0 0
2 55 85
2 0 0
2 56 141
3 0 0
2 78 219
4 0 0 2 h c r a M -y r a u n a
J 21 240
NECAE regist er, 2000/ 2004
I nclusion cr it er ia
Ty pe 1 and t y pe 2 diabet es pat ient , w it h a
m ed i ca l d i a g n o si s o f d i a b et es m el l i t u s co n f i r m ed
t h r o u g h a f a st i n g p l a sm a g l u co se t e st , m e n a n d
w o m e n , co m i n g f r o m Ri b e i r ã o Pr e t o - SP a n d t h e
r egion, w ho w er e r egist er ed at t he NECAE bet w een
Sept em ber 17t h 2000 and March 2nd 2004 and accept ed
t o par t icipat e in t h e st u dy by sign in g t h e f r ee an d
infor m ed consent t er m .
Ex clusion cr it er ia
Pat ient s were excludedo in case of gest at ional
diabetes; incom plete register; if they could not be located;
r efused t o par t icipat e in t he st udy ; died; m ent ioned
difficulties to participate in the care due to work or study
or m entioned participation in other care offered through
Table 2 - Dist r ibut ion of diabet es pat ient s r egist er ed
in t he NECAE according t o exclusion crit eria. Ribeirão
Pr et o/ SP, 2004- 2005
a i r e t i r C n o i s u l c x
E No
e t a p i c it r a p o t l a s u f e
R 94
s e s s e r d d a d n u o f n
U 41
y d u t s r o k r o w o t e u d e t a p i c it r a p o t y tl u c if f i
D 26
s r e t s i g e r e t e l p m o c n
I 12
s h t a e D 3 e r a c e c n a r u s n i h tl a e h n i n o it a p i c it r a P 3 t s e t e s o c u l g a m s a l p g n it s a f r e t f a s i s o n g a i d d e m r if n o c t u o h t i w s t n e it a P 2 e r o m y n a c it e b a i d g n i e b t o n d e n o it n e M 1 s e t e b a i d l a n o it a t s e G 1 l a t o
T 183
St udy populat ion
I n accordance wit h t he inclusion and exclusion
cr it er ia, t he st udy populat ion consist ed of 57 t y pe 1
and t y pe 2 diabet es pat ient s, w ho w er e called upon
t o v isit t h e NECAE an d r eceiv e clar if icat ion s ab ou t
t h e r e s e a r c h o b j e c t i v e s a n d s t e p s . D u r i n g t h e
realizat ion of t his st udy, t hree pat ient s were lost , t wo
o f w h o m d u e t o d eat h an d o n e t o ab an d o n m en t .
Hence, t he st udy populat ion included 54 t y pe 1 and
t y pe 2 diabet es pat ient s.
I n st r u m en t
Th e Pat ien t Sat isf act ion q u est ion n air e w as
elab or at ed t o assess p at ien t sat isf act ion w it h t h e
s y s t e m i z e d c a r e t h e y r e c e i v e d , a f t e r t h e
i m p l e m e n t a t i o n o f t h e S D M p r o t o c o l . Th i s
q u e s t i o n n a i r e w a s t r a n s l a t e d t o Po r t u g u e s e . I t
co m p r i se s e i g h t q u e st i o n s, t w o o f w h i ch cl o se d
m ult iple- choice and six open.
Pr o ced u r e
Th e Pat ien t Sat isf act ion q u est ion n air e w as
s e l f - a p p l i e d , t a k i n g c a r e t o p r e s e r v e p a t i e n t s ’
anonym it y. For illit erat e pat ient s or wit h som e kind of
lim it at ion t o fill out t he quest ionnaire t hem selves, t he
i n s t r u m e n t w a s a p p l i e d t h r o u g h a f a c e - t o - f a c e
int erview, wit h a m ean durat ion of 15 m inut es. I n t his
c a s e , t h e i n t e r v i e w s w e r e c a r r i e d o u t b y t h e
r esear ch er r espon sible for apply in g t h e in st r u m en t ,
who did not belong t o t he SDM t eam , t hus guarant eeing
dat a reliabilit y. To organize t he dat a, a dat abase was
creat ed in SPSS 11.5, using double ent ry. To analyze
t he answ er s r elat ed t o user sat isfact ion, descr ipt iv e
analysis was used, wit h result s expressed in absolut e
figu r es an d per cen t ages. Th e pr oj ect w as appr ov ed
b y t h e I n st i t u t i o n a l Re v i e w Bo a r d a t EERP- USP,
pr ot ocol num ber 03172002.
RESULTS AND DI SCUSSI ON
Char act er izat ion of diabet es pat ient s at t ended at t he
Nu r sin g Edu cat ion Cen t er f or Adu lt s an d Elder ly in
t he SDM Pr ot ocol
The 54 t y pe 1 and t y pe 2 diabet es pat ient s
were bet ween 29 and 78 years old, wit h a m edian of
60 years. Wom en were predom inant ( 74.1% ) , wit h a
m edian of 6 1 y ear s. Male pat ien t s cor r espon ded t o
25.9% , wit h a m edian of 60 years.
What sk in color is concer ned, m ost pat ient s
( 59. 3% ) w er e w hit e. As t o civ il st at us, 68. 5% w er e
m ar r ied . Wit h r esp ect t o occu p at ion , 4 2 . 6 % w er e
r et ir ed. Relat ed t o edu cat ion , 5 9 . 3 % did n ot f in ish
basic educat ion. As t o fam ily incom e, 29.6% indicat ed
bet w een one and t w o m inim um wages ( Table 3) .
Table 3 - Nu m er ical an d per cen t age dist r ibu t ion of
p a t i e n t s a t t e n d e d a t t h e N ECA E a c c o r d i n g t o
sociodem ographic var iables. Ribeir ão Pr et o/ SP,
2004-2 0 0 5
s a c i f á r g o m e d o i c o S s i e v á i r a
V nº %
r o l o c n i k S e t i h
W 32 59.3
o t t a l u
M 14 25.9
n a c i r e m A -o r f
A 8 14.8
l a t o
T 54 100
s u t a t s li v i C d e i r r a
M 37 68.5
d e w o d i
W 10 18.5
e l g n i
S 7 13.0
l a t o
T 54 100
n o it a p u c c O d e r it e
R 23 42.6
k r o w e s u o
H 18 33.3
k r o
W 13 24.1
l a t o
T 54 100
l e v e l n o it a c u d E e t a r e t il
lI 1 1.9
d e z it a b a h p l a t o
N 2 3.7
n o it a c u d E c i s a B d e h s i n if n
U 32 59.3
n o it a c u d E c i s a B d e h s i n i
F 3 5.6
n o it a c u d E y r a d n o c e S d e h s i n i
F 9 16.7
n o it a c u d E r e h g i H d e h s i n if n
U 3 5.6
n o it a c u d E r e h g i H d e h s i n i
F 4 7.4
l a t o
T 54 100
e m o c n i y li m a F ) * s e g a w m u m i n i m ( e g a w m u m i n i m 1 o t p
U 3 5.6
s e g a w m u m i n i m 2 -1
> 16 29.6
s e g a w m u m i n i m 3 -2
> 12 22.2
s e g a w m u m i n i m 4 -3
> 9 16.7
s e g a w m u m i n i m 4
> 14 25.9
l a t o
T 54 100
As t o t he t y pe of diabet es, 53.7% indicat ed
t ype 2 and 14.8% t ype 1. I t is rem arkable t hat 31.5%
cou ld n ot in d icat e t h e t y p e of d iab et es. Wh at t h e
d i a g n o s i s t i m e i s c o n c e r n e d , 3 4 . 5 % m e n t i o n e d
b e t w e e n 1 a n d 5 a n d b e t w e e n 6 a n d 1 0 y e a r s
respect ively. Of t he 31.5% of pat ient s who could not
in d icat e t h eir d iab et es t y p e, w e f ou n d t h at 5 2 . 9 %
m ent ioned t hey had known t he diagnosis bet ween one
and fiv e year s ( Table 4) .
Ta b l e 4 - Nu m er i ca l a n d p er cen t a g e d i st r i b u t i o n ,
at t ended at t he NECAE, accor ding t o diagnosis t im e
and diabet es indicat ed by t he pat ient . Ribeirão Pret o/
SP 2004- 2005
s i s o n g a i D
e m i t
e m i t s i s o n g a i D 1
e p y
T Type2 Didnotknow Total o
N % No % No % No %
s r a e y 5
-1 2 25.0 10 34.5 9 52.9 21 38.9
s r a e y 0 1
-6 3 37.5 10 34.5 6 35.3 19 35.2
s r a e y 5 1 -1
1 - - 2 6.8 1 5.9 3 5.5
s r a e y 0 2 -6
1 3 37.5 2 6.8 1 5.9 6 11.1
0 2
> - - 5 17.4 - - 5 9.3
l a t o
T 8 100 29 100 17 100 54 100
I n t er m s of BMI classificat ion, 40.7% of t he
t ype 1 and t ype 2 diabet es pat ient s had class I obesit y,
16.7% class I I and 7.4% class I I I . The m ost frequent ly
in d icat ed co- m or b id it ies w er e ar t er ial h y p er t en sion
( 6 1 . 1 ) , obesit y ( 3 5 . 2 % ) , dy slipidem ia ( 3 1 . 5 % ) an d
per ipher al vascular disease ( 24.1% ) . Wit h r espect t o
living habit s, it was found t hat 57.4% of t he pat ient s
pract iced som e kind of physical act ivit y; none of t he
pat ient s sm ok ed; 35. 2% used t o sm ok e and 50. 0%
used t o consum e alcoholic beverages, while a m aj orit y
( 8 8 . 8 % ) m e n t i o n e d so ci a l d r i n k i n g . As t o f a m i l y
a n t e c e d e n t s o f d i s e a s e , t h e h i g h e s t f r e q u e n c y
cor r esp on d ed t o d iab et es m ellit u s, w it h 7 9 . 6 % of
pat ient s, followed by art erial hypert ension wit h 72.2% .
Ob e s i t y, d y s l i p i d e m i a a n d h y p e r u r i c e m i a w e r e
m ent ioned less fr equent ly.
What t he pat ient s’ follow- up is concerned, in
t h e 1 2 m on t h s b ef or e t h e SDM, it w as f ou n d t h at
5 7 . 4 % in d icat ed f ollow - u p b y m ean s of a m ed ical
co n su l t a t i o n e v e r y t h r e e o r f o u r m o n t h s. Ab o u t
edu cat ion , 8 3 . 3 % m en t ion ed h av in g r eceiv ed som e
k in d of d iab et es ed u cat ion , 1 8 . 5 % ab ou t p h y sical
a ct i v i t y, 1 3 . 0 % n u t r i t i o n a l e d u ca t i o n a n d 1 . 9 %
p sy ch ol og i cal accom p an i m en t . Du r i n g t h i s p er i od ,
29.6% of t he pat ient s perform ed t he foot exam inat ion,
2 4 . 1 % t h e e y e e x a m a n d o n l y 1 1 . 1 % t h e
m icr oalbu m in u r ia ex am r ia.
Descript ion of diabet es pat ient s’ sat isfact ion aft er t he im plem ent at ion of t he SDM Pr ot ocol
When planning an Educat ion Pr ogr am , t her e is a need t o t ake int o account t he pat ient s’ sat isfact ion, because t hat is what produces t he m ot ivat ion t o m ake t h e a d j u s t m e n t n e e d e d i n t e r m s o f m e d i c a t i o n t reat m ent , food planning, physical act ivit y, foot care, self- m onit or ing of capillar y glucose, am ong ot her s.
W h e n a n a l y z i n g t h e d i a b e t e s p a t i e n t s ’ sat isfact ion w it h t h e in for m at ion t h ey r eceiv ed t h at cont r ibut ed t o cont r ol t he disease, it w as found t hat 32 ( 59.3% ) of t hem indicat ed infor m at ion r elat ed t o food, 18 ( 33.3% ) relat ed t o m edicat ion and 17 ( 31.5% ) t o glucose cont rol, as shown by t he following report s.
[ ...] I learned how t o eat in order t o lose weight [ ...] I learned t o
eat well [ ...] eat lit t le at t he right t im e, eat a lot of veget ables,
having a snack before sleeping [ ...] I learned a lot of useful
t hings, such as reeducat ing t he anxiet y t o eat [ ...] ; I learned how
t o t ake t he m edicat ion correct ly [ ...] how t o value t he result s of
t he m edicines I t ook [ ...] I learned how t o use t he insulin and t he
ot her m edicam ent s [ ...] ; I learned how t o cont rol t he blood sugar
level [ ...] I learned t he care needed t o m aint ain a sat isfact ory
cont rol, avoiding hyper and hypoglycem ia [ ...] .
These report s show t hat t he needs are relat ed t o t he fact ors t hey value as adult and elderly subj ect s. Thus, it is known t hat adult s are int erest ed in learning what is useful and necessary for t heir progress( 12). I t should be highlight ed t hat , during care at t he NECAE, t h e p a t i e n t s p a r t i c i p a t e d i n d e c i s i o n s a b o u t m odificat ions needed in t he car e t hey w er e offer ed.
Wh en an aly zin g w h at f eelin g s t h e p at ien t s ex pr essed about t he cont r ol of t heir disease, it w as found t hat m ost of t hem 34 ( 62.9% ) indicat ed living n or m ally w it h t h eir diabet es, an d t h at 2 7 ( 5 0 . 0 % ) m ent ioned good cont rol of t heir diabet es. This m akes u s t h in k t h at , d esp it e t h e d if f icu lt ies t h e p at ien t s pr esent t o adapt t o t he t r eat m ent accor ding t o t he algor it hm s of t he SDM pr ot ocol, m ost of t hem seem t o m anage t o live adequat ely w it h t heir disease.
Mor eover, consider ing t he feelings r elat ed t o t h ei r d i sease, t h e p at i en t s i n d i cat ed t h at , b ef o r e par t icipat ing in car e t hr ough t he SDM pr ot ocol, t hey did not have t he knowledge needed for diabet es self-m an ag eself-m en t , an d t h at t h eir p ar t icip at ion f av or ed learning t o cont rol t heir disease. When assessing care offered t hrough t he SDM prot ocol, 44 ( 81.5% ) pat ient s considered it excellent , 6 ( 11.1% ) good, and 4 ( 7.4% ) sat isf act or y. Wh en assessin g pat ien t sat isf act ion in an ot h er car e ser v ice t h at u sed SDM pr ot ocol, t h ey also revealed t heir sat isfact ion w it h t he care( 13).
m ore professionals; t he creat ion of a volunt ary pat ient com m ission t o v isit t he ill at hom e and t o or ganize ot her Cent er act ivit ies; shor t er consult at ion t im e per pat ient ; provision of m edicat ion offered at Basic Healt h Unit s by t he Cent er and est ablishm ent of urgency care in case of pr oblem s.
Heal t h i n st i t u t i o n s r ev eal t h ei r i n cr easi n g con cer n w it h u ser sat isf act ion . I t is ob ser v ed t h at healt h service providers are becom ing m ore involved w it h pat ien t sat isfact ion , becau se t h er e is ev iden ce t hat t his det er m ines t r eat m ent success, car e qualit y and pat ient s’ ret urn t o t he healt h service.
Th e pat ien t ’s sat isfact ion also con st it u t es a valuable feedback t o assess t he care offered and t he w o r k d o n e b y t h e m u l t i p r o f e s s i o n a l t e a m . Th i s im poses a const ant search t o ident ify t he fact ors t hat prom ot e t he sat isfact ion of pat ient s at t ended at healt h ser v ices. The fact or s r elat ed t o pat ient s’ sat isfact ion w it h t he healt h ser v ice ar e t r anslat ed as confidence, u p d a t i n g , c o m p e t e n c e , h u m a n i t y , r e a d i n e s s , p u n c t u a l i t y, c o r d i a l i t y a n d t e c h n i c a l - s c i e n t i f i c p r e p a r a t i o n o f t h e m u l t i p r o f e s s i o n a l t e a m a n d or ganizat ion of t he w or k envir onm ent( 14- 15).
For a lon g t im e, h ealt h ser v ices r em ain ed dist ant fr om t he possibilit y of assessm ent by user s, allegin g t h at t h ey do n ot h av e t ech n ical k n ow ledge a n d , t h e r e f o r e , l a ck p r e p a r a t i o n t o p e r f o r m t h e a ssessm en t( 1 5 ). No w a d a y s, t h e a ssessm en t u ser s
m ake is used wit h a cert ain reserve, as it is influenced by different sit uat ions, expect at ions and ant ecedent s, m aking t he delim it at ion of crit eria for it s assessm ent d i f f i c u l t . N e v e r t h e l e s s , a s c a r e p r o c e s s e s a r e co m p l e x , i t i s n o t e n o u g h t o k n o w t h e p a t i e n t s’ assessm ent . Ther e is a need t o decom pose t he car e pr ocess an d iden t if y, in each of it s par t s, w h o t h e users are and w hat t heir needs are.
CONCLUSI ON
As t o t h e in f or m at ion r eceiv ed du r in g car e through SDM, the patients indicated that it attended to their needs, with 59.3% m entioning inform ation related to food, 33.3% to m edication and 31.5% to glucose control. Another highly relevant factor refers to the assessm ent of care, which 81.5% of the patients considered excellent. Pat ient sat isfact ion is a valuable feedback t o validat e t he st rat egies used and t he cont ent s offered in diabet es educat ion program s, t o m odulat e t he work d y n a m i cs a n d t o p r o v i d e i m p o r t a n t el em en t s f o r per m anent educat ion of t he m ult ipr ofessional t eam . Ack n o w l e d g i n g t h e d i f f i cu l t i e s t o e l a b o r a t e u se r sat isfact ion m easurem ent inst rum ent s, t he use of t he q u e s t i o n n a i r e i n o t h e r s t u d i e s o f t h i s k i n d i s r ecom m ended, w it h a v iew t o com par ing t he r esult s obt ained in differ ent healt h cont ex t s.
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