KNOW LEDGE AND ATTI TUDE: I MPORTANT COMPONENTS I N DI ABETES EDUCATI ON
Fláv ia Fer nanda Luchet t i Rodr igues1 Mar ia Lúcia Zanet t i2 Manoel Ant ônio dos Sant os3 Tat ian e Apar ecida Mar t in s4 Valm i D. Sousa5 Car la Regina de Sousa Teix eir a6
Rodr igues FFL, Zanet t i ML, Sant os MA, Mar t ins TA, Sousa VD, Teixeira CRS. Know ledge and at t it ude: im por t ant
com ponent s in diabet es educat ion. Rev Lat ino- am Enfer m agem 2 0 0 9 j ulho- agost o; 1 7 ( 4 ) : 4 6 8 - 7 3 .
This descr ipt ive cr oss- sect ional st udy w as conduct ed fr om Mar ch t o Novem ber 2007 at a r esear ch and com m unit y ser vices cent er of a Br azilian univer sit y. I t aim ed t o explor e t he know ledge and at t it ude of people w it h diabet es m ellit us w ho w er e at t ending a diabet es self- car e educat ion pr ogr am . The sam ple w as com posed of 82 adult s w it h d iab et es m ellit u s. Dat a w er e collect ed t h r ou g h t h e Por t u g u ese v er sion s of t h e Diab et es Kn ow led g e Quest ionnair e ( DKN- A) and t he Diabet es At t it ude Quest ionnair e ( ATT- 19) . Result s r evealed t hat 78.05% of t he par t icipant s obt ained scor es higher t han eight on know ledge about diabet es, w hich indicat es t hey have know ledge and under st and t he disease. Scor es on at t it ude r anged fr om 25 t o 71 suggest ing difficult y in coping w it h t he disease. We con clu de t h at alt h ou gh par t icipan t s obt ain ed a good scor e on k n ow ledge, t h eir at t it u de did n ot change so as t o m or e adequat ely cope w it h t he disease.
DESCRI PTORS: diabet es m ellit us; nur sing; k now ledge; at t it ude
CONOCI MI ENTO Y ACTI TUDES: COMPONENTES PARA LA EDUCACI ÓN EN DI ABETES
Est udio t r ansv er sal, r ealizado en un cent r o de inv est igación y ex t ensión univ er sit ar ia br asileño, en el per íodo de m ar zo a nov iem br e de 2007. El obj et iv o fue v er ificar conocim ient os y act it udes de per sonas con diabet es m ellit us que par t icipaban de un pr ogr am a de educación en el aut o cuidado en diabet es. Com o m ét odo se usó una m uest r a const it uida por 82 adult os con diabet es m ellit us. Par a r ecolección de los dat os fuer on ut ilizadas v er sion es por t u gu esas de los cu est ion ar ios Diabet es Kn ow ledge Qu est ion n air e ( DKN- A) y Diabet es At t it u de Quest ionnair e ( ATT- 19) . Los r esult ados m ost r ar on que 78,05% t uv ier on punt aj es super ior es a 8 en r elación al con ocim ien t o en diabet es, in dican do con ocim ien t o y com pr en sión acer ca de la en f er m edad. En cu an t o a la act it ud, los punt aj es var iar on ent r e 25 y 71 punt os, sugir iendo dificult ad en el enfr ent am ient o de la enfer m edad. Se concluy e que, a pesar que los par t icipant es obt uvier on un buen punt aj e en el conocim ient o, t odavía así no m odificar on la act it ud par a el enfr ent am ient o m ás adecuado de la enfer m edad.
DESCRI PTORES: diabet es m ellit u s; en fer m er ía; con ocim ien t o; act it u d
CON HECI MEN TO E ATI TUDES: COMPON EN TES PARA A EDUCAÇÃO EM DI ABETES
Est u d o t r an sv er sal, r ealizad o em u m cen t r o d e p esq u isa e ex t en são u n iv er sit ár ia b r asileir o, n o p er íod o d e m ar ço a novem br o de 2007. O obj et ivo foi ver ificar conhecim ent os e at it udes de pessoas com diabet es m ellit us q u e p ar t icip av am d e u m p r og r am a d e ed u cação p ar a o au t ocu id ad o em d iab et es. Com o m ét od o u sou - se am ost r a con st it u íd a p or 8 2 ad u lt os com d iab et es m ellit u s. Par a colet a d e d ad os f or am u t ilizad as v er sões por t uguesas dos quest ionár ios Diabet es Know ledge Quest ionnair e ( DKN- A) e Diabet es At t it ude Quest ionnair e ( ATT- 19) . Os r esult ados m ost r ar am que 78, 05% t iv er am escor es super ior es a 8 em r elação ao conhecim ent o em diabet es, indicando conhecim ent o e com pr eensão acer ca da doença. Quant o à at it ude, os escor es var iar am en t r e 2 5 e 7 1 p on t os, su g er in d o d if icu ld ad e n o en f r en t am en t o d a d oen ça. Con clu i- se q u e, ap esar d e os par t icipan t es t er em obt ido bom escor e par a o con h ecim en t o, ain da assim n ão m odificar am a at it u de par a o en f r en t am en t o m ais adequ ado da doen ça.
DESCRI TORES: diabet es m ellit u s; en fer m agem ; con h ecim en t o; at it u de
Escola de Enfer m agem de Ribeir ão Pr et o, Univer sidade de São Paulo, WHO Collabor at ing Cent r e for Nur sing Resear ch Developm ent , Br azil: 1Under gr aduat e st udent in Nur sing, e- m ail: flavialuchet t i@gm ail.com ; 2Associat e Pr ofessor, e- m ail: zanet t i@eer p.usp.br ; 4Under graduat e st udent of t he Nur sing Diplom a Pr ogram , e- m ail: t at iane.m ar t ins@usp.br ; 6Facult y, e- m ail: car lar st @eer p.usp.br.
Faculdade de Filosofia, Ciências e Let ras de Ribeir ão Pr et o, Univer sidade de São Paulo, Brazil: 3Facult y, e- m ail: m asant os@ffclr p.usp.br. The Univer sit y of Kansas, Unit ed St at es: 5Associat e Pr ofessor, e- m ail: vdsousa@uncc.edu.
I NTRODUCTI ON
S
elf- car e edu cat ion is an essen t ial elem ent in t h e t r eat m en t of a p er son w it h d iab et es an d it sim port ance is acknow ledged in several st udies carried
out in com m unit ies w it h differ ent socioeconom ic and
cult ural profiles( 1- 2). Effect ive educat ion of people w it h
d i a b e t e s m e l l i t u s a b o u t se l f - ca r e r e q u i r e s h e a l t h
p r o f essi o n a l s t o h a v e k n o w l ed g e o f p sy ch o so ci a l ,
epidem iological and phy siopat hological aspect s of t he
disease in addit ion t o pedagogical abilit ies, capacit y
t o co m m u n i ca t e , l i st e n , u n d e r st a n d a n d a l so t o
negot iat e w it h t he m ult ipr ofessional healt h t eam( 3).
Healt h pr ofessionals’ know ledge, abilit ies and
st r at egies can posit iv ely influence behav ior al change
in indiv iduals w it h diabet es so as t o adher e t o diet ,
physical act ivit ies, m onit or ing blood glucose and t aking
or al m edicat ion an d in su lin , w h ich en able adequ at e
m et abolic con t r ol( 4 - 5 ). Adh er en ce t o t h ese m easu r es
r e d u ce s ch r o n i c co m p l i ca t i o n s a n d t h e n e e d f o r
h ospit alizat ion( 6 ).
A significant correlat ion bet w een at t it ude and
know ledge for people w it h diabet es suggest s t hat m or e
k n o w l e d g e i s a sso ci a t e d w i t h a p r e d i sp o si t i o n t o
assum e self- care( 2). I n t he part icular case of diabet es
m an ag em en t , t h is p r ed isp osit ion en ab les r ed u ct ion
o f s t r e s s a s s o c i a t e d w i t h t h e d i s e a s e , h i g h e r
r e ce p t i v i t y t o t h e t r e a t m e n t , t r u st o f t h e m u l t i
-pr of ession al t eam , h igh er self - est eem an d sen se of
self- efficacy, and a m or e posit iv e per cept ion of one’s
healt h and social accept ance( 7).
The need t o dev elop t eaching act iv it ies and
ed u cat ion in h ealt h t h at is f ocu sed on p eop le w it h
diabet es and t heir fam ilies, so as t o pr ovide know ledge
an d st r en gt h en an act iv e at t it u de in r elat ion t o t h e
disease, is r elat ed t o t he pr ev ent ion of com plicat ions
t h r ou g h m an ag em en t of t h e d isease, w h ich allow s
people t o live bet t er w it h t heir condit ion( 3,5,8).
One of t he goals of t he Pr ogr am a Saúde par a
Todos [ Healt h for All Pr ogr am ] in 2010 is t o pr ov ide
f o r m al ed u cat i o n o n d i ab et es sel f - car e t o 6 0 % o f
in d iv id u als w it h d iab et es, ex ceed in g t h e 4 0 % g oal
est ablished in 1998. A significant deficit of know ledge
an d ab ilit y h as b een ev id en ced in 5 0 % t o 8 0 % of
indiv iduals w it h diabet es( 9). Gly cem ic cont r ol, v er ified
t hrough hem oglobin A1c, is achieved in less t han half
of pat ient s w it h t ype 2 diabet es( 9).
To im plem ent t his educat ive pr ogram one has
t o consider t he gender and et hnicit y or cult ur e of t he
t ar g et p o p u l at i o n as w el l as t h e ag e an d l ev el o f
e d u ca t i o n o f t h e p o p u l a t i o n( 1 ). Th e e v a l u a t i o n o f
in div idu al ch ar act er ist ics of t h e t ar get popu lat ion is
r e co m m e n d e d f o r p l a n n i n g a d i a b e t e s e d u ca t i o n
p r o g r am , si n ce ag e, ed u cat i o n an d so ci o eco n o m i c
l e v e l s a r e v a r i a b l e s t h a t i n f l u e n ce a cq u i si t i o n o f
k now ledge( 2). Char act er ist ics such as gender and age
have been t he m ost st udied ones, t hough associat ion
b et w een g en d er an d acq u i si t i o n o f k n o w l ed g e f o r
diabet es has not r eached conclusiv e r esult s( 1).
I n a d d i t i o n , o n e h a s t o k n o w i n d i v i d u a l s’
at t it u d es t ow ar d d iab et es in or d er t o d ev elop t h eir
ab ilit ies t o m an ag e d iab et es. Th is st u d y con sid er s
at t it ude as a pr edisposit ion t o adopt self- car e act ions.
Th er e ar e f ew st u d i es f ocu si n g on t h e b en ef i t s of
pr ogr am s an d edu cat ion al in t er v en t ion s in diabet es
conduct ed in t he cont ext of specific cult ures. There is
a scarcit y of Brazilian st udies evaluat ing t he effect of
diabet es educat ion, especially in r elat ion t o changing
at t it udes t o adher e t o self- care( 10). Ther e is, how ever,
a consensus in t he lit erat ure t hat changes of at t it ude
t hat occur dur ing educat ional pr ocesses can im pr ov e
qualit y of care and reduce direct and indirect cost s in
heat h( 1,11).
Based on t he above, t his st udy aim ed t o ver ify
t he k now ledge and at t it udes of people w it h diabet es
m ellit us w ho w er e at t ending an educat ional pr ogr am
on diabet es self - car e.
METHOD
Th i s d escr i p t i v e cr o ss- sect i o n al st u d y w as
co n d u ct ed i n a r esea r ch a n d co m m u n i t y ser v i ces
cent er at a univ er sit y in a cit y in t he int er ior of São
Paulo, Br azil bet w een Mar ch and Novem ber 2007. This
cent er w as chosen because a m ult ipr ofessional t eam
co m p o se d o f n u r se s, n u t r i t i o n i st s, p sy ch o l o g i st s,
p h y s i c a l e d u c a t o r s a n d n u r s i n g a n d p s y c h o l o g y
under gr aduat e st udent s car e for people w it h diabet es.
Ev er y si x m o n t h s t h i s cen t er o f f er s a p r o g r am o f
diabet es educat ion t o about 48 people w it h diabet es.
The num ber of par t icipant s is subj ect t o t he phy sical
space and hum an r esour ces av ailable at t he t im e.
Th e d i a b e t e s e d u c a t i o n p r o g r a m d i v i d e s
pat ient s int o gr oups of 12 because sm all gr oups favor
good com m unicat ion bet w een pat ient s and t he w or k
t eam . Th e f ou r gr ou ps ar e sim u lt an eou sly at t en ded
t o ev er y Tu esd ay b y on e t h e f ollow in g sp ecialt ies:
nur sing, nut r it ion, psychology and physical educat ion.
t h e dev elopm en t of edu cat ion al pr ogr am s t o people
w i t h d i a b e t e s i n t h e Am e r i ca s( 9 ). To d e v e l o p t h e
p r og r am con t en t , sev er al t each in g st r at eg ies w er e
u sed : d r am at izat ion , r ole- p lay in g , g r ou p d y n am ics,
and t he shar ing of ex per iences, am ong ot her s.
Th e sam p l e o f t h i s ex p l o r at o r y st u d y w as
com posed of 82 adult s w it h diabet es m ellit us w ho w er e
at t ending a diabet es self- car e educat ion pr ogr am . A
sy st em at ized scr ip t w as d ev elop ed con sid er in g t h e
f ollow in g sociod em og r ap h ic v ar iab les: g en d er, ag e,
sch o o l i n g , m ar i t al st at u s an d o ccu p at i o n , an d t h e
follow ing clinical v ar iables: diagnosis and t r eat m ent .
For dat a collect ion concer ning know ledge and at t it ude
t h e Por t u gu ese v er sion s of t h e Diabet es Kn ow ledge
Q u e s t i o n n a i r e ( D K N - A ) a n d D i a b e t e s A t t i t u d e
Q u e s t i o n n a i r e ( ATT- 1 9 ) w e r e u s e d . Th e s e
quest ionnaires w ere recent ly t ranslat ed t o Port uguese
an d v alidat ed in Br azil( 1 2 ). Th e follow in g coefficien t s
w ere found in t he analysis of reliabilit y and t est - ret est
of in st r u m en t s: Kappa coefficien t s v ar ied fr om 0 . 5 6
t o 0.69 for t he DKN- A and fr om 0.45 t o 0.60 for t he
ATT- 19, w hich indicat e a m oderat e level of r eliabilit y
for bot h . Th u s, t h e in st r u m en t s pr esen t ed adequ at e
r e l i a b i l i t y t o b e u se d i n t h e st u d y. Th e i n t e r n a l
con sist en cy in d ex , Cr on b ach ’s alp h a, f ou n d in t h is
st udy was 0.72 for t he DKN-A and 0.79 for t he
ATT-1 9 . Th e s e a r e c o n s i d e r e d a d e q u a t e i n t e r n a l
con sist en cy lev els.
The DKN- A is a self- applied quest ionnaire wit h
1 5 m ult iple- choice quest ions about differ ent aspect s
relat ed t o diabet es general knowledge. I t present s four
b r o ad cat eg o r i es: b asi c p h y si o l o g y, i n cl u d i n g h o w
insulin act s; hypoglycem ia; gr oups of foods and t heir
r ep lacem en t s; m an ag em en t of d iab et es in case of
som e ot h er d isease; an d g en er al p r in cip les in t h e
disease car e. The scale is 0- 15 and for each it em a
score of 1 is at t ribut ed for correct answ ers and 0 for
in cor r ect an sw er s. I t em s 1 t o 1 2 p r esen t a sin g le
correct answer, whereas it em s 13 t o 15 present som e
correct answers and all of t hem have t o be checked so
as t o obt ain a scor e of 1 . Scor es h igh er t h an eigh t
indicat e t he pat ient has knowledge concerning diabet es.
The ATT- 19 is also a self- applied quest ionnair e
an d m easu r es psy ch ological adj u st m en t t o diabet es
m e l l i t u s. I t w a s d e v e l o p e d t o m e e t t h e n e e d t o
ev alu at e t h e d isease’s p sy ch olog ical an d em ot ion al
aspect s and is com posed of 19 it em s t hat include six
f a ct o r s: st r ess a sso ci a t ed w i t h d i a b et es m el l i t u s;
r ecept iv it y t o t he t r eat m ent ; t r ust in t he t r eat m ent ;
p er so n al ef f i cacy ; p er cep t i o n o f h eal t h an d so ci al
accept ance. Quest ions 11, 15 and 18 have an inver se
score. The m ain applicat ion of t he scale of at t it ude is
t o t h e ev alu at ion of edu cat ion al in t er v en t ion s. Each
answ er is m easur ed by a five- point Liker t it em ( t ot ally
d isag r ee – scor e 1 u p t o t ot ally ag r ee – scor e 5 ) .
Tot al scor e var ies fr om 19 t o 95 point s. Scor es higher
t han 70 indicat e a posit ive at t it ude t ow ar d t he disease.
To ob t ain d at a r eg ar d in g sociod em og r ap h ic
an d clin ical v ar iab les an d also v ar iab les r elat ed t o
k now ledge and at t it ude, a face- t o- face int er v iew w as
car r ied out w it h an av er age dur at ion of 30 m inut es.
First , t he researcher clarified t he st udy obj ect ives and
t h en each par t icipan t sign ed t h e f r ee an d in f or m ed
co n se n t a g r e e m e n t . I n t e r v i e w s w e r e i n d i v i d u a l l y
c o n d u c t e d i n a p r i v a t e r o o m . A n s w e r s w e r e
sim ult aneously r ecor ded in t he for m it self dur ing t he
in t er v iew s.
A dat abase w as dev eloped and v alidat ed by
d ou b le en t r y. Div er g en t d at a w er e cor r ect ed . Dat a
w er e analyzed in t he SPSS Pr ogr am 11.5 and r esult s
w er e p r esen t ed t h r ou g h d escr ip t iv e st at ist ics. Th e
p r o j e c t w a s a p p r o v e d b y t h e Re s e a r c h Et h i c s
Com m it t ee at t he Univer sit y of São Paulo at Ribeir ão
Pr et o, Br azil, Pr ot ocol No. 0773/ 2007.
RESULTS
Th e m a j o r i t y o f p a r t i ci p a n t s w e r e f e m a l e
( 6 4 . 6 % ) w i t h a n a v e r a g e a g e o f 6 1 . 2 8 y e a r s
( SE= 11.37) , m arried ( 68.3% ) ; 69.5% were ret ired or
hom em akers; 35.4% of t he part icipant s had up t o eight
y ear s of educat ion, 47.6% had nine t o 12 y ear s and
9.8% had m ore t han 12 years of educat ion. I t is wort h
m ent ioning t hat 7.3% did not have form al educat ion.
I n a d d i t i o n , t h e m a j o r i t y o f p a r t i ci p a n t s ( 5 8 . 5 % )
r epor t ed t h at t h ey f ollow ed t h e pr escr ibed diet an d
t ook oral ant i- diabet ic drugs t o cont rol t he disease.
Fi g u r e 1 - Sco r e s o b t a i n e d b y p a r t i ci p a n t s w i t h
d iab et es in t h e q u est ion n air e DKN- A in r elat ion t o
k now ledge of t he disease
0 2 4 6 8 10 12 14 16
0 20 40 60 80 100
Patients with diabetes
K
nowledge
The disper sion of scor es obt ained in t he
DKN-A quest ionnair e in r elat ion t o people’s k now ledge of
d i a b e t e s i s o b s e r v e d i n Fi g u r e 1 . Th e m a j o r i t y
( 7 8 . 0 5 % ) o b t a i n e d s c o r e s h i g h e r t h a n e i g h t o n
diabet es k now ledge, w hich indicat es good k now ledge
and underst anding of diabet es safe- care. Sim ilar levels
o f c o r r e c t a n s w e r s w e r e f o u n d b e t w e e n m a l e s
( 6 5 . 0 5 % ) a n d f e m a l e s ( 6 4 . 4 0 % ) . I n t e r m s o f
educat ion, t he highest scor es ar e cor r elat ed w it h up
t o 1 2 y ear s of sch oolin g f or m en , an d 1 2 or m or e
y ear s of schooling for w om en.
We observed t hat t he highest levels of cor rect
an sw er s cor r esp on d ed t o t h e q u est ion s con cer n in g
hypoglycem ia and t he low est r at es w er e obt ained for
quest ions r elat ed t o t he m anagem ent of diabet es in
t he int er cur r ence of anot her disease.
0 10 20 30 40 50 60 70 80 90
0 10 20 30 40 50 60 70 80 90
Patients w ith diabetes
A
tti
tu
de
Score
Fi g u r e 2 – Sco r e s o b t a i n e d b y p a r t i ci p a n t s w i t h
diabet es on t h e qu est ion n air e ATT- 1 9 in r elat ion t o
at t it udes for coping w it h t he disease
Fi g u r e 2 sh o w s t h e d i sp e r si o n o f sco r e s
obt ained by pat ient s w it h diabet es in t he quest ionnaire
ATT- 1 9 in r elat ion t o cop in g at t it u d es. Th e ATT- 1 9
sco r e s v a r i e d f r o m 2 5 t o 7 1 p o i n t s, w h e r e a s i t s
m in im u m scor e is 1 9 poin t s an d m ax im u m scor e is
9 5 p oin t s. Scor es h ig h er t h an 7 0 in d icat e p osit iv e
at t it u des t ow ar d t h e disease. Th ese r esu lt s su ggest
t hat alt hough t he par t icipant s pr esent ed good lev els
o f k n o w l e d g e , t h e y d i d n o t p r e se n t a ch a n g e o f
at t it ude, t hat is, t hey did not acquir e a posit ive at t it ude
so as t o cop e w it h t h e d isease. Wom en ( 5 2 . 0 7 % )
display ed m or e posit iv e at t it udes t ow ar d t he disease
t han m en ( 50.70% ) .
I t i s a l s o w o r t h m e n t i o n i n g t h a t t h e
p a r t i ci p a n t s w i t h l o w e r l e v e l s o f e d u ca t i o n , b o t h
g e n d e r s , o b t a i n e d h i g h e r s c o r e s i n t h e ATT- 1 9
quest ionnair e indicat ing bet t er coping.
DI SCUSSI ON
The available scient ific know ledge concer ning
d iab et es m ellit u s is ack n ow led g ed as an im p or t an t
r e so u r ce t o g u i d e m u l t i p r o f e ssi o n a l t e a m s i n t h e
decision- m ak ing pr ocess r elat ed t o t he t r eat m ent of
t he disease and also t o pr epar e t he t eam t o educat e
p a t i e n t s w i t h d i a b e t e s t o a cq u i r e k n o w l e d g e a n d
adher e t o self- car e. How ev er, one has t o dist inguish
b e t w e e n a c q u i s i t i o n o f k n o w l e d g e a n d l e v e l o f
i n f o r m at i o n . Kn o w l ed g e i s m o r e t h an r ep r o d u ci n g
i n f o r m a t i o n – i t p r e s u m e s c h a n g e o f a t t i t u d e s ,
behav ior and life habit s( 13).
Th i s s t u d y e x p l o r e d t h e k n o w l e d g e a n d
at t it ude of people w it h diabet es w ho w er e at t ending a
diabet es self- car e educat ion pr ogr am . Result s suggest
t hat t he m aj or it y of par t icipant s obt ained a good level
o f k n o w l e d g e co n ce r n i n g d i a b e t e s a n d st r a t e g i e s
n e e d e d t o a d h e r e t o se l f - ca r e . Th e se r e su l t s a r e
con sist en t w it h an ot h er st u d y( 1 4 ) r ep or t in g t h at an
edu cat iv e pr ogr am on diabet es im pr ov es k n ow ledge
o f d i a b e t e s a n d a cq u i si t i o n o f se l f - ca r e a b i l i t i e s.
Alt hough t his is a non- ex per im ent al, descr ipt iv e and
cross- sect ional st udy, it s result s are consist ent w it h a
r e c e n t q u a s i - e x p e r i m e n t a l s t u d y t h a t r e v e a l e d
incr eased know ledge of pat ient s w it h diabet es aft er a
12- m ont h pr ogr am of diabet es educat ion( 15).
I n r elat ion t o at t it u d e as ev alu at ed b y t h e
ATT- 1 9 , w e o b ser v ed t h at t h e m aj o r i t y p r esen t ed
scor es below 70 point s, w hich indicat e t hat t hey did
n o t a c q u i r e a p o s i t i v e a t t i t u d e t o w a r d c h a n g e s
ex pect ed in life st y le so as t o obt ain good m et abolic
cont r ol. How ev er, one has t o t ake int o account t hat
know ledge does not alw ays lead t o change of at t it udes
t ow ar d t he daily dem ands t he t r eat m ent im poses on
pat ient s’ r out ine.
Anot her st udy t hat invest igat ed seven fact or s
r el a t ed t o a t t i t u d e - n eed o f ed u ca t i o n , p a t i en t ’ s
adher ence, sev er it y of t he disease, r elat ion of lev els
of blood glucose, diabet es com plicat ions, t he im pact
of diabet es on t he pat ient ’s life, pat ient ’s aut onom y
and healt h t eam – r evealed t hat t he highest diver gence
w as relat ed t o t he need t o t rain healt h professionals( 16).
Anot her st udy evaluat ing at t it udes t ow ar d t he
disease of 5 3 1 in div idu als—2 5 2 h ealt h pr ofession als
and 279 people w it h diabet es—also show ed significant
differences in t he at t it ude of healt h professionals and
pat ien t s t ow ar d diabet es( 1 7 ). Bot h gr ou ps agr eed on
t h e sev er it y of t y p e 2 d iab et es, t h e v alu e of st r ict
g l y ce m i c co n t r o l a n d t h e d i se a se ’ s p sy ch o so ci a l
im p act , b u t d isag r eed on p at ien t ’s au t on om y. Th is
st udy also show ed t hat no significant differences w ere
found bet w een people w it h t ype 1 and t ype 2 diabet es
w it h t ype 1 and t ype 2 diabet es, w ho had had pr evious
ex p er i en ce i n d i a b et es ed u ca t i o n , p r esen t ed h i g h
scor es for coping w it h t he disease( 17).
Th e f i n d i n g s o f a t h i r d st u d y a r e a l so i n
a g r e e m e n t w i t h t h e r e su l t s p r e se n t e d a b o v e . I t
com par ed at t it udes of pat ient s w it h t y pe 2 diabet es
w it h t h ose of h ealt h pr ofession als in r elat ion t o t h e
m anagem ent of diabet es and it show ed t hat pat ient s’
at t it u d es an d op in ion s ar e d et er m in an t in t h e car e
an d con t r ol of t h e disease. Hen ce, at t it u des t ow ar d
d iab et es ar e closely r elat ed t o t h e b eh av ior h ealt h
p r o f e ssi o n a l s a d o p t d u r i n g ca r e d e l i v e r y. H e a l t h
pr of ession als con sider t y pe 2 diabet es m or e sev er e
and im por t ant t han pat ient s do. Nur ses and nut r it ionist s
w er e consider ed t o be t he pr ofessionals w ho should
m ost encour age pat ient s t o m ake t heir ow n decisions
on t he daily t r eat m ent of diabet es, consider ing t heir
closeness t o pat ient s and t im e spent dur ing nur sing
and nut r it ion consult at ions( 18).
Co n s i d e r i n g t h a t t h e s t u d y p a r t i c i p a n t s
at t ended t he pr ogr am of educat ion in diabet es offer ed
by a com pet ent m ult ipr ofessional t eam and obt ained
scor es t h at su ggest acqu isit ion of k n ow ledge of t h e
m ain aspect s n eeded t o m an age t h e disease, m or e
i n v e s t m e n t i s n e e d e d i n s t r a t e g i e s c a p a b l e o f
st r engt hening posit iv e at t it udes t ow ar d t he dem ands
i m p o se d b y d i a b e t e s o n d a i l y l i f e . H o w e v e r, t h e
p ar t icip an t s’ scor es of at t it u d e w er e n ot ev alu at ed
befor e st ar t ing t he pr ogr am and it r epr esent s one of
t h e st u dy lim it at ion s becau se w e can n ot em pir ically
co n cl u d e w h et h er t h e p r o g r am co n t r i b u t ed t o t h e
i m p r o v e m e n t o f t h e p a r t i c i p a n t s ’ p s y c h o l o g i c a l
adj u st m en t t o t h e disease, w h ich is r elat ed t o self
-ca r e.
New educat ional st r at egies ar e needed so as
t o en able people w it h diabet es t o obt ain k n ow ledge
t o m an age t h e disease an d also t o in cor por at e t h is
k n ow ledge in t h eir daily r ou t in e, t h at is, k n ow ledge
can t r an sf or m peoples’ at t it u de t ow ar d t h e disease.
Th u s , o n e h a s t o t a k e i n t o a c c o u n t p a t i e n t s ’
p a r t i c u l a r i t i e s i n r e l a t i o n t o c o m p l a i n t s , i . e .
m edicat ions’ side effect s and signs and sy m pt om s of
hypoglycem ia, w hich oft ent im es are neit her descr ibed
in scien t if ic lit er at u r e n or in r epor t s of people w it h
d iab et es.
Diabet es significant ly changes t he relat ionship
pat ient s have w it h t heir ow n bodies and w it h t he w or ld
t hat surrounds t hem and rest r ict ions on eat ing habit s
m ak e t h em m or e aw ar e of t h eir lim it at ion s. Th at is
w h y t h e con f lict bet w een t h e desir e t o eat an d t h e
im per ious need t o r efr ain fr om such desir e is alw ay s
pr esent in t he daily life of people w it h diabet es. This
c o n f l i c t m i g h t b e a n i m p o r t a n t e l e m e n t i n
u n der st an din g t h e par t icipan t s’ low scor es obt ain ed
in relat ion t o posit ive at t it udes t o cope w it h t he disease.
H e a l t h p r o f e s s i o n a l s a r e i n t e r e s t e d a n d
c o n c e r n e d w i t h p a t i e n t s a c h i e v i n g t h e g o a l s o f
m et abolic cont r ol but do not alw ays t ake int o account
w hat pat ient s say, feel or do. Hence, car egiver s need
t o be m or e sensit iv e t o pat ient s’ non- ex pr essed and
ex pr essed com plaint s so t hat t he clinical decision is
sh ar ed w it h a v iew t o st r en g t h en t h e p r of ession
al-p a t i e n t b o n d , w h i c h i s e s s e n t i a l t o a c q u i r e a n d
m aint ain posit iv e at t it udes. Suspicions in r elat ion t o
cer t ain aspect s of t he t r eat m ent can t r igger behavior s
t h at im p ed e t h e m ain t en an ce of m et ab olic con t r ol.
Th ese beh av ior s ar e r elat ed t o a set of v alu es an d
assum pt ions adopt ed by t he per son w it h diabet es and
w hich m odulat e acquir ed k now ledge( 2, 10, 15).
Th e r ole of t h e m u lt idisciplin ar y t eam is t o
i d e n t i f y co n st r a i n i n g b e l i e f s h e l d b y p e o p l e w i t h
d i a b et es a n d w h i ch h i n d er t h ei r ca p a ci t y t o seek
solut ions for t heir pr oblem s( 10,15). An int er est ing coping
st rat egy is t o reinforce facilit at ing beliefs and at t it udes,
t hat is, t hose t hat can st r engt hen t r ust in t he t eam ,
w h ich r esu lt s in a less am b iv alen t b eh av ior t ow ar d
t he t reat m ent . Addit ionally, t he m ult iprofessional t eam
sh ou ld v alu e t h e su p p or t p ar t icip an t s r eceiv e f r om
t h eir p ar t n er s, n eig h b or s an d f r ien d s. Valu in g t h is
suppor t can st r engt h posit ive at t it udes w it h a view t o
m o d i f y b e h a v i o r t o w a r d t h e t r e a t m e n t . Su p p o r t
sy st em s offer ed by m u lt ipr ofession al t eam s an d t h e
ex change of ex per iences w it h ot her people w it h t he
sam e d isease an d w h o f ace sim ilar d if f icu lt ies ar e
b e l i e v e d t o b e d e t e r m i n i n g f a c t o r s i n c h a n g i n g
pat ient s’ behav ior( 2, 10, 15).
Th i s st u d y h as m et h o d o l o g i cal l i m i t at i o n s.
Because t his is a descr ipt ive and cr oss- sect ional st udy,
it does n ot allow on e t o m ak e in f er en ces r egar din g
t he effect of t he educat ive pr ogr am on t he acquisit ion
of k now ledge and par t icipant s’ change of at t it ude or
y et t o m ak e gen er alizat ion s t o ot h er popu lat ion s of
people w it h diabet es m ellit us. Dat a w er e collect ed in
a sin g le ed u cat iv e cen t er at a u n iv er sit y, w h ich is
p r o b a b l y d i s t i n c t f r o m o t h e r c e n t e r s , c l i n i c s o r
ou t pat ien t f acilit ies t h at deliv er car e t o people w it h
diabet es m ellit us. Despit e t hese lim it at ions, t he result s
o f t h i s s t u d y p r o v i d e i m p o r t a n t s u p p o r t t o t h e
evaluat ion of t he clinical pr act ice of car e deliver ed t o
fut ur e st udies w it h ot her m et hods and a lar ger num ber
of par t icipant s.
CONCLUSI ON
D e s p i t e t h e p a r t i c i p a n t s ’ g o o d s c o r e f o r
know ledge of diabet es and self- car e, at t it udes did not
change t ow ar d m or e adequat e coping st r at egies. We
r einfor ce t he need t o cont inuously ev aluat e diabet es
ed u ca t i o n p r o g r a m s so a s t o r ed i r ect ed u ca t i o n a l
st r at egies t o be m eaningful for people w it h t he disease,
enhance t heir readiness for learning and consequent ly
r einfor ce posit iv e at t it udes t o cope w it h t he disease.
I t is im port ant t o highlight t hat t he scarcit y of scient ific
lit erat ure in Brazil w it h w hich t o perform a com parat ive
analysis hindered t he underst anding of t he im plicat ions
o f t h e o b t a i n e d r e su l t s f o r t h e r e a l i t y i n Br a zi l .
Ther efor e, fur t her r esear ch is needed so as t o enable
f u t u r e com par ison s.
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