A Pilot Study of Support and Education Groups for College Students With Insulin-Dependent Diabetes Mellitus ROSE SHALOM, MD
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College students with insulin-dependent diabetes mellitus often ignore the care of their illness. Faced with managing this illness independently for the first time, they lack the knowledge and experience to do so effectively. Their need to establish autonomy often prevents them from seeking the advice of health professionals. In view of this, the author undertook a pilot study to investigate the role of a peer support group on a college campus as a means of improving the diabetic students’ management of their illness. Three closed-membership groups met for 10 weekly sessions. Hemoglobin A, (the measure of average blood sugar over the preceding3-month interval) determinations prior to participation in the group ranged from 4.0 to 11.7, with a mean of 8.16; after participation in the group, the mean hemoglobin A, levels of group members dropped to 6.10 (p < .001). (Hemoglobin A,, measures lower than 6.2 reflect physiologic blood sugar measures of someone without dia-
betes.) These results suggest that the peer-group approach may be a viable way to improve the metabolic control of young adults with diabetes at the time in their lives when they are learning to manage their illness independently.
College students with insulin-dependent diabetes mellitus (IDDM) manage their diabetes poorly.’ This neglect leads to chronic hyperglycemia and results in poor grades, chronic fatigue, and multiple infections. If such neglect continues into their adult lives, which it often does, the students may face premature diabetesrelated complications.
Rose Shalom is with the Department of Psychiatry at Duke University, Durham, North Carolina. She presented this rnaterial at the 143rd Annual Meeting of the American Psychiatric Association in New York City in May 1990.
VOL 39, MAY I991
Some authors have noted, for different patient groups, that educational programs have helped patients with diabetes better manage their i l l n e ~ s ~others ’~; have observed that patients with diabetes find support groups useful in coping with IDDM.4*5 In an attempt to reach the college-aged patients, the author undertook a pilot study of educational-support groups offered at the University of North Carolina Student Health Service for students with IDDM. The goal was to determine whether participation in the group improved the metabolic control of the participants’ diabetes.
METHOD Subjects Twenty-three of the 55 undergraduate and graduate students with IDDM enrolled at the University of North Carolina (total enrollment is about 20,000) responded to recruitment efforts. These efforts consisted of a form letter mailed to each student who identified IDDM as a medical problem on a college-entry questionnaire and advertisements in the campus newspaper. The letter and the advertisements alerted the students of the existence of a diabetes support group. Students were recruited at the beginning of three separate semesters over a 2-year period. Group members‘ ages ranged from 17 to 31 years, with a mean age of 20 years, and they had had diabetes from 6 months to 10 years, with a mean of 6 years. Two (loo/,) of the participants had been recently diagnosed as having diabetes-related complications. Eight (40%) had voiced difficulties in their relationships with their parents. At entry into the group, hemoglobin A,s on the group members ranged from 4.0 to 11.7, with a mean of 8.16. (Nondiabetic ranges for hemoglobin A, are from 2.5 to 6.2, with a mean of 4.8.)
2 77
COLLEGE HEALTH Measurements FIGURE 1 Hemoglobin A,, Before and After Participation in Diabetes Group
Before and after the group experience, we drew blood from all participants for hemoglobin A,, determinations, which were performed by Roche Biomedical Laboratories, using BioRad's ionic exchange column. The data were later analyzed using paired t tests. Levels below 6.2 were considered to be in the nondiabetic range. All 20 group participants obtained pregroup and postgroup hemoglobin A,, determinations, and all completed pre- and postgroup diabetes knowledge ,and behavior questionnaires.' At the last group session, all participants wrote an essay in answer to the question, "How did the group experience affect you?"
Description of Group Sessions
P < .001
Each of the three groups met weekly for 10 consecutive 1%-hour sessions. Membership was closed after the first meeting in order to foster a climate of trust. At each group session, discussion focused on a diabetes-related topic. The first 30 minutes were devoted to a formal presentation relevant to the college-aged student with IDDM, and the remaining hour was an open discussion and sharing of personal concerns of living with diabetes. The contents of individual group sessioris are outlined in a separate publication.6
(pailred t test]
Pregroup (mean = 8.1)
Postgroup (mean = 6.1)
Hemoglobin A,, for 20 group participants prior to and 3 months after the beginning of the support and educational group. Hemoglobin A,, determinations were done by Roche Medical Laboratories.
RESULTS The data in Figure 1 show that participation in the group resulted in a statistically significant improvement in the level of hemoglobin A,, among group participants. Before participation in the group, the participants' hemoglobin A,, levels ranged from 4.0 to 11.7, with a mean of 8.16, SE = 0.46, SD = 2.07. After participation in the group, the hemoglobin A,, levels ranged from 4.0 to 10.4, with a mean of 6.10, SE = 0.37, SD = 1.67. 7 his change was significant at the p < .001 level. Table 1 categorizes the participants' responses to the question "How did the group experience affect you?" Participants felt more supported and changed some importani diabetes care-related behaviors during their involvement with the group.
DISCU SSlON The improvement in hemoglobin A,, in the participants of the support groups suggested that educational-support groups may be an effective way to improve metabolic control in a young-adult population with type I diabetes. Some possible explanations for the improvement in hemoglobin A,, in the group participants are the simple passage of time, the educational component of the group experience, the contact with healthcare professionals, or the psychosocial adjustment that may have occurred as a result of participation in the group. Cumulative clinical experience with this patient population and literature in the field support the assertion
2 78
TABLE 1 Answers to "How Did the Group Experience Affect You?"
Comment
Percentage of response
I Felt supported More knowledgeable about diabetes Greater comfort in seeking medical input Improved adherence to designated diet Began routine exercise regimen
1 00
90 85 85 45
I
that the first three of these explanations, in and of themselves, are unlikely to explain the findings.'.* What is it, then, that group participants got that enabled them to manage their diabetes better?As the data in Table 1 indicate, all participants felt supported emotionally after the group sessions. These students felt different about being individuals with diabetes, and, once they "felt better" (probably, as a result of feeling less alone with their illness), they were able to use their emotional energies to carry out the tasks of taking care of their condition. In the group discussions, students expressed many feelings about their diabetes that they had considered unacceptable to express to their friends, relatives, or
IACH
INSUUN-DEPENDENT DlABE TICS physicians. They could discuss their anger at having this illness, their fear that they would be a burden to their families, their sadness that no one seemed to understand them, and their frustration at not being "like everyone else." These previously unexpressed feelings had made them feel strange, abnormal, and unacceptable. After talking things over in the accepting atmosphere of the group, the diabetic students realized that they were not alone with their feelings. This sense of acceptance from others who were struggling with similar concerns allowed them to feel less anxious and less isolated, They became more accepting of themselves and their diabetes and less prone to unrealistic extremes in their diabetes-related behaviors. Literature exists to support the contention that emotional adjustment can have a significant influence on metabolic contr01~~'~ and psychosocial variables can determine diabetes-related behaviors." Others have also shown that corrective changes occur as a result of a group experience.'* These changes are believed to occur as a result of the interpersonal learning, the sense of universality, the support, and the imitative behavior that is part of a healthy group process. The explanation that improved metabolic control arose from feeling psychologically supported by the group experience will need to be tested and confirmed, and research using formal psychological testing before and after participation in the support group is called for. A control group randomized to an educational program without the element of psychological support will also have to be evaluated. In the interim, this study suggests that the group therapy treatment model, when combined with some medical education, may be useful in helping young adults with type I diabetes achieve better metabolic control. This intervention may be important during the college years, the time in the life of young adults with diabetes when they are learning to reshape their patterns of being and behaving. INDEX TERMS diabetes, group, psychological, young adults
ACKNOWLEDGMENTS The author wishes to thank JaniceJ. Ryan, John Middleton, Robert M. Anderson, EdD, David M. Hawkins, MD, Mark N. Feingloss, MD, Judith C. Cowan, MD, James A. Blumenthal, PhD, and David J. Halperin, PhD, for their assistance.
VOL 39, MAY 7991
REFERENCES 1. Draasch A. Personal communication. 2. Mazzuca SA, Moorman NH, Wheeler ML, et al. The Diabetes Education Study: A controlled trial of the effects of diabetes patient education. Diabetes Care. 1986;9:1-10. 3. Laron Z, Galatzer A, Amir S, et al. A multidisciplinary, comprehensive, ambulatory treatment scheme for diabetes rnellitus in children. Diabetes Care. 1979;2:342-348. 4. Oehler-Giarrantana J, Fitzgerald RG. Group therapy with blind diabetics. Arch Gen Psychiatry. 1980;37:463-467. 5. Pelser HE, Groen MJ, Stuyling de L, Dix PC. Experiences in group discussions with diabetic patients. Psychother Psychosom. 1979;32:257-269. 6. Shalom R, Ryan J . Diabetes Support Groups for Young Adults: A Facilitator's Manual. Alexandria, VA: American Diabetes Association; 1989. 7. Bloomgarden ZT, Karmally RD, Metzger J, et al. Randomized, controlled trial of diabetic patient education: Improved knowledge without improved metabolic status. Diabetes Care. 1987;10:263-271. 8. Mauuca SA. Does patient education in chronic disease have therapeutic value?I Chron Dis. 1982;35:521-529. 9. Jacobson AM, Hauser ST. Behavioral and psychological aspects of diabetes. In: Ellenberg M, Rifkin H, eds. Diabetes Mellitus: Theory and Practice. New Hyde Park, NY: Medical Examination Publishing; 1981: 1037-1052. 10. Tattersall R. Brittle diabetes. Clin Endocrinol Metab. 1977;6:403-419. 11. Delarnater AM, Kurtz SM. Stress and coping in relation to metabolic control in adolescents with type I diabetes. 1 Dev Behav Pediatr. 1987;8: 136-1 40. 12. Tattersall RB, McCulloch DK, Aveline M. Group therapy in the treatment of diabetes. Diabetes Care. 1985;8:180188. 13. Yalom ID. The Theory and Practice of Group Psychotherapy. 3rd ed. New York: Basic Books; 1985.
A print ready health service newsletter, written especially for the campus community; mailed four times during the school year, for reprint and distribution. Healthy Hints contains current information on health issues and promotes healthy living. For reprints, information, or brochure, call or write: Gretta Buller 410 13th Avenue SE Rochester, MN 55904 507-289-6859
279
~
_____~
_____
College students with insulin-dependent diabetes mellitus often ignore the care of their illness. Faced with managing this illness independently for the first time, they lack the knowledge and experience to do so effectively. Their need to establish autonomy often prevents them from seeking the advice of health professionals. In view of this, the author undertook a pilot study to investigate the role of a peer support group on a college campus as a means of improving the diabetic students’ management of their illness. Three closed-membership groups met for 10 weekly sessions. Hemoglobin A, (the measure of average blood sugar over the preceding3-month interval) determinations prior to participation in the group ranged from 4.0 to 11.7, with a mean of 8.16; after participation in the group, the mean hemoglobin A, levels of group members dropped to 6.10 (p < .001). (Hemoglobin A,, measures lower than 6.2 reflect physiologic blood sugar measures of someone without dia-
betes.) These results suggest that the peer-group approach may be a viable way to improve the metabolic control of young adults with diabetes at the time in their lives when they are learning to manage their illness independently.
College students with insulin-dependent diabetes mellitus (IDDM) manage their diabetes poorly.’ This neglect leads to chronic hyperglycemia and results in poor grades, chronic fatigue, and multiple infections. If such neglect continues into their adult lives, which it often does, the students may face premature diabetesrelated complications.
Rose Shalom is with the Department of Psychiatry at Duke University, Durham, North Carolina. She presented this rnaterial at the 143rd Annual Meeting of the American Psychiatric Association in New York City in May 1990.
VOL 39, MAY I991
Some authors have noted, for different patient groups, that educational programs have helped patients with diabetes better manage their i l l n e ~ s ~others ’~; have observed that patients with diabetes find support groups useful in coping with IDDM.4*5 In an attempt to reach the college-aged patients, the author undertook a pilot study of educational-support groups offered at the University of North Carolina Student Health Service for students with IDDM. The goal was to determine whether participation in the group improved the metabolic control of the participants’ diabetes.
METHOD Subjects Twenty-three of the 55 undergraduate and graduate students with IDDM enrolled at the University of North Carolina (total enrollment is about 20,000) responded to recruitment efforts. These efforts consisted of a form letter mailed to each student who identified IDDM as a medical problem on a college-entry questionnaire and advertisements in the campus newspaper. The letter and the advertisements alerted the students of the existence of a diabetes support group. Students were recruited at the beginning of three separate semesters over a 2-year period. Group members‘ ages ranged from 17 to 31 years, with a mean age of 20 years, and they had had diabetes from 6 months to 10 years, with a mean of 6 years. Two (loo/,) of the participants had been recently diagnosed as having diabetes-related complications. Eight (40%) had voiced difficulties in their relationships with their parents. At entry into the group, hemoglobin A,s on the group members ranged from 4.0 to 11.7, with a mean of 8.16. (Nondiabetic ranges for hemoglobin A, are from 2.5 to 6.2, with a mean of 4.8.)
2 77
COLLEGE HEALTH Measurements FIGURE 1 Hemoglobin A,, Before and After Participation in Diabetes Group
Before and after the group experience, we drew blood from all participants for hemoglobin A,, determinations, which were performed by Roche Biomedical Laboratories, using BioRad's ionic exchange column. The data were later analyzed using paired t tests. Levels below 6.2 were considered to be in the nondiabetic range. All 20 group participants obtained pregroup and postgroup hemoglobin A,, determinations, and all completed pre- and postgroup diabetes knowledge ,and behavior questionnaires.' At the last group session, all participants wrote an essay in answer to the question, "How did the group experience affect you?"
Description of Group Sessions
P < .001
Each of the three groups met weekly for 10 consecutive 1%-hour sessions. Membership was closed after the first meeting in order to foster a climate of trust. At each group session, discussion focused on a diabetes-related topic. The first 30 minutes were devoted to a formal presentation relevant to the college-aged student with IDDM, and the remaining hour was an open discussion and sharing of personal concerns of living with diabetes. The contents of individual group sessioris are outlined in a separate publication.6
(pailred t test]
Pregroup (mean = 8.1)
Postgroup (mean = 6.1)
Hemoglobin A,, for 20 group participants prior to and 3 months after the beginning of the support and educational group. Hemoglobin A,, determinations were done by Roche Medical Laboratories.
RESULTS The data in Figure 1 show that participation in the group resulted in a statistically significant improvement in the level of hemoglobin A,, among group participants. Before participation in the group, the participants' hemoglobin A,, levels ranged from 4.0 to 11.7, with a mean of 8.16, SE = 0.46, SD = 2.07. After participation in the group, the hemoglobin A,, levels ranged from 4.0 to 10.4, with a mean of 6.10, SE = 0.37, SD = 1.67. 7 his change was significant at the p < .001 level. Table 1 categorizes the participants' responses to the question "How did the group experience affect you?" Participants felt more supported and changed some importani diabetes care-related behaviors during their involvement with the group.
DISCU SSlON The improvement in hemoglobin A,, in the participants of the support groups suggested that educational-support groups may be an effective way to improve metabolic control in a young-adult population with type I diabetes. Some possible explanations for the improvement in hemoglobin A,, in the group participants are the simple passage of time, the educational component of the group experience, the contact with healthcare professionals, or the psychosocial adjustment that may have occurred as a result of participation in the group. Cumulative clinical experience with this patient population and literature in the field support the assertion
2 78
TABLE 1 Answers to "How Did the Group Experience Affect You?"
Comment
Percentage of response
I Felt supported More knowledgeable about diabetes Greater comfort in seeking medical input Improved adherence to designated diet Began routine exercise regimen
1 00
90 85 85 45
I
that the first three of these explanations, in and of themselves, are unlikely to explain the findings.'.* What is it, then, that group participants got that enabled them to manage their diabetes better?As the data in Table 1 indicate, all participants felt supported emotionally after the group sessions. These students felt different about being individuals with diabetes, and, once they "felt better" (probably, as a result of feeling less alone with their illness), they were able to use their emotional energies to carry out the tasks of taking care of their condition. In the group discussions, students expressed many feelings about their diabetes that they had considered unacceptable to express to their friends, relatives, or
IACH
INSUUN-DEPENDENT DlABE TICS physicians. They could discuss their anger at having this illness, their fear that they would be a burden to their families, their sadness that no one seemed to understand them, and their frustration at not being "like everyone else." These previously unexpressed feelings had made them feel strange, abnormal, and unacceptable. After talking things over in the accepting atmosphere of the group, the diabetic students realized that they were not alone with their feelings. This sense of acceptance from others who were struggling with similar concerns allowed them to feel less anxious and less isolated, They became more accepting of themselves and their diabetes and less prone to unrealistic extremes in their diabetes-related behaviors. Literature exists to support the contention that emotional adjustment can have a significant influence on metabolic contr01~~'~ and psychosocial variables can determine diabetes-related behaviors." Others have also shown that corrective changes occur as a result of a group experience.'* These changes are believed to occur as a result of the interpersonal learning, the sense of universality, the support, and the imitative behavior that is part of a healthy group process. The explanation that improved metabolic control arose from feeling psychologically supported by the group experience will need to be tested and confirmed, and research using formal psychological testing before and after participation in the support group is called for. A control group randomized to an educational program without the element of psychological support will also have to be evaluated. In the interim, this study suggests that the group therapy treatment model, when combined with some medical education, may be useful in helping young adults with type I diabetes achieve better metabolic control. This intervention may be important during the college years, the time in the life of young adults with diabetes when they are learning to reshape their patterns of being and behaving. INDEX TERMS diabetes, group, psychological, young adults
ACKNOWLEDGMENTS The author wishes to thank JaniceJ. Ryan, John Middleton, Robert M. Anderson, EdD, David M. Hawkins, MD, Mark N. Feingloss, MD, Judith C. Cowan, MD, James A. Blumenthal, PhD, and David J. Halperin, PhD, for their assistance.
VOL 39, MAY 7991
REFERENCES 1. Draasch A. Personal communication. 2. Mazzuca SA, Moorman NH, Wheeler ML, et al. The Diabetes Education Study: A controlled trial of the effects of diabetes patient education. Diabetes Care. 1986;9:1-10. 3. Laron Z, Galatzer A, Amir S, et al. A multidisciplinary, comprehensive, ambulatory treatment scheme for diabetes rnellitus in children. Diabetes Care. 1979;2:342-348. 4. Oehler-Giarrantana J, Fitzgerald RG. Group therapy with blind diabetics. Arch Gen Psychiatry. 1980;37:463-467. 5. Pelser HE, Groen MJ, Stuyling de L, Dix PC. Experiences in group discussions with diabetic patients. Psychother Psychosom. 1979;32:257-269. 6. Shalom R, Ryan J . Diabetes Support Groups for Young Adults: A Facilitator's Manual. Alexandria, VA: American Diabetes Association; 1989. 7. Bloomgarden ZT, Karmally RD, Metzger J, et al. Randomized, controlled trial of diabetic patient education: Improved knowledge without improved metabolic status. Diabetes Care. 1987;10:263-271. 8. Mauuca SA. Does patient education in chronic disease have therapeutic value?I Chron Dis. 1982;35:521-529. 9. Jacobson AM, Hauser ST. Behavioral and psychological aspects of diabetes. In: Ellenberg M, Rifkin H, eds. Diabetes Mellitus: Theory and Practice. New Hyde Park, NY: Medical Examination Publishing; 1981: 1037-1052. 10. Tattersall R. Brittle diabetes. Clin Endocrinol Metab. 1977;6:403-419. 11. Delarnater AM, Kurtz SM. Stress and coping in relation to metabolic control in adolescents with type I diabetes. 1 Dev Behav Pediatr. 1987;8: 136-1 40. 12. Tattersall RB, McCulloch DK, Aveline M. Group therapy in the treatment of diabetes. Diabetes Care. 1985;8:180188. 13. Yalom ID. The Theory and Practice of Group Psychotherapy. 3rd ed. New York: Basic Books; 1985.
A print ready health service newsletter, written especially for the campus community; mailed four times during the school year, for reprint and distribution. Healthy Hints contains current information on health issues and promotes healthy living. For reprints, information, or brochure, call or write: Gretta Buller 410 13th Avenue SE Rochester, MN 55904 507-289-6859
279
