Psychological Reports, 1979, 44, 683-690. @ Psychological Reports 1979

FACTORS RELATED T O DIABETIC CLIENTS' KNOWLEDGE ELAINE D. DYER' Brigham Young University

ANNA-LEE CHALFANT V e t e r ~ n Administration s Center Prescott, Arizona

ROBERTA C. COLE Shadow Hills, Cali/ornia

ELIZABETH M. DONAHUE Stunford University Medical Center

SUSAN FRANKLlN Stanford University Medical Center

NELL HICKOK Chemeketa Community College Salem, Oregon

DIANNE N. ISHIDA St. Francis Hospbul Honolulrr, Hazuaii

MARILYN M. KUNISHI St. Francis Hospital Honolulrr, Hazuaii

LYNN HICKS NUGENT Veterans Administration Center Prescotr, Arizona

SALLY PLAISTED Stanford Universiiy Medical Center

Summ~y.-Conditions facilitating diabetics' learning were sought. Diabetic clients (N = 114) from five hospitals in Western United States were studied to determine relationships between clients' knowledge, demographic descriptors, and various teaching approaches. Relationships were analyzed using correlation, multiple correlation and t tests. High pretest scores, as determined by multiple regression ( R .a), were obtained by clients who: ( a ) were beaer educated, ( b ) had obtained information in a hospital, (c) had diabetes longer, and ( d ) were younger. High posttest scores, determined by multiple regression ( R .53), were obtained by clients who: ( a ) were bater educated, ( b ) were younger. ( c ) obtained diabetic information on an outpatient basis, and ( d ) had read more written material about diabetes. High difference scores, determined by multiple regression ( R .40), were obtained by clients who: ( a ) were more recently diagnosed, ( b ) received insttuction in an outpatient course, and ( c ) had less formal education. Knowledge scores of clients who received instruction in the hospital or on an outpatient basis were not different at pretest but were at posttest. Diabetic clients learned more about management of their disease in classes taught after hospitalization.

Diabetes is a relatively common disease and presents problems which must be dealt with for the remainder of a client's life. Diet, activity levels, illness, and insulin must be coordinated. Clients must learn about their disease in order to live a nearly normal life. Teaching programs for people with diabetes vary widely. The place of instruction may be in the hospital, a clinic associated with a hospital (Salzer, 'Requests for reprints should be made to Elaine D. Dyer, Director of Research, College of Nursing, Brigham Young University, 401 12th Avenue, Salt Lake City, Utah 84103.

684

E. D.DYER, ET AL.

1975), or the patient's home (Burton, 1975). Young and Huffman ( 1975) studied 2 3 adult patients whose onset of diabetes occurred during adulthood and found only three were following a diabetic diet. They concluded that customary methods of dietary instruction were ineffective unless the dynamics of life style were taken into consideration. Engle ( 1975) described a method to win clients' cooperation. She suggested a thorough, concise, and understandable instructional program. Bille (1977), in his study of patients' knowledge in relation to teaching format and patients' compliance, concluded that patients learn nearly as well in an unstructured setting as they do with a structured teaching format. H e found that compliance was not significantly related to patients' knowledge of his disease. His study suggested a warm, interpersonal relationship with the professional person elicited posthospital compliance with the prescribed treaunent. The chronic nature of diabetes presents particular problems in clients' achievement and maintenance of physical, psychological, and social adjustment. Clients need to understand the interrelationships between the disease process and treatment. Knowledge about promotion and maintenance of health gives the diabetic client alternatives in living with his health problems. Objectives of the diabetic teaching programs in the five institutions participating in this study were judged by investigators to be approximately equal. .All attempted to teach the interrelationships of diet, activity level, insulin, and health fluctuations. All required clients to plan menus and make food-serving substitutions. Each program spent time individualizing instruction to include the life styles of participants. Clients were encouraged to ask questions. Factors associated with clients' knowledge about diabetes, ability to make food-serving substitutions and to live with the disease are not well described in the literature. This investigation focused on finding correlates of clients' high knowledge scores, particularly the relationship of these scores to clients' demographic descriptors, and various teaching approaches. METHOD Several measuring instruments were developed. Clients' knowledge.-An instrument was developed to measure clients' knowledge of diabetes and the relationships of diet, activity level, and insulin. One investigator attended an American Diabetic Association Workshop to obtain information about diabetic teaching programs. Information from this workshop and a diabetic teaching study published by Veterans Administration Regional Medical Education Center in Salt Lake City, provided the framework for the instrument developed and used in this study (Fraser, 1974). The investigators revised and added questions so concent would be applicable in each of the participating institutions. The final measuring instrument contained 36 questions judged to be important by a dietitian specializing in dia-

INSTRUCTION PROGRAMS FOR DIABETICS

685

betic teaching, physicians, the investigators, and their colleagues from the five participating institutions. Questions focused on clients' knowledge in four areas: ( a ) pathology of the diabetic disease process, ( b ) relationships among diet, activity levels, health fluctuations, and insulin requirements, (c) ability to discern the equivalency of various foods, and ( d ) ability to make foodserving substitutions. Scores on the test could vary from 1 to 36. Retest reliability in a pilot study of five diabetic clients' knowledge total scores was .72. Demographic questionnahe.-Clients' demographic data were obtained, such as age, sex, educational level, height, weight, number of years since diagnosis as a diabetic, and how their diabetes was controlled. Diabetic teaching program questionnaire.-Teaching program descriptions were obtained such as number of hours of instructions, number and types of instructors, number of written handouts, number of visual aids, and whether the instruction was received in the hospital or after discharge. Classes planned menus and had practice making food substitutions. Practice was obtained making selections from menus. Not all institutions provided practice in a cafeteria or restaurant. Clients participated in an educational program only after their diabetes was under control. Measwing potoco1.-Protocols for obtaining institutional and client consent were developed as well as a protocol for administration of the test before and after instruction. These were instituted to ensure consistency of measurement in the five study sites. Privacy was maintained through the use of a coding system. Client popa1ation.-Diabetic clients, 18 yr. of age and older, able to complete the Demographic Questionnaire without assistance were eligible for the study. All clients meeting these criteria who entered the five institutions from July to December, 1976, and who agreed to participate were included. Less than 2% of the eligible clients refused. Clients younger than 18 yr. were not included since they were not frequent clients at participating institutions. Hospitalized patients were from Palo Alto, California and Prescott, Arizona; the outpatients from Salem, Oregon, and both from Honolulu, Hawaii and Burbank, California. Data analysis.-An intercorrelacion matrix was developed to show the relationship of each variable with every other variable. Multiple regression was used to determine the best set of predictors for patients' knowledge. Pretest, posttest, and difference scores were dependent variables. t ratios were used to compare differences between those receiving instruction in the hospital and those receiving instruction after discharge. RESULTS As indicated in Table 1, the average client was 53 yr. of age, 66 in. tall, weighed 166 Ib., and had had diabetes 5 yr. The group was 53% females and

686

E. D. DYER, ET AL. TABLE 1 MEANSA N D

STANDARD DEVIATIONS (N= 114)

M

SD

Age ( yr. ) Height (in.) Weight (lb.) Years had diabetes Hours of instruction Pretest Score Posttest Score Difference Score

all socioeconomic levels were represented. Clients reported receiving an average of 2 hr. of diabetic instruction prior to entering the present program. Their mean score was 16 points out of a possible 36 points on the pretest and 21 points on the posttest, a gain of 5 points. Table 2 presents the number of clients using various sources for information about diabetes. It also indicates the way diabetes was controlled and whether or not they were hospitalized at the time diabetic instruction was received. TABLE 2 Nubiea~OF CLIENTS( N = 114) INDICATING "YES"PRIOR TO TEACHING PROGRAM Source and Method Used as Source of Diabetic Information Relatives Friends Books Pamphlets Magazines M.D. R.N. Dietitian Method of Diabetes Control Insulin Pills Diet In hospital teaching program In outpatient teaching program

% Yes 33 30 43 52

33 78

43 41 38 32

74 40 60

Teaching programs.-Diabetic teaching in the five participating facilities covered the same objectives and basic content areas. Individual or group teaching was done using a variety of methods: lectures, discussions, audiovisual materials, and handouts. Instructors were usually staff nurses or diabetic clinical

TABLE 3

1 Age

2 Height 3 Weight 4 Education 5 ~ears/~Lbetic 6 Hospitalized Information Source 7 Relative 8 Friend 9 Book 10 Pamphlet 11 Magazine 12 M.D. 13 R.N. 14 R.D. 15 Hours Treatment 16 Insulin 17 Pills 18 Diet Knowledge Test 19 Pretest -29 02 -01 44 27 -03 18 -02 35 37 33 16 33 44 -31 00 02 37 04 -21 15 14 22 32 22 0 9 14 21 20 Posttest 21 Diff. Cornpositescores 0 1 02 03 -13 -30 -18 -05 16 -18 -10 -15 -10 -23 -29 22 Relatives, -21 -17 02 2 1 -16 -06 83 83 32 33 26 20 16 16 Friends 23 Book, Pamphlet, -18 09 -07 29 26 07 31 2 8 86 85 83 33 27 29 Magazine 24 M.D., R.N., -17 -21 -03 19 22 15 31 0 6 32 34 33 58 81 85 R.D. Note.-Decimal points have been omitted. At P.OGr = .19; at P.m r = .25; N = 114.

19 01

33 13 10 03

10 10

57

-20 -27

12 -02 -57

35

-04

0 1 -06

10

17

19

10 02 -02

41

30 -17

36

28

37

16 42

20 -28

23

05

07

08

39

E. D . DYER, ET AL.

688

specialists. Degree of involvement of physicians and allied health professionals differed in each institution. Relationsh$s.-Relationships among variables are presented in Table 3. The pretest total score, posttest score, and difference scores were entered as variables in the intercorrelation matrix to study the relationships of variables with knowledge scores. Sources of information were summed and entered as composite scores. Information received from relatives and friends was summed as an indicator of information obtained at home. Books, pamphlets, and magazines were summed as an indicator of written information. Physicians, registered nurses, and registered dietitians were summed as an indicator of information received from professionals. The best predictors for pretest scores obtaining a multiple correlation of .65 which accounts for 43% of the variance are shown in Table 4. Only variables adding at least 1% additional variance were interpreted. TABLE 4

SUMMARY OF PRETEST SCOREMULTTPLEREGRESSION Step 1 2 3 4 5

Variable Education Instruction from M.D.,R.N., R.D. Years had diabetes Age (younger obtained higher scores) Information from books, pamphlets, magazines

Multiple R

Ra

R' Change

.43 .5 5 .55 .64 .65

.19 .31 .36 .41 .43

.19 .12

.04 .06 .O 1

Clients' educational level accounts for 19% of the variance in scores. Receiving information from physicians, nurses, and dietitians accounts for 12% of the variance. Number of years having diabetes and age add an additional 10%. Reading written information adds only 1%. In short, high pretest scores were obtained by clients who were better educated, received information from health professionals, had diabetes for a longer time, were younger, and read more written material about diabetes. The best predictors of posttest scores obtaining a multiple correlation of .54 which accounts for 29% of the variance are shown in Table 5. Educational TABLE 5 SUMMARY OF POSITEST SCOREMULTIPLEREGRESSION Step 1 2 3 4 5

Variable Educational level Age Hospitalized currently Information from books, pamphlets, magazines Information from M.D., R.N., R.D.

Multiple R

Ra

Ra Change

.37 .46 .50 .53 .54

.14

.14 .07 .04 .03 .O 1

.21 .25 .28 .29

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INSTRUCTION PROGRAMS FOR DIABETICS

level accounts for 14% of the variance in posttest scores. Age (younger clients obtained higher scores), outpatient status, and number of written sources used to obtain diabetic information accounted for an additional 14% of the variance. Twenty-eight percent of the variation in posttest scores can be accounted for using these four predictors. The fifth variable, receiving information from health professionals, adds only 1%. In other words, higher posttest scores were obtained by better educated, younger clients who received instruction on an outpatient basis and read more written materials. TABLE 6 SUMMARY OF DIFFERENCE SCOREMULTIPLE REGRESSION Step 1 2 3 4 5

Variable Years had diabetes Information from M.D., R.N., R.D. Hospitalized currently Education Information from relatives and friends

Multiple R

R:'

R' Change

.30 .37

.09 .14 .16 .16 .17

.09 .05 .02 .01 .01

.39 .40 .4 1

The best predictors of change scores obtaining a multiple correlation of .41 which accounts for 17% of the variance are shown in Table 6. Number of years having diabetes accounts for 9% of the variance. Recently diagnosed clients learned more. Receiving information from professional health care workers accounts for an additional 5 % of the variance. Being in an outpatient teaching program, educational level, and receiving information from friends and relatives contributed 4% of the variance. In summary, larger gains in scores between the pre- and posttest were obtained by clients who were recently diagnosed, received information from professional health care workers, were not as well educated, and were taught after discharge from the hospital. The relative effectiveness of hospital- and outpatient-based teaching programs was studied. Table 7 compares knowledge test scores using a t ratio. Differences were not significant at pretest as expected but were different at the 2% level at posttest. The average client in the outpatient teaching proTABLE 7 KNOWLEDCE SCORESCOMPARED BY LOCATION OF PROGRAM

Pretest Outpatient Hospital Posttest Outpatient Hospital

N

M

SD

t

P

78 36

16.46 15.91

6.10 5.04

.47

Factors related to diabetic clients' knowledge.

Psychological Reports, 1979, 44, 683-690. @ Psychological Reports 1979 FACTORS RELATED T O DIABETIC CLIENTS' KNOWLEDGE ELAINE D. DYER' Brigham Young...
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