ORIGINAL ARTICLE

Older diabetic patients’ attitudes and beliefs about health and illness _ Hatice A
gralı and Imatullah Akyar

Aims and objectives. To determine older diabetic patients’ attitudes and beliefs about illness and health. Background. Prevention of metabolic complications and treatment for cardiovascular risk factors are the main aims of the care and treatment of older diabetic patients. For the effective management of diabetes, it is crucial to recognise patients’ beliefs and attitudes about and behaviours towards their health and illness. Design. A descriptive study. Methods. The sample included 70 diabetic patients aged 65 and older. Data were collected using a socio-demographic form and the Health Belief Model Scale. The data were analysed using descriptive statistics, Mann–Whitney U-test, t-test, Kruskal–Wallis test, Welch variance analysis and Spearman correlation. Results. Results showed that older diabetic patients’ attitudes about illness and health were negative. Among individuals aged 65–70 years with more than secondary education and previous employment, mean perceived severity scores were found to be significantly higher than in other groups. The mean perceived barriers scores were found to be higher than in other groups, and this difference was statistically significant for older participants who declared a good economic status, who exhibited good/very good adherence to nutritional therapy and who were exercising and checking their blood sugar regularly. The perceived benefits and recommended activities scores of patients needing more education were significantly higher. Conclusions. Patients who were female, aged 70 and older, and of low educational and economic statuses; who showed poor adherence to treatment and medical nutrition therapy; and who needed diabetes-related training had negative health beliefs and were particularly at risk. Relevance to clinical practice. Determining the personal factors that influence health behaviours can support the development of educational activities for diabetes management, complication prevention and treatment adherence improvement.

What does this paper contribute to the wider global clinical community?

• With advanced age, attitudes and

•

beliefs about health and illness become negative and the perceived severity of disease decreases. Perceived severity, barriers, and benefits and belief in recommended health activities affect the adoption of lifestyle changes and adherence to therapy among the older.

Key words: aged care, attitudes, beliefs, diabetes, nurse Accepted for publication: 5 December 2013

Authors: Hatice A
gralı, MsN, RN, Research Assistant, Faculty of _ Nursing, Hacettepe University, Sıhhıye, Ankara; Imatullah Akyar, PhD, RN, Assistant Professor, Faculty of Nursing, Hacettepe University, Sıhhıye, Ankara, Turkey

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3077–3086, doi: 10.1111/jocn.12540

_ Correspondence: Imatullah Akyar, Hacettepe University Faculty of Nursing Sıhhıye/Ankara, Turkey. Telephone: +90 312 305 15 80 143. E-mail: [email protected]

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gralı and I_ Akyar

Introduction Given the significant rise in life expectancy, the world’s population is getting older. In 2010, an estimated 524 million people were aged 65 years and older, accounting for 8% of the world’s population (World Health Organization 2011). In parallel with the ageing of the world’s population, Turkey’s older population has increased to 8
5% of its total population (Turkish Statistical Institute 2013). Throughout the world, the increase in the older population correlates with an increase in the prevalence of chronic diseases. Diabetes mellitus, which has an important role among chronic diseases, is a disease that can cause expensive and severe complications (DeCoste & Scott 2004). Older individuals are at risk of diabetes mellitus due to many factors, including genetic composition, decreased insulin secretion, an increased adipose tissue proportion, decreased physical activity and medicine use (Beger et al. 2009). According to data worldwide, 366 million people had diabetes in 2011, and by 2030, this number will have risen to 552 million (International Diabetes Federation 2012). The incidence of diabetes peaks between the ages of 45 and 64 in developing countries, whereas the peak is among people 65 years and older in developed countries. In America, the incidence of diabetes among the older is 26
9%, whereas the incidence is 22% in Turkey (Onat 2009, Center for Disease Control 2011). Diabetic patients are expected to switch to a new lifestyle at the moment of diagnosis, to have adequate knowledge and skills, and to maintain a positive attitude to prevent complications and decreased quality of life and to successfully manage diabetes. Prevention of metabolic complications and treatment of cardiovascular risk factors are the essential targets of the care and treatment of older diabetic patients (Biberoglu 2006, Beger et al. 2009). To target the care and effective management of diabetes, it is crucial to recognise patients’ beliefs and attitudes about and behaviours towards their health and illness (Hannah & Alberts 2005). According to the Health Belief Model approach, which is used in identifying individuals’ beliefs and attitudes about and behaviours towards health and treatment, the subjective perceptions of individuals about their health and disease affect their behaviours. An individual’s beliefs about his/ her own health and disease severity and in the usefulness of recommendations influence the patient’s participation in the care and treatment processes (Janz & Becker 1984). Patient characteristics such as age, sex, socioeconomic status, education level, and the type and

3078

duration of diabetes may also affect the perception of disease severity and lead to a patient having a positive opinion about the usefulness of treatment and recommendations (Weinman 1987, Dietrich 1996, Penick 2001, Skinner & Hampson 2001). A study conducted on diabetic patients concluded that health status is considered to be better at young ages and that perceived disease severity increases with age (Akıncı & Gokdogan 2001). Ozcan (1999) also observed that patients with a negative attitude encounter more barriers in diabetes care and performed less adequate self-care compared with those with a positive attitude. Previous studies have emphasised that glucose control, self-care skills and the level of diabetes knowledge are greater in patients with positive attitudes than in other patients (Ozcan 1999, Skinner & Hampson 2001, Celik 2002, Daniel & Messer 2002). Daniel and Messer (2002) determined that patients with lower perceived barriers and higher perceived disease severity exhibited better metabolic control and treatment compliance. These results indicate that assessment of attitudes and beliefs about disease is important for the adoption of positive health behaviours and the achievement of metabolic control (Becker & Janz 1985, Schwab et al. 1994, Tan 2004). Studies performed in Turkey have mostly focused on the knowledge and attitudes of diabetic patients. Based on our literature review, this study is the only study focusing on and discussing the health beliefs of the older population in Turkey. The growing older population and prevalence of diabetes, strains on diabetes management in this group and the inadequacy of previous studies make this research crucial for our country.

Background Patients’ perceptions of a disease and its severity and of their ability to change their lifestyle affect the development of protective behaviours and adherence to treatment. In this context, the Health Belief Model, which is used to explain health behaviours, tries to clarify the individual’s responsibility for care, treatment and health by examining the relationship between health behaviour and compliance (Redding et al. 2000, Finfgeld et al. 2003). The model, developed by social psychologists in 1950, was defined by Rosenstock, Becker and Maiman (cited in Michail 1994) as the relationship between the beliefs and the behaviours of a person and was grounded in the value of a person’s abstaining from disease or being healthy and the expectation that a specific behaviour will lead to the prevention of complications and an improvement in health (Redding © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3077–3086

Original article

et al. 2000, Jane 2001, Hjelm et al. 2002, Ratanasuwan et al. 2005). The model is composed of four essential elements: perceived susceptibility, perceived severity, perceived benefits and perceived barriers. Perceived susceptibility is an individual’s self-perceptions that influence his/her attitudes about his/her own health and how the person feels and perceives himself/herself with regard to a disease or health. Perceived severity is an individual’s perception of a disease as a threat, involving assessment of the severity of a disease and development of protective behaviour. Perceived benefits are an assessment of how effective the precautions recommended for reducing the risk of a disease can be. Perceived barriers are defined as an individual’s consideration of the cost of interventions or the difficulty of recommended actions in the case of a disease and the influence of these factors on the implementation of the mentioned interventions (Becker & Janz 1985, Michail 1994, Redding et al. 2000, Finfgeld et al. 2003). According to the model, the likelihood of following health-related recommendations is influenced by perceived susceptibility, the perceived severity of a disease, and perceived barriers and benefits. This model is often used in the management of chronic diseases, such as diabetes. The health beliefs of diabetic individuals are handled as important factors in healthrelated behaviours. The effective management and control of type 2 diabetes require behavioural compliance. Studies that have used this model and have sampled diabetic patients have shown a significant correlation between people’s health-related beliefs and attitudes about the disease and the behavioural compliance described as necessary for treatment (Schwab et al. 1994, Dietrich 1996, Redding et al. 2000, Hjelm et al. 2002). The compliance of an individual with treatment is important for keeping the disease process under control and for preventing complications (Penick 2001, DeCoste & Scott 2004). In the literature, it has been observed that there is a significant correlation between metabolic control and attitudes towards diabetes and those patients with high HbA1c levels have a negative attitude regarding their health and disease (Daniel & Messer 2002). Another study observed that diabetic patients with high blood pressure also have a negative attitude (Ratanasuwan et al. 2005). These results indicate that the assessment of individuals’ attitudes or behaviours regarding their disease is an important parameter in initiating positive health behaviours and achieving metabolic control (Becker & Janz 1985, Tan 2004).

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3077–3086

Health beliefs of older diabetic patients

Methods Aim The study aimed to determine the attitudes and beliefs of older patients with diabetes about illness and health.

Design The study was conducted as a descriptive study.

Sample The study was conducted in the geriatric clinics of a university hospital in Turkey between 16 July 2012–28 September 2012. The sample included 70 diabetic patients aged 65 and above. The inclusion criteria for participation in the study were an age of 65 years or older, a diagnosis of type 2 diabetes for more than one year, the ability to communicate and willingness to participate. The sample size was determined using power analysis, and to achieve a power of 0
9, 70 patients were recruited for the study (90% power, 5% level of significance and 0
40 effect size).

Instruments Data were obtained using a socio-demographic form and the Health Belief Model Scale. The socio-demographic form was prepared by the researchers based on previous literature. This form was composed of two parts that included 30 questions about various elements, including the sociodemographic characteristics of the patients (nine questions) and disease characteristics and management (21 questions). The Health Belief Model Scale was developed by Tan (2004) based on five subdimensions of the Health Belief Model. The scale comprises five subdimensions and 36 items in total: perceived susceptibility (five items), perceived severity (three items), perceived benefits (seven items), perceived barriers (11 items) and recommended health-related activities (10 items). The items are rated on Likert-type scales ranging from 1 (definitely disagree)–5 (definitely agree). Items 3 and 4 in the subdimension of perceived susceptibility and items 16, 17, 18, 19, 20, 21, 22 and 23 in the perceived barriers subdimension are coded in reverse fashion. The total score is calculated by adding the scores on all items on the scale and dividing the result by the total number of items. A total score of four or above indicates high (positive) health beliefs, and a score lower than four indicates low (negative) health beliefs.

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A validity and reliability study of the scale was con€ ducted by Kartal & Ozsoy 2007 for use in type 2 diabetic patients in Turkey. Based on the analyses, items 3, 17 and 20 were removed from the scale, and the remaining 33 items were translated into Turkish. The test–retest reliability of the scale was calculated to be 0
90, and its internal consistency reliability was calculated to be 0
89.

Data collection The patient files in the geriatric clinics were reviewed to locate diabetic older patients. The patients who met the study criteria and agreed to participate in the study were invited into a different room in the clinic. After the researchers explained the aim of the study, the patients were interviewed by a face-to-face method, and data were collected. The data collection lasted approximately 20 min. The metabolic variables of the patients were obtained from routine test results that were collected one week earlier.

Analyses The study data were analysed with Statistical Package for Social Sciences (SPSS), version 15.0 (SPSS Inc., Chicago, IL, USA). Percentages, averages and standard deviations were used as descriptive statistics. The Mann–Whitney U-test, the t-test, the Kruskal–Wallis test and Welch variance analysis were used to compare the numerical variables. Spearman correlation was used to confirm the existence of a relationship between quantitative variables and to determine its strength. In the study, the overall level of significance was determined to be p < 0
05.

Ethical considerations The study was approved by the Ethics Committee of the University (No: LUT 12/32). Prior to the study, the patients received verbal and written information about the study, and their written consent was obtained. The patients’ participation was voluntary, and 18 patients chose not to participate in the study due to a lack of time or urgent personal commitments.

Results Sample characteristics and diabetes management The mean age of the patients was 71
95  5
01 (min 65, max 85). In total, 60% were women, 67
1% were married, 41
4% had graduated from primary school, 47
1% had

3080

worked in the past, 77
1% had a middle level of income, 31
4% lived with family or a spouse and 88
8% lived in a city. The mean duration of diabetes was 13
11  9
28 years (min 1, max 34). In total, 71
4% were incidentally diagnosed with diabetes, and 54
3% were treated with diet and oral antidiabetics. Approximately three quarters (77
1%) of the patients expressed their adherence to treatment as moderate, and 52
9% declared their adherence to medical nutrition therapy as moderate. Nearly all of the diabetic patients had at least one chronic disease (87
1% with hypertension and 58
6% with hyperlipidaemia). Moreover, 55
7% did not exercise, 70% had their blood glucose measured and 32
9% smoked. Additionally, nearly half of the patients had acute or chronic complications. In particular, 22
9% of the acute complications were hyperglycaemia and 14
3% were hypoglycaemia. Regarding the chronic complications, 22
9% were retinopathy; 18
6%, neuropathy; 5
7%, nephropathy; and 2
9%, foot injuries. Regarding the metabolic control of the patients, their fasting blood glucose, postprandial blood glucose, HbA1c and body mass index values were above the normal ranges. Other values (HDL, total cholesterol, triglycerides, microalbuminuria and blood pressure) were also within the normal ranges.

Health beliefs of patients The mean health belief score of the patients was 3
4  0
4, indicating that their attitudes and beliefs towards health were negative (Table 1). Regarding socio-demographic characteristics, the mean health belief scores of patients aged 65–70 and of patients who defined their economic status as very good/good were higher than those of other groups. It was also found that an increase in education correlated with an increase in health belief scores (p = 0
007) and that patients who had worked in the past had significantly higher scores than did patients who had not (p = 0
045; Table 2). The mean score for perceived susceptibility was significantly higher, given a high educational status (p = 0
003). Table 1 Health belief scores Health Belief Scale

  SS x

Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Recommended health-related activities Total score of the scale

2
9 3
9 3
6 3
1 3
7 3
4

     

0
4 0
5 0
4 0
5 0
5 0
4

Min–Max. 2
3–3
8 2
0–5
0 2
9–5
0 2
2–4
7 3
0–5
0 2
8–4
5

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3077–3086

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3077–3086

2
9  0
4

3
9  0
5

4
0  0
5

3
0  0
3

t = 1
103 p = 0
274

4
0  0
6

3
0  0
4 z = 0
322 p = 0
747

3
6  0
4

3
7  0
5

3
7  0
5

3
5  0
4

z = 2
459 p = 0
014

3
8  0
5

2
9  0
3

z = 0
939 p = 0
348

3
8  0
3

4
3  0
3

3
5  0
5

3
5  0
3

t = 1
205 p = 0
232

z = 1
323 p = 0
186

3
3  0
6

v2 = 4
824 p = 0
090

z = 0
668 p = 0
504

3
5  0
4 3
6  0
5

3
2  0
4

v2 = 11
178 p = 0
004

t = 1
041 p = 0
302

Analyse

3
6  0
4 3
5  0
4

3
9  0
6

3
7  0
4

v2 = 11
687 p = 0
003

2
7  0
3

z = 1
716 p = 0. 086

z = 2
375 p = 0. 018

  SS x

Perceived benefits

2
9  0
4

3
8  0
5 4
0  0
6

z = 0
515 p = 0
607

2
9  0
3 3
0  0
4

4
1  0
4 3
8  0
6

z = 1
002 p = 0
317

3
0  0
4 2
9  0
3

Analyse

  SS x

Analyse

  SS x

Bold indicates significant value (p < 0.005).

Yes (33) Economic status Very good/ good (14) Middle/low (56)

Age 65–70 (30) 71–85 (40) Gender Female (42) Male (28) Educational level Illiterate/ literate (18) Primary school (37) High school and university (15) Having worked before No (37)

Variable (n)

Perceived severity

Perceived susceptibility

Table 2 The scale scores of the patients by demographic characteristics

3
0  0
5

3
4  0
6

3
1  0
6

3
0  0
5

3
8  0
4

3
1  0
5

2
9  0
4

3
0  0
5 3
2  0
6

3
1  0
5 3
0  0
5

  SS x

t = 2
449 p = 0
017

t = 1
642 p = 0
105

F = 2
877 p = 0
630

z = 1
109 p = 0
267

t = 1
246 p = 0
217

Analyse

Perceived barriers

3
6  0
5

3
4  0
4

3
6  0
4

z = 1
568 p = 0
117

3
9  0
5

3
3  0
3

3
4  0
4

3
3  0
3

3
4  0
4 3
5  0
4

3
5  0
4 3
4  0
4

  SS x

Total score

3
5  0
4

t = 1
513 p = 0
135

F = 1
359 p = 0
264

z = 0
489 p = 0
625

z = 1
375 p = 0
169

Analyse

health-

3
8  0
5

3
6  0
4

3
6  0
3

3
7  0
5

3
6  0
3

3
6  0
4 3
7  0
5

3
8  0
5 3
6  0
4

  SS x

Recommended related action

z = 1
939 p = 0
052

z = 2
001 p = 0
045

v2 = 9
889 p = 0
007

z = 1
260 p = 0
208

t = 1
649 p = 0
104

Analyse

Original article Health beliefs of older diabetic patients

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gralı and I_ Akyar

The mean score for perceived severity was statistically significantly related to age (p = 0
018), educational status (p = 0
004) and having worked in the past (p = 0
014). The mean score for perceived barriers was statistically significantly related to economic status (p = 0
017). Age was inversely proportional to perceived severity, and education level was directly proportional to perceived severity. Additionally, patients who had worked in the past expressed increased perceived severity, and economic status was inversely proportional to perceived barriers (Table 2). The mean Health Belief Scale scores of patients who were incidentally diagnosed with diabetes, who had diabetes for longer than five years, who exhibited good or moderate treatment adherence, who exhibited good adherence to medical nutrition therapy and who needed more training about diabetes had higher scores compared with other groups. Patients who had blood sugar measurements (p = 0
037) and patients who exercised (p = 0
003) had health belief scores that were significantly higher (Table 3). The mean scores for adherence to medical nutrition therapy in the subdimension of perceived susceptibility were significantly increased (p = 0
003), as for exercise in the perceived severity subdimension (p = 0
023) and adherence to medical nutrition therapy (p = 0
035), exercise (p = 0
001) and the need for more training (p = 0
046) in the perceived benefits subdimension. Compliance with medical treatment was inversely proportional to perceived susceptibility, and patients who exercised had a high perception of severity. Additionally, patients who complied with medical nutrition therapy, who exercised and who needed more training had a high perception of benefits. Furthermore, the mean score in the subdimension of perceived barriers was high for complying with medical treatment (p = 0
014), having blood glucose measurements (p = 0
017) and exercising (p = 0
025). In addition, the mean score in the subdimension of recommended health-related activities was significantly higher for complying with medical treatment (p = 0
020), complying with medical nutrition therapy (p = 0
027), having blood sugar measurements (p = 0
028), exercising (p = 0
018) and needing more training (p = 0
006) (Table 3). Patients who exhibited poor compliance, who lacked blood glucose measurements and who did not exercise had a lower perception of barriers. Additionally, patients who exhibited poor compliance with medical treatment and medical nutrition therapy, who lacked blood glucose measurements and who did not exercise or need more training had reduced scores for belief in activities recommended in relation to health.

3082

In the study, no correlation was found between the metabolic control values and the health beliefs of patients (p > 0
05, HbA1c r-value = 0
009).

Discussion To improve the health of diabetic patients and to ensure their adoption of positive health behaviours, the health beliefs and attitudes of these patients must be assessed (Dietrich 1996, Daniel & Messer 2002, Tan 2004). This study found that the health belief scores of patients were low and that their health beliefs were negative. In his study of diabetic patients, Tan (2004) determined that the mean scores for the perceived barriers ranged between 2
55  0
86 and 3
82  0
65. Furthermore, the mean scores for health beliefs that were related to recommended health-related activities ranged between 3
07  0
88 and 4
07  0
33, and the health beliefs of the patients were negative. In our study, the total scores for the health beliefs of patients aged between 65–70 were higher than for patients aged between 71–85 (p > 0
05), and those patients’ perception of severity was significantly higher than in the other group (p < 0
05). Tan (2004) found no statistically significant correlations between the age groups of patients and their disease-related health beliefs. In another study, Kır (2003) found that the older diabetic patients were the less inclined and they were to consider recommendations useful. In a study by Akıncı and Gokdogan (2001), it was stated that age was directly proportional to perceived severity. Therefore, health was perceived to be better in younger patients, and the severity of the disease was perceived to be greater in older patients. Studies investigating the importance of gender in diabetes-related attitudes and practices have yielded different results (Coates & Boore 1996, Akıncı & Gokdogan 2001, Wen et al. 2004). Whereas the study by Akıncı and Gokdogan (2001) found no gender differences in perceptions of health and disease, and Coates and Boore (1996) observed that women perceived diabetes as being less risky than did men. Our results also showed that the health beliefs and perceived susceptibility, severity, benefits, barriers and health-related activities scores of women were lower than those of men. This result may be associated with factors such as women’s lower education and socioeconomic levels, lack of awareness about the benefit of health services and limited decision-making. The education level and cultural and socioeconomic statuses of patients are of great importance in the management and control of diabetes (Weinman 1987, Dietrich 1996, Peyrot et al. 1999). Our study showed that © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3077–3086

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3077–3086

Bold indicates significant value (p < 0.005).

3
5  0
4 3
6  0
4 3
6  0
5 3
6  0
4 3
6  0
4 3
3  0
3 3
8  0
3 3
6  0
5 3
4  0
3

v2 = 2
190 p = 0
334

v2 = 0
165 p = 0
921

v2 = 1
360 p = 0
507

z = 1
594 p = 0
111 z = 2
267 p = 0
023

3
9  0
5 4
1  0
4 3
8  0
6 3
9  0
6 3
9  0
5 3
8  0
8 3
8  0
6 3
8  0
5 4
0  0
6 4
0  0
5 3
7  0
6 4
1  0
4

z = 1
995 p = 0
046

3
2  0
7 3
0  0
4

z = 0
211 p = 0
833

4
0  0
4 3
9  0
6

3
8  0
5 3
5  0
4

3
1  0
5 3
1  .5

3
5  0
4 3
6  0
5

z = 0
246 p = 0
806

3
9  0
5 3
9  0
6

z = 0
482 p = 0
630

3
0  0
5

3
2  0
6

3
2  0
6 2
9  0
4

3
3  0
3 3
1  0
6 2
9  0
4

3
1  0
4 3
1  0
6 2
8  0
4

3
0  0
4 3
1  0
5 3
2  0
6

3
1  0
5 3
0  0
6

  SS x

3
4  0
4

z = 3
379 p = 0
001

z = 0
487 p = 0
626

v2 = 6
695 p = 0
035

v2 = 4
523 p = 0
104

F = 0
704 p = 0
498

z = 1
087 p = 0
277

Analyse

z = 0
459 p = 0
646

z = 0
100 p = 0
920

z = 2
241 p = 0
025

z = 2
378 p = 0
017

v2 = 8
609 p = 0
014

v2 = 2
233 p = 0
327

v2 = 1
671 p = 0
434

z = 1
497 p = 0
134

Analyse

Perceived barriers

3
8  0
6

3
8  0
4

3
6  0
4 3
6  0
5

3
6  0
4 3
5  0
4

z = 0
340 p = 0
734

  SS x

Perceived benefits

3
9  0
5 4
0  0
5

Analyse

  SS x

Analyse

  SS x

Diagnosis of diabetes Incidentally (50) 2
9  0
4 z = 0
352 p = 0
725 Suspiciously (20) 2
9  0
4 Duration of diagnosis 1–5 years (20) 2
9  0
4 v2 = 0
137 6–10 years (16) 2
9  0
3 p = 0
934 ≥11 years (34) 2
9  0
4 Compliance with medical treatment Good (6) 3
0  0
3 v2 = 2
057 Fair (54) 2
9  0
4 p = 0
358 Poor (10) 3
0  0
4 Compliance with medical nutrition therapy Good (8) 3
2  0
3 v2 = 11
379 Fair (37) 2
8  0
4 p = 0
003 Poor (25) 3
0  0
4 Blood glucose measurement Yes (49) 3
0  0
4 z = 0
806 No (21) 2
9  0
4 p = 0
420 Regular exercise Yes (31) 3
0  0
4 z = 1
621 p = 0
105 No (39) 2
9  0
3 Education about diabetes Had taken (36) 3
0  0
4 z = 0
865 Not taken (34) 2
9  0
4 p = 0
387 Needing more education Yes (18) 2
9  0
3 z = 0
213 No (52) 2
9  0
4 p = 0
831

Variable (n)

Perceived severity

Perceived susceptibility

Table 3 The scale scores of patients by diabetes and diabetes management characteristics

4
0  0
6 3
6  0
4

3
7  0
4 3
7  0
6

z = 2
727 p = 0
006

z = 0
231 p = 0
817

z = 2
370 p = 0
018

3
8  0
5 3
6  0
4

z = 2
194 p = 0
028

v2 = 7
220 p = 0
027

v2 = 7
822 p = 0
020

v2 = 6
006 p = 0
050

z = 1
401 p = 0
161

Analyse

health-

3
7  0
5 3
5  0
4

3
9  0
2 3
8  0
6 3
5  0
3

3
8  0
2 3
7  0
5 3
4  0
3

3
5  0
5 3
8  0
4 3
7  0
5

3
7  0
5 3
6  0
4

  SS x

Recommended related action

z = 0
247 p = 0
805 z = 1
701 p = 0
089

3
6  0
5 3
4  0
3

z = 3
023 p = 0
003

z = 2
090 p = 0
037

v2 = 5
156 p = 0
076

v2 = 3
384 p = 0
184

v2 = 2
827 p = 0
243

z = 1
450 p = 0
147

Analyse

3
4  0
3 3
4  0
4

3
3  0
3

3
6  0
4

3
5  0
4 3
3  0
3

3
6  0
3 3
5  0
4 3
3  0
3

3
5  0
3 3
5  0
4 3
2  0
3

3
3  0
3 3
5  0
3 3
5  0
4

3
5  0
4 3
3  0
4

  SS x

Total score

Original article Health beliefs of older diabetic patients

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H A
gralı and I_ Akyar

educational status was directly proportional to the perception of susceptibility and severity, that economic status was inversely proportional to the perception of barriers and that patients who had previous work experience had a higher perception of severity (p < 0
05). In the literature, it has been reported that individuals with a high level of education exhibit higher levels of compliance with treatment (Weinman 1987, Dietrich 1996, Peyrot et al. 1999). Furthermore, a study conducted in our country determined that the socio-economic level of diabetic individuals influences their perception of their current health, their perception of diabetes as a severe disease and their consideration of recommendations as useful (Akıncı & Gokdogan 2001). High levels of education and income may affect patients’ perceptions of severity and susceptibility, as these factors ease access to disease-related resources and perception and implementation of recommendations. Treatment for type 2 diabetes, which has a high incidence in old age, is underpinned by medical nutritional therapy, exercise, oral antidiabetic treatment and later insulin treatment (Weinman 1987, Biberoglu 2006). In our study, the compliance of patients with medical treatment and medical nutritional therapy was directly proportional to their health beliefs and to their scores for disease-related perceived susceptibility, severity, benefits, barriers and recommended health-related activities (p < 0
05). Furthermore, patients who exhibited good treatment compliance had more positive beliefs about susceptibility and recommended health-related activities. Additionally, patients who exhibited good compliance with medical nutritional therapy had more positive beliefs about disease-related perceived benefits, barriers and recommended health-related activities (p < 0
05). A study that investigated the diabetic patients’ perceptions of their health and disease demonstrated that individuals had low scores for implementing recommendations even if they had high average scores for perceiving the disease as severe and considering the recommendations useful. This result underlines the necessity of making holistic assessments about patients to determine the reasons that prevent the implementation of treatment (Akıncı & Gokdogan 2001). A study by Kartal (2006) found a statistically significant correlation between diet compliance levels, glucose measurement and exercise practice in patients and their average health belief scores (p < 0
05) and reported that these variables had a positive impact on disease-related health beliefs. Similarly, in our study, the disease-related barrier perception of patients who had their blood glucose measured and their belief in health-related activities were found to be positive (p < 0
05). Additionally, in our study, in patients who did exercise, the disease-related perceived

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severity, benefits and barriers and the belief in recommended health-related activities were found to be more positive than in patients who did not exercise (p < 0
05). The follow-up parameters for diabetes in our study group were observed to be close to the targeted values and thus support these results. The high education and income levels of our group and the long duration of their diabetes histories are considered to be effective in facilitating their compliance, even though the compliance of older individuals with medical treatment and medical nutritional therapy is affected by factors such as additional chronic diseases, and the effort required preparing an appropriate diet. In our study, receiving diabetes-related training did not affect health beliefs (p > 0
05). However, individuals who needed training about diabetes had a positive perception of disease-related benefits and a positive belief in recommended health-related activities (p < 0
05). Daniel and Messer (2002) observed that receiving diabetes-related training led to a statistically significant positive change in the health beliefs of patients. The same study found that patients who received training had a lower perception of diabetes-related barriers and higher perceptions of susceptibility, severity and benefits. The results suggest that older individuals who require disease-related training are more willing to turn the information that they receive into behaviours and that this training could have a positive impact. There was no significant correlation between metabolic control values and health belief scores of patients, in this study. In Daniel and Messer (2002)’s and Penick (2001)’s study, patients with positive attitudes was better on metabolic regulation, and also Ozcan (1999)’s study of patients with poor metabolic control levels were found to have negative attitudes about diabetes. A follow-up study aimed to determine the effect of perceived severity and barriers on glycemic control showed that patients with high perceived severity and low barrier scores had desired HbA1c levels and they tend to adopt life style changes more easily (Daniel & Messer 2002). The difference between the literature and our study is associated with the average baseline metabolic control value scores.

Conclusion Our study showed that older diabetic patients did not tend to perceive diabetes as a serious disease and did not practice recommended activities. They also did not have a strong belief about illness susceptibility. In particular, patients who were female, aged 70 or older, less educated and of a lower economic status; who showed poor adherence to treatment and medical nutrition therapy; and who needed © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3077–3086

Original article

Health beliefs of older diabetic patients

diabetes-related training had negative health beliefs. These individuals are considered to be at risk of poor diabetes management, compliance and cardiovascular complications. Arranging training programs and providing consulting services for older diabetic patients that consider their disease- and health-related beliefs are recommended to improve their disease-related health beliefs and ensure personalised management of their diabetes.

Relevance to clinical practice It is important to understand the health beliefs of older diabetic patients in relation to differences in living with the disease and facing related problems. The results of this study could help in the planning of individual assessments of older adults, the development of educational activities to support good diabetes management, the prevention of complications, the enhancement of treatment adherence and the management of factors influencing health behaviours.

Acknowledgements The research received no specific funding from any institution.

Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be published.

Conflict of interest The authors declare no conflict of interest.

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© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3077–3086