Ma Del Carmem Pérez Rodriguez^I; Isabel Amélia Costa Mendes^II; Miyeko Hayashida^III; Simone de Godoy^IV; Alessandra Mazzo^V; Paula Cristina Nogueira^VI

^IRN. Ph.D. in Fundamental Nursing. Professor and Researcher at Facultad de Enfermería, Universidad Autonoma de San Luis do Potosí, Mexico. E-mail:salinas67@hotmail.com
^IIRN. Full Professor.University of São Paulo at Ribeirão Preto College of Nursing. Study and Research Group on Communication in the Nursing Process. Ribeirão Preto, São Paulo, Brazil. E-mail: iamendes@usp.br
^IIIRN. Ph.D. in Nursing. Laboratory Specialist at University of São Paulo at Ribeirão Preto College of Nursing.Ribeirão Preto, São Paulo, Brazil. E-mail: miyeko@eerp.usp.br
^IVRN. Ph.D. in Sciences. Laboratory Specialist at University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, São Paulo, Brazil. E-mail: sig@eerp.usp.br
^VRN, Ph.D. Professor. University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, São Paulo, Brazil. E-mail: amazzo@eerp.usp.br
^VIRN. Post-doctoral fellow, grantee, Brazilian Scientific and Technological Development Council. University of São Paulo at Ribeirão Preto College of Nursing, General and Specialized Nursing Department. Ribeirão Preto, São Paulo, Brazil. E-mail: paullacn@yahoo.com.br

ABSTRACT

This quasi-experimental study aimed to assess the general physical condition of diabetic patients before and after the implementation of a teaching program based on participatory and traditional communication. The experimental group participated in the teaching program for foot care using participatory communication and the control group used the traditional communication method. Data were obtained through physical examination and interview at three moments: before the beginning at the end of the program and six months after the end of intervention. Most participants were female, with an average age of 52 years. Variables laboratory tests and physical examination showed different profiles (p<0.001), evidencing that the education program based on participatory communication was better than the traditional method. Teaching strategies such as participatory communication can result in greater efficiency in achieving the goals of health education.

Keywords: Diabetes mellitus; prevention & control; education, nursing; health communication.

INTRODUCTION

Non-transmissible chronic illnesses are the main causes of mortality and disability around the world, responsible for 59% of the 56.5 million deaths per year, among whichDiabetes Mellitus (DM), cardiovascular illnesses, obesity, cancer and respiratory diseases stand out¹.

It is estimated that, by 2030, more than 82 million people over the age of 64 will suffer from DM in developing countries and 48 million in developed countries².DM represents one of the main public health problems in the world. Approximately four million deaths per year can be attributed to complications of DM¹.

Among the complications of DM, cardiovascular conditions stand out, which in developed countries represent 70% of deaths among diabetes patients. Arterial hypertension, obesity, high cholesterol levels and smoking figure among the risk factors for this complication^1,3.

Another common complication in DM patients are peripheral neuropathies and the main risk factors related to this complication are high glucose levels and their duration. Neuropathies are responsible for the appearance of injuries at the extreme ends of the feet, the so-called diabetic foot, which can result in a lower limb amputation if not treated appropriately^1,4,5.

DM needs to be prevented and treated in order to avoid further complications. Primary prevention refers to the control and management of risk factors. Secondary prevention refers to early diagnosis and appropriate treatment: control of hypertension, of cholesterol levels and glucose¹.

The objective in this study was to assess the general physical condition of diabetic patients before and after the implementation of a teaching program based on participatory communication and to compare the results with those obtained based on the implementation of a program based on the traditional communication method of teaching.

LITERATURE REVIEW

This study departs from the premise that communication and education are closely linked; they share common objectives and are linked with essential characteristics of human beings for communication and learning, but are independent. Through learning, the human being gains knowledge, skills and attitudes and develops different forms and levels of receiving and responding to health messages, while the communication among the participants determines the extent to which this information is used⁶.

The use of communication in health education serves as the fundamental base of prevention and health promotion actions, aimed at achieving knowledge, attitudes and healthy lifestyles in the population⁷.

In this study, this educative approach was developed with DM patients, mainly due to the fact that this disease stands out because of high morbidity and mortality rates¹, compromising the quality of life8 and high costs for the health system^1,9.

METHODOLOGY

In this quasi-experimental study, the independent variable was manipulated (teaching program based on participatory communication), observing its effect and relation with the dependent variable (the results of implementing the program). After receiving approval from the Research Ethics Committee at the Celaya School of Nursing and Midwifery of the University of Guanajuato, Mexico, the research was developed at the health services of San Luís Potosí, Mexico.

To select the research subjects, the following inclusion criteria were considered: patients diagnosed with type 2 DM more than five years earlier, age between 40 and 65 years, without foot ulcers. Two groups were constituted through a draft, one experimental and one control group, with 77 individuals each. Both worked with the same theme, but the control group worked with the foot care teaching program based on the traditional communication model, taught by the team responsible for the health service. In the experimental group, the program was implemented using the participatory communication method, led by the primary researcher.

Participatory communication is a method that allows the participants not only to acquire knowledge, but also to include it in their daily care practice. This method is intended to address the main aspects, such as: analysis of the situation, patients’ needs and planning of the group’s interactive participation, and teaching-learning and training for the participants.

Both groups received ten hours of activities, divided in five weekly sessions.

To collect the data, an instrument was used with items about the individual’s general physical conditions and the factors related to foot ulcers that favored the appearance of lesions. This instrument comprised three topics: the first addressed the general physical measures, with five items (weight and height to determine the level of obesity, waist circumference and blood pressure); the second corresponded to the laboratory tests (six items); the third topic related to the assessment of the lower limbs. The highest score was attributed when the results of the laboratory tests, the measures or the foot conditions were the most appropriate.

Based on the total score, the individual’s degree of risk for diabetic foot was determined, classified in five levels: very low, low, median, high and very high risk.

To analyze the data, the groups were compared with regard to the variables, using multivariate analysis of the profiles of means. Student’s t-test was used to check for some parallel sequence at the three study times, as well as to compare the means for each condition assessed.

RESULTS AND DISCUSSION

The sociodemographic characteristics of the diabetic patients in this study were also found in other studies that identified a population in the age range over 50 years, mostly female, married, with unfinished primary education and without a paid job^10,11.

As the appearance of foot problems in DM patients is more frequent in the age range between 45 and 65 years, it is important to highlight that the prevalence of the diabetic foot increases with age and with the years of evolution of the DM^4,12,13. The diabetic neuropathy affects 50% of the diabetes patients over 60 years of age and can even be present before detecting the loss of protective sensitivity^2,4. In 7.5% of all diabetics and 15% of patients over 80 years of age, a trophic foot alteration develops, predisposing to ulcers¹².

The predominant diagnosis in both groups was 59.7% for patients who only suffered from type 2 DM in the experimental group and 57.1% in the control group. The second most frequent diagnosis with type 2 DM associated with arterial hypertension.

Studies indicate that arterial hypertension is twice as frequent in diabetic patients than in people without this disease, which contributes to the worsening of the vascular prognosis¹³. In a study involving type 2 diabetes patients registered in the family health program in an interior city in Minas Gerais, 79.4% reported some kind of health problem, 43.8% of whom mentioned arterial hypertension¹¹.

As regards the Body Mass Index (BMI), both groups presented obesity in the three measures. In the two groups, the initial percentage in this category was similar, with variations in the second and third measures: the number of obese patients dropped in the experimental group but increased in the control group during the second and third measures.

The relation between type 2 DM patients and obesity is extremely important. Obesity represents an important determinant of DM and its complications¹, contributing to the difficulty to control the disease, and it causes insulin resistance in the transportation of glucose stimulated by insulin, as well as in the metabolism of fat and muscle tissues¹⁴.

In a study involving type 2 diabetes patients, in which the researchers identified the clinical characteristics of this population, the mean BMI was superior to the normal indices: 25.9 Kg/m²;, with a standard deviation of 6.5 Kg/m²¹¹.Obesity and overweight are important risk factors for the development of chronic illnesses like type 2 diabetes, cardiac diseases and hypertension¹.

In another study undertaken in an interior city in the state of São Paulo with a view to identifying hypertensive patients undergoing outpatient treatment and analyzing their life habits, the researchers found that the predominant BMI values varied between 25 and 29,9 kg/m², classifying the patients as overweight¹⁵.

In a quasi-experimental study developed in Mexico, aimed at using participatory education to modify the BMI of obese type 2 diabetes patients, at the end of the course, the researchers found a BMI of 33.2 ± 2.15 (t: 22.4; p: 0.16), against 33.89 ± 1.96 at baseline. In the experimental group, the final BMI was 31.54 ± 1.71 (t: 11.55; p = 0.003), against 33.63 ± 2.12 at baseline. Therefore, it was concluded that the participatory education intervention contributed to improve the BMI in obese type 2 diabetes patients¹⁶.

In the waist circumference measure, for both groups, the highest percentage was for the category bad, with similar percentages, but with the following difference: in the experimental group, a slight decrease was observed in the second measure, which remained the same in the third. In the control group, the initial percentage in the category bad for waist circumference remained the same in the three measures.

The low variation in the results found for BMI and waist circumference may be related to the type of variable and its modifications. Losing weight over a long period is difficult for most individuals, possibly due to the calorie intake and energy consumption. This regulation seems to be influenced by genetic factors. In addition, environmental factors frequently make it difficult to lose weight for those genetically predisposed to obesity³, making this process slow.

As regards the blood pressure levels in both groups, it was observed that the highest percentage for both the systolic and diastolic pressure was found in the category good and that, although both groups displayed an increase in this category between the first and second measures, in subsequent measures, no significant differences were revealed.

Although blood pressure is considered a common comorbidity of DM, which affects most individuals³, health professionals do not consider the association between DM and arterial hypertension as they should yet. Consequently, there are many undiagnosed individuals for both diseases, which implies a greater risk of evolving to chronic micro and macro-vascular complications which, today, are responsible for the high direct or indirect cost the disease causes^1,14.

As regards the glucose levels, both groups were classified in the category bad before starting the course, with higher percentages for the control group. At the end of the course and six months later, the glucose levels in the experimental group were consideredgood,while the largest percentage continued bad in the control group.

As regards the glycated hemoglobin (Hb) and lipid profile, the highest percentage were found in the category good for the three measures in both groups, but with higher percentages for the experimental group. Glycated hemoglobin is the most indicated test to quantify the risk of chronic complications of DM¹⁷.

Glucose control reduces the appearance and progress of microvascular and neuropathic complications (distal neuropathy is the factor that most contributes to the development of the diabetic foot and future amputation). Hyperglycemia, on the other hand, produces increased collagen glycosylation, favoring the formation of callus and reduced joint mobility, both of which predict the formation of ulcers¹⁸.

A prospective clinical essay developed by theUnited Kingdom Prospective Diabetes Study involved 5,102 type 2 DM patients, with a median 10 years of follow-up. The authors showed the importance of glucose control and blood pressure to reduce problems related to DM. As a result of glucose control, the microvascular complications dropped by 25% when glycated Hb levels remained inferior or equal to 7.0%. For each unit less of glycated HB, the risk of microvascular complications dropped by 25%³.

Dyslipidemias also play an important role in the development of accelerated atherosclerosis in individuals with DM. In these patients, an increased frequency of quantitative abnormalities is observed in the lipoprotein profile. The altered composition and modifications due to oxidation and glycation turn into highly atherogenic particles¹⁹.

It is fundamental for DM patients to receive orientations that contribute to the implementation of effective strategies, and which lie within their reach, in order to maintain appropriate lipoprotein levels and, thus, reduce the risk of foot problems.

In a study undertaken in Mexico, the authors programmed and execute an educative-participatory intervention aimed as showing the advantages of the intervention diet in the control of LDL-cholesterol in type 2 diabetes patients. They found that the group that received the educative-participatory intervention reached a mean post-intervention LDL-cholesterol level of 148.4+/-21.3 when compared to the control group (185+/-24.1) (p<0.05). The authors concluded that the educative-participatory intervention, through the promotion of a new lifestyle focused on type 2 DM patients, contributed to improve the metabolic levels of LDL-cholesterol²⁰.

As regards the assessment of the feet, the result of the coincidence test was not significant (p>0.934)upon the first measure. The coincidence was significant for the second and third measures though (p=0.003 and p<0.001).

Different studies have shown that, when diabetes patients receive systematic and continuing education, the number of days of hospitalization and emergency care due to complications drops, including amputations, and also delays the appearance of chronic complications, granting a better quality of life^5,21.

Therefore, DM patients should receive orientations about the risk factors and appropriate conducts. The patients should understand the complications of losing protective sensitivity, the importance of daily foot surveillance and appropriate foot care, and need to develop skills for daily foot inspection³.

In this study, the results of the different measures indicated that the participatory method significantly improved the learning about foot care (influencing actual foot care) in comparison with the traditional method.

In a study involving diabetes patients, discussing knowledge construction in educative support groups through participatory dialogue, the authors highlighted the contribution of all participations in the development of knowledge, learning and teaching. They included that recreational therapy represents not only a moment for education or the establishment of support bonds and relations, but is also a space where individuals can talk, be heard and understood. The educative practices, which consider the human being in the construction of the care process, contributed by turning self-care into reality, and reduced the risk of developing of the diabetic foot, which entailed consequences for the patients’ autonomy and wellbeing²².

As regards the risk level of foot injuries, obtained by adding up the scores of the variables physical measures and laboratory test results, since the first measure, the experimental group obtained the highest percentage for the very low risk level, with even higher percentages in subsequent measures. In the control group, on the other hand, despite higher percentages for the very low risk level in the three measures, the percentages were not that high. In the experimental group, the final measure was lower than the first.

These results underline the premise that teaching is not merely information transfer, but should essentially aim to incorporate this knowledge in the people involved²³. This scenario represents the main focus of interest in health communication.

In a study undertaken through educative sessions focused on diabetes patients with a view to assessing their knowledge level about DM, the researchers identified that only half of the sample obtained scores classified as good. They concluded that the didactic techniques, thematic contents and quality of the information the teaching staff provided about glycemic control, knowledge about the disease and self-care to the type 2 diabetes patients who participated in the educative sessions²⁴.

Hence, it is important and necessary to use different social communication techniques, among which participatory communication stands out, which permits using information as an instrument to change attitudes and practices, and its use in health influences leads to changes in human behavior and the factors related to this behavior which direct or indirectly promote health²⁵.

The use of communication in health education represents the fundamental base of prevention and promotion actions, with a view to gaining knowledge, attitudes and healthy lifestyles for the population⁷.

           
CONCLUSION

Based on the results of this study, it is concluded that, in both groups, most participants were classified as low risk in the physical evaluation; in the experimental group, however, this percentage increased more than in the control group, as some participants changed from medium risk to low risk.

The obesity and overweight percentages found in both groups studied indicate the immediate need to address this theme through more effective prevention strategies. Obesity represents an important health problem, not only because of its importance in the development and control of DM, but also because of the difficulty observed to appropriately control it after the disease has established.

In comparison with the traditional method, the educative intervention strategy through the participatory communication method proved its greater efficacy in the knowledge gaining and in the laboratory test results. Therefore, it can be concluded that the teaching intervention based on participatory communication enhanced learning and foot care conducts, although medium and long-term assessments are needed whether the retention of learning continued.

The approach and the group management should be incorporated into the health professionals’ tasks and responsibilities, especially for nurses, as they have sufficient knowledge to enhance these group dynamics by combining knowledge about the disease, the population’s culture and the holistic view characteristic of nursing, avoiding the predominant fractioned care guided by the biological model.

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Recebido em: 29.10.2012
Aprovado em: 05.02.2013