RESEARCH ARTICLES

Conceptions of illness from hypertension and Diabetes Mellitus among a group of hospital inpatients

Natália Pimentel Gomes Souza^I; Glória Yanne Martins de Oliveira^II; Ana Lívia Araújo Girão^III; Lívia Marques Souza ^IV; Samia Jardelle Costa de Freitas Maniva^V; Consuelo Helena Aires de Freitas^VI

^I Nurse. Master in Clinical Care in Nursing and Health at the State University of Ceará. Member of the Research Group of Adult and Family Health. Fortaleza, Ceará, Brazil. E-mail: nataliapimentel88@yahoo.com.br
^II Master's Student in Graduate Program Clinical Care in Nursing and Health at the State University of Ceará. Member of the Research Group of Adult and Family Health. Fortaleza, Ceará, Brazil. E-mail: gloria_yanne@hotmail.com
^III Master's Student in Graduate Program Clinical Care in Nursing and Health at the State University of Ceará. Member of the Research Group of Adult and Family Health. Fortaleza, Ceará, Brazil. E-mail: liviaag_@hotmail.com
^IV Nurse. Member of the Research Group of Adult and Family Health. Fortaleza, Ceará, Brazil. E-mail: liviaamarques@hotmail.com
^V Nurse. Master in Clinical Care in Nursing and Health at the State University of Ceará. Member of the Research Group of Adult and Family Health. Fortaleza, Ceará, Brazil. E-mail: samia_jardelle@yahoo.com.br
^VI PhD in Nursing. Professor, Department of Nursing. State University of Ceará. Leader of the Research Group of Adult and Family Health. Fortaleza, Ceará, Brazil. E-mail: consueloaires@yahoo.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.15579

ABSTRACT

This descriptive study to identify health education needs among diabetic and hypertensive hospital inpatients was conducted from September to December 2011 through semi-structured interviews and field observation of 10 inpatients at a public hospital in Fortaleza. The patients were highly dependent and severely disabled, besides lacking knowledge about their pathologies, leading to failure to adhere to treatment. Strokes were the main clinical complication. Non-drug therapy was cited as important, although drug treatment symbolizes the patients’ self-care better. It was concluded that nurses should perform health education in the care plan for this clientele.

Keywords: Hypertension; Diabetes Mellitus; health education; nursing.

INTRODUCTION

Chronic non-communicable diseases (NCDs) gain increasing space in the healthcare setting. The highlight of this study is the high blood pressure (hypertension) and type 2 diabetes mellitus (T2DM), considered risk factors for other diseases that cause high cost, both economically and socially. As a result, we emphasize the importance of actions associated with the prevention, early diagnosis and treatment to effectively control¹.

In this context, based on the activities developed in the Research Group of Adult and Family Health, State University of Ceará, in a tertiary public hospital, it was realized that illness by DM and/or hypertension is a suitable field for the implementation of nursing educational activities. Such experiences enabled the formulation of questions that motivated the study: What do hospitalized patients know about T2DM and/or hypertension? How is self-care performed?

This is a cutting of the research project Health-disease process in the daily life of people with hypertension and diabetes mellitus: meanings and beliefs in promoting clinical nursing care . The aim of this study was to identify the learning needs in health of hypertensive and diabetic patients hospitalized due to hypertension and/or type 2 diabetes.

LITERATURE REVIEW

Currently, over 60% of global deaths are due to NCDs. In Brazil, these diseases play significant role among the leading causes of morbidity and mortality ². According to epidemiological studies, hypertension has a high prevalence and its frequency may vary from 22.3% to 43.9%³. Regarding T2DM, it manifests in almost 8% of the adult population, and there is an increasing growth in emergence of this disease as age raises, reaching 17% in the elderly ⁴.

It is known that therapeutic adherence of patients with hypertension and/or type 2 diabetes means a challenge for health professionals, including nurses, particularly because illness requires daily and continuous care.

To that end, health promotion initiatives are means for disease prevention and control of disease⁵. For the better the patient's knowledge about the disease, the better their actions for prevention, healthy habits and continuity of care will be; at the same time, the lower the incidence of complications^{6, 7}.

However, therapeutic adherence to treatment in chronic illness situation pervades not only the personal motivation of the patient. Different variants interfere in this process, such as low socioeconomic status, self-care disability and knowledge about the disease, among others.

METHODOLOGY

This is a descriptive study of quantitative and qualitative approach⁸, conducted in a tertiary public hospital in the city of Fortaleza, from September to December 2011. Participants were a total of 10 hospitalized patients, during the period of data collection, due to complications from hypertension and/or type 2 diabetes, selected through intentional sampling⁹. As for the exclusion criterion we adopted: presenting damaged physical or mental condition that could prevent the interview. The number of the participants was defined by saturation, which is when the data, from the inclusion of new participants, start to present, according to the researcher's point of view, some redundancy or repetition⁹. To ensure the anonymity of the participants, we assigned to each of them letter I from interviewed and a subsequent number.

Initially, we went to the field to know about the work dynamics in inpatient units. The following collection instruments were used: checklist, semi-structured interview and field observation. The checklist was adopted to identify diabetic and hypertensive patients, through medical records analysis; they contained patient identification data, diagnosis and admission date, sex, age, blood pressure and blood glucose. Interviews were recorded and stored in audio files, and the average duration of each was 30 minutes. They were consisted of two parts, the first inquired about the sociodemografic data; while the second contained questions concerning knowledge about hypertension and/or type 2 diabetes. With regard to the observation, data were recorded in a field diary. In patients with impaired physical mobility, we employed the Barthel Index (BI), which assesses the degree of dependence in activities of daily living.

The data were processed through categorical thematic analysis technique, as the following recommended steps¹⁰. Interviews were transcribed in full. Next, there were successive readings, with a view to material exploration and text cut in record units. The following thematic categories were formulated: Characterization of the study participants, Patients' knowledge about the disease (hypertension and/or type 2 diabetes) and Primary health care. Content analysis was based in the literature concerning the subject.

In quantitative approach, we calculated the absolute frequency and the arithmetic mean, as the statistical analysis.

Ethical and legal principles in research with human beings were respected¹¹. As recommended, the data collection occurred by signing the Informed Consent Form by the participants. The research project was approved by the Research Ethics Committee of the State University of Ceará, in the opinion No. 05050534-3.

RESULTS AND DISCUSSION

Characterization of study participants

We investigated 10 hospitalized patients, two patients had diabetes mellitus and hypertension concomitantly, four had SAH and four had DM, separately. The mean age was 59.6 years old. Seven participants were men and three were women. We identified diversified marital status: married men and women or living together, single, widowed or divorced. We highlight that five patients lived with their wives and three with their daughters, who would take care of patients after hospital discharge.

It was found low levels of education, and many did not complete elementary school. The average schooling was 4.7 years of study. The average family income was R$ 934.2/month. As for the occupation, five were retired, two developed informal activities, two had formal work and one was unemployed.

Considering the low income and low educational level of the subjects studied, the lower socioeconomic status is associated with higher prevalence of hypertension, and increased risk of injury in target organs and cardiovascular events, as a result of limited access to health care¹².

With regard to identification of other modifiable risk factors, three people were smokers, two drank alcohol regularly, eight were sedentary. Only two exercise, jogging, three times a week. Blood pressure values ranged between 140-179/80-110. Among diabetic patients, the mean capillary glucose level was 197 mg/dL.

As noted, the major clinical complication was cerebrovascular accident (CVA/stroke), diagnosed in five people. Three people were hospitalized for diabetic complications, including diabetic foot, manifested in two patients.

Stroke is a leading cause of death in the adult population, and hypertension and type 2 diabetes has are among its main risk factors. However, mortality is only one of public health measures of the stroke impact. Another equally important is the physical disability¹³.

The incidence of stroke is higher after 65 years old, with an increasing risk with higher age. The population aging, associated with risk factors for cerebrovascular disease¹⁴ such as hypertension, type 2 diabetes, smoking, alcohol consumption, obesity and dyslipidemia, explain, in part, the high incidence of stroke.

Thus, we sought to know the health status of these patients with regard to the degree of dependence in activities of daily living, using the BI. Thus, according verification, three patients had moderate dependence, with varied score between 65 and 80; one revealed severe dependence, scoring 50; and one a light dependence, with BI equivalent to 90 points. Patients with severe and moderate dependence indicated greater propensity for developing pressure ulcers. Three of them had skin lesions in at least one of the body parts: sacral, trochanteric and calcaneus.

The BI is a scale that guides the care of patients in progress of functional capacity. In this context, an initial score higher than 60 relates to shorter hospital stays and higher probability to reintegrate to life in the community after hospital discharge¹⁵.

After hospital discharge, about 80% of stroke patients continue in need of special care because of the residual disabilities¹⁶. Thus, in most cases, the family, in the figure of informal or family caregiver takes responsibility of care. However, to ensure continuity in the treatment and prevention of complications, it is necessary to prepare the patient and family caregiver, through health education.

It was shown to be relevant to characterize hospitalized patients by predicting the care to be planned and executed by health professionals, including nurses.

Patients' knowledge about the disease

To perform self-care, hypertensive and/or diabetic person needs specific knowledge and skills to achieve results. Thus, patients were asked about the illness. Several reports have shown a lack of knowledge. We met the symbolic construction about the disease, as explained in the statements:

Diabetes is sweet blood, is having sugar in the blood. (I2)

About diabetes, I know I cannot eat sugar. (I10)

When the pressure is high, I get a headache. (I6)

According to the theoretical framework of symbolic interacionism, the exposed propositions occur as a result of interaction of people within a social structure, of their human actions as participants in the world¹². Thus, the obtained statements result from the individual and community life experiences, and the disease has, for each respondent, a unique meaning derived from their experiences as subjects in the world.

Because these are chronic diseases, treatment of hypertension and/or type 2 diabetes is permanent. In this sense, for adherence to therapeutic plan, it is necessary the systematic clarification in order to guide the patient about the disease and its consequences in the long term, as well as the benefits from the accomplishment and maintenance of the established goals^13,17.

The situation found in the study was worrying because these people had been undergoing treatment for hypertension and/or type 2 diabetes for a more than 5 years, and still showed lack of knowledge about the disease, which interfered with self-care. Thus, some patients have neglected health care, demonstrating lack of adherence to treatment, as noted in the speeches:

I do not follow a diet, I eat what I want. (I4)

I eat greasy food, salty food, I don't even take the blood pressure medication properly. (I6)

In this context, educational guidelines, besides informing about the disease, help the patient in the recognition of symptoms of lack of control of hypertension and/or T2DM, as well as on the side effects of any medications taken. Therefore, educational interventions aim to prevent sequelae, hospitalizations and deaths related to acute and chronic complications of these diseases. As the main strategy, we seek to ensure adherence to the prescribed treatment and the adoption of a healthy lifestyle^13,17.

Other patients defined hypertension and/or T2DM based on clinical complications that lead to hospitalization, stroke, retinopathy and diabetic foot. Statements derived from illness experience.

Hypertension is the risk of thrombosis. (I1)

Diabetes impairs vision and cause wounds. (I5)

Given the speeches, illness is still characterized as an unknown world, because patients held a minimum knowledge. Knowledge about the health status and the means to improve it is essential to maintain the quality of life. So it is nurses' responsibility to provide information to make them aware of the proper self-care.

In the hypertension and/or diabetes treatment, the keystone lies in the control of blood pressure and glucose levels. However, care to this population should include strategies to promote quality of life and well-being¹⁸. In this context, health education is presented as a fundamental strategy of care, being a facilitator tool for community empowerment, contributing to the promotion of health. Thus, health professionals and users need to establish a dialogical relationship based in the therapeutic listening, respect and appreciation of experiences, life histories and worldview¹⁹.

It was observed in the studied scenario and it was recorded in the field diary that many did not promote any educational activity related to hypertension and/or T2DM or to home care. Others, when they performed it, they would limit to the dissemination of isolated information during the execution of a procedure, without proper planning the educational needs of patients. As evidenced, we realized the weakness in the health education practice by professionals in the research location.

It should be professionals' responsibility, especially nurses, the implementation of an individualized care plan, answering questions, giving guidelines, providing opportunities for patients to verbalize their life experiences, and how they take care of their own health.

In the speeches, questions related to diseases occurred, strengthening the lack of knowledge.

Can I be cured by just taking the medicine? (I1)

Can I eat sugar in some way? I have difficulty in using sweetener. (I4)

I would like to learn about my disease [diabetes]. (I7)

As it can be seen, patients wanted to know more about the disease process, revealing that the hospital stay is also conducive to the development of educational interventions. Therefore, it is essential to provide the necessary knowledge to strengthen self-care, and allow that therapeutic actions are built together with patients and incorporated into their lives.

The fundamental role of man is to be subject rather than object in transforming process, a task that requires, during their action upon reality, a deepening of their awareness of reality, object of contradictory actions of those who want to keep it as it is and those who want to transform it. So if the ontological vocation of man is to be subject and no object, one can only develop it by, while reflecting on their condition, introducing themselves into them, critically and creatively, acting not as a mere spectator, but intervening in it²⁰.

Through the educational process, possibilities of adaptation to chronic disease are discovered, taking into account the individual lifestyle, with their family backgrounds and dimensions of work and socialization, and the creation of health-promoting agents, providing support and mutual respect between users and staff that should act as cooperator in this promotion.

Primary health care

Primary care reported was daily use of medicines:

I take the medicine, I do not let them lack. (I1)

However, it must be highlighted that the control of SAH and/or T2DM is not only to that extent, other care must be taken in equal importance to achieve satisfactory results.

Most research deals with adherence to drug prescription and reinforces its importance. However, changes in eating habits and lifestyle, that is, the non-drug treatment, are recommended for all patients, regardless of disease stage¹⁷.

Treatment for hypertension and/or MD is for life, with or without drugs. The first is performed through weight control, improving dietary pattern, reducing salt consumption, moderating alcohol consumption, exercising regularly, smoking abstention and controlling psycho-emotional stress; since the drug treatment is based on the use of drugs¹⁵.

Another care mentioned by two people was physical activity prior to hospitalization.

I walk three times a week. (I4)

This practice is a beneficial measure for the reduction of the clinical variables of patients with SAH and/or T2DM, particularly in relation to blood glucose levels and body mass index, as well as it composes the treatment plan and provides greater social interaction¹⁸.

Following a proper diet was cited by a hypertensive person and a diabetic patient, as is observed in the statements:

I try to eat low-salt, low-fat. (I10)

You have to follow the diet, to eat with no sugar. (I5)

However, much of the group reported difficulty in dietary control, mainly related to salt intake:

I try to reduce the salt, but it is difficult. (I2)

I like salty food. (I7)

These findings are consistent with data from other study¹⁸, in which the main difficulty in the treatment of hypertension was the adoption of a low sodium diet. Other studies also show similar results ^21,22.

Given the above, one can see that educational interventions are needed. Health education of people with SAH and T2DM is intended to influence the patient's behavior in getting effective changes³, equipping them so that, through their own resources, they can develop mechanisms to identify and prevent complications.

CONCLUSION

The study allowed reflections on care in illnesses by SAH and DM. In this sense, the work of nurses with patient and family in the implementation of health education with a view to self-care is essential, whether at home or in health services.

From the thematic categories presented- Characterization of study participants; Patients' knowledge about the disease (hypertension and/or DM); Primary health care-, it was evident the presence of complications of basic illnesses and ignorance of the participants with respect to self-care activities.

Study results cannot, however, be generalized, because we recognize the limitations, particularly with regard to the small number of participants and unique setting. However, it is expected to provide tools for professional nursing practice that works with these clients. Similarly, it is intended to explain the path taken so that other researchers can confirm or refute the findings.

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