RESEARCH ARTICLES

Categories of self-care among older adults with diabetes: a sociopoetic study

Iraci dos Santos^I; Renata Gomes Machado Guerra^II; Leandro Andrade da Silva^III

^IPhD in nursing. Full Professor and Visiting Professor, Department of Nursing Fundamentals and Program of Graduate Nursing Faculty of the State University of Rio de Janeiro. Brazil. Email: iraci.s@terra.com.br
^IIMaster in Nursing Program at the Graduate School of Nursing at the State University of Rio de Janeiro. Nurse Lieutenant at the State of Rio de Janeiro Civil Police. Brazil. Email: renatagomesmv@gmail.com
^IIINurse. Occupational Therapist. PhD student, Program Graduate School of Nursing at the State University of Rio de Janeiro. Professor of Castelo Branco Institute of Rio de Janeiro. Brazil. Email: proflandrade@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.16498

ABSTRACT

This study sought to identify categories of self-care among older adults with diabetes, considering their physical, mental and spiritual dimensions. The sociopoetic method was applied via the stages of the researcher-group, consisting of 10 participants in the self-care course and research, who engaged in the artistic technique Experiencing the body as a minimum territory using free drawing, in 2012, in Rio de Janeiro, Brazil. Prominent among the results were the categories: difficulties in self-control in living with diabetes; self-care to raise self-esteem; optimism and perseverance in caring for diabetes; caring for body and mind; and understanding the importance of living with the family. It was concluded that, despite diabetes-related self-care, older adults have difficulty restricting their intake of sugars and carbohydrates. Accordingly, public health policies for older adults should make a priority of self-care promoted by trained professionals, with a view to constructing knowledge collectively and planning actions for this purpose.

Keyword: Nursing; self-care; gerontology; qualitative research.

The nurse's role with elderly diabetes patients is focused on self-care (SC) guidance for, it is necessary. Generally, they have limited knowledge to live with this disease, neglecting how much life habits related to diet, physical activity and self-administration of drug therapy.

Here, it should be noted that the demographic growth of the elderly population in Brazil, from the 1960s, significantly altered the population pyramid ¹. Whereas the unpreparedness of the people and the difficulties to face the SC can lead to comorbidities, it is assumed that the nursing orientation for self-care will lead to lifestyles with quality.

Given the increasing of this population, associated with chronic diseases, it is implementing educational programs for the elderly, encouraging them to learn SC for health, preventing disability and postponing death². Thus, the nurse acts in the education/care process of individuals with diabetes to inform and clarify questions about the disease, investigating and assessing their limitations and of their family, aimed at preventing injuries resulting from this disease.

The care components are subsidies for the systematization of nursing actions, on the understanding that the nurse meets human needs, considering the body physical, mental and spiritual dimensions, constituents of the human being's completeness³. It is noted also that the effective control of glycemia and consequent prevention of complications of this disease are related to the SC. For the verification of blood glucose levels, correct administration of medicines and insulin, and healthy eating are important to the adequacy of that control.

The sick elderly generally has limitations relating to: decreased vision, hearing loss, memory impairment, mobility, and decreased fine motor coordination, increased tremors, depression and loneliness, and other clinical diseases, and reduced financial resources⁴. They is more susceptible to injuries, since dealing with problems in physiological, psychological and social aspects arising from the aging process process. Therefore, they are frequent users of the healthcare system.

To learn the current preparation status of the elderly living with diabetes, a search was conducted in the databases, Virtual Health Library (VHL), and in Scientific Electronic Library Online (SCIELO), using the key words: elderly,Diabetes Mellitus and self-care, and the criteria for inclusion-complete articles; publications in the period from 2000 to 2012 in the languages Portuguese, Spanish and English.

Among 1358 studies found, 232 were selected because they met the above criteria. Of these, 21 were found in Latin American literature and Caribbean Center on health sciences (LILACS) and 211 in theMedical Literature Analysis and Retrieval System Online (MEDLINE). This describes a synthesis of the results of that search.

To promote behavioral change, the guidelines for the sick include subjective, emotional, economic, social and cultural aspects, as they influence the practice of self-care. Their training regarding the engagement depends on the partnership with health professionals and other areas of knowledge, such as law, sociology, economics, psychology and architecture. It is believed that they will never reach the SC without this effective intersectoral participation ⁵.

Living with the disease in question, in itself, brings the client many restrictions and changes in living standards. Coupled with the demands of treatment, due to the aging process, towers the reduction of the sense of freedom and living well. Therefore, the elderly individual ceases to be an object of treatment, to become a citizen with the right to decision and opinion, interested in getting the best for himself, able to perform actions of care within their limitations or dependencies imposed by the pathology⁵.

There is influence of education level and family income, understanding and adherence to self-care by the elderly person with diabetes. This is one of the factors that figure among the difficulties encountered in the control and treatment of this disease, because the diet and medications, when not offered by the health service, means an increase in family expenditure⁶. Therefore, their income and/or their family influences their self-care.

Clients were characterized with diabetes according to socio-demographic and economic variables, describing health, functional capacity and utilization of healthcare services. In all daily life activities (DLA) a dependency percentage was obtained, that is, the subject cannot perform them, and require help from third parties⁷.

Another publication, warning that the professional should have knowledge about aging and the limitations of the elderly individual in order to care for and educate them properly as well as their family members⁸.

Verifying in this search in the database, the lack of studies focusing on nursing orientation for SC, with the elderly, and their method of care for living with diabetes, was delimited the problem: what are the categories of self-care presented by elderly people in order to live with diabetes?

Its aim was to identify the categories of self-care presented by older people with diabetes considering their physical, mental and spiritual dimensions.

THEORETICAL-METHODOLOGICAL REFERENTIAL

We chose the socio-poetic, qualitative, descriptive method. Inserted in the paradigm of the humanities and social sciences, the socio-poetics, a philosophy and practice of caring for, educating, researching, and imposing the collective construction of knowledge⁹.

The path of the researcher is theoretically based in: Pedagogy of the oppressed by Paulo Freire, contributing to the development of six research steps of the Researcher Group (RG), analytical device of this method; Institutional analysis, René Lourau trend, mainly the device concepts and analyzer; René Barbier mythopoetic Listen, where listening and silence give the pace of the creation of persons; Theatre of the oppressed by Augusto Boal, considering their role-experiences to express gestures, hidden, repressed knowledge; and the Schizo-analysis of Gilles Deleuze and Felix Guattari⁹, emphasizing the notion related to the becoming of these authors.

In socio-poetics, the RG produces the survey data by the institutional researcher, which acts as a facilitator by applying the following philosophical socio-poetic principles: The body is a source of knowledge; The RG is a co-producer of knowledge; In reading the research data are favored the cultures of resistance and dominated; It appreciates the role of creativity in the artistic type learn, in the know and in the search; It is important the ethical sense, spiritual, and human shapes and contents in the construction of knowledge. It is emphasized that the development for the chosen method simultaneous application of their theoretical and philosophical principles⁹.

For the search field, we opted for the Open University for the Elderly, State University of Rio de Janeiro. As for RG composition, we attempted to contact that institution of elderly individuals that met the inclusion criteria: older than or equal to 60 years, officially registered and monitored at the outpatient clinic of the Elderly Care Center; accept to participate in the study / course of self-care for living with diabetes, sign the Informed Consent (IC); and have diabetes. Exclusion criteria: have visual impairment and / or motor making self-care impossible; impossibility of locomotion. Only 10 people met the established criteria.

Through socio-poetic method developed in 2012, the six stages/socio-poetic workshops: The RG institution; Thematic research (negotiation of the subject presented by institutional researcher and / or choose the guiding research question, schedule of days, times and location for the research); Socio-poetic workshops (preceded by sensitivity and dynamic relaxation) for administration of the course of self-care and development of research, that is, the data output by Body Dynamics technique as Minimum Territory (BDMT), initial analysis of the data produced by the RG ; presentation to the analysis of the RG of the data produced by the facilitator(s); Against analysis of data produced by the RG; Validation of the knowledge produced by the co-researchers; Socialization of results and evaluation of Socio-poetic workshops.

In the self-care course for eldery living with diabetes, the RG was asked about body care, emphasizing the care of the feet, offering even an online brochure on this subject; physical exercise; leisure opportunities; specific diet, providing them, a recipe for sugar restriction given by a nutritionist. They were also offered a diet/light snack at all of the workshops.

They applied an artistic free drawing technique to develop the BDMT¹⁰, considering the guiding questions: How do I take care of myself to live well? What are my food preferences, considering diabetes and self-care? Which SC activities do I develop? What I need to know to care for myself, living with diabetes? Each creation, expressed in body design, was analyzed by co-researchers themselves (the study participant) and then by them, explained in writing. Such descriptions were placed and/or attached in the drawings.

The researcher and research facilitators examined the drawings by comparing them to descriptions of co-researchers and the answers of these questions formulated for elaboration of the drawing in the BDMT. Each drawing delimited individual topics, revealing the thought structure of the co-researchers. In this work, the categorial analysis of sub-themes group provided the delimitation of thematic categories, composing the socio-poetic qualifier study. Even them the dichotomies were highlighted, the oppositions in the data produced, alternative and existing choices in all the RG productions⁹.

The development of this research was approved by the Research Ethics Committee of UERJ, Protocol 033.3.2012, in conformity with the standards described in resolution No. 466/2012, which emphasizes the ethical commitment with research participants. The RG signed the IC form and agree to the disclosure of your answers to the questions guiding the research, it respected their privacy.

The statements obtained were identified by co-researcher the designation, Co-researcher B... Co-researcher J.

A study limitation is for fact that he is an excerpt of the dissertation, in which only presents the results obtained with one of the three research techniques used in the development of the dissertation.

RESULTS AND DISCUSSION

The emerging themes of this study are discussed below.

Difficulties of self-control while living with diabetes

In this category, the following sub-themes emerged insecurity, fragility and difficulty in control, revealing the fragility of the elderly person in relation to their living with impaired health from diabetes:

I felt good for my age. I was very dynamic. After the fall, I feel weak, without the strength to walk. I'm depressed. I'm too skinny. I am skin and bones. The weakness that I feel in my legs is because of diabetes. I can't walk alone. (Co-researcher A)

fragility syndrome refers to the biological syndrome, which is the physical body size, characterized by decreasing homeostatic booking and reducing the body's ability to resist stress resulting in cumulative declines in multiple physiologic systems, causing adverse effects, and vulnerability⁷. In this testimony there is sensed sadness with personal physical appearance and decreased independence, conveying the uncertainty, insecurity and inability to exercise autonomy and conviction with the control of their lives^3,10,11.

Physiological changes and difficulties faced by older people and their families are considered strange, and at the same time, weak and fragile are targeted as illness, weakness and risk of falls⁸. If this participant identifies difficulties and plan strategies to run a health behavior, it puts into practice the perceived self-efficacy, highlighted in the Health Promotion Model Theory by Nola Pender¹².

Self-care in living with diabetes and raising self-esteem

Formed by sub-themes control, self-care and self-image, this category indicates the tranquility of the co-researcher in the care and control of diabetes, demonstrating concern for the consequences of poor control.

I take care of myself. I can't do things as before. I love to eat everything, but try to follow a diet. I can't control myself from not eating too much. I can maintain my weight and take care of my diabetes. I don't want to have other problems. I take care of myself to feel good and beautiful. (Co-researcher B)

Here is ratified the concept of self-image, the representation of our body formed in our mind, the way they present them self to themselves^10,13 . It confirms that body image is the picture that each has of themselves. In addition, may suffer interference as illnesses, limitations and aging¹¹.

Optimism and perseverance in diabetes care

In this category were defined, the sub themes optimistic living; perseverance for living with diabetes; and caring for the illness. A co-researcher demonstrates optimism and expectation that everything will work, returning to the past, to childhood:

It was a great time in my life and I miss eating the fruits right from the trees I have have difficulty today, eating fruit, bec,ause I ate several, today I know I can't. I'm diabetic, but I feel good and confident that I can take care of myself. The drawing I made is me today, happy and well. (Co-researcher C)

The eating plan is recommended daily consumption of two to four servings of fruits, one being rich in vitamin C and three to five servings of vegetables raw and cooked¹⁴. It is observed that the co-researcher unaware of the necessary care, but search this knowledge for self-care. Self-care with the body of a person requires special learning, aimed at health promotion and changes produced by disease and the prevention of complications ^13,14.

Living peacefully with diabetes

In this category the sub-themes perseverance, careful, quietness and dependency were delimited. There is, in the pattern description produced by a co-researcher D has a peaceful life, gets along well with their disease and is perseverant:

I feel good. I take care of my body, my life in the best way possible. I follow everything that my wife says, I take the medication she gives me, she knows the schedules, and she takes care of me. In this picture, I'm thinking about tomorrow with all pride and panache. I try to live my life in peace. (Co-researcher D)

This statement confirms that dependency can occur at all ages, but increases in prevalence when age increases by the onset and development of chronic diseases, which can lead to different dependency types and levels¹¹. In this case, it is seen that even being able to perform certain DLAs, the co-researcher needs the help of his wife, in tasks such as taking his medications on time. Then it becomes necessary for the supervision and monitoring of the caregiver¹⁵.

The burden of diabetes in life

This category is made up of the sub-themes: revolting, conformity, difficulty in controlling the diet and self-care. In the analysis of the statements, it is seen that a co-researcher revolts with his illness, but takes care, because he knows the complications resulting from carelessness.

Diabetes is the devil. Why does this disease exist? There's no way for us to live with it. I don't go to parties because I can't eat. I want to eat everything, salty and sweet. Today I feel better after I lost weight. I don't like being a diabetic, but I take care of myself because I know the consequences. (Co-researcher E)

The difficulty of the food control was constantly in the RG statements, because the prohibition of certain food ends up generating dismay in people to go to parties and may lead them to social isolation and thus they end up avoiding leisure activities.

It agrees that leisure has high significance towards society, for being a source of cultural creation, search and rescue of human beings and of favoring new socialization¹².

Self care always to live longer and better

Sub-themes delimited in this category: balance, optimism and self-care. The description of the drawing demonstrates the care that the co-researcher has with their body when making allusion to the balance of nature. Their care has proved to maintain balance in life with tranquility and well-being.

I feel like a tree because I like nature and I like myself, and I like taking care of myself. I'm always doing a diet. I'd rather not taste sweets. I hope they can find a cure for diabetes. In the meantime, I take care to live longer. I take care of my body and hygiene. I do the necessary tests and always when there is something wrong with my health, I seek the doctor. (Co-researcher F)

This speech confirms that people are committed to adopting behaviors from which they anticipate the benefits derived, personally appreciated ^12,13. Thus, it should be noted that care and hygiene with the body, associated with the good eating habits and leisure, make the mos peaceful and balanced DLAs, improving the comfort/well-being.

Understanding the importance of coexistence with the family

The sub-themes discouragement, hard power, control and self-care formed this category. It was observed that the co-researcher enjoys eating and misses eating whatever they want. They know the importance of exercise to control diabetes, but are discouraged from doing it. In the description of their drawing, the importance of family is highlighted:

I wanted to go to the June Festival with my daughter and my granddaughter, which are my family. I love the June Festival and eating the delicious things. I like the music too. I take care of myself; I diet though like to eat everything. I don't have the energy to do physical exercise. I have to control myself from eating candy. It would be very nice if they found the cure for diabetes. (Co-researcher G)

Family, along with society and the state have a duty to ensure the elderly all of the rights of citizenship, ensuring their participation in the community, defending their dignity, well-being and the right to life⁸. Family support is important in the aging process, there is the view the relationship of affection and safety. In some cases, this relationship can also be financial help or even dependence.

Self-care with the body and the mind

Analyzing the description of free drawing, which were, delimited in the sub-themes self-care and self-esteem, self-image, it is noted, and the success and happiness with care, in this category. Self-esteem and self-image are strong traces in the care of the body, including mainly clothing, accessories and makeup:

I'm look for and I like to take care of myself. I always wear makeup and dress up with high spirits. I just can't wear very high heels because they hurt my knees. When I became diabetic, I was upset, but to no avail, so I looked take care of me so that I don't worsen. I do everything to take care of me and I'm always at peace with life. I love getting out, meeting people, and exchanging information. I love to eat, but I control myself. (Co-researcher H)

Health promoting behaviors through nutrition, physical activity and time occupation in varied activities, emphasize the desirable condition for the harmony of the body. Active lifestyle is crucial in health promotion. The adoption of health-promoting behaviors refers to prior conduct related, which, assuming direct and/or indirect effects, is a probability for the achievement of results^12,13,16. Like other co-researchers, this member of the RG values the search for new knowledge to take care of the body/health and learning new things.

Conscious carelessness

In this category, the following sub-themes were delimited: difficulty in feeding control and oversight. It was noticed that the co-researcher is aware of his careless, including the practice of physical exercise. Their body dissatisfaction, weight gain and knee pain in discouraging self-care.

My diabetes is very shoddy. I end up eating too much. I just like things that I cannot have: chocolate, sweets, fried, unhealthy. I gain weight, and then I feel a lot of pain in my knees. I really want them to find the cure for diabetes. It's terrible not being able to eat things. I do not exercise, being very discouraged to walk. (Co-researcher I)

Given the impaired, body self-image interferes in self-care, and intensify the joint pain, preventing physical activity. There is a possibility of serious risks of developing more comorbidities arising from uncontrolled diabetes. It is recalled that the metabolic syndrome is responsible for the promotion of premature atherosclerosis and early risk of cardiovascular disease¹⁷.

Living happy al of the time

The sub-themes delimited in the latter category: optimism, difficulty in controlling their diet and self-care. In the following description of the drawing, the self-esteem and self-care.

I am, always happy! I feel accomplished and I thank God. I can't control the diabetes. I take care of me, do the tests and go to the doctor regularly. I didn't want to be a diabetic, nobody really likes, but I have to take care to live longer. The greatest difficulty is to control my mouth. Now I try to follow the diet. (Co-researcher J)

When the handle is in the perspective of self-esteem, it is assumed the use of the physical body to a subtle care, i.e. a sort of food for the spirit, which favors the promotion of self-knowledge and self-growth, seeking to organize subjective and/or social forces that can transform the human being, and, consequently, their destiny^18,19.

CONCLUSION

The investment in public health policies aimed at the elderly population, concerning the prevention of illnesses, can contribute to health promotion, here understood as self-care, since the age range for children and teens. Such investment can be done since the training of health professionals and of interdisciplinary teams, to work with people, to the teaching/learning of self-care, to live with well-being, even in limiting situations due to illness.

Thus, the guiding questions of this investigation were answered, reaching to answer (goal) of the formulated research problem, namely, the categories of self-care adopted by members of the group-researcher, through the development of body dynamics as a minimum territory.

In the analysis of the RG statements, it was concluded that the participants fear the complications of diabetes, but believe and cheer for the cure of this disease and, therefore, the hope of a cure has always been present among them.

Then, alert to the importance of maintenance and/or creation of groups of citizens, to discuss and research themes such as self-care for all who have and/or not a healthy coexistence. That way it will be possible to build the awareness needed fro self-care for the welfare/quality of life.

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