ENTRAR            

ORIGINALS

Influence of the social support in the control of the diabetes*

José María Ponce González,¹ Antonio Velázquez Salas,² Enrique Márquez Crespo,³ Luis López Rodríguez,⁴ Mª Luz Bellido Moreno^5
1Case Manager Nurse of D. Paulino García Donas Health Centre in Alcalá de Guadaíra. South Seville DSAP. ²Nurse. Assistant manager of the Care unit for the South Seville DSAP. ³Nurse. Doña Mercedes Health Centre, Dos Hermanas. South Seville DSAP. ⁴Nurse. Research Unit. Virgen del Rocío University Hospital. Seville, Spain. ⁵Registered nurse. Assistant Manager of Nursing Unit, San Hilario Health Centre, Dos Hermanas, South Seville DSAP, Seville, Spain

Mail delivery: José Mª Ponce González. Centro de salud Alcalá de Guadaíra D. Paulino García Donas. C/ Eugenio Noel s/n. 41500 Alcalá de Guadaíra (Sevilla) España

Manuscript received by 29.1.2009
Manuscript accepted by 6.3.2009

Index de Enfermería [Index Enferm] 2009; 18(4): 224-228
*Research Proyect funded by Consejería de Salud de la Junta de Andalucía with expedient number 0195/2006

How to cite this document

Abstract

Introduction: The social support is an interactive process in where emotional aid is obtained, instrumental and affective of the social network that surrounds to us, having a protective effect on the health and shock absorber of the stress that supposes a disease. The adverse situations that generate stress in the individual and accompany by a vital change, reach the category of stressful life events being an obstacle after the fulfilment of the therapeutic regime.
Objective: To determine if the social support that perceive the diabetics influence in the metabolic control. Methodology: Multicentric cross-sectional descriptive study of the scope of the Primary Care, in 246 diabetics type 2, where they will be moderate the metabolic control (number of HbA1c), and perception of the social support, by questionnaire MOS. For the analysis of the data, it determined averages, standard deviations and percentage by means of SPSS and to study the relation of variables Test of Chi-square, Test t-Student, and multivariant logistic regression. Results: The 88.6 % of the studied subjects perceived good social support. The comparison of averages of HbA1c with Perception of Social Support did not show association. Nevertheless in a first cut with the first studied patients it was appraised statistically significant differences of 1 point in the average number of HbA1c with an IC 95% (0.2 - 1.75) p=0.01 and after putting under multivariant logistic regression to the perception of social support obtained a model that significant association of HbA1c represents (p=0.02 and OR=2.3) and IMC (p= 0.04 and OR= 1.15). Discussion: Questionnaire MOS requires an enhancing climate so that the answers of the patient are trustworthy and this climate it can create the time of professional relation.
Key-words: Social support/ Diabetes/ Primary Care.

Introduction

    Diabetes mellitus (DM) constitutes an enormous health problem on both a personal and public level. It is one of the main causes of disability and premature death in most developed countries, and significantly decreases the quality of life of those affected.¹
One of the strategies used by diabetic patients in order to live with the disease is obtaining help and support not only from health professionals, but also from people in their social networks, and most importantly, their families. It is believed that this support is able to compensate for the effects of stress caused by the disease.
    The concept of social support is a relatively recent one. It arose in the 1970s in the British school of anthropology at the University of Manchester. It is defined as an interactive process by which a person obtains emotional, instrumental and affective help from his or her surrounding social network.²
This framework of social relationships is identifiable in the social network, and it is possible to observe the close relationship between the network and social support. Therefore, when the network becomes smaller, we can observe a decrease in perceived social support.³
    Social support is a factor which has a protective or beneficial effect on many health-related parameters. The action mechanism of social support on health is not completely understood, but there are two hypotheses: the first is the buffer effect theory, by which the effect of social support is determined by its role as a modulator of adverse situations that create stress in the individual; the other theory states that social support is an agent which directly causes disease.⁴
    We must point out that the causes of adverse situations that create stress in individuals and in families may be environmental, psychological or social, and that these factors reach the level of stressful life events (SLEs) when they are perceived as negative or undesired, and when they are accompanied by a vital change. These stressful situations are an obstacle to going through with a treatment regimen. The relationship between various SLEs and disease has been studied for several disease types.⁵
    Social and family support is a determining factor for treatment adherence in diabetics. Social support is effective from an instrumental standpoint, as it facilitates compliance with treatment, and it is also considered effective at dampening the stressful effects caused by diabetes and its treatment.⁶
    Among the main aspects that relate family to chronic illness, we find that a) the family may influence the course of the chronic illness, meaning that the combination of the family and the disease type may have a positive or negative effect on the course of the chronic disease, and b) the family is a resource. We must point out that the family is the main source of the support that a chronically ill patient uses to successfully overcome the problems caused by the disease; here, the primary caregiver plays an important role by providing the most instrumental, affective and emotional support.⁷
    Studies exist that show the impact that social support has on processes having to do with health and mortality,⁸ as well as its beneficial effect on the evolution of chronic diseases.⁹ The effect of social support on the clinical evolution and prognosis of diabetes is well-known.¹⁰
    A recent systematic review carried out by Van Dam H.A. et al.¹¹ on social intervention in the care of type 2 diabetes supports the hypothesis that specific social activities assist with diabetes self-care and control.
    In addition to stress and a feeling of guilt, some patients express frustration and denial upon being diagnosed because the disease implies limitations and giving up certain things. The profile of this health problem, which generates stress in the area of self-care, requires a process of adapting daily activities and gaining information and understanding, as well as developing skills for learning to live with the disease without interference.¹² One of the most commonly-used coping mechanisms among diabetics is the search for social support. In addition to increasing adaptation through helpful strategies, such as providing access to information, social support can facilitate effective coping through increasing a patient's motivation to commit to adapted behaviour.¹³
    Since such an obvious relationship exists between social support and health, there is a growing interest in measuring that support. There are many instruments for doing so, but few have been validated and even fewer can be used in daily practice. One of these instruments is the MOS social support questionnaire (Medical Outcomes Study: study group for analysing different styles of medical practice in primary care) which was created in the United States in 1991, and which was recently validated for the Spanish environment by De la Revilla.³ It is a brief, multidimensional questionnaire that enables us to evaluate both quantitative aspects (social network size) and qualitative ones (social network dimensions: emotional/informational, instrumental, affective and positive social interaction). Its use will permit us to detect situations in which there is a high social risk level in order to intervene in patients and their social surroundings. Other effective instruments for measuring social support are the Family Apgar test, the Duke-UNK questionnaire or the simplified Blake-McKay method.¹⁴
    For defining situations having to do with social support, the NANDA (North American Nursing Diagnosis Association)¹⁵ Taxonomy has a nursing diagnosis called Impaired Social Interaction, defined as ineffective, quantitatively insufficient or excessive social exchange, which can be related to a lack of ability or knowledge about the manner to create reciprocity, or to the absence of significant people, among other factors. On the other hand, impaired social support can often be a cause of or a factor related to the nursing diagnosis of Ineffective Management of Therapeutic Regimen.
    In the presence of these diagnoses based on the result criteria (NOC Taxonomy),¹⁶ the nurse may propose improvements in social interaction frequency (social implication) and/or the perceived and actual availability of help (social support). To do so, the nurse may amend the treatment plan to include some specific activities from some of the following nursing interventions (NIC taxonomy):¹⁷ Support System Enhancement, Family Involvement, or Socialisation Enhancement, among others.
    Studies on social support and its influence on health are a research priority according to the WHO Regional Office for Europe. In the field of diabetes, one of the objectives listed in the St Vincent Declaration is to elaborate, develop and evaluate global programmes for detecting and controlling diabetes and its complications, with self-care and social support as its main components.¹⁸
    On the other hand, we must highlight the fact that analysing the effect of social networks on health and studying the effectiveness of certain interventions are scientific and technological priorities for the Spanish Ministry of Health and Consumer Affairs and its incentives for Programmes Promoting Biomedical and Health Science Research.¹⁹
    For all of the reasons explained above, the general purpose of this study is to determine if there is an association between social support as perceived by diabetic patients assisted in our Primary Care nursing division and metabolic control (amount of glycated haemoglobin HbA1c). Our specific objectives, aside from producing a socio-demographic and clinical description of our sample, are to measure patients' social network, social support and SLEs.

Method

    We completed a transversal descriptive study in the primary care field which lasted two years and involved seven health centres in the province of Seville. These include two urban centres in the Seville health district, two rural centres in the South Seville District, and three mixed centres in industrial areas, also in the South Seville district.
    The study population consisted of type 2 diabetics who were included in the primary care programme for chronic patient control and monitoring (chronic patients in nursing care) in the centres listed above. The necessary minimum sample size was established at 240 individuals. We proposed a layered sample by health centre according to the centre's weighted importance based on the percentage of type 2 diabetics found in its roster total. The selection of individuals from each centre was done by a systematic random-draw method with a 4:1 ratio. The final sample for the study included 246 individuals.
    Inclusion criteria were as follows: patients with DM-2 who were assisted by their assigned nurses at the health centre through the primary care programme for chronic patient control and monitoring and who gave consent to participate in the study. Exclusion criteria were as follows: patients with impaired advanced functions due to dementia, a psychiatric disorder or another illness that prevented them from perceiving the degree of social support they received, and patients who did not consent to participate in the study. While the investigation was in progress, confidentiality was guaranteed for the clinical data of the subjects, and all were asked to give informed consent.
    The study variables examined socio-demographic and clinical data. Socio-demographic: age, sex, marital status number in household; Clinical: DM treatment, years of DM evolution, Body Mass Index (BMI), HBP, dyslipidaemia, ineffective management of therapeutic regimen (IMTR) and or treatment non-compliance (DdE NANDA), dependent variable [HbA1c score] and independent variables (Stressful Life Events, social network [no. social contacts] and perceived social support).
    Instruments employed were the Holmes and Rahe Social Readjustment Scale for stressful life events (high impact was understood to be > 150 LCU); the MOS questionnaire for measuring the social network (normal size was understood to be > 6); and the perception of social support, using global, emotional, instrumental and affective scores (good social support is understood to be results higher than 57, 30, 12 and 15 in each respective case).
    The first step in data analysis was statistical optimisation using graphical and analytical methods to explore the information and detect any aberrant observations. Subsequently, to describe information from the sample, we calculated means and standard deviations for numerical variables and percentages for non-numeric ones. All of the statistical calculations were done using SPSS statistical software, version 12.0. In order to study the relationship between qualitative variables, we used the chi-squared test with a continuity correction. When comparing numeric variables between two groups, we used the Student-t test for comparing means.
    Lastly, we constructed a logistic regression model in order to study the possible associations between variables while controlling confounder variables..

Results

    The study population (n = 246) contained more females (55.7%), had a mean age of 69.5 years (+/- 9.9 years), was married (66.3%) and came to the clinic accompanied (42.7%) by partners (60.4%) or by children (29.2%); their households contained an average of 2.8 people.
    69.8% treated their diabetes with diet and oral antidiabetics and had been living with a disease average of 9.96 years (+/-7.5).
    The average BMI among patients was 30.52 (+/- 5.4) and the HbA1c was 7.44 (+/- 1.3) mg/dl. 53.8% were at a high level of risk according to HbA1c values (> 7mg/dl); within this group, 24% had values above 8mg/dl.
    72.7% had associated HBP and 53.7%, associated dyslipidaemia.
    24.2% managed their therapeutic regimen ineffectively and 12.7% were non-compliant. We must highlight that 9.8% met both conditions.
    7% of patients had a low social network (between 0 and 1 social contacts).
    We discovered that 11.4% perceived low social support and 88.6% perceived good support; of the latter, 82.9% perceived good emotional support; 85.5%, good affective support; and 88.6%, good instrumental support.
    80% of patients listed an SLE in the past year, and these amounted to a mean of 73.54 (+/- 71.8) life change units (LCUs). Only 11.8% presented a high SLE impact (> 150 LCUs).
    Quantitative variables are described in table 1. We found no significant differences among patients in rural, urban or peripheral areas.
    In our study, when we examined social network (number of friends) and social support (MOS) we found that a strong social network offered 80% more protection, that is, those with a weak social network had five times more risk of having poor social support (raw OR = 0.2, with a 95% CI [0.06-0.7]).
    Comparing HbA1c means with the social network, perceived social network or stressful life events showed no statistically significant differences.
    However, a cut of the first 62 patients in the study showed statistically significant differences of one point in the mean HbA1c score with a 95% CI (0.2-1.75) p = 0.01, and after using multivariate logistic regression for perceived social support (MOS questionnaire), we obtained a model that showed a significant association between HbA1c OR = 2.3 with a 95% CI (1.14-4.08) p = 0.02 and BMI with an OR = 1.15 with a 95% CI (1.02-1.3) p = 0.04. This means that we can state that patients with poor social support risked having a HbA1c score and BMI that were 2.3 and 1.15 times higher respectively than those for patients with good social support, with a determination coefficient R² = 0.15. The difference between these patients and the rest of the sample was that the patient/nurse relationship was a long-standing one.
    In the study population, we saw that ineffective management of therapeutic regimen (IMTR) decreased HbA1c scores by 0.4mg/dl with a 95% CI (0.02-0.8). We can therefore state that with the same treatment, going from IMTR to EMTR improved HbA1c by 0.5mg/dl with the 95% CI claimed above.
Patients with HbA1c below 8mg/dl had an average of 3.5 more points in their total MOS score, but this was not statistically significant (p = 0.1), and an average of 13.1 more point in their Holmes score, which also was not statistically significant either (p = 0.2).

Conclusions and discussion

    In conclusion, according to the results of the study, our sample showed no association between perceived social support and metabolic control in diabetic patients treated in our primary care centre nursing divisions.
    The only difference that we found between the patients in the first cut and the rest of the patients in the study is the degree of trust in their nurse based on the length of the professional relationship. The MOS questionnaire contains questions of an emotional and affective nature and requires a favourable setting for the patient's responses to be trustworthy; this setting can be achieved where there is a long-standing professional relationship. In terms of its efficacy the questionnaire is valid, but in terms of effectiveness, the tendency is what we observed above.
    We believe that one limitation in our study was its high number of field researchers due to the study taking place in multiple centres; there may have been more variability in the observations than if only two or three researchers had participated.
    The results of this study will enable researchers who use the MOS questionnaire to monitor the bias mentioned above.
    We must identify the psychosocial risk factors that help us detect impaired social interaction and predict ineffective individual treatment regime management or treatment non-compliance; these situations can be prevented by carrying out specific activities.
    In agreement with De la Revilla,³ our study shows that those with a weak social network have a higher risk of receiving poor social support. We disagree with Heredia Galán⁶ with respect to situating the percentage of diabetics complying with treatment below 60%; in our population, compliance is present in 73%.
    In our study, we find that approximately 80% of patients listed an SLE in the past year. This corroborates the high prevalence of psychosocial problems that are seen in primary care centres.

Acknowledgements

    We would like to offer our sincere thanks to all patients who gave their consent to participate in the study, and to all of the nurses in the collaborating health centres, particularly those who actively participated in collecting data for this study. Thank you to Bermejales and Ronda Histórica in the Seville DSAP, and to San Hilario and Doña Mercedes in Dos Hermanas, Don Paulino García Donas in Alcalá de Guadaíra, Arahal and Las Cabezas de San Juan, all in the South Seville DSAPn.

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