Download Emosi dan Diabetes Self

Emotion and Diabetic Self-Management
in Diabetic Patients in Yogyakarta:
An Exploration Study
This study aimed to identify the elicited emotions when diabetic
patients manage their disease. Focus Group Discussions were held
with 20 outpatients with non-insulin-dependent diabetes mellitus
(NIDDM) from three hospitals in Yogyakarta, and interviews were
made with two doctors. The study results showed that the patients
experienced fear, anxiety, sadness, shock, and worry when initially
diagnosed with diabetes by the doctor. The subjects reported that
they felt shocked, worried, anxious, and bored when they should
take routine medicines, diet, engage in exercise regularly, and
monitor their glucose level. However, some subjects could accept
their disease and stayed calm and less anxious. They were
optimistic and believed that medicine would help them to achieve
better health condition. They routinely took their medicine, felt less
worrry about their disease, and were enthusiastic in joining with
other patients in Persadia (Persatuan Diabetes Indonesia) (Diabetes
Patients Club of Indonesia).
Keywords: diabetes, emotion, self-management
I.INTRODUCTION
Diabetes mellitus (DM) is a disease caused by malfunctioning of insulin, both
in terms of quantity and quality, so that the balance is interrupted and the glucose
level consequently tends elevated (Tjokroprawiro, 2004). There are two categories of
diabetes: (a) insulin-dependent diabetes mellitus (IDDM) or type-1 diabetes and (b)
non-insulin-dependent diabetes mellitus (NIDDM) or type-2 diabetes. Type-1
diabetes is caused by combination of genetic factor and immunology process that
impair beta cells in the pancreas which producse insulin, the hormon that regulates
the usage and storage of glucose. This insulin deficiency will result in accummulation
of glucose in the blood, called hyperglicemia. This type of diabetes may occur in any
age, but may be diagnosed in younger age. In type-2 diabetes, the genetic
component is relatively strong. Type-2 diabetes is caused by combination of
dysfunction in beta cell and insulin resistance. Almost 80 percent of patients with
type-2 diabetes are obese, and obesity is the main contributor of insuline resistance
(Cox & Gonder-Frederick, 1992).
According to Zimmet (in Tjokroprawiro, 2004), at least there are 110.4 millions
people with obesity in the world with between 1.2 and 22 percent prevalence. This
figure increased to one and a half higher in 2000 (became 175.4 million) and twice
higher in 2010 (became 239.3 million). In the United States of America, 6 percent of
its population had diabetes and diabetes is the seventh highest cause of mortality. In
Indonesia diabetes is suffered by between 5 and 7 percent of its population or around
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14 million people (http://www.republika.co.id/metformin_diabetes.htm). A survey
done by the WHO showed that Indonesia ranks fourth among countries with greatest
number of people with diabetes in the world after India, China, and the United States
of America. According to Health Ministry’s data, the aggregate number of diabetic
outpatients and inpatients in hospitals is the highest among all endocrine diseases
(http://www.depkes.go.id/index.php?Option=news&task=viewarticle&sid=1183&Itemi
d=2). The average age of patients is between 18 and 64. In one year, diabetic
patients lose 8 days on average compared to people without diabetes who lose 1.7
days (American Diabetes Association/ADA in Feifer & Tansman, 1999). While the
indirect loss due to diabetes such as productivity loss has not been calculated in
Indonesia, the indirect loss is likely much higher than the medication cost itself
Based on these facts, diabetes management is an evidently very important
issue. Four components involved in the management of diabetes are medical care,
diet, exercise, and glocose level monitoring (Cox & Gonder-Frederick, 1992).
Aurbach et al. (in Taylor, 2006) said that active self-management is the key to control
diabetes successfully. Delamater et al. (2001) mentioned that psychososial factors
may affect compliance to medication and glicemic control.
According to Fisher, Delamater, Bertelson, and Kirkley (1982), one reason for
the emergence of great attention from psychology to diabetes is the fact that diabetes
is a chronic disease which involves psychological and behavioral aspects. The latest
literature on diabetes sees diabetes as a self-regulation process because the
patients need to regulate metabolism process such as monitoring and “managing”
glucose level (Gonder-Frederick & Cox; Wing, et al., in Cox & Gonder-Frederick,
1992). The patients should follow doctor’s intructions, which are not easy for them to
do. Patients are required to follow the instructions of diabetes management while at
the same time they are also aware that the possible complications due to diabetes
are almost inevitable. Dalewitz, et al. and Rubin and Peyrot (in Keers, et al., 2004)
mentioned that many patients had difficulties to carry out self-management and this
lead to poor glucose control or various psychosocial problems. For example, Kirkley
(in Fisher et al., 1982) found that change in life style while struggling with diabetes
could lead to negative emotions and conflict in the patients. Kirkley further said that
the resulting negative emotions like anger, guilty feeling, anxiety, and sadness may
cause overeating or even consuming inadvisable foods. If this condition is not
seriously handled, it may affect the treatment process and interfere with daily
activities which in turn negatively impacts self-esteem, zest for living, and quality of
life.
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II. RESEARH OBJECTIVE
This study aimed to explore emotions elicited when diabetic patients manage
their disease.
III. METHOD
This study used qualitative method in collecting the data. Unlike quantitaive
method which specifies the variables prior to data collection, qualitative method is
specifically oriented to exploration, discovery, and inductive logic. Focus Group
Discussion was used as data collection technique. The discussion took place in the
hospitals where the subjects went for medical checking of their disease.
Subjects
The subjects of this study were 20 diabetic patients, 10 of them (8 females
and 2 males) came from Wirosaban Public Hospital, 3 (2 females, 1 male) from
Bethesda Hospital; and 7 (3 females and 4 males) from Panti Rapih Hospital.
IV. RESULTS AND DISCUSSIONS
The results of this study indicated that when the subjects were diagnosed with
diabetes, various reactions occurred. Some of them were frightened, shocked,
disbelieved, difficult to accept the reality, startled, or sad. One of them felt afraid
because she was carrying her third child. She imagined that she might deliver
overweight baby. She was shocked and unwilling to speak for several days. Another
finding suggests that the affected individual did not believe that he got diabetes since
he was an athlete. Still another patient was shocked because he was thoughtful
enough with his diet for knowing that his mother had diabetes. Such negative
emotions usually occurred right after the patients were diagnosed with chronic
disease, in this case diabetes. They experienced a crisis as indicated either by
physical, social, or psychological imbalance (Moos, in Taylor, 2006). However, the
data also demonstrated that some subjects did not experience such negative
emotions. Those who stayed calm and were not nervous or shocked and did not feel
that their condition was not worse than others were able to accept their condition and
be aware that they have diabetes and think that many other people have the same
condition as well. These subjects did not experience any crisis and could quickly
adapt to their illness. In other words, they were capable of coping (Taylor, 2006). The
majority of sucjects who did not indicate negative emotions when they were
diagnosed with diabetes came from families with diabetes. They were aware that
they will very likely to get the same disease.
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The author observed that it patients who stayed calm seemed indicating a
kind of defense mechanism, a denial. Taylor (2006) said that denial is an emotional
response. As a defense mechanism, it enables the patient to avoid further impacts of
his/her disease. The patient behaves as if his/her disease was not serious. In this
study, it was indicated by the patient’s statement that “stay calm” is the best, while
exercise was important thing to do. One of those subjects who stayed calm felt that
such position have benefiting effect in that it enables them to lower or avoid negative
emotions. This was indicated by the following statement, “I do not want to think about
diabetes. I make myself busy with positive, productive activities.” Such statement
suggests that “stay calm” is a means to cope with the disease. Coping is a process to
deal with demands burdensome or beyond an individual’s capacity to handle, either
external or internal to him/her (Taylor, 2006).
In addition to the above mentioned emotions, the doctor said in the interviews
with them that they found some of their diabetic patients were anxious and very
concorned about their disease, but some were indiffirent to their disease. This latter
mental state lead them to break their diet and eat whatever they want. This finding
was consistent with Kirkley’s (in Fisher et al., 1982) that negative emotions occur
people with diabetes incuding anger, guilty feeling, anxiety, and sadness, which may
lead them to consume foods which are not suggested, either in terms of quantity or
types, by their nutrician. Doctors also found that patients’ awareness about their
disease often came too late, when complications had been occurring. In addition, the
doctors also observed that those patients who were aware of their disease had
higher compliance. On the contrary, the compliance to diabetic management of those
who were unaware of things relevant to diabetes or ignored their disease were found
low.
As mentioned above, the four componentf of diabetic management are
medical treatment, diet, exercise, and glucose level monitoring (Cox & GonderFrederick, 1992). Different reactions in part of subjects suggest that diabetic selfmanagement was far from easy. One subject mentioned about anger feeling. Another
subject reported uncomfortable feeling for being dependent to medication. Long-term
care of diabetes was found boring and tiring. Not all subjects experienced such
negative feelings, however. Some subjects stayed calm and complied to their
medication regime, did not feel bored, and monitored their glucose level regularly.
They were ware that medication helps. The results of this study also indicated that
some subjects tried to motivate themselves. One thing that motivated them was
bethinking that their life is for their children and their grandchildren.
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The diet effort resulted to some negative emotions as well. One subject stated
that one initially felt afraid when required to diet, but the fear gradually disappeared.
The result of this study indivated that food management is a diabetic management
component which is difficult to accomplish. The patients learned about the 3 J (jenis
[type], jadwal [schedule], jumlah [quantity]) principle in managing food, but they had
difficulty in bringing it into practice. The subjects said that it had been difficult for
them to prevent themselves from snacking and consuming foods they should avoid.
Moreover, they also had difficulty in food management. In general, the subjects were
knowledgeable and aware about dieting, but they found difficulties in controlling
themselves. In other words, their self-control was low. Self-control is a key to diet
management in diabetes. Peyrot, McMurry, & Krueger (in Taylor, 2006) mentioned
that the capability of self-control lead to better control of glucose level.
This result was consistent to Dalewitz et al. and Rubin and Pyrot (in Keers, et
al., 2004) that suggested that many patients find difficulties in self-management. In
this present study, doctors even found some patients felt frustrated because no
matter how hard they had tried to manage their disease, their glucose level remained
high. In addition, some subjects mentioned that the exercise they should do routinely
made them bored. One subject preferred relying on medication to manage the
disease to doing exercise.
This study results also indicated that the subjects had been helped by the
activities provided by Persadia (Diabetes Patients Club) such as doing exercise
together, gatherings, and seminars. They were enthusiastic in participatig in the
activities and being with their peer patients. This indicated that there was mutual
support between patients. Such social support is necessary to help patients in
managing their disease. Research has indicated that social support accelerates
patient’s recovery (Taylor, 2006).
V. IMPLICATIONS
An important finding of this study was that the patients initially felt afraid, anxious,
sad, shocked, and worried when they were diagnosed with diabetes by the doctor.
The subjects reported feeling shocked, frightened, uneasy, and bored when they had
to comply with routine medication, diet, regular exercise, and routine glucose
checkings. However, some subjects who were aware of possible diabetes reported
that they could accept their disease, stayed calm, and felt only a little concerned
about their disease. They were optimistic and believed that medication would help
them to make their condition better. They routinely took their medications, felt only a
little worry, and were enthusiastic to join Persadia. It could be thus concluded that
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emotions the clients experienced might affect their diabetic self-management.
Positive emotions would lead to good self-management, while on the contrary
negative emotions would lead to poor self-management.
Patients with negative emotions had lower productivity, lower quality of social
life and familial relationship, and lower use of leisure time (Mayou et al., in Misra &
Lager, 2008) or, in other words, they have lower quality of life. Quality of life is a
multidimentional construct containing individual subjective perception of subjective
well-being, satisfaction, and happiness (Rubin, in Misra & Lager, 2008).
REFERENCES
Cox, D.J., & Gonder-Frederick, L. (1992). Major development in behavioral diabetes
research. Journal of Consulting and Clinical Psychology, 60, 4, 628-638.
Delamater, A.M., Jacobson, A.M., Anderson, B., Cox, D., Fisher, L., Lustman, P.,
Rubin, & Wysocki, T. (2001). Psychosocial therapies in diabetes: Report of
psychosocial therapies working group. Diabetes Care, 24, 7, 1286-1292.
Feifer, C., & Tansman, M. (1999). Promoting psychology in diabetes primary care.
Professional Psychology: Research and Practice, 30, 1, 14-21.
Fisher, E.B., Delamater, A.M., Bertelson, A.D., & Kirkley, B.G. (1982). Psychological
factors in diabetes and its treatment. Journal of Consulting and Clinical
Psychology, Vol. 50, No. 6, 993-1003.
Keers, J.C., Links, T.P., Bouma, J., Gans, R.O.B., ter Maaten,J.C., Wolffenbuttel,
B.H.R., Sluiter, W.J., & Sanderman, R. (2004). Do diabetelogists recognise
self-management problems in their patients? Diabetes Research and Clinical
Practice, 66, 157-161
Misra, R., & Lager, J. 2008. Predictors of quality of life among adults with type 2
diabetes mellitus. Journal of Diabetes and Its Complications, 22, 217-223.
Taylor, S.E. (2006). Health psychology. New York:McGraw-Hill,Inc.
Tjokroprawiro, A. (2004). Hidup sehat dan bahagia bersama diabetes. Jakarta:
Penerbit PT Gramedia Pustaka Utama.
http://www.depkes.go.id/index.php?option=news&task=viewarticle&sid=1183&Itemid
=2 diakses tanggal 22 Mei 2007
(http://www.republika.co.id/metformin_diabetes.htm).
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