Research On Diabetes Self-management Behavior Among Rural Patients

Diabetes mellitus has been considered as one of the major global public health problem, resulting in millions of death directly every year. Moreover, as we know, diabetes is a critical factor in non-communication diseases epidemiology in that it will mass increase the risk of cardiovascular, peripheral nervous and renal disease, hence increasing the severity of global public health, and heavily burden upon individuals, families and the whole nation.Among strategies for preventing or controlling diabetes prevalence, health promotion with its core—behavior intervention, is expected to be the most efficient. Of all the models to improve diabetes behavior, a wealth of literature has suggested the model of facilitating patients to build a self-management lifestyle. In practice, however, it has not reached scholars' expectation and needed deep discussions and investigations. In recently 20 years, psychosocial factors are one of the academic focuses, and self efficacy is perceived as the core factor substantially influencing self-management and essential target in diabetes behavior interventions. Other psychological reactions, such as perceived severity, perceived influence, perceived effect, or perceived barrier, have also been discovered and portrayed to be elements of importance.In china, nevertheless, only a few research focused on health belief or self-management in rural diabetes patients. As we know, in rural china, socioeconomic level is comparatively lower, its culture has distinct feature, health service resources are insufficient with unfair distribution, patients'health behavior encounter strong economic and social barriers, and their health belief in chronic illness is more special than citizens. Thus, it is still a question needed investigation whether self-efficacy would play the important role in self-management behavior as previous literature concluded. Besides, although other psychosocial factors were agued correlating with self-efficacy and jointly acting on self-management behavior, we have not seen any similar work done among rural diabetes patients, which called on our great interest. We viewed such a study on socioeconomic environment, patient perceived belief, self-efficacy and their influence on self- management was valuable for policy making and academic research.To make this study more thoroughly, we adopted mixed method research deign in methodology, a deign combining quantitative and qualitative methods. We chose two representative towns in Xianjun of Zhejiang Province as the research sets, and used a two-stage cluster sampling method to obtain the aimed object. Totally 282 eligible diabetes patients completed our survey questionnaire, with the responsing rate of 79.4%. In qualitative stage, individual interview were the main approach being used. These interviewees were chosen in a representative way, and the interview contents were constructed by ourselves according to the research topics. Quantitative questionnaire included several assessment instruments:Diabetes Self-Care Scale, Diabetes Management Self-Efficacy, Personal Model of Diabetes Inventory, and Diabetes Culture perceived barrier Scale.Data collecting encompassed processes of blood glucose measurement, qualitative interview and quantitative survey. Value of individual blood glucose was measured by the physicians and nurses from local health services centers before breakfast, using portable blood glucose measurement instrument. We applied face-to-face interview approach for qualitative data collecting, and recorded by taping instrument with permission of the interviewees. Health service staff interview was executed under open-talk type, while diabetes patient interview under semi-structural type. Quantitative survey including several steps:questionnaire design, pre-survey, pilot study, local investigator training, field formal survey, data input, and data classification. In addition, we did the re-input work to examine the input quality, where 5% of total number was sampled and re-entered.The data analysis process was similarly divided to two parts:qualitative framework analysis and quantitative data statistical analysis. During qualitative analysis, all the taping information was transformed to words sentence by sentence. Totally 12 Health service staff interview records and 85 diabetes patient interview records were transformed. After that, framework approach was applied to analyze them, which mainly consisted of four steps:identifying a thematic framework, indexing, charting and interpretation. Contents of the patient interview were additional transformed to semi-quantitative form and further charted, classified and interpreted.During the process of quantitative analysis, we firstly tested reliability and validity of the scales by the statistical software of SPSS. In that way, internal consistency (Standardized Cronbach's a) and exploratory factor analysis was calculated or performed for Diabets Self-Care Scale, Diabetes Management Self-Efficacy, Personal Model of Diabetes Inventory, and Diabetes Culture perceived barrier Scale. To model the relationship between psychological factors and self-management behavior, we employ linear regression statistical model, in which self-management behavior was the dependent variable, while the total scores of self-efficacy, personal illness perceptions and their sub-scale were regarded as independent variable. Moreover, we applied Amos 7.0 statistical software to execute certain type of Path Analysis, bringing psychological factors above, age, gender and income together to systematically build self-management behavior model.Qualitative framework analysis identified the results as follow:patients in rural area viewed differently the way in which how diabetes was developed, prevented or controlled. Diabetes knowledge, health belief and coping skills varied across age, gender, and income groups, while self-management performance, however, was still far from satisfaction among the 85 patients. More than 75 percent of the enrolled patients responded with good medical adherence, most of them said they changed dietary habit, a few of population participated in physical exercise, and ordinary patients rarely paid attention to foot care. Besides, few people held glucose measurement instruments at home, and only a few visited health services centers regularly for glucose measurement. From the viewpoints of local health service staff, low level of self-management performance in rural areas due to well self-feeling of glucose control or incorrect health belief. The problem was even worse among the unagricultural labor group, for they knew the seriousness, but did nothing for change, and were still involved risk behavior. For these patients, in local health service staff opinions, economic status was no longer the major barrier, rather, subject psychological factors influenced a lot. People living in rural area spent less money in health and neglected prevention, treatment, and recovery of common diseases. Furthermore, they cared about body feeling, led a life of pleasure currently, but lack future goals and interest.Quantitative survey results focused on hypothesis testing using linear model, and found:blood glucose value of diabetes patients before breakfast was associated with self-care level(r=0.22, p=0.03); Self-efficacy had linear correlation with self-care level(r=0.38, p?0.01); Personal illness perceptions had linear correlation with self-care level (r=0.42, p?0.01); Culture perceived barrier had linear correlation with self-care level(r=-0.27, p=0.01); The partial regression coefficient of self-efficacy in self-management behavior linear model had statistical significance compared to zero(t=2.63, p?0.01); The partial regression coefficient of personal illness perceptions in self-management behavior linear model had statistical significance compared to zero(t=3.81, p?0.01); The partial regression coefficient of culture perceived barrier in self-management behavior linear model had statistical significance compared to zero(t=-2.20, p?0.03); no interaction was found between self-efficacy and personal illness perceptions(t=0.22, p=0.82), self-efficacy and culture perceived barrier (t=0.64, p=0.52). Path analysis showed that the total model had statistical significance(Chi-square=11.2, p=0.02) when object factors, psychological factors and self-management behavior was included. Age, income and gender factors respectively had standardized effect values of-0.120,0.200 and-0.155 on self-management behavior, while their direct effect values were-0.141,0.147 and 0.000. For self-efficacy, personal illness perceptions and culture perceived barrier, their effect values (only direct) were 0.322,-0.176 and 0.362.After discussion, the study produces a range of conclusions as follow:Rural area currently is undergoing profound changes in socioeconomic environment, and hence the amounts of diabetes patients is obviously increasing; Health belief in mind have reformed compared to the past, yet traditional culture still imposes widely impact on these populations; On the whole, diabetes self-management behavior has limited variation, featuring prominently with medication adherence; Patients lack health behavior plan for future healthy life, body feeling becomes their critical impetus; Self-management performances vary across individuals, for which psychological factors act as key roles; More confidence—higher self-efficacy level—promotes these patients performing better self-management behavior. Illness perception towards diabetes control, especially seriousness/impact perception, has positive influence on self-management behavior, while treatment effect/compliance control perception seems to be invalid; Variation of sub-culture, for instance future value perception would also somehow affect behaviors; Poverty culture caused by long-term poor economic status is prevalent in rural area, which leads to a large gap between poor population and other else in health belief and behavior. It would be expected that this study has certain academic value for future research on mix method research design, Chinese diabetes self-management and self-efficacy, as well as policy value for government health strategy development.