The Impact of Orem’s Self-Care Model on the Quality of Life In Patients With Type II Diabetes

Abstract

Diabetes mellitus is a chronic disease that reduces the quality of life in patients. Therefore, this research aimed to the effect of Orem’s self-care model on the quality of life(QOL) in patients with type II diabetes at Ilam, Iran. A quasi-experimental study was performed on 80 patients with type II diabetes in Ilam in the year 2015. The research tools used in this study were a demographic questionnaire and the SF-36 survey. The patients were divided randomly into control and experimental groups. Orem’s self-care programme was performed in six 60-90 minute sessions for six weeks in the experimental group. The data were analysed using SPSS software and descriptive and inferential statistics. The findings showed that the mean and standard deviation of the quality of life in the experimental group before and after the intervention were 47.1 ± 9.21 and 67.91 ± 12.87 respectively, which was statistically significant (P <0.001). however, in the control group it was 47.66 ± 8.4 and 47.41 ± 8.6 respectively, indicating that there was no statistically significant difference (p> 0.05).Regarding the effectiveness of self-care programmes based on Orem’s theory on the quality of life in patients with diabetes, it is suggested that in nursing care this self-care programme can be used for patients with diabetes to improve their (QOL).

Introduction

Diabetes is one of the most common chronic diseases in the world. The number of suffering cases is on a dramatic rise due to lifestyle changes, reduced mobility and obesity. In 2011, 366 million people had diabetes. The number is estimated to reach 552 million by 2030 (1, 2). It is expected that the Middle East will have the highest increase in diabetes in the next few decades. In contrast to the developed countries where diabetes occurs in people over 65 years of age, in the ME the increase is mostly in the age group of 45 to 64 years. In Iran, about 7.7 percent of the adult population of 25 to 64 years of age, i.e. the equivalent of ~2 million people has diabetes; half of whom are undiagnosed. In addition, 16.8 percent or ~4.4 million people have impaired fasting glucose (2, 3). Diabetic patients struggle with physical & psychological problems such as depression, anxiety, helplessness, lack of mobility and obesity, which ultimately lead to reduced QOL. As a result, QOL is of particular importance in patients with diabetes (4). The QOL has been described as a multidimensional concept that includes the areas of health and physical function, mental health, social functioning, satisfaction with treatment, worry about the future and a sense of well-being (5). An obvious relationship exists between the QOL and physical disorders, and symptoms of chronic diseases and physical disorders have a direct impact on all aspects of quality of life (6).

Since the main goal in the treatment of all diseases is to increase the patients’ performance, to improve the QOL and help them to achieve a satisfactory quality of life, it would only be possible by providing the self-care programmes and finding appropriate solutions to help those patients (7). Previous studies suggest a lack of awareness about their disease and proper functioning in the patients with diabetes, and, as a result, non-compliance with their treatment. So, to control these diseases, it is important to identify the educational needs of patients, even more than the proper treatment (8).

Self-care is effective, learned, informed and objective activities and behaviours of a person that are done in concrete situations of life, by the person himself or his relatives. The aim of self-care is to regulate the effective factors on growth and patient’s performance in relation to life, health, and well-being. Self-care behaviour is affected by the total skills and knowledge that a person has and uses for his practical efforts (9).Self-care is considered as an important and valuable principle because it emphasizes the active role of people in their own healthcare, not the passive. Many health organizations and healthcare providers consider promoting self-care as a strategy to reduce the high costs of medical services (10).

Orem’s self-care model is one of the most complete self-care theories that provides a good clinical guide for planning and implementing the principles of good self-care (11). Orem believes that human beings can take care of themselves and whenever this ability is distorted in a person, nurses can help individuals to regain this ability by providing direct care, and compensatory educational support (12). According to Orem, the nurse’s role has been introduced as a facilitator and agent of change (13).

Due to the chronicity of diabetes, a person with diabetes should cooperate in all phases of the control and treatment and should be able to do self-care activities. Self-care is crucial for the control of diabetes and includes self-monitoring of blood glucose, diet, setting insulin dosage, and doing regular physical activity (14–16). Since an important part of daily care in patients with diabetes is provided by the person himself or a family member, learning self-care skills is necessary for patients with diabetes (17).

One of the main elements of self-care is patient education and self-care also requires the ability to self-medicate. Nurses must teach the patient how to solve problems and make decisions (18). Given the role of support and nursing care and its impact on QOL in chronic diseases (19) and considering that the results of various studies have shown that the use of education and care models helps to improve the condition of the patients (20–23), the present study was conducted to aim the effect of Orem’s self-care on QOL in Diabetes II patients in Ilam, Iran.

Materials and Methods

In this quasi-experimental study, the experimental and control groups was designed pre-test and post-test following the previous studies (4, 24, 25) 80 patients with type II diabetes previously referred to the clinics of Ilam in 2015 were enrolled in the study. The subjects were randomly divided into control and experimental groups. Inclusion criteria included diabetes type II, at least one year post-diagnosis time, age between 18 and 65 years, and literacy of reading and writing. Exclusion criteria included diabetes type I, more than two sessions absence from training interventions, hospitalization during the intervention, the risk of DKA or non-ketone hyperglycaemic hyperosmolar syndrome, hypertension, severe cardiovascular disease, uncontrolled hypertension and well-known mental disorders.

The instruments used in this study were a demographic questionnaire and QOL survey (SF-36). SF-36 questionnaire has 36 questions that measure eight dimensions related to health including physical function, role limitations due to physical health, role limitations related to emotional health, energy, emotional health, social functioning, bodily pain, and general health. All questions have at least two and a maximum of six options and the maximum score obtained for each subscale is 100 and the minimum is zero. The higher score indicates better QOL. The QOL was considered desirable (71-100), somewhat desirable (31-70) and undesirable (0-30) (19).

In Orem’s self-care model, the ability and defects in the patient are examined and nursing interventions are designed for self-care by the patient according to the identified needs of the help-seeker. The process of application of Orem’s model in this study was as follows: first, using Orem’s assessment form, some information on the demographic characteristics of the patient, patient’s specific need for self-care related to the health (such as, medical information, previous medical history, diagnoses, medications, allergies, and patient expectations) and their general care needs (such as, body systems, health, usual patterns of daily life, and the perception of their social interactions) were collected Patient’s needs about the disease, health and diagnostic tests and other requirements for registration were determined. The patient’s ability to meet those needs was assessed. Finally, the appropriate plan was designed and developed to fit the patient’s needs. It should be noted that the programme was implemented only in the experimental group. In the intervention group, the programme was performed over six group sessions (each group contained five people) for 60 to 90 minutes. The content of the classes included a variety of educational material such as the etiology, types, clinical signs and symptoms, diagnostic tools and treatments of diabetes complications, risk factors, eye care, foot care, blood glucose self-measurement, observation of the recommendations, appropriate diet, how to comply with prescribed drug regimen, setting the time of using drugs, importance of physical activity and how to perform self-care. After the training sessions, a pamphlet of the taught material was given to the patients in the experimental group. In this study, patients were followed for 12 weeks and at the end of the twelfth week, they again completed the data collection instruments.

Ethical considerations include permission by Research Ethics Committee of the University of Medical Sciences of Ilam, Iran also, no cost was incurred to the patient. Participants were justified about the training sessions, informed consent was obtained from participants, and subjects were assured of the confidentiality of data and their right of withdrawal from the study at any time during the study. Data were analysed using SPSS version 20; descriptive statistics (mean, percentage, absolute and relative frequency) for individual variables and chi-square test for comparison of individual groups. Paired t-test was used to compare the QOL before and after the intervention.

To compare the QOL scores between the intervention and control groups independent t-test was used, and to compare the mean difference based on personal characteristics, t-test (for two groups) and ANOVA (for more than two groups) were used.

Findings

The mean age of subjects in the experimental and control groups was 43.80 ± 11.93 and 44.30 ± 9.8 years, respectively; and mean years post-diabetes was 7.28 ± 3.15 and 6.41 ± 2.25 years, respectively. Chi-square and t-test results showed that patients at experimental and control groups were not statistically significant different in terms of demographic characteristics (sex, age, marital status, occupation, education, and income). Also, no significant difference was found regarding disease-related characteristics (duration of disease, family history of diabetes, complications of diabetes such as diabetic retinopathy and diabetic nephropathy, medications for diabetes, medical examination, and other chronic diseases other than diabetes) and the overall average score of quality of life between experimental and control groups (Table 1).

Table 1: The demographic features and disease characteristics of the patients in experimental and control groups

demographic features		experimental	control
		N(%)	N(%)
Gender	male	21(45)	23(57.5)
	female	19(55)	17(42.5)
marital status	Single	37(92.5)	37(92.5)
	Married	3(7.5)	3(7.5)
	illiterate	20(50)	21(52.5)
education	Diploma and low literate	13(32.5)	12(30)
	Collegiate	7(7.5)	7(7.5)
job	Practitioner	20(50)	19(47.5)
	Housekeeper	17(42.5)	15(37.5)
	Unemployed	3(7.5)	6(15)
	Less than 500 thousand Rials	17(42.5)	17(42.5)
income	500 to 1 million	7(17.5)	7(17.5)
	More than 1 million	16(50)	16(50)
Family history of diabetes	Yes	17(42.5)	19(47.5)
	No	23(57.5)	21(52.5)
Diabetic retinopathy	Yes	15(37.5)	14(35)
	No	26(62.5)	26(65)
Diabetic neuropathy	Yes	18(45)	17(42.5)
	No	22(55)	23(57.5)
Regular examination by doctor	Yes	9(22.5)	9(22.5)
	No	31(77.5)	31(77.5)

The results of table 2 shows that implementation of Orem self care model helped to improve the QOL of patients in experimental group in all aspects of QOL questionnaire except for the general health and emotional role.

Table 2: comparing the mean and standard deviation scores of quality of life survey before and after the intervention in experimental and control groups

Dimension Quality of life	before the intervention		P	After the intervention		p
	M±SD			M±SD
	experimental	control		experimental	control
Physical Function	36.25±5.59	35.97±5.44	0.35	54.12±13.30	36.32±4.98	.000
Physical role	36.95±6.06	36.97±5.45	0.37	43.47±8.3	36.37±5.9	0.02
Bodily pain	61.17±12.6	61.65±12.17	0.62	64.87±16.1	61.27±12.3	0.001
general health	54.37±13.08	56.67±10.17	0.53	55.80±11.55	55.5±10.85	0.74
Vitality	37.55±6.84	38.02±6.78	0.83	69.37±9.79	37.75±6.91	0.04
Social function	56.62±9.89	57.5±8.53	0.19	62.47±16.52	56.95±8.80	.000
Emotional role	60.75±12.39	61.3±12.04	0.59	61.67±10.549	61.35±11.95	0.36
mental health	32.4±7.24	33.27±6.66	0.45	72.22±16.54	33.77±7.11	.000
Quality of life	47.01±9.21	47.66±8.40	0.84	61.97±12.81	47.41±8.60	0.001

The results of show that the QOL of patients in the control group had no significant difference before and after the intervention; but, Orem’s Self Care model enhanced the QOL of patients in the experimental group.

Discussion

The findings of this study showed that before the intervention, the QOL for the majority of the studied patients was moderate. 60% of the diabetic patients in the study of Ghanbari and Kazemnejad had a poor quality of life ⁽²⁶⁾. Due to its chronic nature, undesirable prognosis all aspects of the health and QOL are affected in diabetic patients. In the present study, the implementation of Orem’s self-care model on the QOL for people with diabetes was effective except for the general health and emotional role. Orem’s self-assessment form for the assessment of these patients was more focused on the physical aspects. It can be said that based on the form, the self-care needs of patients in all four dimensions of health cannot be fully determined. Another factor is patients’ emphasis on improvement of the health condition while admitted to the hospital, rather than other aspects of health, psychological, social or spiritual matters and they expressed their needs less in those respects. Most studies confirmed the effect of Orem’s self-care on improving their physical condition. In this regard, Ghafourifard et al. demonstrated that the implementation of Orem’s self-care model resulted in a significant increase in self-care score in five aspects of diet, physical activity, blood glucose monitoring, medicine diet, drug, and diabetic foot care ⁽²⁷⁾. Shahbaz et al. showed that the implementation of Orem’s self-care model promotes self-care behaviours in diabetic foot ulcers ⁽²⁸⁾. Shahbodaghi et al showed in a study that with the implementation of the self-care programme for diabetes and its complications according to the regulatory protocol, diastolic blood pressure differences between the two groups in the first, second and third months after intervention were statistically significant ⁽²⁹⁾.

Other studies that investigated the effect of applying Orem’s self-care model on the QOL of patients with diabetes have shown mixed results about the effect of this model in the eight dimensions of QOL. Among the causes of discrepancies in the results of these studies and the present study, the difference in sample size, the number of people in each group, type, number and variety of teaching methods to the patients, the duration of training sessions and post-test interval after the last session seems important. Obviously, the design and development of the self-care educational programme vary based on hospital facilities, conditions and available time. In the study of Shams et al. up to 15 people attended each training session, but the present study was conducted in small groups of 5 people ⁽⁴⁾. In the study of of Saieedpour et al, the implementation of three one-hour sessions over three weeks of self-care led to an increased QOL of patients with diabetes in all aspects of life questionnaire. Although the duration of treatment in that study is less than the present study but it was effective in all aspects, even in general health and emotional role, that showed no statistically significant improvement in our study ⁽³⁰⁾. In a study by Ganjloo et al., the self-care model on QOL was conducted in patients with Type II diabetes. Results showed in the experimental group all aspects of QOL improved significantly ⁽³¹⁾. In the studies by Saieedpour et al. as well as Ganjloo et al training was performed through presentations, questions and answers, group discussions, videos and pamphlets ^{(31, 32)}. In the present study, there were no hospital facilities to use all these five teaching methods. Only group education method in small groups of five people was used and pamphlets were given at the end of training sessions. Other causes of the inconsistency of our results with these two studies could be related to differences in demographic characteristics of subjects in these studies.

Studies have shown the influence of the use of self-care model on the QOL in patients with other diseases as well. Among them are studies on the QOL of cancer patients undergoing chemotherapy by Karbaschi et al., the physical and mental aspects of QOL of patients with MS by Masoudi et al all aspects of QOL for haemodialysis patients by Naroui et al., physical and mental QOL for patients with migraine by Omatreza et al., and the quality of life in patients with hypothyroid goitre point by Rahimi et al. ^(33–38).

One of the goals of clinical nursing is helping to improve the QOL of patients. Based on the results of the present study that showed the improved QOL in diabetic patients, nurses in clinical care can use this model and provide patients with the necessary care training to increase the QOL of these patients. Also, due to the effectiveness of this model of care, nursing teachers can emphasize on this self-care model in the education of nursing students to provide the grounds to improve the QOL of patients with diabetes.

It is suggested that further research should be conducted on the impact of different models such as continuous care model and partnership care model on QOL to find a care model suitable to Iranian culture and provide the necessary conditions for increasing the quality of life.

Acknowledgement

The authors thank all the respected patients for their patience and participation in this study. We also thank the esteemed expert of Student Research Committee. This research project is approved by Ilam University Student Research Committee, therefore, we would also like to thank them for the financial support.

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