THE HEALTH BEHAVIOUR OF BLACK INSULIN DEPENDENT DIABETIC PATIENTS

Accurate measurement of patient compliance with medical regimes is notably difficult. Most authorities agree that knowledge alone is insufficient in bringing about compliance and that the key to success with long term treatment regimes is responsible for self care and an adequate support system which encompasses both professional and non-professional support (Finnerty 1978. Becker & Maiman 1980. Dunn 1986). Cox’s interaction model of Client Health Behaviour attempts to explain human responses to ill health and medical treatment; central to this model is the relationship between client and health care provider. Additional factors to be considered within this model include client educational standard, environmental resources, motivational level, disease understanding and affective response (Cox 1982).


B e v in d in g e w o rd b e s p r e e fk en aanbevelings gemaak.
insulin syringes each thus requiring a monthly visit to the clinic by the client.Equipment for home glucose monitoring is not supplied and blood sugar levels are done once a month at the respective clinics.

O B JE C T IV E S O F S T U D Y
These were to:i) identify the responses of Black adult insulin-dependent diabetics toward their disease ii) enquire into the experience of the family living with a diabetic member iii) establish the perspective of registered nursing staff regarding diabetes and their expectations of insulin-dependent diabetic clients iv) determine monthly clinic attendance records as an indicator of treatment compliance and service utilisation.

Procedure and sample
During the period 1 January 1987 to 30 June 1987, 20 insulin-dependent diabetics were selected, all of whom agreed to participate in the project.Criteria for selection required clients to have had a medically-confirmed diagnoses of insulin-dependent diabetes millitus (I D.D M.) for at least one year and to have been resident in and around the tw o study hospitals and attending clinics at the respective hospitals.
Hospital patient records were used to gain access to I.D.D.M. patients and every tenth card was drawn until a quota of 10 subjects fulfilling selection criteria from each hospital was achieved.
In order to probe the attitudes of registered nursing staff, a convenience sample of 15 nurses attending staff meetings at each hospital was selected.
A retrospective descriptive study design was e m p lo y e d , m a k in g use o f sta n d a rd ise d interviews implemented by the researcher with th e I.D .D .M .c lie n ts .A s ta n d a rd is e d questionnaire was distributed to the registered nursing staff for their independent completion.Clients were seen at least twice, on the first occasion at the clinic and on the second, either in their own homes or at the clinic, at which m eeting a fam ily m em ber was invited to participate.
Review of the clinic records over a 10-month period revealed the patients' attendance records, random blood sugar levels, and details of general health.The mean age of the clients was 46 years (range 14-73 years).Of the group 12 (60%) were female and 8 (40%) were male.Twelve clients had 8 -1 2 years schooling.Two of these had tertiary education, whereas eight clients had received 4 -7 years schooling.Of the 6 unemployed people 2 were scholars and 3 were receiving state pensions.
The mean m onthly incom e o f em ployed members of the group was R523 (std.deviation R402.27).All clients were resident with family members.

MOTIVATION
In attem pting to determ ine this variable, questions relating to the following were asked of the clients:i) nature of information given about diabetes by health professionals, and the use made of this information ii) client's desire for competency in managing his condition iii) depth of understanding of diabetes shown by client.
Eight clients appeared positively motivated, nine gave mixed responses and three responded negatively.All the respondents said that they were given information about diabetes and its management and all thought that they were competent with the giving of insulin injections.
Fourteen clients found it difficult to adhere to the diet and nine of them were not taking the recommended between-raeal snacks because they could not afford them or were not hungry.

COGNITION
Cognitive appraisal is defined as the patient's interpretation and understanding of his disease and its management.Fifteen patients (75%) showed a reasonable understanding of the disease, its problem s and im portance o f compliance with the diet, exercise and the in s u lin re g im e .D if f ic u lty w ith m eal preparation related to the impression that the diabetic diet is expensive and too different from family food preferences (Table 1).M ost respondents (70%) knew the importance of eating a snack before strenuous exercise, and all got exercise from their work, sport, housework or gardening.
Five clients were aware of blood and urine m o n ito rin g s y s te m s a n d r e p o r te d the importance of this to coping with their disease, and three (15%) were aware of the significance of daily testing of blood sugar and expressed concern about not being able to have testing agents available.None of the clients wore a medic-alert bracelet although a few of them knew about it.

AFFECTIVE RESPONSE
Health behaviour cannot be explained only on the basis of rational thought and understanding as emotions can interfere with cognition and substantially affect behaviour.The affective response was tested by exploring whether the patient experienced negative feelings towards the disease.In 75% of cases sadness and a sense of loss of good health was expressed.As many as 60% reported feeling worried about their health, a few (15%) said they were jealous of non-diabetics and 15% reported feelings of depression.These emotions seemed to affect dietary compliance but clients reported never missing their insulin doses.Poorly controlled blood su g a r lev els w ere ex p e rien ced as discouraging and demotivating.
On in te rv iew , all the fam ilies ap p eared supportive of the diabetic sufferer but fear of the disease and an inability to cure or control it were experienced as highly stressful.Some of the recommendations made by families are listed in Table 2. Thirteen families (65%) expressed a desire to be more involved when health information is given and were critical of the lack of support they were given by the health services.

CLIENT-PROFESSIONAL INTERACTION
Cox suggests that this interaction is determined by four components and that its sucess varies according to patient singularity and the health care need that is expressed.

(i) T he provision of health inform ation
Most cl i en ts (60%) gave posi ti ve responses with respect to their relationships with the staff.At both clinics the nurses gave diabetes education in regard to its clinical manifestations and management before the doctors arrived for the clinics.Late arrival meant missing the talks.
Several admitted forgetting what was said.No w ritten material was handed out.Clients knowledge of foot care, the importance of wearing shoes and routine eye testing was poor.
Although 11 patients reported eye problems, none had been referred for eye testing.As part of the questionnaire completed by the registered nurses, respondents were asked to rank a list of items related to diabetic care, and 90% ranked eye testing as the least important aspect of care.
A ll c lie n ts w ere c o m p e te n t in i n s u l ^ administration and 17 (85%) were rotati ng t l ^P injection sites.
The n u rses in general app eared to have favourable impressions as regards treatment c o m p lia n c e , an d 27 (9 0 % ) w ere o f the impression that patients are well motivated in the control of their disease.
The most important reasons they gave for non-compliance were: 1) dietary problems (40%) and one nurse commented thus:-"The moment the nurses mention vegetables and fruit, patients stop listening because they cannot afford these".
2) inadequate knowledge of the disease (33%) 3) financial difficulty (65%) In g e n e r a l, n u rs in g s ta f f s e e m e d ^f c over-estimate patient satisfaction wi th their a r e and their motivation as far as disease control is concerned.
(ii) Degree o f em otional su p p o rt given by the sta ff The relationship between client and staff was difficult to assess accurately.Clients reported liking the staff and were obviously reticent about negative criticism.Many were unhappy about seeing different doctors at each visit, and would prefer continuity in this area.The greater proportion of time at the clinics appeared to be spent with the nurses rather than the doctors.Most nurses (90%) felt that the medical and nursing support of patients was adequate and were more critical of lack of support from the families.
(iii) Decisional C ontrol Decisional control refers to the degree of individual decision making regarding health.This aspect was difficult to evaluate and the impression of the authors is that clients are largely passive within the health care system.

Curationis. Vol. 14. No. 2. Aueust 1991
When asked to make suggestions for improving the di abeti c heal th servi ce several were rel uctant to comment, others did not have anythi ng to say, and all said that they doubted if any of their s u g g e s tio n s w o u ld be c o n s id e r e d or implemented.

(iv) Utilization of the service
This was measured by clinic attendance over a 10 month period, as recorded on the patients' clinic cards.
The reasons given for irregular clinic attendance included: (i) an adequate supply of insulin (ii) waiting periods of 4 -9 hours at the clinic From this it was apparent that the reasons for regular clinic attendance and monthly blood glucose monitoring was ill-understood.
S S R action with care appeared directly linked to the amount of time spent at the clinic.Better clinic attendance was observed at Hospital A where there is a separate diabetic clinic.In addition snacks are available for waiting clients at this hospital and lengthy waiting times have been reduced by storing the patient records in the clinic itself.Only 9 (45%) clients reported satisfaction with their medical care.Major reasons for dissatisfaction centered around long waiting times at clinics, inability tochoose their doctor and being given too little equipment.

h e a l t h o u t c o m e
F ive c lie n ts a p p e a re d to be fre e fro m com plications o f diabetes, 8 (40% ) were hypertensive, 11 (55%) reported eye and 2 reported peripheral vascular problems.All clients had fluctuating blood glucose levels -6 shaved readings below 9,5 mmol/1 and the r ^B n d e r were all above this level.Only 2 of the respondents considered themselves to be generally well and free of other illnesses.

DISCUSSION
H ealth o u tc o m e in long term illn e ss is influenced by the type of service and level of satisfaction with the treatment regime.Lack of Personalized care discourages regular clinic utilization (Finnerty 1978).The client their families and the nurses have all expressed the belief that the service is not adequate and the registered nurses have identified one of the problems as inadequate patient education.This is a result of a lack of in-service education for the nurses and overcrowding in the wards which does not afford nurses the time to give the necessary health education to new diabetic patients and their relatives.
Both the patients and families expressed the desire for more information and inclusion of families in the management of diabetes.The need for follow up by community nurses was often expressed.
Dietary compliance appeared to be a major problem.Both Glasgow andMcCaul (1986) andM cCullock (1983) Data were analysed according to the central c o m p o n e n ts o f C o x 's m o d el, n am ely :background dem ographic variables, client s in g u la rity (d e fin e d as a co m p o u n d of -Curationis.Vol.14, No. 2. August 1991 background variables, motivation, cognitive appraisal and affective response), clientprofessional interaction and health outcome.Dem ographic inform ation (n=20)

REFERENCESG
ladness L indiw e X aba M .Soc.Sci.(NURS) R N R M R C H N P rincipal, N gw elezana C ollege o f N ursing N G W E LE ZAN A, E M P A N G E N I Sandra R uth D ew a r M .Sc. (M ED.Sc.) R N R M R C H N L ecturer D epartm ent o f N ursing, U niversity o f N atal Curationis, Vol.14, No. 2, August 1991