Medycyna Metaboliczna, 2014, tom XVIII, nr 3

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60
MAGORZATA BERNAS, ZOFIA SZCZEKLIK-KUMALA
KNOWLEDGE AND MOTIVATION IN CONSTRUCTING AN
EFFECTIVE THERAPEUTIC EDUCATION PROGRAMMES
FOR BETTER DIABETES MELLITUS CARE
WIEDZA I MOTYWACJA W BUDOWANIU SKUTECZNYCH PROGRAMW
TERAPEUTYCZNEJ EDUKACJI W OPIECE DIABETOLOGICZNEJ
Warszawski Uniwersytet Medyczny
Towarzystwo Edukacji Terapeutycznej, Warszawa
STRESZCZENIE. Edukacja terapeutyczna stanowi podstaw leczenia osb z chorobami przewlekymi. Powinna by wbudowana w system
planowej opieki diabetologicznej. Program terapeutycznej edukacji i jego realizacja u osb z cukrzyc zwiksza jako leczenia i ycia pacjen-
tw umoliwia odpowiednie do ich indywidualnych potrzeb zmiany w stylu ycia, samoobserwacj i samokontrol oraz przestrzegalno w
wykonywaniu zalece leczniczych. Programy terapeutycznej edukacji mona przekazywa pacjentom w zakresie samej wiedzy i umiejtnoci
technicznych lub te mog oni otrzymywa wiedz oraz wpywy pedagogiczne budujce jednoczenie ich motywacj i pozytywne zachowania.
Przedstawione badanie wskazuje, e programowe oparcie edukacji o czynniki motywacyjne jest bardziej skuteczne w budowaniu pozytyw-
nych zachowa i wynikw leczenia pacjentw.
Sowa kluczowe choroby przewlekle, cukrzyca, edukacja terapeutyczna, wiedza terapeutyczna, motywacja terapeutyczna.
SUMMARY. Therapeutic education is a fundamental component in the prophylactics and therapy of chronic diseases. It should be inbuilt into the
system of the planned, holistic diabetes mellitus care. The programme of the therapeutic education and its realization by the persons with diabe-
tes mellitus augments the quality of therapy outcomes and life of patients. It enables respectively to the individual needs of the patients the
medically needed transformations in the life style, self-observation, self-control and better compliance. The therapeutic education therefore could
be more effective if it is composed of 2 basic activities 1) transfer of the science and skills and also 2) building up the respective motivation for
realization of the medical recommendations in real life.
The therapeutic education programmes could be presented in practice to the patients only in the area of science and skills or they may deliver
science and skills enriched by the pedagogically and socially constructed motivation.
Presented studies objectively indicate, that the educational programmes based on the motivation are more effective in creation of the proper
patient behaviour and the quality of real application of the medical recommendations and the quality of life.
Key words chronic diseases, diabetes mellitus, therapeutic education, therapeutic science, therapeutic motivation.
BACKGROUND IDEAS AND ASSUMPTIONS
Therapeutic education of patients with incurable, chro-
nic disease is not a simple transfer of the information. This
complicated process exerts a formative infuence on all
parties involved - patients, educators and people allegedly
from outside - society. This is summarised in table 1.
In addition, the members of all three interacting groups
as shown in table 1 are, at the same time, subjects and
objects of educational formation. The force, which seems to
keep together and move the whole complicated education
process seems to be mainly that of spiritual character moti-
vation plays a greater role than the technical promises.
EXISTENTIAL VALUES AND DIABETES EDUCATION
In Poland, the tradition of psychologically-minded
education in chronic disease has a long history. It began
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almost 100 years ago with the philosophical concept of
the spiritual force of motivation called by E. Twardow-
ski, a Polish philosopher of this time, - FIAT. It me-
ans I should do - the meaningful, rational use from the
life potential (1). In Poland, the works of Victor E. Frankl
(2), an Austrian psychiatrist and philosopher, creator of
many important therapeutic ideas and refections related
to human spiritual needs and drives and to the role of cre-
ative personality, were also well accepted and developed.
According to this personalistic approach human existence
is based on the implementation of positive values, which
creates a sense of meaningful life and subsequently an in-
ternal force to activate the motivation.
One may list several such values (3, 4, 5):
a. actions according to personal convictions - freedom to act,
b. self - understanding and self-realization - freedom of
choice,
c. satisfaction from the results of actions - successes,
d. life quality - fulflling the accepted standards,
e. positive basic life goals - mostly areas related to
education, profession and social position,
f. positive social relations, good family development, so-
cial recognition,
g. voluntary engagement in actions and enrichment of life
by an altruistic attitude,
h. positive, personal experience in successful coping with
stress.
Diabetes mellitus endangers all existential values.
Conversely the preservation or reconstruction of exi-
stential values builds up the motivation of a diabetic per-
son. This attitude, according to Frankl could be named
logotherapeutics. In this particular term the word lo-
gos means rather understanding, rationalization or
education. Many Polish psychologists (Florian Zna-
niecki, Maria Ossowska, Z.J. Lipowski,) have developed
the idea of the logotherapeutics of Frankl in a working
concept of creative education in chronic disease, based on
the priority of building the motivation and enriching the
personality before delivering technical information.
The pedagogical base for diabetes mellitus education
in Warsaw is under strong infuence of these humanistic
and personalistic concept (3, 4, 5). It simply means that
education should be aimed at re-shaping the personality
of the patient, at enforcing the psychosocial mechanisms
of positive motivation and positive change in the behavio-
ur. A diabetic patient should at frst transform his illness,
his pains into new values and into new therapeutic beha-
viour (6, 7).
According to these assumptions one could defne dia-
betes mellitus education by 6 obligations or tasks it has
to materialize:
a. formulate educational and psychosocial diagnosis enab-
ling holistic behavioral and technical teaching;
b. construct positive motivation (the force of FIAT of
Twardowski), better contact of the patient with himself
and other people, a creative attitude toward potential
new life values;
c. increase the psycho-social resistance to stress and the
capability of coping with the handicap;
d. counteract anxiety, fatigue, depression, frustration;
e. equip the patient with all the necessary knowledge and
skills enabling him to fulfl all the technical needs for
proper control of his diabetes mellitus;
f. and fnally, assure the patient, that he is able to fulfl
his social role, to obtain a good quality of individual
life, a suffcient level of autonomy, in order to eliminate
external and internal discrimination (8, 9, 10).
It is felt, thai this way of educating a diabetic patient
may more effectively and for a longer time help to com-
pensate both the psychosocial and biological disturbances
of the so-called diabetic existence.
STUDY AIMS
Already in our earlier study observations we disco-
vered, that a signifcant gap existed in our practice be-
tween knowledge and action of educated patients. After
the formal, structured education programme, as used in
Patient Treating team Society
Knowledge
Skills
Sense of life
Existential values
Behaviour
Autonomy
Rationalized
compliance
Possible partnership with patient
Utilization of full medical potential
Near normoglycemia or highest possible
metabolic corrections
Minimal side-effects of therapy
Secondary prevention of late complica-
tions
Better benefit/cost ratio financial burden
with increased social result
Less hospitalization, less morbidity and
mortality, more productivity
Better prognosis
lncreased quality
of life
Better prognosis for doctor-patient
cooperation
Better life quality for patient, his family
and social group
Table 1. Advantages for different groups under influence of educational intervention.
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our Center at the beginning of its educational practice, we
were able to increase signifcantly the level of knowledge
but not the level of motivation. The level of metabolic
control remained very often not changed, when such edu-
cational intervention was delivered.
Keeping in mind the ideas of personalistic, psycholo-
gical mechanisms in shaping personality and behaviour
through education as described above and, in addition,
this particular experience, we have designed a program-
me oriented at stimulating primarily motivation. This pro-
gramme became an object of observation and of experi-
mental evaluation.
This we attempted to achieve by comparing the outco-
mes and the results of 2 programmes implemented in the
same organizational setting:
1. the programme more oriented toward increasing kno-
wledge - PK
2. the programme more oriented toward increasing moti-
vation - PM
METHODS
Programmes. The general characteristics of the two pro-
grammes under comparison could be described as below:
Teaching. Both programmes were taught according to
a basic, written syllabus (8). Practical teaching was divided
into units. Every unit of education was based on a series of
questions and answers. This was the standarization of tea-
ching permitting reproducibility.
The programmes were taught at the diabetic school. It
was organized as follows:
Methods used for the knowledge-oriented programme
were: 30 min lectures - preprogrammed as educational
units - reproducible, practical exercises in self - control,
injection, adapting the insulin dose, diet composition and
glycemic index and glucose load calculations, simulation
of the sick day rules.
For materialization of the motivation-oriented pro-
gramme other teaching forms were also applied such as
I. Knowledge oriented
programme
II. Motivation oriented
programme
1. Metabolism,
What is diabetes?
Diagnostic criteria.
Control criteria
1. Glucose, glycemia.
What is diabetes?
Symptoms, therapeutic
aproach, goals, means.
2. Materials for self-control.
Methods, results, documen-
tation, interpretation.
2. Compensation of diabetes
mellitus and solving life
problems with therapy.
Ways to stay in good
condition
3. Emergency situations:
prevention, hyperglycemia
and ketonuria - testing.
3. Sense of life, quality of life.
Life values, personality, self
control, home laboratory
goals, data, interpretation of
results, life situations, liberal
diet, more freedom from
self-control.
4. Components of a diabetic
diet, daily allowances,
planning the diet, food ex-
changes, diet composition,
preparation of meals.
4. Prevention of hyperglyce-
mia and ketonuria.
5. Economics of the diet,
organization of the kitchen,
5. Enjoying food, the dia-
betic kitchen, what is good
in a diabetic diet also for the
non-diabetic, measured and
non-measured diet.
5 consecutive days/week, 2x2 hours daily;
Short lectures, group discussions programmed and free,
metaplan method;
Practical exercises;
Entrance and final evaluation by interview and multiple
choice questions test.
During the programme glucose determination strips,
manual enzymatic method, HbA
1
/microcolumns/were also
performed.
6. Insulin actions, prepara-
tions, self-control, principles
of increasing and decreasing
the dose, algorhytms of
insulin application, injection.
6. History of insulin, insulin
actions.
Choice of preparations and
dose, what is a good dose,
injection.
7. Hypoglycemia.
Mechanism, risk of hypo-
glycemia, self-diagnosis,
intervention glucagon
injection.
7. Prevention of hypogly-
cemia - too much insulin;
intervention - sweets,
glucose, glucagon, family
support.
Social relations. chronic
complications.
8. Chronic complications.
Organs involved, limitation
of family life, contraindica-
ted professions.
8. Presentation of other
patients experience, free
discussion, what is most
helpful in prevention.
9. Social regulations for
diabetics.
9. Life perspective, pro-
fessional carriers with
examples, establishment of
family, hobbies, altruistic
attitude. Partnership with
the treating team.
Prevention of complications.
10. No family involvement,
no telephone contact.
10. Family participation,
telephone contact during
programme.
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inter-patient discussions with the teacher
as an animator; clinical and psychologi-
cal analyses defning the psychosocial
profle.
The teaching team was composed of
physicians, nurses, a psychologist, and
dietician. No member of the team had
a formal licence to teach but training had
been delivered by pedagogues and psy-
chologists. In fgure 1 the way of presen-
ting the topic What is diabetes? - wit-
hin the motivation oriented programm is
examplifed.
In the motivation-oriented program-
me the educators had the task of incor-
porating into the programme many items
not present in the knowledge-building
activities such as for example the general,
psychological aspects of the non-curable
disease, the possibility of organizing the
whole life around new values and possi-
bilities, a new sense of life not a worse
one - life without diabetes mellitus. The
educators were instructed to build the
positive alliance between the patient, the
treatment team and the social group, to
show the perspective and potential of an
autonomic style of life, ways to increase
the quality of life and ways of controlling
late complications. Also during this programme two
experiments in self-control were organized - the infu-
ence of a nutritional error on blood glucose (200 g of
sweet cake) and of physical exercise on blood pressure
(bicycle ergometer). In the motivation-oriented pro-
gramme close family members and friends suggested
by the patient took part.
Patients. The criteria for including or rejecting the can-
didates with type 1 diabetes mellitus for the study were as
follows:
The number of patients under study was: 30 females
and 23 males - 53 cases.
The study was entered by 59 patients - 53 fnished the
whole observation plan.
Among them 28 participants were randomized to the
knowledge-oriented programme and 25 to the motivation-
-building education.
Statistical signifcance was evaluated with Student`s
t test for paired data.
RESULTS AND DISCUSSION
One week after completing the programmes changes
in knowledge and in motivation levels were assessed by
multiple-choice tests composed of 60 questions: 30 for
testing knowledge and 30 for measuring motivation. Each
correct answer was given 2 points and the maximum po-
ints possible was 120.
Scores above 70 were considered positive results of the
test, below this number they were regarded as negative.
The results of testing before and after completing the pro-
grammes under comparison are presented in tables 2 and 3.
By comparing the level of knowledge, before and af-
ter the knowledge-oriented programme, it was possible to
calculate, that the average index of change in knowledge
was 22. It means, that after the programme the number of
patients with positive multiple choice tests went up from
2 to 24. At the same time the index of change in the moti-
vation calculated in the same manner went up only by 2,
that is from 6 to 8 (tab. 2).
Inclusion Non-inclusion
Age: 22-28 years
Duration of diabetes mellitus:
5 years or less
No symptoms of chronic
complications - besides
background retinopathy;
Sufficient family support;
insulin: 2 or more injections.
Any concomittant disease;
Predicted poor compliance;
Less than secondary level of
general education.
Number of patients with
results
Knowledge testing
questions
Motivation testing
questions
positive
negative
before
2 (a)
26
after
24 (b)
4
before
6 (a)
22
after
8 (b)
20
p < 0,05
Index of change (b-a)
= 22
p > 0,05
Index of change (b-a)
= 2
Number of patients with
results
Knowledge testing
questions
Motivation testing
questions
positive
negative
before
4 (a)
21
after
19 (b)
6
before
5 (a)
20
after
23 (b)
2
p < 0,05
Index of change (b-a)
= 15
p > 0,05
Index of change (b-a)
= 18
Table 2. Number of positive and negative results (for explanation see text)
of the test composed of 60 multiple (17) choice questions among them
30 questions testing knowledge and 30 motivation-before and after kno-
wledge-oriented programme: 28 patients.
Table 3. Number of positive and negative results (for explanation see text)
of the test composed of 60 multiple (17) choice questions among them
30 questions testing knowledge and 30 motivation-before and after kno-
wledge-oriented programme: 25 patients.
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As described in table 3, the other group composed of
25 participants with IDDM underwent in a similar dia-
betic school the motivation-oriented programme. After
this type of education the index of change in the kno-
wledge, calculated in the same way as described above,
went from 4 up to 19, an increase of 15. The index of
change for motivation went up at the same time from 5 to
23, an increase of 18. All these changes were statistically
signifcant at the p level of 0,05. The motivation-orien-
ted programme was in our Diabetic School more effective
in infuencing both the motivation and the knowledge. It
was also possible to show a statistically signifcant cor-
relation between the knowledge and the motivation (r =
0,62) after this programme.
The observation suggests, that the motivation-orien-
ted programme is clearly preferred, because it permits an
increase in both knowledge and motivation at the same
time. This was not the case after the knowledge-oriented
programme.
As also shown in other studies the increase of the level
of knowledge concerning diabetes mellitus self-control is
in the majority of cases not able to positively infuence
motivation at the same time and therefore the personali-
ty of the patients and their behaviour (6). The effects of
education may appear in both the educated and in the con-
trol group (7-9). This points to the so called Hawthorne
effect resulting from more attention being paid by the
patients to the disease, due only to participation in the
study. In a more precisely designed study however, the
structured education programmes infuenced clearly the
metabolic control for several months.
It is obvious, that the educational programmes could
be more or less effective in reaching the goals. Constru-
cting a programme comes after considering such impor-
tant factors as recruitment of patients for a Diabetic
School and streaming them according to level of gene-
ral education and cultural status or type of personality
(9,10, 11).
In our hands, the motivation-oriented programme rea-
lized with a psychological approach aimed at developing
internal motivation was clearly more effective in compa-
rison with the knowledge-oriented programme alone.
CONCLUSIONS
1. Teaching according to the knowledge-oriented pro-
gramme increased mostly knowledge. It did not correlate
with an increase in motivation, meaning the readiness to
put knowledge into practice.
2. Educating the IDDM patients according to the moti-
vation-oriented programme was signifcantly more effec-
tive in increasing both knowledge and motivation.
PIMIENNICTWO
1. Tatarkiewicz W.: Historia flozofi, Wyd. Naukowe
PWN, Warszawa, 1970.
2. Frankl V.E.: The concept of man in psychotherapy,
Proceedings of the Royal Society of Medicine, 1954,
47, 975.
3. Tato J.: Filozofa w medycynie, Wyd. Lekarskie
PZWL, Warszawa, 2003.
4. Heszen I., Sk H.: Psychologia zdrowia, Wyd. Nauko-
we, PWN, 2007.
5. Tato J., Czech A.: Cukrzyca Podrcznik Edukacji Te-
rapeutycznej, Wyd. Naukowe PWN, Warszawa, 2000.
6. Lacroux A., Assal J.P.: Therapeutic Education of Pa-
tients, wyd. Vigot, Pary, 2000.
7. Steciwko A., Baraski J.: Relacja lekarz-pacjent, zro-
zumienie i wsppraca, wyd. Elsevier, Urban and Part-
ner, Wrocaw, 2013.
8. International Diabetes Federation, International Stan-
dards for Diabetes Education, IDF, Bruksela, 2003.
9. Tato J., Czech A., Bernas M., Szczeklik-Kumala Z.,
Biernacka E.: Socjologia cukrzycy, Wyd. Tow. Eduka-
cji Terapeutycznej, Warszawa oraz Esculap d, 2013.
10. Young-Hyman D.: Psychosocial factors affecting ad-
herence, quality of life and well-being: felping the
patients cope. W: Medical management of type 1 dia-
betes, S. Bode ed., wyds. 4, ADA, Alexandria 2004,
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Adres do korespondencji:
M. Bernas
Katedra i Klinika Chorb Wewntrznych, Endokrynologii i Diabetologii
WUM
Szpital Brdnowski
ul. Kondratowicza 8
03-238 Warszawa