MAGORZATA BERNAS, ZOFIA SZCZEKLIK-KUMALA

KNOWLEDGE AND MOTIVATION IN CONSTRUCTING

THERAPEUTIC EDUCATION PROGRAMMES FOR BETTER
DIABETES MELLITUS CARE
WIEDZA I MOTYWACJA W BUDOWANIU PROGRAMW
TERAPEUTYCZNEJ EDUKACJI W OPIECE DIABETOLOGICZNEJ
Warszawski Uniwersytet Medyczny
Towarzystwo Edukacji Terapeutycznej, Warszawa

STRESZCZENIE. Edukacja terapeutyczna stanowi podstaw leczenia osb zchorobami przewlekymi. Powinna by wbudowana wsystem
planowej opieki diabetologicznej. Program terapeutycznej edukacji ijego realizacja uosb zcukrzyc zwiksza jako leczenia iycia pacjen-
tw umoliwia odpowiednie doich indywidualnych potrzeb zmiany wstylu ycia, samoobserwacj isamokontrol oraz przestrzegalno
wwykonywaniu zalece leczniczych. Programy terapeutycznej edukacji mona przekazywa pacjentom wzakresie samej wiedzy iumiejtnoci
technicznych lub te mog oni otrzymywa wiedz oraz wpywy pedagogiczne budujce jednoczenie ich motywacj ipozytywne zachowania.
Przedstawione badanie wskazuje, eprogramowe oparcie edukacji oczynniki motywacyjne jest bardziej skuteczne wbudowaniu pozytywnych
zachowa iwynikw leczenia pacjentw.

Sowa kluczowe cukrzyca, edukacja terapeutyczna, terapeutyczna wiedza, terapeutyczna motywacja.

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 diabetes 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 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 diabetes mellitus, therapeutic education, therapeutic science, therapeutic motivation.

BACKGROUND IDEAS AND ASSUMPTIONS In Poland, the tradition of psychologically-minded edu-

Therapeutic education of patients with incurable, chron-
ic disease is not asimple transfer of the information. This
complicated process exerts aformative influence on all
parties involved patients, educators and people from
outside society.
cation in chronic disease has along history. It began almost
100 years ago with the philosophical concept of the spir-
itual force of motivation called byE. Twardowski, aPol-
ish philosopher of this time, FIAT. It means Ishould
do the meaningful, rational use of the life potential (1).
In Poland, the works of Victor E. Frankl (2), an Austrian

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psychiatrist and philosopher, creator of many important
therapeutic ideas and reflections related tohuman spiritual
needs and drives and tothe role of creative personality,
were also well accepted and developed. According tothis
personalistic approach human existence is based on the
implementation of positive values, which creates asense
of meaningful life and subsequently an internal force toac-
tivate the motivation.
One may list several such values (3, 4, 5):
a. actions according topersonal convictions freedom
toact,
b. self understanding and self-realization freedom of
choice,
c. satisfaction from the results of actions successes,
d. life quality fulfilling the accepted standards,
e. positive basic life goals mostly areas related toeduca-
tion, profession and social position,
f. positive social relations, good family development, so-
cial recognition,
g. voluntary engagement in actions and enrichment of life
byan altruistic attitude,
h. positive, personal experience in successful coping with
stress.
Diabetes mellitus endangers all existential values.
The preservation or reconstruction of existential values
builds up the motivation of adiabetic person. This attitude,
according toFrankl could be named logotherapeutics. In
this particular term the word logos means rather under-
standing, rationalization or education. Many Polish
psychologists (Florian Znaniecki, Maria Ossowska, Z.J.
Lipowski,) have developed the idea of the logotherapeu-
tics of Frankl in aworking 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 influence of these humanistic and
personalistic concept (3, 4, 5). It simply means that educa-
tion should be aimed at re-shaping the personality of the pa-
tient, at enforcing the psychosocial mechanisms of positive
motivation and positive change in the behaviour. Adiabetic
patient should at first transform his illness, his pains into
new values and into new therapeutic behaviour (6, 7).
According tothese assumptions one could define dia-
betes mellitus education by6 obligations or tasks it has
tomaterialize:
a. formulate educational and psychosocial diagnosis ena-
bling 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, acreative attitude toward potential
new life values;
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c. increase the psycho-social resistance tostress 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 tofulfil all the technical needs for
proper control of his diabetes mellitus;
f. and finally, assure the patient, that he is able tofulfil
his social role, toobtain agood quality of individual
life, asufficient level of autonomy, in order toeliminate
external and internal discrimination (8, 9, 10).
It is felt, thai this way of educating adiabetic patient
may more effectively and for alonger time help tocom-
pensate both the psychosocial and biological disturbances
of the so-called diabetic existence.
STUDY AIMS
Already in our earlier observations wediscovered, that
asignificant gap existed in our practice between knowl-
edge and action of educated patients. After the formal,
structured education programme, as used in our Center
at the beginning of its educational practice, wewere able
toincrease significantly the level of knowledge but not
the level of motivation. The level of metabolic control re-
mained very often not changed, when such educational
intervention was delivered.
Keeping in mind the ideas of personalistic, psycho-
logical mechanisms in shaping personality and behaviour
through education as described above and, in addition, this
particular experience, wehave designed aprogramme ori-
ented at stimulating primarily motivation. This programme
became an object of observation and of experimental
evaluation.
This weattempted toachieve bycomparing the out-
comes and the results of 2 programmes implemented in
the same organizational setting:
1. the programme more oriented toward increasing knowl-
edge PK
2. the programme more oriented toward increasing moti-
vation PM
METHODS
Programmes. The general characteristics of the two
programmes under comparison could be described as
below:
Teaching. Both programmes were taught according
toabasic, written syllabus (8). Practical teaching was di-
vided into units. Every unit of education was based on
aseries of questions and answers. This was the standariza-
tion of teaching permitting reproducibility.
The programmes were taught at the diabetic school.
Itwas organized as follows:
21

5 consecutive days/week, 2x2 hours daily;
Short lectures, group discussions programmed and free,
metaplan method;
Practical exercises;
Entrance and final evaluation byinterview and multiple choice
questions test.
During the programme glucose determination strips, manual
enzymatic method, HbA1 /microcolumns/ were also performed.
Methods used for the knowledge-oriented programme
were: 30 min lectures programmed 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
inter-patient discussions with the teacher as an animator;
clinical and psychological analyses defining the psycho-
social motivation.
I. Knowledge oriented programme
1. Metabolism,
What is diabetes?
Diagnostic criteria.
Control criteria
2. Materials for self-control.
Methods, results, documentation, interpretation.
3. Emergency situations: prevention, hyperglycemia and ketonuria
testing.
4. Components of adiabetic diet, daily allowances, planning the diet,
food exchanges, diet composition, preparation of meals.
5. Economics of the diet, organization of the kitchen,
6. Insulin actions, preparations, self-control, principles of increasing
and decreasing the dose, algorhytms of insulin application, injection.
7. Hypoglycemia.
Mechanism, risk of hypoglycemia, self-diagnosis, intervention
glucagon injection.
8. Chronic complications. Organs involved, limitation of family life,
contraindicated professions.
9. Social regulations for diabetics.
10. No family involvement, no telephone contact.
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The teaching team was composed of physicians, nurses,
apsychologist, and dietician. No member of the team had
aformal licence toteach but underwent training bypeda-
gogues and psychologists.
In the motivation-oriented programme the educators had
the task of incorporating 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 possibilities, anew sense of life
not aworse one life without diabetes mellitus. The educa-
tors were instructed tobuild the positive alliance between
the patient, the treatment team and the social group, toshow
the perspective and potential of an autonomic style of life,
ways toincrease the quality of life and ways of controlling
late complications. Also during this programme two ex-
periments in self-control were organized the influence of
anutritional error on blood glucose (200g of sweet cake)
and of physical exercise on blood pressure (bicycle ergom-
eter). In the motivation-oriented programme close family
members and friends suggested bythe patient took part.
II. Motivalion oriented programme
1. Glucose, glycemia.
What is diabetes?
Symptoms, therapeutic aproach, goals, means.
2. Compensation of diabetes mellitus and solving life problems
with therapy. Ways tostay in good condition
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. Prevention of hyperglycemia and ketonuria.
5. Enjoying food, the diabetic kitchen, what is good in adiabetic
diet also for the non-diabetic, measured and non-measured diet.
6. History of insulin, insulin actions.
Choice of preparations and dose, what is agood dose, injection.
7. Prevention of hypoglycemia too much insulin; intervention
sweets, glucose, glucagon, family support.
Social relations. chronic complications.
8. Presentation of other patients experience, free discussion,
what is most helpful in prevention.
9. Life perspective, professional carriers with examples,
establishment of family, hobbies, altruistic attitude. Partnership
with the treating team.
Prevention of complications.
10. Family participation, telephone contact during programme.
 Patients. The criteria for including or rejecting the candi- bymultiple-choice tests composed of 60 questions: 30 for
dates with type 1 diabetes mellitus for the study were as follows: testing knowledge and 30 for measuring motivation. Each
correct answer was given 2 points and the maximum points
Inclusion Non-inclusion
possible was 120.
The results of testing before and after completing the pro-
Age: 2228 years Any concomittant disease; grammes under comparison are presented in tables 1,2,3.
Duration of diabetes mellitus: Predicted poor compliance; Bycomparing the level of knowledge, before and af-
5 years or less Less than secondary level of ter the knowledge-oriented programme, it was possible
No symptoms of chronic general education. tocalculate, that the average index of change in knowledge
complications besides was22. It means, that after the programme the number of
background retinopathy; patients with positive multiple choice tests went up from
Sufficient family support; 2 to24. At the same time the index of change in the moti-
insulin: 2 or more injections. vation calculated in the same manner went up only by2,
that is from 6 to8.
The number of patients under study was: 30 females and As described in table 3, the other group composed of
23 males 53 cases. 25 participants with type 1diabetes mellitus underwent
The study was entered by59 patients 53 finished the in asimilar diabetic school the motivation-oriented pro-
whole observation plan. gramme. After this type of education the index of change
Among them 28 participants were randomized tothe in the knowledge, calculated in the same way as de-
knowledge-oriented programme and 25 tothe motivation- scribed above, went from 4 up to19, an increase of 15.
building education. The index of change for motivation went up at the same
Statistical significance was evaluated with Student`s time from 5 to23, an increase of 18. All these changes
t test for paired data. were statistically significant at the p level of 0,05.
The motivation-oriented programme was in our Diabet-
RESULTS AND DISCUSSION ic School more effective in influencing both the motivation
and the knowledge. It was also possible toshow astatisti-
One week after completing the programmes changes cally significant correlation between the knowledge and
in knowledge and in motivation levels were assessed the motivation after this programme.

Tab. 1. Assessment of the knowledge oriented educational programme influence (as described in text) on the therapeutic
knowledge and therapeutic motivation of patients with diabetes mellitus type 1.

Results of testing Testing the therapeutic knowledge Testing the therapeutic motivation
(questionnaire) befor-school-after befor-school-after

Number of points 2 24 68

Index of change 24 2 = 22 82=2

Tab. 2. Assessment of the motivationoriented educational programme influence (as described in text) on the therapeutic knowledge
and therapeutic motivation of patients with diabetes mellitus type 1.

Results of testing Testing the therapeutic knowledge Testing the therapeutic motivation
(questionnaire) befor-school-after befor-school-after

Number of points 4 19 5 23

Index of change 19 4 = 15 23 5 = 18

Tab. 3. Correlation between therapeutic knowledge and motivation levels of patients with diabetes mellitus type 1 after education
with knowledge oriented and motivation oriented programmes (details/see text).

Correlation coefficient after knowledge oriented programme Correlation coefficient after motivation oriented programme
0,18 0,62
not significant significant
p > 0,05 p < 0,05

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 The observation suggests, that the motivation-oriented
programme should be 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 topositively influence
motivation at the same time and respectively the person-
ality of the patients and their behaviour (6). This points
tothe so called Hawthorne effect resulting from more
attention being paid bythe patients toknowledge about
the disease, due toparticipation in the study. In amore
precisely designed study however, the structured education
programmes influenced clearly the metabolic control for
several months (7,8).
It is obvious, that the educational programmes could
be more or less effective in reaching the goals for many
reasons. Constructing aprogramme comes after consider-
ing such important factors as recruitment of patients for
aDiabetic School and streaming them according tolevel
of general education and cultural status or type of personal-
ity (9,10, 11).
In our hands, the motivation-oriented programme real-
ized with apsychological approach aimed at developing
internal motivation was clearly more effective in compari-
son with the knowledge-oriented programme alone.
CONCLUSIONS
1. Teaching according to the knowledge-oriented pro-
gramme increased mostly knowledge. It did not corre-
late with an increase in motivation, meaning the readi-
ness toput knowledge into practice.
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2. Educating the type 1 diabetes patients according tothe
motivation-oriented programme was significantly more
effective in increasing both knowledge and motivation.
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