Diabetic patients from two clinics were studied to determine relationships

between knowledge, management, and control of the disease. No relation

was found between management and control. A number of questions
are raised for further study.

A STUDY OF DIABETIC PATIENTS AT HOME

Julia D. Watkins, R.N., M.P.H.; T. Franklin Williams, M.D., F.A.P.H.A.; Dan A. Martin, M.D.,
F.A.P.H.A.; Michael D. Hogan, M.S., M.P.H.; and E. Anderson, M.P.H.*

Introduction affected in turn by a patient's knowledge

ANY guides and procedures have
been written on the premise that
persons with diabetes mellitus can con-
trol their disease by carrying out the
prescribed regimen. Although we now
think that factors other than "what they
know" and "what they do" may be im-
portant in controlling the disease, we
still think that it is important for the
patient to apply all available knowledge
in the management of his disease. Only
a few studies of the relationships among
knowledge, management, and control
have been reported. To the investigator's
knowledge, no published study has been
carried out previously in the homes of
diabetics to observe their skills and
learn of their management.
The purpose of this study was to find
out what a specific population of clinic
patients actually does about diabetes and
to study the relationship among what
these people know, what they do, and
their state of diabetic control. Figure 1
of the previous article' shows the as-
sumption that good or poor management
of the disease can affect day-to-day con-
trol and that this management will be
*With the assistance of V. Coyle; B. A.
Cook, B.S.N.; I. K. Lyle, M.S.W.; J. T.
McLamb, B.S.
of his disease.
Sample
The sample of patients studied previ-
ously in Metabolic Clinics No. 1 and
No. 21 was reevaluated according to
the same criteria for inclusion in that
study. In one clinic all other patients
who met the criteria and who attended
clinic within a four-month period were
added to the sample. Because an undue
proportion of these patients was in poor
or very poor control, five others meeting
the same criteria and judged to be in
good or fair control were later added.
Of 75 patients with whom contact was
attempted, 60 were visited at home.
Methodology
Interviews with and observations of
the patients at home were carried out
by two public health nurses and a med-
ical student. Over-all knowledge of dia-
betes and actual home management
were assessed by structured protocols.
Patients were asked to demonstrate
their daily routines of insulin adminis-
tration and urine testing.
Two physicians estimated the level of
day-to-day control of the disease accord-

4S2 VOL. 57. NO. 3. A.J.P.H.


ing to information from the medical
record and the home interview. Dia-
betic control was rated as "good,"
"fair," "poor," and "very poor" fol-
lowing the criteria in Appendix B of
the previous article.'
Definitions and Scoring
"Home management" was defined as
the way in which a patient carries
out regimens related to (1) insulin ad-
ministration, (2) insulin dosage, (3)
urine testing, (4) meals and spacing,
and (5) foot care. Henceforth it will
be called "management." Definitions,
scoring, and "acceptable" performance
related to these five areas are shown in
Appendix A.
Although physical activity was recog-
nized as a very important area of man-
agement, the method used to obtain in-
formation proved to be inadequate.
The knowledge test consisted of 18
questions about various aspects of dia-
betes. Scoring was based on the number
of correct answers.
Results
The study sample of 60 patients had
the following characteristics:
(1) The average age of those seen was 55
years, ranging from 16 to 81.
(2) Fifty-three per cent had less than a
seventh grade education and only 15 per
cent finished high school.
(3) On the average, the patients had had the
disease for 14 years (range 2 to 42).
(4) Twenty-two per cent of patients were
classified as being in "good or fair" dia-
betic control; 43 per cent were in "poor"
control, and 35 per cent in "very poor"
control. The small number in "good and
fair" control is not too different from
the findings in the other populations which
have been studied.'
Scores for the patients in the five
areas of management may be found in
Appendix B.
A. Insulin Administration-Although
MARCH, 1967
DIABETIC PATIENTS AT HOME
no patient was without a needle and
syringe, 33 per cent had "unacceptable"
equipment and 77 per cent sterilized it
in an "unaccepifable" manner. Eighteen
per cent did not sterilize it at all. Com-
bining the two, 80 per cent performed
"unacceptably" in insulin administra-
tion. Although no criteria were set up
to determine instances of infection, the
interviewers thought that they were rare.
B. Insulin Dosage-Thirty-one (over
half) of the 60 patients made an error
in dosage. Some patients thought they
were supposed to take a dose different
from that prescribed; some simply
looked at the wrong calibration on the
syringe. Some mixed long-acting and
short-acting insulin incorrectly; some
even attempted to measure amounts of
10-15 units more than was possible to
measure in the syringe. Two of the 31
patients were taking a kind of insulin
different from that prescribed. Finally,
nine made more than one of these
errors. The magnitude of error in in-
sulin dosage ranged from 5 per cent to
100 per cent with a third of all patients
making an error of 15 per cent or more.
Most disturbing to the investigators
were the errors due to the use of the so-
called "convertible" (U40-U80) syringe,
where the patient may measure U40 in-
sulin on the U80 side of the syringe or
vice versa, thus making possible an
error of 100 per cent. Of 34 patients
using the U40-U80 syringe, seven (21
per cent) made this kind of error, an
error which could be prevented by re-
moving this syringe from the market.
C. Urine Testing-A third of the pa-
tients "tested urine correctly" according
to the definition, regardless of how they
used the results. Thirty-two per cent
either tested less than once a day or,
however they tested it, they and/or their
physicians did not use the results, so
that the test was of no value. In only
23 per cent of cases were the results
of the test helpful in regulating diet and
insulin; 45 per cent actually tested and
453
Table 1-Comparison of over-all knowl-
edge and over-all management
Unacceptable
management in-
Knowledge 0-3 areas 4-5 areas
Good (10-18
right answers) 20 6 26
Poor (0-9
right answers) 12 22
Total 32 28
Chi2=8.55, significant at the 1% level (1 d.f.)
Correlation coefficient of knowledge and management=
0.44, significant at the 1% level.
used the results in a way which was
likely to be detrimental to their diabetic
control.
D. Meals and Spacing-An attempt
was made to estimate food intake
through the use of the 24-hour recall of
food eaten. If a patient were following
a prescribed diabetic diet regimen, one
day should be typical of his day-to-day
pattern. However, an analysis of the
caloric intake and of the weight record
indicated that this one day's recall could
not be representative of the subject's
daily diet. In order to obtain a simpler
measure of the degree to which a pa-
tient's diet might affect control, regu-
larity and spacing of meals were con-
sidered without regard to the type or
quantity of food (see Appendix A for
further explanation). Only 16 of the 60
patients, about 25 per cent, were judged
to have "meals" and "reasonable spac-
Table 2-Comparison of knowledge and performance of urine tests
Knowledge acceptable
Good (2-3 right answers) 11
Poor (0-1 right answers) 3 13
Total 14 (23%)
Chi2 = 10.40, significant at the 1% level (2 d.f.)
454
ing" of meals, which would be "ac-
ceptable" for a diabetic patient taking
long-acting insulin.
E. Foot Care-Twenty-nine patients
Total (about half) were found to be giving
themselves "good" foot care, as defined
in this study.
F. Over-all Management-Only one
patient demonstrated practice which was
34 acceptable in all five areas of manage-
ment. Seven more fell short in only one
60 area, while 28 (approximately half)
showed "unacceptable" management in
four or five areas studied. It is a dis-
couraging picture.
G. Management and Knowledge-The
relationship between over-all manage-
ment and knowledge was investigated.
The knowledge protocol tested general
knowledge of the disease with emphasis
on "knowing why." In this study we
cannot determine the relationship be-
tween "knowing how" and "doing" al-
though we assume the patients who man-
aged well knew how. However, we did
find that those who know in general
about diabetes also manage better than
those who do not (Table 1). The cor-
relation coefficient of over-all knowledge
with over-all management was found to
be statistically significant at the 1 per
cent level. The relationship also held
true for certain specific areas-for
example, those who knew something
about the meaning of sugar in the urine
made better scores on over-all use of
urine tests (Table 2).
H. Management and Duration-Does
Performance-
not useful misleading Total
6 8 25
19 35
19 (32°%) 27 (45%) 60 (100%)
VOL. 57, NO. 3. A.J.P.H.
 DIABETIC PATIENTS AT HOME

Figure 1-Per cent of patients making
errors in insulin dosage according to
years duration of their disease
& 100-
0
ax
._.5 80-
0 1-5 6-10 1 I-IS
60
bs 40
-3c 17
7 "very poor" control might not have bet-
20-
a.
o based on a cross-sectional study. We
0 1-5 6-10 11-15
Duration of Diabetes
the length of time a person has had dia-
betes affect either what he knows or
what he does about it? In this study,
duration did not appear to be related
to knowledge but the longer a patient
had had the disease, the more errors
he made in insulin dosage (Figure 1).
It was found that duration and errors
were significantly correlated at the 5 per
cent level. Only 33 per cent of those
having diabetes ten years or less made
errors, while among those having it
longer almost 64 per cent made errors.
No significant relationship was demon-
strated between the present age of the
patient and errors, nor between dura-
tion of the disease and the other areas
of management.
11
I. Management and Control-There
was no significant correlation between
16-20 21-42 any of the individual management areas
which might affect control and the con-
trol scores, nor between over-all man-
agement and control (Table 3). This
does not say that those having "poor" or
ter control with better management. We
must bear in mind that these data are
might hope to see the 44 patients in
16-20 21-42 poor control who are managing inade-
- Years
quately in one or more areas (93.6 per
cent of all those in poor control) move
to a better state of control if they man-
aged better. However there is an indi-
cation that management may not be
the over-riding factor in control, as can
be seen by those 12 patients in "good
or fair" control (92.3 per cent of all
those in good or fair control) who are
managing inadequately. Other factors
affecting control are discussed further in
the accompanying article.'
No relationship was demonstrated
between the duration of the disease and
the control state.
J. Knowledge-Similar to the find-
ings in other studies,' those patients in

Table 3-Relation of over-all nianagement to control*

Number of patients who
performed inadequately in-
Control 0 areas 1 area 2 or 3 areas Total

Good and fair 1 3 9 13

Poor and very poor 3 14 30 47

Total 4 17 39 60
* Over-all management in this table includes areas of performance which might
be expected to affect control of diabetes directly-urine tests, insulin dosage and diet.

MARCH, 1967 455

poorer control actually knew more about
diabetes than those in better control
(Table 4).
Discussion
Although we cannot generalize from
this sample, it is obvious that these
clinic patients, who on the average have
had their disease for 14 years, need
more help than they are getting in all
areas of management. It is particularly
evident that the longer they have had
diabetes, the more help they need in
getting the right dose of insulin. What
sort of help is needed?
It seems logical to approach this by
looking for the reasons behind poor
over-all management, and progressive de-
terioration in management over the
years-particularly in the matter of in-
sulin dosage. The following possible
reasons are certainly familiar: (1) in-
creasingly poor eyesight, (2) misunder-
standing of the prescribed treatment,
(3) lack of actual knowledge as to why
the treatment recommended is important
or how to carry it out, and (4) lack of
motivation.
Great emphasis is put on teaching the
newly-diagnosed diabetic, both in the
hospital and at home, but more may
need to be done (1) in reassessing and
alleviating poor eyesight and (2) in re-
assessing both knowledge and manage-
ment from time to time, following a
specific plan.
One should be cautious about follow-
ing the reassessment of knowledge and
management with hasty corrections of
errors. In at least one instance it was
found that both the patient and the doc-
tor thought she was taking a certain
amount of insulin which was the written
order when she was actually taking only
half of the specified dose, due to the
U40-U80 syringe; and yet she had been
taking this amount for some time and
was rated as being in fair control. Think
of the insulin shock she might have
456
encountered had she been told to double
her dose.
In making reassessments for the pur-
pose of individual care, and in institut-
ing further research, the following ques-
tions are pertinent:
(1) What are the most effective ways
of eliminating misinterpretations and
misunderstandings?
(2) How much do those who manage
poorly really know about how to man-
age? For instance, a patient may know
how to measure a particular dose of in-
sulin on a particular syringe, but does
he understand the meaning of the cali-
brations on the syringe and of the dif-
ferent strengths of insulin so that he
can change the dose accurately when
advised to do so?
(3) If patients have the resources
and the necessary knowledge but lack
motivation, what are the reasons? Do
they try, then get discouraged because
trying seems to make no difference?
This might be true of the so-called
"brittle" diabetics. Do they find that
errors do not affect them seriously, so
they become careless? This might be
true of those who have the milder forms
of the disease.
(4) When is re-instruction in the
traditional sense and when is less formal,
but professionally appropriate, suppor-
tive attention effective in stimulating pa-
tients to manage better? There is some
Table 4-Relation of knowledge to con-
trol
Right answers
on knowledge-
Control 0-8 9-18 Total
Good (score 0-8) 17 12 29
Poor (score
9 and above) 9 22 31
Total 26 34 60
Chi2=4.13, significant at the 5% level (1 d.f.)
VOL. 57. NO. 3. A.J.P.H.
 DIABETIC PATIENTS AT HOME

evidence from previous and current
studies which indicates that perform-
ance improves with supportive atten-
tion.23 Valuable information might be
obtained by studying the effectiveness
of close and continuous support given
by public health nurses over a period of
time.
Only when we have some answers to
these questions can we know what kind
of nursing intervention may improve
management, and whether, in fact, this
will help in the control of the disease.
Summary
Sixty diabetic patients from two
metabolic clinics were studied to de-
termine the relationships among knowl-
edge, management, and control of the
disease. Patients were rated on man-
agement of insulin, urine tests, diet,
foot care, and disease control. Forty-
eight had "unacceptable" practice in
administering insulin. Thirty-one pa-
tients made errors in insulin dosage; 27
used urine tests in a way which would
probably affect control adversely; 44
had meals and spacing of meals unac-
ceptable for diabetics; 31 carried out
poor foot care. Those who knew more
about diabetes managed better. The
longer they had the disease, the more
insulin errors they made. No relation-
ship was found between management
and control, but those in poorer con-
trol knew more about the disease. The
following questions are raised for fur-
ther study: (1) What are the most ef-
fective ways of eliminating misinterpre-
tations or misunderstandings? (2) How
much do diabetics really know about
how to carry out their regimens? (3)
If patients have the necessary resources
and knowledge but lack motivation,
what are the reasons? (4) When should
re-instruction and when should support
be used to stimulate patients to manage
better ?
REFERENCES
1. Williams, T. F., et al. The Clinical Picture of Dia-
betic Control, Studied in Four Settings. A.J.P.H.
57,3:441 (Mar.), 1967.
2. Bowen, R.; Rich, R.; and Schlotfeldt, R. Effects
of Organized Instruction for Patients with a Diag-
nosis of Diabetes Mellitus. Nursing Res. 10:151
(Summer), 1961.
3. Watkins, J. D., and Williams, T. F. Unpublished
observations.

The authors are affiliated with the University of North Carolina Schools of
Medicine and- Public Health, Chapel Hill.
This paper was presented before the Public Health Nursing Section of the
American Public Health Association at the Ninety-Third Annual Meeting in
Chicago, Ill., October 21, 1965. It was revised and resubmitted for publication
in January, 1966.
The study was supported in part by PHS Grant No. W-00074.

See Appendix A on pages 458-459

MARCH. 1967 457

 APPENDIX A-SCORING AND DEFINITIONS

Score
Area of Accept- Unaccept-
management able able Explanations and Definitions
Insulin 0 =acceptable equipment and sterilization
Adminis- 1 = acceptable equipment, unacceptable sterilization
tration 0 1-3 2 = unacceptable equipment, acceptable sterilization
3 = unacceptable equipment, unacceptable sterilization
Acceptable equipment: One syringe in good condition
(good=without heavy sediment and with legible
calibrations); one sharp needle; one pan of adequate
size for boiling or, if soaked in alcohol, one covered
container; alcohol; cotton.
Acceptable sterilization: If boiled-boiled five minutes;
syringe and needle covered with water; barrel and
plunger separated; syringe and needle removed and
assembled without contamination.
If soaked in alcohol: Syringe and needle kept in
alcohol (unassembled) in a covered container; con-
tainer boiled at least once a week; alcohol changed
at least once a week; syringe and needle removed
and assembled without contamination.
Insulin 0=error of less than 15%
dosage 0 1 1 =error of 15% or more
Percentage error = the difference between number of
units measured by patient and number of units pre-
scribed by physician.
Urine 0 = collects at least 1/day, tests correctly, regulates
testing 0-2 3-6 insulin accordingly, and keeps record for M.D.
1= collects at least 1/day, tests correctly, keeps record
for M.D., but does not regulate insulin himself
2= collects at least 1/day, tests correctly, regulates
insulin accordingly, but does not keep record for
M.D.
3=collects and tests correctly 1/day or more, but does
not keep record nor regulate insulin
4=collects, tests correctly less than 1/day, or collects,
tests incorrectly but does not keep record nor
regulate insulin
5= collects and/or tests incorrectly, keeps record for
M.D.
6 = collects and/or tests incorrectly and regulates in-
sulin himself
6=collects and/or tests incorrectly, regulates insulin,
and keeps record for M.D.
0-2 = helpful
3-4=useless, inadequate
5-6=harmful, misleading
Tests correctly=tests second voided specimen collected
within one hour of first voiding; tests/reads results
according to directions for method used.
Meals A meal contains at least one food from the meat or
and milk group or dried peas or beans plus at least one
spacing 0-1 2-7 other food, and is eaten as part of the breakfast,
dinner, supper sequence.

458 VOL. 57, NO. 3, A.J.P.H.

 DIABETIC PATIENTS AT HOME

APPENDIX A-(Continued)
Score
Area of Accept- Unaccept-
management able able Explanations and Definitions
Meals Reasonable spacing means four to six hours between
and meals, or longer if a between-meal feeding was eaten.
spacing 0-1 2-7 One point for omission of each meal.
One point for unreasonable spacing.
One point for omission of protein content in bedtime
feeding.
One additional point for omission of entire bedtime
feeding.
A score of more than one is considered unacceptable
because all patients in this study were on long-acting
insulin, a bedtime feeding with protein was pre-
scribed, and the definition of a meal is minimal.
Foot One point for unsatisfactory care in each of five areas.
care 0-1 2-5 Areas: (a) bathing, (b) cutting toenails, (e) wearing
garters, (d) care and use of socks, (e) care and use
of shoes.
0-1=satisfactory care in>four areas
2-5=satisfactory care in<four areas
Satisfactory care based on judgment of observer.

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MARCH, 1967 459