Factors related to nursing diagnosis, ineffective self-health management, among diabetics

Abstracts

OBJETIVO: Investigar los factores relacionados al diagnóstico de enfermería autocontrol ineficaz de la salud en usuarios, del servicio de atención básica a la salud, con Diabetes mellitus tipo 2, tratados con antidiabéticos orales (AO), según el sexo. MÉTODOS: Estudio de análisis secundario de un banco de datos de investigación realizada, entre enero y julio del 2009, en los domicilios de 377 usuarios de 12 centros de salud de la familia de Fortaleza-CE. Para determinar la presencia del diagnóstico de enfermería fue realizada una analogía entre las preguntas del test Medida de Adhesión al Tratamiento y cuatro de las cinco características definidoras del diagnóstico investigado. RESULTADOS: los hombres tenían un sentimiento de impotencia mayor (30,4%) que el de las mujeres (18,4%) respecto a la toma de los AO (p=0,034). Las mujeres consiguieron percibir mejor los beneficios de la toma correcta de los AO en el control de la Diabetes (p=0,002). CONCLUSIÓN: Los factores de carácter socioeconómico importantes, en el control de la enfermedad, como la demanda excesiva y déficit de apoyo social fueron predominantes y significativos entre los hombres.

Cooperación del paciente; Diabetes mellitus tipo 2; Agentes hipoglucémicos; Diagnóstico de enfermería

ORIGINAL ARTICLE

Factors related to nursing diagnosis, ineffective self-health management, among diabetics^*

Fatores relacionados ao diagnóstico de enfermagem autocontrole ineficaz da saúde entre diabéticos

Factores relacionados al diagnóstico de enfermería autocontrol ineficaz de la salud entre diabéticos

Roberto Wagner Júnior Freire de Freitas^I; Márcio Flávio Moura de Araújo^II; Niciane Bandeira Pessoa Marinho^III; Marta Maria Coelho Damasceno^IV; Joselany Áfio Caetano^IV; Marli Teresinha Gimeniz Galvão^IV

^IMaster in Nursing. Assistant Professor of Universidade Federal do Piauí - UFPI - Floriano (PI), Brazil

^IIMaster in Nursing. Graduate Student (PhD) of the Nursing Post-Graduation Program, Universidade Federal do Ceará - UFC - Fortaleza (CE), Brazil. Assistant Professor I of Universidade Federal do Maranhão - UFMA - Imperatriz - (MA), Brazil

^IIIMaster in Nursing. Specialist in diabetes and hypertension

^IVPhD in Nursing. Professor of the Nursing Post-Graduation Program, Universidade Federal do Ceará - UFC - Fortaleza (CE), Brazil

Correspoding Author

ABSTRACT

OBJECTIVE: To investigate the related factors of the nursing diagnosis, ineffective self-health management, in clients with Type 2 diabetes mellitus treated with oral antidiabetic (AO), receiving primary health care services, according to gender.

METHODS: A secondary analysis of database research conducted between January and July 2009, in the homes of 377 users of 12 family health centers in Fortaleza-CE. To determine the presence of the nursing diagnosis, an analogy was made between the test questions Measure Treatment Adherence and four of the five defining characteristics of the diagnostic search.

RESULTS: Men had a greater sense of powerlessness (30.4%) than women (18.4%) about the need for taking the AO (p = 0.034). Women were better able to understand the benefits of taking AO to ensure proper control of their diabetes (p = 0.002).

CONCLUSION: Socioeconomic factors important in controlling the disease, such as excessive demand and social support deficit, were prevalent and significant among men.

Keywords: Patient compliance; Diabetes mellitus type 2; Hypoglycemic agents; Nursing diagnosis

RESUMO

OBJETIVO: Investigar os fatores relacionados ao diagnóstico de enfermagem autocontrole ineficaz da saúde em usuários, de serviço de atenção básica à saúde, com Diabetes mellitus tipo 2, tratados com antidiabéticos orais (AO), segundo o sexo.

MÉTODOS: Estudo de análise secundária de um banco de dados de pesquisa realizada, entre janeiro e julho de 2009, nos domicílios de 377 usuários de 12 centros de saúde da família de Fortaleza-CE. Para determinar a presença do diagnóstico de enfermagem foi realizada uma analogia entre as questões do teste Medida de Adesão ao Tratamento e quatro das cinco características definidoras do diagnóstico pesquisado.

RESULTADOS: Os homens tinham um sentimento de impotência maior (30,4%) que as mulheres (18,4%) acerca da tomada dos AO (p=0,034). As mulheres conseguiram perceber melhor os benefícios da tomada correta dos AO no controle do Diabetes (p=0,002).

CONCLUSÃO: Fatores de caráter socioeconômico importantes no controle da doença como a demanda excessiva e deficit de apoio social foram predominantes e significativos entre os homens.

Descritores: Cooperação do paciente; Diabetes mellitus tipo 2; Hipoglicêmicos; Diagnóstico de enfermagem

RESUMEN

OBJETIVO: Investigar los factores relacionados al diagnóstico de enfermería autocontrol ineficaz de la salud en usuarios, del servicio de atención básica a la salud, con Diabetes mellitus tipo 2, tratados con antidiabéticos orales (AO), según el sexo.

MÉTODOS: Estudio de análisis secundario de un banco de datos de investigación realizada, entre enero y julio del 2009, en los domicilios de 377 usuarios de 12 centros de salud de la familia de Fortaleza-CE. Para determinar la presencia del diagnóstico de enfermería fue realizada una analogía entre las preguntas del test Medida de Adhesión al Tratamiento y cuatro de las cinco características definidoras del diagnóstico investigado.

RESULTADOS: los hombres tenían un sentimiento de impotencia mayor (30,4%) que el de las mujeres (18,4%) respecto a la toma de los AO (p=0,034). Las mujeres consiguieron percibir mejor los beneficios de la toma correcta de los AO en el control de la Diabetes (p=0,002).

CONSLUSIÓN: Los factores de carácter socioeconómico importantes, en el control de la enfermedad, como la demanda excesiva y déficit de apoyo social fueron predominantes y significativos entre los hombres.

Descriptores: Cooperación del paciente; Diabetes mellitus tipo 2; Agentes hipoglucémicos; Diagnóstico de enfermería

INTRODUCTION

Currently, Diabetes mellitus type 2 (DM 2) is considered one of the main public health problems in Latin America, both due to the number of people affected by impairments and premature mortality, and the costs involved in the management and treatment of its complications⁽¹⁾. Nowadays, about 78% of diabetic individuals in Latin America present inadequate glycaemic control, characterized by fasting venous glycaemia of >110mg/dL⁽²⁾.

Another current concern is the growth of mortality due to DM among men. According to data from Brazil's Department of Health, between 1980-2005, it increased from 9.6% to 19.5%, with a variation of 103.6%, the highest among 34 registered causes of death. However, only seven Brazilian capitals present a higher DM diagnosis among men⁽³⁾. A previous research indicates prevalence of 5.7% and 3.5% for females and males, respectively⁽⁴⁾.

Considering such data, the following conclusion is drawn: if a larger number of men who have DM die when compared to women, even though men are the minority, it is likely that they present a worse metabolic control. This is supported by the National Policy for Men's Health, from Brazil's Department of Health, which affirms that men's non-adherence to integral health activities leads to the increase of diseases and mortality in this group⁽³⁾.

Considering such context, the amount of drugs used to try and establish normoglycaemia for these subjects is enormous. However, this is annulled upon the non-adherence presented by these patients in relation to the drugs⁽⁵⁾. Meta-analyses show that the adherence to the medical treatment among individuals with DM 2 is of 67.5%, considered low, when compared to the adherence to other treatments⁽⁶⁾.

One of the ways nurses can provide quality and organized healthcare to a DM 2 patient is by using the nursing healthcare systematization (NHS)⁽⁷⁾. One of its elements is the nursing diagnosis, defined by the North American Nursing Diagnosis Association (NANDA), as a clinical judgement of individual, families and the community's responses to the vital processes, and current or potential health problems. Therefore, it is possible to affirm that nurses diagnose human responses/experiences upon the health-illness process⁽⁸⁾.

Within the problematic regarding medical treatment adherence, the nursing diagnosis that is best suited for patients who do not effectively adhere to medical treatments is the Ineffective Health Self-Control, defined as dissatisfactory regulation and integration of a therapeutic regimen standard to daily life, for diseases and sequelae treatment, in order to achieve health specific goals⁽⁸⁾.

Considering the DM 2 scenario, an aggressive glycaemic control, besides reducing diabetics' vascular complications along time, is responsible for decreasing in costs. This emerges when patients adhere to the use of OA and/or insulin. Nevertheless, it is important to highlight that demographic and self-medication factors, besides patients knowledge of diabetes are involved in the adherence phenomenon⁽⁶⁾.

Identifying human responses with regard to medication intake should be a continuous process, especially among DM 2 patients assisted at primary healthcare centres, so that nurses can discover which factors are involved in the non-adherence to the medical treatment, and consequently interfere to stop micro and macro-vascular complications.

It is important that studies associating nursing diagnoses and certain characteristics of the studied group are performed. This belief is justified by the benefits resulting from these researches, such as acquiring knowledge on risk factors and factors related to the problem in question⁽⁹⁾. Besides, there is a lack of publications that compare gender and DM⁽⁴⁾. Therefore, the objective of the present study is to investigate factors related to the nursing diagnosis "Ineffective Health Self-Control" in primary healthcare centre users with Diabetes mellitus type 2, treated with oral anti-diabetics, according to gender.

METHODS

The present is a supplementary study, which was developed based on the secondary analysis of the research "Oral anti-diabetic therapy adherence among users of the primary healthcare network of Fortaleza-Ceará" database. The mentioned research took place between January and July 2009, in 12 family healthcare centres, located in Fortaleza. The metropolis, which is in the Northeast region of Brazil, is divided in six geo-economic areas, and had 173,000 diabetic individuals registered in its primary healthcare network, in 2008. Therefore, in order to obtain representative data on the subject in that city, 12 DM Healthcare Centres were chosen, according to convenience, two in each of the six city areas. The selected healthcare units are located in different neighbourhoods, with different infra-structures, services offered, and socioeconomic situation.

The sample was distributed into conglomerates, and for its calculation, the formula for infinite populations was used. The variable "non-adherence to medical therapy among primary healthcare centre diabetic users" was chosen as the outcome, and its adopted prevalence was of 60%⁽¹⁰⁾, the significance level and the sample error were (a=0,05) and 5%, respectively. The sample size was of 369 diabetic individuals. A 10% rate was added to this number, considering data loss, refusals, hospitalizations, abandonment, incorrect information and/or not available information. However, because some users wanted to participate in the study, the sample was enlarged to 437 subjects.

As the present study objective was to identify factors related to the nursing diagnosis "Ineffective Health Self-Control", the final sample of this investigation was comprised of data from the 377 classified subjects, as non-adherent to medical treatments with OA. In order to assess the hypoglycaemic medication intake, the Treatment Adhesion Measurement Test (TAM) was applied to each DM 2 patient, in their domiciles⁽¹¹⁾.

In order to do so, the investigated individuals answered to the following yes/no questions:

1. Have you ever forgotten to take the DM 2 pills?

2. Have you ever been negligent when taking the DM 2 pills?

3. Have you not taken the DM 2 pills, at any occasion, for having felt better?

4. Have you not taken the DM 2 pills, on your own initiative, for having felt worse?

5. Have you ever taken more than one or several DM 2 pills, on your own initiative, for having felt worse?

6. Have you ever interrupted the medical treatment for having forgotten to buy the medication?

The subjects who answered "no" to all the above questions were considered adherent to the treatment⁽¹¹⁾.

In order to determine the presence of the nursing diagnosis "Ineffective Health Self-Control", an analogy between the TAM questions and four or five defining characteristics of the researched diagnosis was made, as demonstrated on Chart 1. When at least one of the defining characteristics was present, the above mentioned nursing diagnosis was considered.

Further on, a check list instrument was created, with the 16 factors related to the referred diagnosis, according to NANDA 2009-2011 version. The check list was assessed by three nursing PhDs, in order to confirm its applicability. On that occasion, the evaluators verified that, based on the database information, it would only be possible to investigate ten out of the 16 factors related to the researched diagnosis, namely: Therapeutic Regime Complexity, Knowledge Deficit, Economic Difficulties, Impotency, Perceived Seriousness, Excessive Demand, Social Support Deficit, Healthcare System Complexity, Perceived Benefits, and Perceived Barrier.

The Therapeutic Regimen Complexity was considered present when patients had at least one comorbidity associated to DM 2, and took OA amounts > four times a day.

In order to identify the Knowledge Deficit, the Batalla Test was used to assess patients' knowledge on their disease. This test was adapted to DM 2 and involved three questions: Is DM 2 a lifelong illness? Can DM 2 be controlled with a diet and medication? Mention two or more organs that can be affected by the DM. Those who did not correctly answer all questions were classified as individuals with a knowledge deficit⁽¹²⁾.

The Economic Difficulties factor was comprised of patients who belonged to classes D and E, according to the Brazilian Economic Classification Criteria⁽¹³⁾. The Impotency factor was detected when patients needed relatives to help them take medications. As to the Perceived Seriousness factor, it was considered present when subjects affirmed DM 2 is a lifelong disease.

The Excessive Demand was considered present when individuals affirmed they were responsible for the family income source. At to the Support Deficit, it was mentioned when subjects did not regularly participated (at least once a week) in some social support network, such as neighbours associations, or groups, such as self-help, religious, and politics groups, among others.

In order to try and measure the Healthcare System Complexity, the following questions were asked to clients: Did you understand the guidelines on how to take the DM 2 pills? How often do you search for the DM 2 service centre? Based on these questions, the previously mentioned factor was considered when subjects answered "Yes" to the first question and al least "once every two months" to the second question. Finally, the Perceived Benefits factor was considered present when patients knew that the disease could be controlled with a diet and medication, and the Perceived Barriers, when they reported side effects caused by the medication.

Data were triple typed and stored in an Excel database. The information processing occurred through the SPSS software, version 17.0. The adopted confidence interval was of 95%. When analysing the factors related to the Ineffective Health Self-Control Diagnosis in association with the category variables, Fisher's Exact Test and the Chi-Square Test were used.

The research project was approved by Research Ethics Committee of the Health Sciences Centre, Universidade Federal do Ceará, according to Protocol n.º 47/09.

RESULTS

The present research results showed a larger participation of women (69.5%), white (47.3%) and mixed race individuals (35.3%). Subjects between 18 and 92 years old were studied. They were distributed among the following age brackets: 18-59 (41.1%), 60-69 (29.5%), 70-79 (20.1%) and 80-92 years old (9.3%). The individuals' average age was 63.1 years old (SD±11.6). Another characteristic found in the studied sample that deserves to be mentioned is education. It was possible to verify that the average education time was 4 years and 3 months (SD±3.7). The educational background is divided among a predominant group with incomplete basic education (37.9%) and functionally illiterate subjects (23.5%), with less than 6.0% having finished this educational stage.

With regard to marital status, more than half of the sample was either married or living in a common law partnership (56.5%), while the minority was single (6.9%); 85.6% had their own house; about half of the subjects studied lived with a nuclear family, comprised of a partner, children and/or grandchildren (45.8%), and 69.0% were catholic.

Considering the socioeconomic panorama, it was possible to verify a low income scenario, which can be demonstrated by the supremacy of the C (40.9%) and D (47.9%) economic classes. The average monthly family income was R$ 783.1 Reais (SD±574.5). The main OA used were metformin (22.9%), glybenclamid (21.5%), and the association of both (43.5%). The average number of such medication taken a day was 3.0 (SD±1.7) daily pills.

The "Ineffective Health Self-Control" diagnosis prevalence was of 86.3%, 73.1% of which were females (p=0.386). The predominant related factors investigated, that is, those above 70%, were: Excessive Demand (70.2%), Perceived Seriousness (72.4%), Knowledge Deficit (74.8%), Healthcare System Complexity (84.6%), Social Support Deficit (85.1%) and Perceived Benefits (89.5%).

When analysing the distribution of the factors related to the Ineffective Health Self-Control diagnosis, based on gender, the following findings were verified (Table 2): non-adherent male diabetic individuals present a higher impotency feeling (30.4%) than women (18.4%) upon the DM 2 medical therapy (p=0.034), besides, they also report a lack of social support (p= 0.016), and excessive demand (p= 0.000).

Even when classified as non-adherent to the OA therapy, women could better perceive the benefits of the correct medication intake in the DM 2 metabolic control (p=0.002)

DISCUSSION

Diagnoses are essential for the future of professional and evidence-based nursing care, besides favouring efficiency, safety and personalization of patient care. With regard to subjects with DM 2, once factors that contribute to the non-adherence to treatments are recognized through the Ineffective Health Self-Control diagnosis, nurses will be able to identify the main problems related to such behaviour. Moreover, when they associate them to the gender issues, the applied treatment will be more successful, due to its specificity.

Researches performed to verify the relationship between the adherence behaviour and patients' external, relational, and internal factors, have been receiving attention in the literature⁽¹⁴⁾. However, the variable methodological quality, and the absence of a golden standard to measure adhesion might result in misjudgements regarding the studied adhesion and non-adhesion factors, mainly in quantitative researches⁽¹⁵⁾.

Therefore, the fact that there are partial result divergences between the present study and two other similar publications consulted comes with no surprise. The first study did not verify any significant association among the use of OA and socio-demographic, clinical, and patient factors. The second study concluded that the main factors related to the non-adherence to the treatment were the duration of the disease and the therapeutic regimen complexity⁽¹⁶⁾.

In relation to the studied nursing diagnosis, the socio-demographic item was prevalent through the factors: Knowledge and Social Support Deficit, Economic Difficulties, and Excessive Demand.

In this investigation, the social support deficit (p= 0.016) and the excessive demand (p= 0.000) were higher for non-adherent men.

One of the plausible explanations to elucidate why men are predominantly non-adherent in relation to the above mentioned factors is that women tend to care more for themselves, and are historically and anthropologically responsible for their family's healthcare. They are more attentive to diseases symptoms, and visit primary healthcare centres earlier and more often than men. Finally, the existence of female-focused healthcare programs in the Family Healthcare Strategy in Brazil favours the early diagnosis and a better DM 2 follow up for women^(4,17). Nevertheless, it is relevant to say that there are investigations where no significant DM 2 treatment adhesion differences were found based on gender^(18-20).

In the present research, the excessive demand factor illustrated who was the main family provider and males were, in the majority of times, responsible for providing. There are evidences that show a higher prevalence of DM 2 and lower adhesion to the treatment, mainly among males, if they are from a lower socio-economic level of the population, which could be associated to the work division based on gender^(4-5,21). Moreover, it is important to consider that their budget is, more often than not, insufficient to afford the expenses related to the DM 2 therapy, such as those related to the diet, skin, and shoes, among others⁽¹⁰⁾.

Another question to be thought over is the fact that aspects such as education and cultural beliefs, for example, might interfere in the control of the diabetic therapeutic regimen⁽²²⁾. Therefore, the participation in operational groups, which characterized the factor "social support deficit" in the present study, can be beneficial when providing integral healthcare to diabetics, for the group's cohesion and the psychological intimacy environment established may favour the discussion of beliefs and feelings related to the disease and its treatment. However, the participation of males with DM in such activities was smaller in comparison to women⁽²³⁾.

The impotency factor, determined in this study by the need of help to take OA, could be conditioned to age and to the number of medicines taken for DM 2, as well as the associated comorbidities. In fact, those who have an OA monotherapy regimen or receive insulin present 36% higher adhesion in comparison to those who use several medicines⁽²⁴⁾. Furthermore, subjects with DM 2 who live alone face other problems besides those related to the disease, thus the involvement of a family member facilitates the medical treatment adhesion⁽²⁵⁾. With regard to the gender, it is possible that help from women and/or relatives might have been incorporated to the daily life activities, mainly when patients are elderly males.

Another significant finding in the present research was the perceived barrier factor, which approached the diabetic individual's awareness of his/her disease and therapeutic activities, such as diet and eating habits, which were less perceived by male patients. No investigations associating this fact with gender were found. The knowledge diabetics had about their disease, however, has been explored in Brazil, and results showed that 28.6% and 32.2% of diabetic individuals did not know the cause or effect of medicines used in their therapies, respectively^(26-27).

Chronicle or long-term treatments generally present a lower adhesion, since therapeutic regimens demand great efforts from patients, who have to change life habits to meet the treatment demands, in some circumstances. In the case of men, qualitative researches verified several reasons for it, but generally speaking, it is possible to group low adhesion causes in two main determining groups, namely: socio-cultural barriers, and institutional barriers. Hence, the feeling of "losing" motivation and the difficulty to access healthcare centres can illustrate the situation⁽³⁾.

Therefore, it is important for these individuals to have the correct answers to their doubts on the clinical management of their problem. This enhances professional credibility, and consequently decreases the number therapeutic doubts, for diabetics will not have self-care parameters if the information is inaccurate or absent⁽²⁸⁾.

CONCLUSION

The present article presented frailties when surveying the studied nursing diagnosis "Ineffective Health Self-Control. Firstly, there was neither a nursing appointment, nor were all factors related to the mentioned diagnosis used. Secondly, it was not possible to associate the surveyed factors prevalence with important aspects of the DM 2 metabolic control, such as: nutritional state, regular practice of physical activities, diet, and venous glycaemia. Such limitations are due to the secondary aspect of data used in this study.

Even upon these limitations, it was valid for revealing that socio-economic factors are important for the disease control, i.e., excessive demand, and social support deficit, which were significant and predominant among men. The same was observed when questions related to the subject were asked, such as those related to impotency and lack of benefits perception when treating the disease. Notwithstanding, new studies will be necessary to verify the prevalence of all factors related to the diagnosis among DM 2 patients and their relation with the medical adhesion.

It was possible to verify that men felt more impotent than women with regard to the OA intake. Women were able to better perceive the benefits of correctly taking the OA to control diabetes.

Considering the results found, it is necessary for primary healthcare professionals to be careful when dealing with male DM 2 patients, since socio-cultural and demographic components may interfere in the DM 2 metabolic control, causing patients to not come back to the healthcare centre, not understand the guidelines, and impact on their feelings upon the disease limitations, and the acquisition of therapeutic items, among others. Such aspects also depend on therapeutic communication, provided through domicile visits and supervision of the OA intake.

The medical treatment adhesion problem among diabetic individuals requires a multi-professional strategy, thus, another important aspect is the qualification of those with direct contact with the community, the health agents, who daily go to patients' houses. Teaching these professionals, as well as applying simple indirect adherence methods may help detecting non-adhesion cases in the community. Further on, such findings could be confirmed through a nursing appointment and the Ineffective Health Self-Control diagnosis.

AKNOWLEDGEMENTS

To Conselho Nacional de Desenvolvimento Cientifico e Tecnológico (National Council for the Scientific and Technological Development) for the support, according to Process nº 473826/2007-0, Citation MCT/CNPq 15/2007 - Universal.

REFERENCES

• 1. Santos MA, Zanetti ML. Difficulties of diabetic patients in the illness control: feelings and behaviors. Rev Latinoam Enferm. 2007;15(6):1105-12.
• 2. Lopez Stewart G, Tambascia M, Rosas Guzmán J, Etchegoyen F, Ortela Carrión J, Artemenko S. Control of type 2 diabetes mellitus among general practitioners in private practice in nine countries of Latin America. Rev Panam Salud Publica = Pan Am J Public Health. 2007;22(1):12-20.
• ³
  Brasil. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política nacional de atenção integral à saúde do homem: princípios e diretrizes. Brasília: Ministério da Saúde; 2008.
• 4. Goldenberg P, Schenkman S, Franco LJ. Prevalência de diabetes mellitus: diferenças de gênero e igualdade entre os sexos. Rev Bras Epidemiol. 2003;6(1):18-28.
• 5. Grant R, Adams AS, Trinacty CM, Zhang F, Kleinman K, Soumerai SB, et al. Relationship between patient medication adherence and subsequent clinical inertia in type 2 diabetes glycemic management. Diabetes Care. 2007;30(4):807-12.
• 6. DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care. 2004;42(3):200-9. Comment in: Med Care. 2004;42(3):197-9.
• 7. Milhomem ACM, Mantelli FF, Lima GAV, Bachion MM, Munari DB. Diagnósticos de enfermagem identificados em pessoas com diabetes tipo 2 mediante abordagem baseada no Modelo de Orem. Rev Eletrônica Enferm. 2008;10(2):321-36.
• ⁸
  North American Nursing Diagnosis Association. Diagnósticos de enfermagem da NANDA: definições e classificação 2009-2011. Porto Alegre: Artmed; 2010.
• 9. Vasconcelos FF, Araújo TL, Moreira TMM, Lopes MVO. Association among nursing diagnoses, demographic variables, and clinical characteristics of patients with high blood pressure. Acta Paul Enferm. 2007;20(3):326-32.
• 10. Araújo MFM, Damasceno MMC. La adhesión del diabético al tratamiento farmacológico com hipoglicemiantes orales: una investigación bibliográfica. Enfermería Integral. 2008;(84):68-73.
• 11. Delgado AB, Lima ML. Contributo para a validação concorrente de uma medida de adesão aos tratamentos. Psicol Saúde Doenças. 2001;2(2):81-100.
• 12. Batalla Martínez C, Blanquer Laguarta A, Ciurana Misol R, Garcia Soldevilla M, Jordi Cases E, Pérez Callejón A, et al. Cumplimiento de la prescripción farmacológica en pacientes hipertensos. Aten Primaria. 1984;1(4):185-91.
• 13. Associação Nacional de Empresas de Pesquisas (ANEP). Critério de classificação econômica Brasil.[citado 2009 Fev 14]. Disponível em: http://www.datavale-sp.com.br/CCEB.pdf
• 14. Valle EA, Viegas EC, Castro CAC, Toledo Junior AC. A adesão ao tratamento. Rev Bras Clin Ter. 2000;26(3):83-6.
• 15. Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther. 2001;26(5):331-42.
• 16. Mateo JF, Gil-Guillén VF, Mateo E, Orozco D, Carbayo JA, Merino J. Multifactorial approach and adherence to prescribed oral medications in patients with type 2 diabetes. Int J Clin Pract. 2006;60(4):422-8.
• 17. Tavares DMS, Rodrigues FS, Silva CGC, Miranzi SSC. Caracterização de idosos diabéticos atendidos na atenção secundária. Ciênc Saúde Coletiva. 2007;12(5):1341-52.
• 18. Rozenfeld Y, Hunt JS, Plauschinat C, Wong KS. Oral antidiabetic medication adherence and glycemic control in managed care. Am J Manag Care. 2008;14(2):71-5.
• 19. Gimenes HT, Zanetti ML, Haas VJ. Fatores relacionados à adesão do paciente diabético à terapêutica medicamentosa. Rev Latinoam Enferm. 2009;17(1):46-51.
• 20. Silva I, Pais-Ribeiro J, Cardoso H. Adesão ao tratamento da diabetes Mellitus: a importância das características demográficas e clínicas. Referência. 2006;2(2):33-41.
• 21. Voss JD, Nadkarni MM, Schectman JM. The Clinical Health Economics System Simulation (CHESS): a teaching tool for systems- and practice-based learning. Acad Med. 2005;80(2):129-34.
• 22. Swaby P, Wilson E, Swaby S, Sue-Ho R, Pierre R. Chronic disease control and compliance-the HOPE worldwide Jamaica experience. West Indian Med J. 2001;50 Suppl 1:51-3.
• 23. Santos MA, Péres DS, Zanetti ML, Otero LM. Grupo operativo como estratégia para a atenção integral ao diabético. Rev Enferm UERJ. 2007;15(2):242-7.
• 24. Dailey G, Kim MS, Lian JF. Patient compliance and persistence with antihyperglycemic drug regimens: evaluation of a medicaid patient population with type 2 diabetes mellitus: evaluation of a medicaid patient population with type 2 diabetes mellitus. Clin Ther. 2001;23(8):1311-20.
• 25. Huang CL, Wu SC, Jeng CY, Lin LC. The efficacy of a home-based nursing program in diabetic control of elderly people with diabetes mellitus living alone. Public Health Nurs. 2004;21(1):49-56.
• 26. Gimenes HT, Zanetti ML, Otero LM, Teixeira CRS. O conhecimento do paciente diabético tipo 2 acerca dos antidiabéticos orais. Ciênc Cuid Saúde. 2006;5(3):317-25.
• 27. Pace AE, Ochoa-Vigo K, Caliri MHL, Fernandes APM. O conhecimento sobre diabetes mellitus no processo de autocuidado. Rev Latinoam Enferm. 2006;14(5):728-34.
• 28. Apóstolo JLA, Viveiros CSC, Nunes HIR, Domingues HRF. Illness uncertainty and treatment motivation in type 2 diabetes patients. Rev Latinoam Enferm. 2007;15(4):575-82.

*

Pesquisa realizada em 12 serviços de atenção básica de Fortaleza (CE), Brasil.

Publication Dates

• Publication in this collection
  01 Aug 2011
• Date of issue
  2011

History

• Received
  05 Aug 2010
• Accepted
  27 Dec 2010