Fatores comportamentais determinantes de adesão a programas/terapêuticas de prevenção: o caso da diabetes

Tese de doutoramento em Ciências da Saúde, no ramo de Ciências Biomédicas, apresentada à Faculdade de Medicina da Universidade de CoimbraEnquadramento A diabetes corresponde a uma condição clínica cujas características não se encerram ao domínio médico. Nesse sentido a psicologia da saúde desempenha um papel de relevo para a compreensão das consequências psicológicas da diabetes e dos fatores psicológicos e comportamentais determinantes no autocuidado efetivo da doença e, consequentemente, na adesão à terapêutica. Assim, a investigação de aspetos relacionados com a adesão tem vindo a ser alvo de interesse e de preocupação na área da saúde. É de capital importância conhecer os fatores que influenciam a adesão, percebendo a associação estabelecida entre variáveis internas e externas ao doente, assim como variáveis relacionais. A este propósito é de referir que a maior parte da investigação conduzida neste âmbito é de natureza correlacional, o que dificulta uma compreensão do modo como estes fatores se relacionam entre si para influenciar a adesão, bem como da mudança que pode ocorrer ao longo do tempo no que respeita aos autocuidados da diabetes. Paralelamente há a referir que em muitos dos estudos foram utilizadas diferentes definições de adesão pelo que se torna difícil a sua comparação. Como tal, foi nosso objetivo avaliar estas dimensões de modo a poder perspetivar o desenvolvimento de estratégias promotoras de adesão ao regime terapêutico quer a nível educacional, quer comportamental, ou ainda conjugando estes dois elementos. Metodologia O presente trabalho integra sete estudos empíricos de desenho transversal, realizados numa amostra de 347 indivíduos com diagnóstico de diabetes, recrutados nas consultas de endocrinologia do Centro Hospitalar Universitário de Coimbra e na Associação Protetora de Diabéticos de Portugal. As variáveis em estudo foram fundamentalmente avaliadas através de instrumentos de autorresposta estandardizados que permitiram recolher dados sobre cada uma das dimensões a estudar. No que respeita ao critério de adesão à terapêutica recorreu-se ao critério bioquímico hemoglobina glicada (HbA1c). Resultados No seu conjunto, os resultados dos estudos realizados sugerem a existência de uma clara distinção entre diabetes tipo 1 e diabetes tipo 2. As pessoas com diabetes tipo 1 tendem a apresentar valores mais elevados ao nível da dimensão intimidade do suporte social, da debilitação em atividades sociais, do autocuidado alimentar e dos vários domínios da qualidade de vida analisados. Por seu turno, as pessoas com diabetes tipo 2 evidenciam níveis mais elevados de autoestima e de atitudes positivas face aos médicos e à medicina. As diferenças entre a diabetes tipo 1 e tipo 2 estendem-se igualmente à forma como as variáveis em estudo se associam entre si. Um outro achado relevante prende-se com as diferenças encontradas tendo em consideração os pontos de corte da HbA1c. Outro dado consistentemente encontrado foi o facto das variáveis depressão e adesão se relacionarem de forma distinta em função do tipo de diabetes e do tipo de terapêutica. No tocante aos resultados alcançados relativamente à adesão e perfil de saúde do doente com diabetes constatou-se que os doentes que aderem à terapêutica evidenciam um melhor perfil de saúde comparativamente com os que não aderem. Relativamente à análise dos fatores comportamentais determinantes da adesão terapêutica foram de igual modo observadas diferenças em função do tipo de diabetes, tendo emergido estruturas fatoriais distintas. Por último, os resultados inerentes aos fatores preditores de adesão evidenciam a depressão como o principal preditor de adesão na diabetes tipo 2 e de não adesão na diabetes tipo 1. Para além da depressão, ainda se revelaram preditoras as variáveis perfil de saúde da diabetes, autoestima e qualidade de vida – dimensão meio ambiente, no caso da diabetes tipo 2. Conclusões Na globalidade os resultados destes estudos reforçam a importância do envolvimento ativo das pessoas no seu próprio processo de tratamento, dado que este é imprescindível e não pode ser assumido por outra pessoa para além de si próprio. Entendemos, portanto, que esta investigação nos conduziu para uma perspetiva holística no que respeita à conceptualização da diabetes. Nesta sequência sublinhamos a importância de intervenções psicoeducativas que capacitem o doente a fazer de forma consciente e responsável as suas escolhas, dado que estas acarretam consequências não negligenciáveis para si mesmo. É de salientar que estas intervenções só poderão revelar eficácia se forem desenvolvidas numa sólida infraestrutura de saúde pública, organizada e envolvendo os profissionais de saúde e os doentes. Em nosso entender só assim poderá ser assegurada uma resposta adequada às exigências da qualidade dos cuidados a prestar. Palavras Chave: Diabetes tipo 1 e tipo 2, determinantes no autocuidado, fatores comportamentais, adesão, terapêutica. Diabetes is a clinical condition with facets that are not limited to the medical field. Thus health psychology plays a significant role in understanding psychological consequences of diabetes and psychological and behavioral factors that influence effective self-care determinants of this disease and, consequently, therapeutic adherence. Therefore, research on aspects related to therapeutic adherence has deserved interest and concern in healthcare. The identification of factors influencing adherence and the association between patients’ internal and external variables as well as relational variables are important issues in this area of knowledge. It is worth of note that the majority of studies conducted in this domain are correlational studies, which does not allow the understanding of how these factors relate to each other to influence therapeutic adherence and the change in diabetes self-care that can occur over time. Besides, in many studies different definitions of adherence are used what makes comparisons difficult to establish. In this context, this investigation sought out to assess these dimensions considering the fact that they are core elements for the development of strategies promoting therapeutic adherence including educational and behavioral aspects, as well as the combination of these two components. Method This research project comprises seven empirical studies with a cross sectional design, conducted on a sample of 347 participants with a diabetes diagnose that were recruited at the endocrinology consultation of the Centro Hospitalar Universitário de Coimbra and at the Associação Protetora de Diabéticos de Portugal. Studied variables were assessed through the use of standardized self-report instruments. The adherence criterion used was the biochemical criteria HbA1c. Results Taken together, results from the studies suggest the existence of a clear distinction between type 1 diabetes and type 2 diabetes. Type 1 diabetes patients tend to show higher values on the intimacy dimension of social support, impairment in social activities, nutrition self-care and in the various domains of quality of life. In turn, type 2 diabetes patients present higher levels of self-esteem and positive attitudes towards doctors and medicine. Differences between type 1 and type 2 diabetes also extend to the way studied variables are associated with each other. One more important finding concerns the differences taking into account HbA1c cutoffs. Another finding consistently found was the fact that depression and adherence relate differently depending on the type of diabetes and the type of treatment approach. Regarding the results on adherence and diabetes patient health profile patients who adhere to therapy show a better health profile compared to those who do not adhere. Concerning the analysis of behavioral adherence determinants differences were found depending on the type of diabetes, having emerged distinct factor structures. Finally, results inherent to predictors of adherence show that depression is the only significant predictor of adherence in type 2 diabetes and one of the predictors of non-adherence in type 1 diabetes. Besides depression, in type 2 diabetes, diabetes health profile, self-esteem and quality of life - environmental dimension were also significant predictors. Conclusions Overall, results reinforce the importance of the active involvement of patients in their own treatment process, as an essential issue that cannot be assumed by others. Therefore, we believe this investigation led us to adopt a holistic perspective regarding diabetes conceptualization. Consequently, it is important to emphasize the role of psychoeducational interventions that empower patients, leading them to make conscious and responsible choices, since these choices entail non-negligible consequences for themselves. It should be noted that these interventions can only prove effective if developed in a solid, organized public health infrastructure, involving health professionals and patients. In our opinion this is the only way an appropriate response can be ensured to the requirements of quality of care to be provided.Background Diabetes is a clinical condition with facets that are not limited to the medical field. Thus health psychology plays a significant role in understanding psychological consequences of diabetes and psychological and behavioral factors that influence effective self-care determinants of this disease and, consequently, therapeutic adherence. Therefore, research on aspects related to therapeutic adherence has deserved interest and concern in healthcare. The identification of factors influencing adherence and the association between patients’ internal and external variables as well as relational variables are important issues in this area of knowledge. It is worth of note that the majority of studies conducted in this domain are correlational studies, which does not allow the understanding of how these factors relate to each other to influence therapeutic adherence and the change in diabetes self-care that can occur over time. Besides, in many studies different definitions of adherence are used what makes comparisons difficult to establish. In this context, this investigation sought out to assess these dimensions considering the fact that they are core elements for the development of strategies promoting therapeutic adherence including educational and behavioral aspects, as well as the combination of these two components. Method This research project comprises seven empirical studies with a cross sectional design, conducted on a sample of 347 participants with a diabetes diagnose that were recruited at the endocrinology consultation of the Centro Hospitalar Universitário de Coimbra and at the Associação Protetora de Diabéticos de Portugal. Studied variables were assessed through the use of standardized self-report instruments. The adherence criterion used was the biochemical criteria HbA1c. Results Taken together, results from the studies suggest the existence of a clear distinction between type 1 diabetes and type 2 diabetes. Type 1 diabetes patients tend to show higher values on the intimacy dimension of social support, impairment in social activities, nutrition self-care and in the various domains of quality of life. In turn, type 2 diabetes patients present higher levels of self-esteem and positive attitudes towards doctors and medicine. Differences between type 1 and type 2 diabetes also extend to the way studied variables are associated with each other. One more important finding concerns the differences taking into account HbA1c cutoffs. Another finding consistently found was the fact that depression and adherence relate differently depending on the type of diabetes and the type of treatment approach. Regarding the results on adherence and diabetes patient health profile patients who adhere to therapy show a better health profile compared to those who do not adhere. Concerning the analysis of behavioral adherence determinants differences were found depending on the type of diabetes, having emerged distinct factor structures. Finally, results inherent to predictors of adherence show that depression is the only significant predictor of adherence in type 2 diabetes and one of the predictors of non-adherence in type 1 diabetes. Besides depression, in type 2 diabetes, diabetes health profile, self-esteem and quality of life - environmental dimension were also significant predictors. Conclusions Overall, results reinforce the importance of the active involvement of patients in their own treatment process, as an essential issue that cannot be assumed by others. Therefore, we believe this investigation led us to adopt a holistic perspective regarding diabetes conceptualization. Consequently, it is important to emphasize the role of psychoeducational interventions that empower patients, leading them to make conscious and responsible choices, since these choices entail non-negligible consequences for themselves. It should be noted that these interventions can only prove effective if developed in a solid, organized public health infrastructure, involving health professionals and patients. In our opinion this is the only way an appropriate response can be ensured to the requirements of quality of care to be provided