Postoji li povezanost između zdravstvenog lokusa kontrole i kliničkih ishoda u bolesnika sa šećernom bolešću tip 2 u općoj medicini Hrvatske?

Background: The aim of this study was to explore correlation between health locus of control (HLOC) and clinical outcomes in patients with diabetes mellitus type 2 (DMT2). Subject and methods: Cross-sectional study. A multistage, stratified proportional sampling was used to draw a random sample of 46 GPs and, systematic sampling of the first 6 DMT2 patients visiting the chosen GPs with recently registered blood pressure, lipid and glycaemic profile. The patients completed Croatian version of HLOC (ZKL-90-2) and socio-demographic data questionnaires after signing informed consent. Results: DMT2 patients mostly displayed internal HLOC, followed by circumstances, powerful others and chance. Almost all observed objective clinical outcomes, except fasting blood glucose and LDL cholesterol, are in correlation with internal HLOC scale. Correlations were mostly negative. The patients considering themselves to be in command over diabetes obtained the lower scores at total cholesterol (p=0.014), triglycerides (p=0.037), systolic (p=0.003) and diastolic blood pressure (p=0.025). Positive correlation with Es and Eo scales measuring external HLOC was found regarding levels of LDL cholesterol (p=0.032), triglycerides (p=0.009) and systolic (p=0.001) blood pressure. HbA1c (p=0.001). Fasting blood glucose (p=0.002) was higher in patients believing in external circumstances. Conclusion: DMT2 patients who believed they had control over their disease obtained better disease outcomes than those believing in external circumstances.Pozadina: Cilj ovog istraživanja bio je istražiti postoji li povezanost između zdravstvenog lokusa kontrole (ZLK) i kliničkih ishoda u bolesnika sa šećernom bolešću tip 2 (ŠBT2). Ispitanici i metode: Presječno istraživanje. Stratificiranim reprezentativnim slučajnim uzorakovanjem odabrano je 46 liječnika opće/obiteljske medicine koji su potom odabrali prvih 6 bolesnika koji su ih posjetili tijekom perioda istraživanja, a koji su imali nedavno zabilježenu vrijednost arterijskog tlaka, lipidni profil te kratkoročnu i dugoročnu vrijednost vrijednost glukoze. Po davanju informiranog pristanka bolesnici sa ŠBT2 ispunili su hrvatsku verziju upitnika za procjenu zdravstvenog lokusa kontrole (ZKL-90-2) i upitnik o sociodemografskim podacima. Rezultati: U bolesnika sa ŠBT2 većinom je bio izražen unutarnji lokus kontrole, potom je slijedila vjera u okolnosti, moćne druge i utjecaj slučaja. Većina proučavanih objektivnih kliničkih ishoda DMT2, osim glukoze na tašte i LDL kolesterola u korelaciji su sa skalom koja mjeri unutarnji ZLK. Korelacije su većinom negativne, bolesnici koji su imali izražen unutarnji ZLK imali su niže vrijednosti ukupnog kolesterola (p=0.014), triglicerida (p=0.037), sistoličkog (p=0,003) i dijastoličkog (p=0,025) arterijskog tlaka. Utvrđene su pozitivne korelacije skala Es i Eo (koje mjere vanjski ZLK) s razinama: LDL kolesterola (p=0,032), triglicerida (p=0,009) i sistoličkog arterijskog tlaka (p=0,001). Utvrđene su više vrijednosti HbA1c (p=0,001) i glukoze na tašte (p=0,002) u bolesnika koji su imali izreženo vjerovanje u utjecaj okolnosti (vanjski ZLK). Zaključak: Bolesnici sa ŠBT2 koji su imali izražen unutarnji lokus kontrole imali postignute bolje vrijednosti kliničkih ishoda liječenja ŠBT2 u odnosu na bolesnike koji su imali izražen vanjski lokus kontrole

Postoji li povezanost između zdravstvenog lokusa kontrole i kliničkih ishoda u bolesnika sa šećernom bolešću tip 2 u općoj medicini Hrvatske?

Background: The aim of this study was to explore correlation between health locus of control (HLOC) and clinical outcomes in patients with diabetes mellitus type 2 (DMT2). Subject and methods: Cross-sectional study. A multistage, stratified proportional sampling was used to draw a random sample of 46 GPs and, systematic sampling of the first 6 DMT2 patients visiting the chosen GPs with recently registered blood pressure, lipid and glycaemic profile. The patients completed Croatian version of HLOC (ZKL-90-2) and socio-demographic data questionnaires after signing informed consent. Results: DMT2 patients mostly displayed internal HLOC, followed by circumstances, powerful others and chance. Almost all observed objective clinical outcomes, except fasting blood glucose and LDL cholesterol, are in correlation with internal HLOC scale. Correlations were mostly negative. The patients considering themselves to be in command over diabetes obtained the lower scores at total cholesterol (p=0.014), triglycerides (p=0.037), systolic (p=0.003) and diastolic blood pressure (p=0.025). Positive correlation with Es and Eo scales measuring external HLOC was found regarding levels of LDL cholesterol (p=0.032), triglycerides (p=0.009) and systolic (p=0.001) blood pressure. HbA1c (p=0.001). Fasting blood glucose (p=0.002) was higher in patients believing in external circumstances. Conclusion: DMT2 patients who believed they had control over their disease obtained better disease outcomes than those believing in external circumstances.Pozadina: Cilj ovog istraživanja bio je istražiti postoji li povezanost između zdravstvenog lokusa kontrole (ZLK) i kliničkih ishoda u bolesnika sa šećernom bolešću tip 2 (ŠBT2). Ispitanici i metode: Presječno istraživanje. Stratificiranim reprezentativnim slučajnim uzorakovanjem odabrano je 46 liječnika opće/obiteljske medicine koji su potom odabrali prvih 6 bolesnika koji su ih posjetili tijekom perioda istraživanja, a koji su imali nedavno zabilježenu vrijednost arterijskog tlaka, lipidni profil te kratkoročnu i dugoročnu vrijednost vrijednost glukoze. Po davanju informiranog pristanka bolesnici sa ŠBT2 ispunili su hrvatsku verziju upitnika za procjenu zdravstvenog lokusa kontrole (ZKL-90-2) i upitnik o sociodemografskim podacima. Rezultati: U bolesnika sa ŠBT2 većinom je bio izražen unutarnji lokus kontrole, potom je slijedila vjera u okolnosti, moćne druge i utjecaj slučaja. Većina proučavanih objektivnih kliničkih ishoda DMT2, osim glukoze na tašte i LDL kolesterola u korelaciji su sa skalom koja mjeri unutarnji ZLK. Korelacije su većinom negativne, bolesnici koji su imali izražen unutarnji ZLK imali su niže vrijednosti ukupnog kolesterola (p=0.014), triglicerida (p=0.037), sistoličkog (p=0,003) i dijastoličkog (p=0,025) arterijskog tlaka. Utvrđene su pozitivne korelacije skala Es i Eo (koje mjere vanjski ZLK) s razinama: LDL kolesterola (p=0,032), triglicerida (p=0,009) i sistoličkog arterijskog tlaka (p=0,001). Utvrđene su više vrijednosti HbA1c (p=0,001) i glukoze na tašte (p=0,002) u bolesnika koji su imali izreženo vjerovanje u utjecaj okolnosti (vanjski ZLK). Zaključak: Bolesnici sa ŠBT2 koji su imali izražen unutarnji lokus kontrole imali postignute bolje vrijednosti kliničkih ishoda liječenja ŠBT2 u odnosu na bolesnike koji su imali izražen vanjski lokus kontrole

„Mouse fever“ – hemorrhagic fever with renal syndrome – case report

U ovom članku prikazan je slučaj prethodno zdravog 42-godišnjeg drvosječe koji je obolio od hemoragijske vrućice s bubrežnim sindromom (HVBS) ili epidemijske nefropatije. Hemoragijska vrućica s bubrežnim sindromom akutna je infektivna bolest uzrokovana hantavirusima, a glavni rezervoar su glodavci (riđa voluharica i miševi). U Hrvatskoj postoje dva tipa hantavirusa: Puumala i Dobrava-Belgrade. Puumala virus je najčešći oblik hantavirusa u našoj zemlji. Uzročnik je blagog i srednje teškog oblika HVBS. Čovjek se najčešće zarazi udisanjem aerosola koje sadržavaju virus ili drugim kontaminiranim izlučevinama (mokraćom, stolicom, slinom) inficiranih glodavaca. Osnovna značajka HVBS je oštećenje bubrežne funkcije različitog stupnja sve do bubrežnog zatajenja. Česti simptomi su vrućica, glavobolja, bolovi u leđima i bolovi u trbuhu. Dobrava-Belgrade tip virusa uzrokuje težu kliničku sliku s krvarenjima, plućnim i neurološkim simptomima. Tijek HVBS može se podijeliti u pet faza, a to su: febrilna, hipotenzivna, oligurijska, poliurijska i rekonvalescentna faza. Ne postoji specifično liječenje za HVBS, stoga je vrlo važna rana dijagnostika i adekvatno simptomatsko liječenje.PA case of previously healthy 42-year-old woodman who saffered from haemorrhagic fever with renal syndrome (HFRS), also called epidemic nephropathy, is presented. Haemorrhagic fever with renal syndrome belongs to emerging infections. It is caused by hantaviruses. Those viruses are transmitted to humans by rodents, bank vole and mice being the main reservoirs. Two types of hantaviruses are identified in Croatia: Puumala virus and Dobrava-Belgrade virus. Puumala virus is the most frequent hantavirus in our country. It causes mild to moderate form of HFRS. People are infected by inhaling aerosolised virus particles shed through urine, faeces or saliva. The main characteristic of HFRS is renal dysfunction or renal failure with rare haemorrhagic anifestations. Other frequent symptoms are fever, headache, backpain and gastrointestinal symptoms. Dobrava-Belgrade type of virus causes more severe disease with bleedings, pulmonary symptoms and neurological complications. The course of HFRS is divided into five stages: febrile, hypotensive, oliguric, diuretic and convalescent phase, but these phases are not always clinically evident. There is no specific antiviral therapy. Therefore, it is very important that family physicians working in the regions where HFRS usually occures, have it in mind in cases of patients with sudden onset of fever or flu-like symptom

COMMUNICATION AND HEALTH OUTCOMES IN PATIENTS SUFFERING FROM GASTROINTESTINAL DISEASES

Unatoč rezultatima istraživanja koji ukazuju na jasnu povezanost komunikacije liječnika i pacijenta i zdravstvenog ishoda, nedovoljno su jasni mehanizmi njihova djelovanja. Iako razgovor sam po sebi može biti terapijski (umanjenjem pacijentove tjeskobe, pružanjem nade i utjehe), komunikacija između liječnika i pacijenta većinom utječe na zdravstvene ishode neizravnim putem. Proksimalni ishodi interakcije uključuju razumijevanje, povjerenje i dogovor liječnika i pacijenta. Navedeno utječe na intermedijarne ishode (povećanje adherentnosti, bolju vještinu samokontrole i samoliječenja) te u konačnici na zdravlje i blagostanje pacijenta. Sedam je domena putem kojih komunikacija može dovesti do unaprjeđenja zdravlja: povećanjem dostupnosti skrbi, povećanjem pacijentova poznavanja karakteristika bolesti i liječenja, zajedničkim razumijevanjem problema, donošenjem kvalitetnih medicinskih odluka, unaprjeđenjem terapijskog saveza, jačanjem socijalne podrške, jačanjem osnaženosti i zastupanja pacijenta, te povećanjem pacijentove sposobnosti nošenja s emocijama. Iako su ove domene utvrđene temeljem potreba onkološkog pacijenta, one su svakako primjenjive i u drugim zdravstvenim stanjima, pa tako i u skrbi bolesnika koji boluju od gastrointestinalnih bolesti.Although survey results indicate clear connection between the physician-patient communication and health outcomes, mechanisms of their action are still insuffi ciently clear. The aim was to investigate the specifi city of communication with patients suffering from gastrointestinal diseases and the impact of good communication on measurable outcomes. We performed PubMed (Medline) search using the following key words: communication, health outcomes, and gastrointestinal diseases. Seven pathways through which communication can lead to better health include increased access to care, greater patient knowledge and shared understanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency and empowerment, and better management of emotions. Although these pathways were explored with respect to cancer care, they are certainly applicable to other health conditions as well, including the care of patients suffering from gastrointestinal diseases. Although proposing a number of pathways through which communication can lead to improved health, it should be emphasized that the relative importance of a particular pathway will depend on the outcome of interest, the health condition, where the patient is in the illness trajectory, and the patient’s life circumstances. Besides, research increasingly points to the importance of placebo effect, and it is recommended that health professionals encourage placebo effect by applying precisely targeted communication skills, as the unquestionable and successful part of many treatments. It is important that the clinician knows the possible positive and negative effects of communication on health outcomes, and in daily work consciously maximizes therapeutic effects of communication, reaching its proximal (understanding, satisfaction, clinician-patient agreement, trust, feeling known, rapport, motivation) and intermediate outcomes (access to care, quality medical decision, commitment to treatment, trust in the system, social support, self-care skills, emotional management) to improve the health of patients he cares for

“Grandma’s Old Tricks“- A Qualitative Study of Lay People’s Experiences in Treatment and Prevention of Common Cold and Influenza

We aimed to explore lay people’s perception of common cold and influenza as well as their experience in treatment and prevention of those conditions, with emphasis on the reasons impacting their decision towards influenza vaccination. 24 semi-structured, individual interviews were conducted, then transcribed and analysed to find emerging themes and sub-themes. Textual data were explored inductively using content analysis to generate categories and explanations. Five major themes and explanatory models of lay people’s perspective emerged from the data. The participants expressed satisfying knowledge regarding influenza and common cold symptoms, length, transfer and treatment options as well as described a clear distinction between those two diseases. On the other hand, they emphasized the same general preventative measures for both common cold and influenza, considering influenza vaccination primarily an option for chronic, old or bedridden patients and health workers. Facilitators in the vaccination decision making process were health professionals’ (mostly general practitioners’) recommendation, anxiety regarding influenza and possible complications, existence of chronic diseases and positive vaccination experience. As main reasons against vaccination participants stated perception of being at low risk for influenza, opinion that vaccination is necessary only for bedridden and old people, chronic patients or health workers and questionable effectiveness of the vaccine. Participants’ influenza vaccination knowledge was insufficient, which should direct further interventions, especially having in mind low vaccination rates. Since participants perceived general practitioner’s recommendation as a crucial facilitator in forming their positive attitude towards vaccination, practitioners are invited to assess and, when needed, modify inappropriate perception towards influenza prevention when leading person centred consultations

Family medicine - A safe future

Cilj: Istražiti stavove pacijenata prema obiteljskoj medicini, odnosno ustanoviti pridonosi li obiteljska medicina kvalitetnijoj zdravstvenoj skrbi pojedinca i obitelji, kao i doznati razloge koji su važni za postojanje obiteljske medicine u zdravstvenom sustavu urbanih i ruralnih područja. Ispitanici i metode: U četiri gradske i četiri seoske ordinacije provedeno je presječno istraživanje. Anketama koje su ispunjavali pacijenti stariji od 18 godina prikupljeni su podaci o dobi, spolu, stručnoj spremi, te broju članova obitelji koji su u skrbi istog obiteljskog liječnika. Ispitanici su odgovarali na pitanje drže li da obiteljska medicina pridonosi kvalitetnijoj zdravstvenoj skrbi za pojedinca i obitelj, te što drže razlozima koji su važni za postojanje obiteljske medicine. Rezultati: Uzorak je sačinjavalo 960 ispitanika, od čega 428 (44,58%) muškaraca i 532 (55,42%) žene. Većina ispitanika (N = 382, 39,79%) bila je starija od 60 godina. 494 (51,46%) ispitanika registrirano je u seoskim, a 466 (48,54%) u gradskim ordinacijama obiteljske medicine. Većina ispitanika u seoskim ordinacijama imala je nižu stručnu spremu (N = 277, 56,07%), dok je većina ispitanika u gradskima ordinacijama imala srednju stručnu spremu (N = 302, 64,81%). Značajno veći udio ispitanika u seoskim ordinacijama (N = 145, 29,35%) naveo je da su svi članovi obitelji u skrbi istoga liječnika (χ 2 = 23,27, p < 0,001). Od 960 ispitanika, njih 736 (76.67%) u potpunosti se složilo da obiteljska medicina pridonosi kvalitetnijoj skrbi. Za 510 (53.13%) ispitanika najvažniji razlog postojanja obiteljske medicine bio je poznavanje pacijenta. Zaključak: Sukladno stavovima pacijenata obiteljska medicina osigurava cjelokupnu, kontinuiranu skrb za pacijenta i doprinosi kvaliteti zdravstvene skrbi u cjelini.Aim: To investigate patients’ attitudes regarding family medicine, their opinion on the contribution of family medicine to the quality of health care and their perception of family medicine advantages. Participants and methods: A cross-sectional questionnaire-based study was performed in four urban and four rural family practices. Patients aged 18 years or more provided data on their age, sex, educational level and proportion of family members who were in care of the same family doctor. Patients expressed their opinion on the contribution of family medicine to the quality of health care and their perception of family medicine advantages. Results: Out of 960 patients, 428 (44.58%) men and 532 (55.42%) women, 494 (51.46%) patients were registered in urban and 466 (48.54%) in rural family practices. Most of the patients (N = 382, 39.79%) were aged 60 years or more. The majority of patients in rural practices had finished primary school (N = 277, 56.07%) and the majority of patients in urban practices had finished secondary school (N = 302, 64.81%). A significantly higher proportion of patients in rural practices reported having one family doctor taking careof all family members (N = 145, 29.35%) (χ 2 = 23.27, p < 0.001), 736 (76.67%) patients fully agreed that family medicine contributes to higher care quality. For 510 (53.13%) patients, the main advantage of family medicine was knowing the patient. Conclusion: According to patients’ opinion, family medicine provides holistic, continuing care to patients and contributes to a higher quality of health care

Information systems and the electronic health record in primary health care

The implementation of information systems into primary health care opened the possibilities of providing integrated and co-ordinated health care, improved in quality and focused on the healthcare user. The healthcare system, researchers, physicians, and patients have recognised the benefits offered by informatics, but also raised questions that have yet to be answered

Say it in Croatian - Croatian translation of the EGPRN definition of Multimorbidity using a Delphi consensus technique

Patients coming to their family physician (FP) usually have more than one condition or problem. Multimorbidity as well as dealing with it, is challenging for FPs even as a mere concept. The World Health Organization (WHO) has simply defined multimorbidity as two or more chronic conditions existing in one patient. However, this definition seems inadequate for a holistic approach to patient care within Family Medicine. Using systematic literature review the European General Practitioners Research Network (EGPRN) developed a comprehensive definition of multimorbidity. For practical and wider use, this definition had to be translated into other languages, including Croatian. Here presented is the Croatian translation of this comprehensive definition using a Delphi consensus procedure for Forward/Backward translation. 23 expert FPs fluent in English were asked to rank the translation from 1 (absolutely disagreeable) to 9 (fully agreeable) and to explain each score under 7. It was previously defined that consensus would be reached when 70 % of the scores are above 6. Finally, a backward translation from Croatian into English was undertaken and approved by the authors of the English definition. Consensus was reached after the first Delphi round with 100% of the scores above 6; therefore the Croatian translation was immediately accepted. The authors of the English definition accepted the backward translation. A comprehensive definition of multimorbidity is now available in English and Croatian, as well as other European languages which will surely make further implications for clinicians, researchers or policy makers

The experience of the diabetes mellitus type 2 patients and myocardial infarction patients in the general practitioner everyday working context

Cilj ovog istraživanja bio je povećanje razumijevanja procesa prilagodbe bolesnika na kroničnu bolest, temeljem istraživanja i opisivanja iskustva bolesnika oboljelih od ŠBT2 ili IM u procesu suočavanja, upoznavanja, prihvaćanja i življenja s ovim kroničnim bolestima, u kontekstu svakodnevnog rada obiteljskog liječnika. Ovo kombinirano kvalitativno i kvantitativno istraživanje (engl. mixed-method research) konceptualizirano je i dizajnirano kao primarno kvalitativno, proceduralne sheme: QUAL+quant, te su i kvalitativni i kvantitativni podaci prikupljeni paralelno u isto vrijeme, sa manjim naglaskom na kvantitativnom dijelu, s ciljem utvrđivanja, konvergiraju li rezultati oba istraživanja u smjeru jednog, zajedničkog razumjevanja istraživanog fenomena. Bolesnici su odabrani metodom namjernog uzorkovanja baziranoj na teoriji (engl. theoretical sampling) koje podrazumijeva tri tipa namjernog uzorkovanja: početno otvoreno, potom aksijalno i završno selektivno, u kojima se fokus uzorkovanja mijenjao prema tipu kodiranja. Uzorkovanje je provedeno paralelno s analizom podataka, do zasićenja kategorija. Istraživanjem je obuhvaćeno 64 bolesnika od kojih 32 bolesnika s registriranom šećernom bolešću tipa 2 (MKB X revizija - E11), i 32 bolesnika s registriranim infarktom miokarda (MKB X revizija - I 21, I22, I23, I24.1 i I25.2). Uzorak ispitanika prikupljen je preko 16 liječnika odabranih slučajnim odabirom iz osnovnog skupa od ukupno 424 liječnika zaposlenih u djelatnosti opće/obiteljske medicine Grada Zagreba, u sva tri Doma zdravlja Grada Zagreba (DZ Zagreb Centar, DZ Zagreb Istok i DZ Zagreb Zapad) (103). U kvalitativnom dijelu istraživanja, metodom problemskog usmjerenog (dubinskog) polustrukturiranog intervjua, prikupljeni su podaci od 64 bolesnika (32 koji boluju od šećerne bolesti tip 2 (ŠBT2) i 32 bolesnika koji su preboljeli infarkt miokarda (IM). Paraleleno s intervjuiranjem, provođena je analiza intervjua vodeći se principima „utemeljene“ teorije (engl. „grounded theory“). U kvantitativnom dijelu istraživanja, kod tih istih bolesnika, standardiziranim upitnicima prikupljeni su podaci o doživljaju bolesti, zdravstvenom lokusu kontrole, zadovoljstvu životom i socijalnoj podršci. U obradi podataka korišteni su: kompjuterski softver Atlas.ti (kvalitativna analiza podataka) i statistički program Statistica, ver. 7.1 (obrada kvantitativnih podataka). Kvalitativnom analizom podataka na principima utemeljene teorije, koji su prikupljeni intervjuiranjem bolesnika oboljelih od ŠBT2 ili IM problemskim, polustrukturiranim dubinskim intervjuom, proizašle su četiri teme vezane uz iskustva bolesnika: 1) bolesnikovo iskustvo prilikom saznanja dijagnoze ili spoznaje da ima ŠBT2 ili IM; 2) bolesnikovo iskustvo s prihvaćanjem ŠBT2 ili IM; 3) bolesnikovo iskustvo sa životnim promjenama uslijed ŠBT2 ili IM; i 4) bolesnikovo iskustvo s čimbenicima koji su utjecali na proces prihvaćanja i tijek življenja sa ŠBT2 ili IM. Utjecaj liječnika pokazao se važnim faktorom olakšanja bolesnikova nošenja s bolešću u svakoj od ovih tema: adekvatnom komunikacijom liječnika (korištenje za bolesnike razumljiva jezika, svjesnost verbalne i neverbalne komunikacije), odnosom liječnika prema bolesniku (uzajamno poštovanje i povjerenje, briga za bolesnika i emocionalna podrška), odnos liječnika prema bolesti (stavom liječnika koji naglašava ozbiljnost bolesti) te pružanje dozirane, strukturirane informacije i edukacije na kontinuiranoj bazi u vremenu po postavljanju dijagnoze, uključujući čest kontakt i postupno proširenje dotadašnjeg fonda bolesnikova znanja o bolesti i liječenju. Kvantitativni rezultati upućuju da je zadovoljstvo života za obje skupine bolesnika (na Thurstonovoj skali od 1-10) prosječno unutar «normale» subjektivne kvalitete života [(bolesnici od IM 6,3±3,0 (M±SD), bolesnici od ŠBT2 6,5±2,4 (M±SD)]. Socijalna podrška za obje skupine bolesnika (na Thurstonovoj skali od 1-10) bila je visoka [1. pitanje: (bolesnici od IM 9,6±1,4 (M±SD), bolesnici od ŠBT2 9,0±2,6 (M±SD)], [2. pitanje: (bolesnici od IM 9,6±1,4 (M±SD), bolesnici od ŠBT2 9,0±2,6 (M±SD)]. Većina bolesnika iz našeg istraživanja imala je izražen unutarnji lokus kontrole zdravlja: (skala I: bolesnici od IM 28,2±2,7 (M±SD), bolesnici od ŠBT2 28,9±2,9 (M±SD). Potom je podjednako bilo izraženo vjerovanje u utjecaj okolnosti i važnih drugih (bolesnici od IM: Eo skala 21,6±3,5 (M±SD), te Evd skala 19,5±2,6 (M±SD); bolesnici od ŠBT2; Evd skala 20,0±4,6 (M±SD), te Eo skala 20,0±3,6 (M±SD). Najmanje je bilo izraženo vjerovanje u utjecaj slučaja, sudbine ili loše sreće (skala Es: bolesnici od IM 14,2±3,4 (M±SD); bolesnici oboljeli od ŠBT2 14,1±4,0 (M±SD). Nije utvrđena statistički značajna razlika između dviju skupina bolesnika u zdravstvenom lokusu kontrole. Procjena doživljaja bolesti, određivanjem prosječnih vrijednosti odgovora bolesnika na linearnoj skali Thurstonova tipa od 0-10, pokazala je visoki skor za skale: trajanje bolesti [bolesnici od IM: 9,4±1,5 (M±SD), bolesnici od ŠBT2: 8,2±3,4 (M±SD)]; kontrola bolesti terapijom [bolesnici od IM: 8,6±1,4 (M±SD), bolesnici od ŠBT2: 8,1±1,9 (M±SD)] i razumijevanje bolesti [bolesnici od IM: 7,5±3,0 (M±SD), bolesnici od ŠBT2: 7,5±2,6 (M±SD)]; a umjereno visokim skale: osobna kontrola nad bolešću [bolesnici od IM 6,6±2,6 (M±SD), bolesnici od ŠBT2: 6,9±2,6 (M±SD) ]; utjecaj na život [bolesnici od IM 6,0±2,8 (M±SD) ], te u bolesnika od IM: zabrinutost za bolest 4,4±3,5 (M±SD), emotivna pogođenost bolešću 5,0±3,1 (M±SD), te jakost simptoma 5,1±3,1 (M±SD). Bolesnici od ŠBT2 procijenili su niskim skale: utjecaj na život 3,7±2,9 (M±SD), zabrinutost za bolest 3,2±3,2 (M±SD), emotivna pogođenost bolešću 3,1±3,5 (M±SD), te identitet bolesti 2,7±2,8 (M±SD). Utvrđena je statistički značajna razlika na skalama utjecaj na život (p=0,004), jakost simptoma (p=0,006) i emotivna pogođenost bolešću (p=0,025) u smjeru doživljaja većeg utjecaja bolesti na život, veće jakosti simptoma i veće emotivne pogođenosti bolešću u bolesnika oboljelih od IM. Bolesnici od IM su u procesu suočavanja, upoznavanja, prihvaćanja i življenja s kroničnom bolešću bili suočeni s većom potrebom za promjenama u dotadašnjem životu, jače pogođeni bolešću, te su se brže prilagođavali na bolest od bolesnika od ŠBT2. Iako su obje bolesti imale kompleksno psihološko značenje i za bolesnike predstavljale psihološki teret tijekom procesa suočavanja, upoznavanja, prihvaćanja i življenja, IM doživljen je kao poštenija „fer bolest“ jer je odmah pokazao svoje simptome, dok je ŠBT2 doživljena kao više „nefer, podmukla bolest“, koja u početku “nema simptoma, a onda te zaskoči s komplikacijama“. Rezultati ovog kombiniranog kvalitativnog i kvantitativnog istraživanja još jednom potvrđuju važnost nalaza literature da osobni, psihološki (emotivni i kognitivni), socijalni i kontekstualni elementi bolesnika igraju važnu ulogu u njegovu zdravstvenom ponašanju, te podržavajući principe bolesniku usmjerene skrbi, potiču zdravstvene profesionalce na istraživanje bolesnikove predodžbe (doživljaja) bolesti kao početne točke za daljnje intervencije ostvarenja preporučenog zdravstvenog ponašanja i optimizacije ishoda liječenja kroničnih bolesnika.The aim of this study was to gain insight into the process of adaptation to chronic illness, based on the investigation and description of diabetes mellitus type 2 (DMT2) patients or myocardial infarction (MI) patients experience, in the process of confrontation, getting acquainted with, accepting and living with those two diseases, in the general practitioner everyday working context. The present mixed-method study was conceptualized and designed as a dominantly qualitative, which is indicated by the following procedural notation: QUAL+quant. That is, both qualitative and quantitative data were collected at the same time, and the primary methodology was qualitative, with a lesser emphasis on the quantitative portion, to determine if the two converge upon a single understanding of the research problem being investigated. The sample was purposeful, based on the method of theoretical sampling, which consisted of three sampling types: initial open coding, than axial coding and final selective coding, with changing of the sampling focus according to the coding type. Sampling process was parallel to data analysis, until the saturation of all categories. 60 subjects were enrolled in study, 30 DMT2 patients and 30 MI patients. In qualitative part of the study, using method of the structured depth interviewing, data on 60 patients experience with their chronic illness were gathered (30 DMT2 and 30 MI patients). In the quantitative part of the study, using standardized questionnaires, data on illness perception, health locus of control, life satisfaction and social support were gathered. The qualitative results were analyzed, parallel to interviewing and based on the principles of grounded theory, using the qualitative data analysis and research software ATLAS.ti, while the quantitative results were analyzed using descriptive nonparametric statistical procedures due to the fact that distributions of all relevant quantitative variables showed a significant decline from normal distribution (Kruskal-Wallis test, Wilcoxson-Mann- Whitney test) Four themes emerged from the qualitative data: patients experience while confronting the diagnosis of DMT2 or MI; patients experience during process of accepting DMT2 or MI; patients experience with DMT2 or MI related life changes; and patients experience with factors influencing process of accepting and life with DMT2 or MI. Quantitative results showed that, for both groups of patients, quality of life was average within an “normal” of subjective quality of life [(MI patients 6.3±3.0 (M±SD), DMT2 patients 6.5±2.4 (M±SD)], while social support was high (MI patients 9.6±1.4 (M±SD), DMT2 patients 9.0±2.6 (M±SD)]. In both groups of patients was mostly expressed believe in internal LOC [(I scale: MI patients 28.2±2.7 (M±SD); DMT2 patients 28.9±2.9 (M±SD)]. Than it was equally expressed believe in dependence of health on circumstances [(Eo scale: MI patients 21.6±3.5 (M±SD); DMT2 patients 20.0±3.6 (M±SD)], and influence of powerful others [(Evd scale IM patients 19.5±2.6 (M±SD); DMT2 patients 20.0±4.6 (M±SD)]. Least of all patients believe in influence of chance, destiny or god [(Es scale: MI patients 14.2±3.4 (M±SD); DMT2 patients 14.1±4.0 (M±SD)]. The patients’ illness perception assessment on an 11-point (0 to10) scale showed the highest median scores±standard deviation: “timeline” (MI patients: 9.4±1.5, DMT2 patients: 8.2±3.4), “treatment control” (MI patients: 8.6±1.4, DMT2 patients: 8.1±1.9), and for “understanding” (MI patients: 7.5±3.0 DMT2 patients: 7.5±2.6), followed by: “personal control” (MI patients 6.6±2.6, DMT2 patients: 6.9±2.6), “consequences” (MI patients 6.0±2.8), and for MI patients: “concern” (4.4±3.5), “emotional response”(5.0±3.1), and “identity” (5.1±3.1). DMT2 patients assessed following scales low: “consequences” (3.7±2.9), “concern” (3.2±3.2), “emotional response”(3.1±3.5), “identity” (2.7±2.8). MI patients assessed significantly higher scales “consequences” (p=0.004), “identity” (p=0.006) and “concern” (p=0.025) than DMT2 patients. MI patients were in the process of confrontation, getting acquainted with, accepting and living with chronic illness faced with need for greater changes in their life (qualitative results), more affected with illness [qualitative results + quantitative results (identity, consequences, concern)], and adjusted faster to their illness than DMT2 patients [qualitative results + quantitative results (identity, consequences, concern)]. Although, both illnesses had complex psychological meaning and for both groups of patients played psychological burden during processes of confronting, getting acquainted with, accepting and living with those two illnesses, MI was perceived as more „fair“ illness since it instantly shows its symptoms, while DMT2 was perceived more „unfair, perfidious“illness, which in the beginning doesn’t show its symptoms, but after some time “it ambush patient with complications“. Results of this mixed/method research once again confirm the importance of the literature finding that patient personal, psychological (emotive and cognitive), social and contextual factors play important role in patients health behavior, and supporting the principles of patient centered care, encourage the health professionals on the investigation of patient illness perception as a starting point for further intervention in order to accomplish recommended heath behavior and optimization of chronic patients treatment outcomes

The experience of the diabetes mellitus type 2 patients and myocardial infarction patients in the general practitioner everyday working context

Cilj ovog istraživanja bio je povećanje razumijevanja procesa prilagodbe bolesnika na kroničnu bolest, temeljem istraživanja i opisivanja iskustva bolesnika oboljelih od ŠBT2 ili IM u procesu suočavanja, upoznavanja, prihvaćanja i življenja s ovim kroničnim bolestima, u kontekstu svakodnevnog rada obiteljskog liječnika. Ovo kombinirano kvalitativno i kvantitativno istraživanje (engl. mixed-method research) konceptualizirano je i dizajnirano kao primarno kvalitativno, proceduralne sheme: QUAL+quant, te su i kvalitativni i kvantitativni podaci prikupljeni paralelno u isto vrijeme, sa manjim naglaskom na kvantitativnom dijelu, s ciljem utvrđivanja, konvergiraju li rezultati oba istraživanja u smjeru jednog, zajedničkog razumjevanja istraživanog fenomena. Bolesnici su odabrani metodom namjernog uzorkovanja baziranoj na teoriji (engl. theoretical sampling) koje podrazumijeva tri tipa namjernog uzorkovanja: početno otvoreno, potom aksijalno i završno selektivno, u kojima se fokus uzorkovanja mijenjao prema tipu kodiranja. Uzorkovanje je provedeno paralelno s analizom podataka, do zasićenja kategorija. Istraživanjem je obuhvaćeno 64 bolesnika od kojih 32 bolesnika s registriranom šećernom bolešću tipa 2 (MKB X revizija - E11), i 32 bolesnika s registriranim infarktom miokarda (MKB X revizija - I 21, I22, I23, I24.1 i I25.2). Uzorak ispitanika prikupljen je preko 16 liječnika odabranih slučajnim odabirom iz osnovnog skupa od ukupno 424 liječnika zaposlenih u djelatnosti opće/obiteljske medicine Grada Zagreba, u sva tri Doma zdravlja Grada Zagreba (DZ Zagreb Centar, DZ Zagreb Istok i DZ Zagreb Zapad) (103). U kvalitativnom dijelu istraživanja, metodom problemskog usmjerenog (dubinskog) polustrukturiranog intervjua, prikupljeni su podaci od 64 bolesnika (32 koji boluju od šećerne bolesti tip 2 (ŠBT2) i 32 bolesnika koji su preboljeli infarkt miokarda (IM). Paraleleno s intervjuiranjem, provođena je analiza intervjua vodeći se principima „utemeljene“ teorije (engl. „grounded theory“). U kvantitativnom dijelu istraživanja, kod tih istih bolesnika, standardiziranim upitnicima prikupljeni su podaci o doživljaju bolesti, zdravstvenom lokusu kontrole, zadovoljstvu životom i socijalnoj podršci. U obradi podataka korišteni su: kompjuterski softver Atlas.ti (kvalitativna analiza podataka) i statistički program Statistica, ver. 7.1 (obrada kvantitativnih podataka). Kvalitativnom analizom podataka na principima utemeljene teorije, koji su prikupljeni intervjuiranjem bolesnika oboljelih od ŠBT2 ili IM problemskim, polustrukturiranim dubinskim intervjuom, proizašle su četiri teme vezane uz iskustva bolesnika: 1) bolesnikovo iskustvo prilikom saznanja dijagnoze ili spoznaje da ima ŠBT2 ili IM; 2) bolesnikovo iskustvo s prihvaćanjem ŠBT2 ili IM; 3) bolesnikovo iskustvo sa životnim promjenama uslijed ŠBT2 ili IM; i 4) bolesnikovo iskustvo s čimbenicima koji su utjecali na proces prihvaćanja i tijek življenja sa ŠBT2 ili IM. Utjecaj liječnika pokazao se važnim faktorom olakšanja bolesnikova nošenja s bolešću u svakoj od ovih tema: adekvatnom komunikacijom liječnika (korištenje za bolesnike razumljiva jezika, svjesnost verbalne i neverbalne komunikacije), odnosom liječnika prema bolesniku (uzajamno poštovanje i povjerenje, briga za bolesnika i emocionalna podrška), odnos liječnika prema bolesti (stavom liječnika koji naglašava ozbiljnost bolesti) te pružanje dozirane, strukturirane informacije i edukacije na kontinuiranoj bazi u vremenu po postavljanju dijagnoze, uključujući čest kontakt i postupno proširenje dotadašnjeg fonda bolesnikova znanja o bolesti i liječenju. Kvantitativni rezultati upućuju da je zadovoljstvo života za obje skupine bolesnika (na Thurstonovoj skali od 1-10) prosječno unutar «normale» subjektivne kvalitete života [(bolesnici od IM 6,3±3,0 (M±SD), bolesnici od ŠBT2 6,5±2,4 (M±SD)]. Socijalna podrška za obje skupine bolesnika (na Thurstonovoj skali od 1-10) bila je visoka [1. pitanje: (bolesnici od IM 9,6±1,4 (M±SD), bolesnici od ŠBT2 9,0±2,6 (M±SD)], [2. pitanje: (bolesnici od IM 9,6±1,4 (M±SD), bolesnici od ŠBT2 9,0±2,6 (M±SD)]. Većina bolesnika iz našeg istraživanja imala je izražen unutarnji lokus kontrole zdravlja: (skala I: bolesnici od IM 28,2±2,7 (M±SD), bolesnici od ŠBT2 28,9±2,9 (M±SD). Potom je podjednako bilo izraženo vjerovanje u utjecaj okolnosti i važnih drugih (bolesnici od IM: Eo skala 21,6±3,5 (M±SD), te Evd skala 19,5±2,6 (M±SD); bolesnici od ŠBT2; Evd skala 20,0±4,6 (M±SD), te Eo skala 20,0±3,6 (M±SD). Najmanje je bilo izraženo vjerovanje u utjecaj slučaja, sudbine ili loše sreće (skala Es: bolesnici od IM 14,2±3,4 (M±SD); bolesnici oboljeli od ŠBT2 14,1±4,0 (M±SD). Nije utvrđena statistički značajna razlika između dviju skupina bolesnika u zdravstvenom lokusu kontrole. Procjena doživljaja bolesti, određivanjem prosječnih vrijednosti odgovora bolesnika na linearnoj skali Thurstonova tipa od 0-10, pokazala je visoki skor za skale: trajanje bolesti [bolesnici od IM: 9,4±1,5 (M±SD), bolesnici od ŠBT2: 8,2±3,4 (M±SD)]; kontrola bolesti terapijom [bolesnici od IM: 8,6±1,4 (M±SD), bolesnici od ŠBT2: 8,1±1,9 (M±SD)] i razumijevanje bolesti [bolesnici od IM: 7,5±3,0 (M±SD), bolesnici od ŠBT2: 7,5±2,6 (M±SD)]; a umjereno visokim skale: osobna kontrola nad bolešću [bolesnici od IM 6,6±2,6 (M±SD), bolesnici od ŠBT2: 6,9±2,6 (M±SD) ]; utjecaj na život [bolesnici od IM 6,0±2,8 (M±SD) ], te u bolesnika od IM: zabrinutost za bolest 4,4±3,5 (M±SD), emotivna pogođenost bolešću 5,0±3,1 (M±SD), te jakost simptoma 5,1±3,1 (M±SD). Bolesnici od ŠBT2 procijenili su niskim skale: utjecaj na život 3,7±2,9 (M±SD), zabrinutost za bolest 3,2±3,2 (M±SD), emotivna pogođenost bolešću 3,1±3,5 (M±SD), te identitet bolesti 2,7±2,8 (M±SD). Utvrđena je statistički značajna razlika na skalama utjecaj na život (p=0,004), jakost simptoma (p=0,006) i emotivna pogođenost bolešću (p=0,025) u smjeru doživljaja većeg utjecaja bolesti na život, veće jakosti simptoma i veće emotivne pogođenosti bolešću u bolesnika oboljelih od IM. Bolesnici od IM su u procesu suočavanja, upoznavanja, prihvaćanja i življenja s kroničnom bolešću bili suočeni s većom potrebom za promjenama u dotadašnjem životu, jače pogođeni bolešću, te su se brže prilagođavali na bolest od bolesnika od ŠBT2. Iako su obje bolesti imale kompleksno psihološko značenje i za bolesnike predstavljale psihološki teret tijekom procesa suočavanja, upoznavanja, prihvaćanja i življenja, IM doživljen je kao poštenija „fer bolest“ jer je odmah pokazao svoje simptome, dok je ŠBT2 doživljena kao više „nefer, podmukla bolest“, koja u početku “nema simptoma, a onda te zaskoči s komplikacijama“. Rezultati ovog kombiniranog kvalitativnog i kvantitativnog istraživanja još jednom potvrđuju važnost nalaza literature da osobni, psihološki (emotivni i kognitivni), socijalni i kontekstualni elementi bolesnika igraju važnu ulogu u njegovu zdravstvenom ponašanju, te podržavajući principe bolesniku usmjerene skrbi, potiču zdravstvene profesionalce na istraživanje bolesnikove predodžbe (doživljaja) bolesti kao početne točke za daljnje intervencije ostvarenja preporučenog zdravstvenog ponašanja i optimizacije ishoda liječenja kroničnih bolesnika.The aim of this study was to gain insight into the process of adaptation to chronic illness, based on the investigation and description of diabetes mellitus type 2 (DMT2) patients or myocardial infarction (MI) patients experience, in the process of confrontation, getting acquainted with, accepting and living with those two diseases, in the general practitioner everyday working context. The present mixed-method study was conceptualized and designed as a dominantly qualitative, which is indicated by the following procedural notation: QUAL+quant. That is, both qualitative and quantitative data were collected at the same time, and the primary methodology was qualitative, with a lesser emphasis on the quantitative portion, to determine if the two converge upon a single understanding of the research problem being investigated. The sample was purposeful, based on the method of theoretical sampling, which consisted of three sampling types: initial open coding, than axial coding and final selective coding, with changing of the sampling focus according to the coding type. Sampling process was parallel to data analysis, until the saturation of all categories. 60 subjects were enrolled in study, 30 DMT2 patients and 30 MI patients. In qualitative part of the study, using method of the structured depth interviewing, data on 60 patients experience with their chronic illness were gathered (30 DMT2 and 30 MI patients). In the quantitative part of the study, using standardized questionnaires, data on illness perception, health locus of control, life satisfaction and social support were gathered. The qualitative results were analyzed, parallel to interviewing and based on the principles of grounded theory, using the qualitative data analysis and research software ATLAS.ti, while the quantitative results were analyzed using descriptive nonparametric statistical procedures due to the fact that distributions of all relevant quantitative variables showed a significant decline from normal distribution (Kruskal-Wallis test, Wilcoxson-Mann- Whitney test) Four themes emerged from the qualitative data: patients experience while confronting the diagnosis of DMT2 or MI; patients experience during process of accepting DMT2 or MI; patients experience with DMT2 or MI related life changes; and patients experience with factors influencing process of accepting and life with DMT2 or MI. Quantitative results showed that, for both groups of patients, quality of life was average within an “normal” of subjective quality of life [(MI patients 6.3±3.0 (M±SD), DMT2 patients 6.5±2.4 (M±SD)], while social support was high (MI patients 9.6±1.4 (M±SD), DMT2 patients 9.0±2.6 (M±SD)]. In both groups of patients was mostly expressed believe in internal LOC [(I scale: MI patients 28.2±2.7 (M±SD); DMT2 patients 28.9±2.9 (M±SD)]. Than it was equally expressed believe in dependence of health on circumstances [(Eo scale: MI patients 21.6±3.5 (M±SD); DMT2 patients 20.0±3.6 (M±SD)], and influence of powerful others [(Evd scale IM patients 19.5±2.6 (M±SD); DMT2 patients 20.0±4.6 (M±SD)]. Least of all patients believe in influence of chance, destiny or god [(Es scale: MI patients 14.2±3.4 (M±SD); DMT2 patients 14.1±4.0 (M±SD)]. The patients’ illness perception assessment on an 11-point (0 to10) scale showed the highest median scores±standard deviation: “timeline” (MI patients: 9.4±1.5, DMT2 patients: 8.2±3.4), “treatment control” (MI patients: 8.6±1.4, DMT2 patients: 8.1±1.9), and for “understanding” (MI patients: 7.5±3.0 DMT2 patients: 7.5±2.6), followed by: “personal control” (MI patients 6.6±2.6, DMT2 patients: 6.9±2.6), “consequences” (MI patients 6.0±2.8), and for MI patients: “concern” (4.4±3.5), “emotional response”(5.0±3.1), and “identity” (5.1±3.1). DMT2 patients assessed following scales low: “consequences” (3.7±2.9), “concern” (3.2±3.2), “emotional response”(3.1±3.5), “identity” (2.7±2.8). MI patients assessed significantly higher scales “consequences” (p=0.004), “identity” (p=0.006) and “concern” (p=0.025) than DMT2 patients. MI patients were in the process of confrontation, getting acquainted with, accepting and living with chronic illness faced with need for greater changes in their life (qualitative results), more affected with illness [qualitative results + quantitative results (identity, consequences, concern)], and adjusted faster to their illness than DMT2 patients [qualitative results + quantitative results (identity, consequences, concern)]. Although, both illnesses had complex psychological meaning and for both groups of patients played psychological burden during processes of confronting, getting acquainted with, accepting and living with those two illnesses, MI was perceived as more „fair“ illness since it instantly shows its symptoms, while DMT2 was perceived more „unfair, perfidious“illness, which in the beginning doesn’t show its symptoms, but after some time “it ambush patient with complications“. Results of this mixed/method research once again confirm the importance of the literature finding that patient personal, psychological (emotive and cognitive), social and contextual factors play important role in patients health behavior, and supporting the principles of patient centered care, encourage the health professionals on the investigation of patient illness perception as a starting point for further intervention in order to accomplish recommended heath behavior and optimization of chronic patients treatment outcomes