ABSTRACT
In contemporary Ghana, several medical problems are being
reported at the general hospitals and clinics for treatment. Most of these
medical problems are accompanied by mental health problems. However, the mental
health elements of the medical conditions are usually neglected though
researches have demonstrated that the associated mental health problems can
influence the prognosis and the course of such illnesses. This study sought to
explore the relationships that exist between patients’ illness perception,
religiosity and their mental health. The target population of the study was all
diabetic patients attending a health facility numbering 250, seeking treatment
for diabetes in the Cape Coast Metropolis in the Central Region of Ghana. A
sample size of 103 diabetic patients from 250 patients was selected through the
convenience sampling technique from the population. Descriptive survey design
involving the quantitative approach was used in the study. Quantitative data
were gathered through questionnaires and were analyzed using descriptive
statistics (frequencies and percentages, means and standard deviation) and
inferential statistics (Pearson correlation and independent sample t-test). The
study revealed that, generally, diabetic patients’ in the metropolis have a
high level of religiosity. Again, result indicated that there was a negative
correlation between diabetic patients’ religiosity and their mental health
(r = -.286**, n = 103, p < 0.05, p=0.003, 2-tailed). Results also indicated that
there was a weak positive relationship between illness perception of diabetic
patients and their mental health(r=.080, n=103, p < 0.05, p = 0.421, 2-tailed).
Based on the findings, a holistic and comprehensive model of healthcare such as
the Biopsychosocial model should be incorporated at the various health centres
across the nation.
CHAPTER ONE
INTRODUCTION
Background of Study
Diabetes can be defined as a situation where an individual’s
body is incapable of producing the hormone insulin in levels required by the
body cells to take up optimal glucose (Kumar & Clark, 2005). Also, Diabetes
mellitus is a metabolic disorder characterized by chronic hyperglycemia with
disturbances of carbohydrate, fat and protein metabolism resulting from defects
in insulin secretion, insulin action, or both.
Further, diabetes mellitus is characterized by gross loss of
weight, frequent urination, excessive thirst and slow healing of wounds. Some
other symptoms of diabetes include chronic fatigue and changes in vision.
Therefore, if the diabetic condition is not well managed it can lead to
complications such as loss of blood circulation to the heart and limbs (Darkwa,
2011). Failure of circulation of blood to the heart and limbs could pose
serious threats to the lives of those suffering from the condition. These
serious complications of diabetes are likely to predispose the diabetes
patients to mental health problems that are commonly found among sufferers of
chronic illnesses (Darkwa, 2011).
There are three broad categories of diabetes mellitus and
these are the Type -1, Type-2 and Gestational diabetes. Type 1diabetes
indicates the processes of beta–cell destruction that may ultimately lead to
diabetes mellitus in which “insulin is required for survival” to prevent the
development of ketoacidosis, coma and death (World Health Organization,
1999). Type II diabetes is the commonest form of diabetes and is characterized
by disorders of insulin secretion and insulin resistance. Gestational Diabetes
(GD) mellitus refers to the onset or initial recognition of glucose intolerance
during pregnancy, usually in the second or third trimester (American Diabetes
Association, 2001).
Diabetes is one notable long term illness that is strongly
associated with mental health such as depression and anxiety. People living
with diabetes are two to three times more likely to have depression than the
general population (Fenton and Stover 2006; Simon, Shear, Thompson, Zalta,
Perlman, Reynolds, Frank, Melhem, Silowash, 2007; Vamos, Mucsi, Keszei, Kopp,
Novak, 2009). As observed for cardiovascular disease, prevalence estimates vary
but the proportionate increase is consistent (Anderson et al 2001).
Analysis of more than 13,000 twins in Sweden found that mid-
and late-life onset of diabetes was associated with a respective 176 per cent
and 63 per cent increase in the risk of dementia (Xu et al 2009). Another study
in Japan reported that over an 11-year period 27 per cent of a group of people
over 60 with diabetes developed dementia compared with 21 per cent of a matched
cohort without diabetes (Ohara, Doi, Ninomiya, Hirakawa, Hata, Iwaki, Kanba,
Kiyohara 2011). The risk of developing dementia is even higher among people who
have depression as well as diabetes (Katon, 2011).
In sub-Saharan Africa (SSA), chronic illnesses are on the
increase, however, growth rates of diabetes mellitus (DM) and hypertension are
among the highest chronic diseases worldwide (Danquah, Bedu-Addo, Terp, Micah,
Amoako, Awuku, Dietz, Giet, Spranger, Mockenhaupt, 2012). In
Ghana, it is estimated that 4 million people are living with diabetes and this
number is expected to rise in the near future (National Diabetes Association of
Ghana, 2012). Thus, several people are living with diabetes and its attendance
complications. It is therefore believed that by 2025, more than 75% of the
world population with diabetes will reside in developing countries and the
countries with the largest populations of adults with diabetes will include:
India, China and the United States (King, Aubert, & Herman, 1998).
Living with any type of chronic disease, the person either
has to make minor or major lifestyle adjustments. Diabetes, in particular, can
eventually take its toll on the emotional, psychological, and physical
wellbeing of any person. These adjustments can lead to either successful
adherence to medical regimens and control of the disease, or among other
things, ineffective or maladaptive coping (Duangdao & Roesch, 2008). How
the individual adjusts to the diabetic condition depends on the resources
available to the individual at personal, community and societal levels.
Several factors have been identified to have a significant
influence on the mental health and illness outcome of diabetic patients. Some
of these factors include illness perception, level of patients‟ religiosity as
well as the patients‟ demographic characteristics. In the case of diabetic
patients, Mosorovic, Brkic, Nuhbegovic and Pranjic (2012) asserted that
diabetes mellitus is a disease that is no longer just an individual problem,
but it is assuming psychological and socio-medical significance of mass
disease. Thus, in trying to reduce the rate of complications associated with
diabetes, both psychological as well as socio-medical factors should be
taken into consideration.
Several factors have been found to influence the levels of
mental health problems among diabetic patients. One of these variables is how
the diabetic patients perceive their illness. Illness perception has been
studied extensively in relation to several medical and psychological
conditions. Perception is described as the process by which an individual
interprets and organizes sensations and events to produce a meaningful experience
of the world (Lindsay & Norman, 1977). These interpretations are guided by
the specific knowledge, beliefs and expectations characterizing the individual
(Alsén, 2009). Perception in terms of illness may be conceptualised as how
people understand and make sense of their diseases and/or disabilities, e.g.
illness perceptions. In this respect, illness perceptions to some extent
correspond to the conceptualizations of illness in contrast to disease (Alsén,
2009).
There are several determinants of health outcomes among
patients suffering from any form of illness and as such, outcomes of medical
management in patients with chronic illness are determined not only by
objective factors but also by behavioural and social factors (Leventhal,
Weinman, Leventhal &Phillips, 2008). Some of these behavioural and social
factors are related to how the patients appraise their illness on several
dimensions. Some of these perceptual dimensions of the illness perception
include the causal attribution, timeline, severity, consequences, understanding
as well as the personal control of the individual over the condition. The
extent of these perceptions to a large extent determines how the
individual patients react to treatment as well as other management regiments.
Furthermore, research has shown that people vary in how they
perceive their health status and that these perceptions often are independent
of the actual physical conditions that are being suffered (Taylor, Kemeny,
Reed, Bower & Gruenewald, 2000). For example, people vary in how they
perceive their possibilities to influence or control their health (Wallston,
2004), whether their condition is acute or chronic (Lau & Hartman, 1983) or
whether or not their specific situation is hopeful (Scheier & Carver,
1985). Such perceptions may in turn determine individuals‟ behaviour as well as
their response to managing health threats related to a disease or a symptom
(Alsén, 2009). Thus, the individual’s active role in terms of thought processes
affect their health outcomes and therefore, Schrag, Jahanshashi and Quinn
(2001) asserted that patients‟ perceptions of their condition are likely to
play an important role in how they adjust to their illness.
Additionally, the individual’s level of religiosity has been
shown to have significant influences on his/her psychological wellbeing.
However, the study of religion in psychology has not been without disagreements
as it is seen as not being scientific. In the past years there has been a
change from negative attitudes in psychology, concerning religion, to the
identification of more positive relations between religion and different aspects
of mental health (Rusu &Turliuc, 2011). Religiosity is a multi-layered
concept involving cognitive, emotional, motivational and behavioural aspects
(Hackney & Sanders, 2003). Richards and Bergin (1997) see religion as a
subset of the spiritual, considering that is possible for someone to be
spiritual without being religious and to be religious without being spiritual. Being
spiritual means having a transcendental relation with a superior being, whereas
being religious means adopting a certain religious creed or church (Rusu
&Turliuc, 2011). However, this separation of religiosity and spirituality
is not the case in our context as spirituality and religiosity cannot be
decoupled. Thus, a religious person in the Ghanaian setting is seen as
spiritual and vice versa.
Furthermore, religion is seen to have important influence on
the individual as well as the society at large. For instance, Frey and Stutzer
(2002) asserted that religion raises happiness because church attendance is an
important source of social support. Also, religion can instill life with
meaning and purpose, and religious people are better at dealing with negative
circumstances in life and church members live healthier lives and live longer which
also contributes to happiness (Frey & Stutzer, 2002). As result of these
influences of religion on the individual, Krause and Wulff (2005) noted that
that church-based friendship may promote a sense of belonging and thus enhance
physical and mental health.
More so, research evidence has pointed to the fact that some
forms of religiosity are associated with specific health related issues. For
example, religiosity has been associated with low levels of depression
(McCullough & Larson, 1999), a personal well-being (Koenig, 2001), positive
social attitudes (Baton et al., 1993), a low risk of divorce and an increase in
the degree of marital functionality (Mahoney, Pargament, Tarakeshwar &
Swank, 2001). Tsang and McCullough (2003) in their analysis of the relationship
between religiosity and health related issues, it was shown that religiosity
correlates significantly with physical and mental health, tolerance, pro-social
behaviour and positive interpersonal relationships. These significant
influences of religiosity on several aspects of individual’s life is worth
exploring to ascertain the extent to which religiosity affects these aspect of
existent.
More so, some demographic characteristics of the diabetic
patients have been shown to predispose them to mental health problems. Some of
these demographic characteristics of the diabetic patients include sex, age,
marital status, duration of illness and type of diabetes among others. For
instance, Jimenez-Garcıa et al., (2011), Guruprasad, Niranjanand and Ashwin
(2012) and Hermanns et al., (2005) found among diabetic patients that the
female sex is a risk factor for development of psychological distress. Other
researchers have also found significant age differences in the development of
mental health problems among diabetic patients (Paddison, 2010; Jimenez-Garcıa
et al, 2011; Jadoon et al., 2012).
From the discussions of the variables above, it becomes
necessary to investigate how these variables relate with one another. That is,
an individual perception of the illness may result in dependence on his/her
religious faith to adjust to the illness. Perceiving the illness as threatening
is usually accompanied by psychological distress. However, these perceptions and
reactions to the illness are usually influenced by individual characteristics.
Therefore, the individual characteristics of the diabetic patients influence
their mental health significantly.
Statement of the Problem
In contemporary Ghana, several medical problems are being
reported at the general hospitals and clinics for treatment. Most of these
medical problems are accompanied by mental health problems. However, the mental health elements of the medical conditions are usually
neglected though researches have demonstrated that the associated mental health
problems can influence the prognosis and the course of such illnesses (Lin et
al., 2004). Even though there has been researches done, there has been a
continuous neglect on the need to adopt holistic measures to health care
provision, such as considering the patient’s religious and psychological needs.
Many diabetes patients find it challenging to make the lifestyle changes necessary
to stay healthy. Making healthy lifestyle choices is important for people with
type 2 diabetes.
Additionally, with the high prevalence of diabetes mellitus
predicted to be very high by 2030 (Shaw, Sicree & Zimmet, 2010) and
affecting people mostly in developing countries, the psychological care and
intervention that is required alongside other orthodox treatment of diseases.
The individual patients may have their own ways of dealing with the mental
health challenges that accompany their illness but the question is, which
individual resources do they use, how do they use them and how these individual
resources affect their general mental health. Therefore, there is the need to
identify the factors that are likely to have significant influence on mental
health of diabetic patients to inform therapy.
In the management of these physical conditions, one would
think that all health-related professionals would be brought on board but the
opposite is what we are facing in Ghana. Thus, psychological care is very
critical in the management of diabetic patients.
Furthermore, one crucial aspect of health that seems to be
ignored in healthcare delivery in the country is the interpretations and
beliefs held by the patients about their illness (diabetes). This is because the
beliefs and perceptions held by an individual about their health conditions to
a large extent influence their health outcomes and treatment regimen. That is,
if the individual perceives his/her illness to be more or less threatening, how
does this affect his/her wellbeing? Therefore, when these beliefs and
perceptions about the illness (diabetes) are not understood and incorporated
into the care of diabetic patients, a lot of problems are neglected as several
researchers have demonstrated a significant association between illness
perception and mental and physical health outcomes (e. g. Broadbent, Donkin
& Stroh, 2011; Petricek, Vrcić-Keglević, Vuletic 2009; Leventhal,
Leventhal, & Cameron, 2001).
More so, a central part of the Ghanaian which is religion
(Gyekye, 1996) seems to be neglected in the provision of healthcare especially
in the physical illnesses. However, as the complications of diabetes are not
limited to only the medical ones, most people rely on their individual
resources such as religion to cope with the illness. The question that arises
is whether the diabetic patients‟ religious resources are utilized in providing
healthcare services as it is well known that prayer camps and healing centers
continue to serve as refuge for patients. To address this shortfall however,
research is needed to examine whether indeed the individual’s level of
religiosity protects him/her against unfavorable consequences of diabetes.
In a nutshell, it is very important to consider factors such
as patients’ perception of an illness and their level of religiosity in
relation to their mental wellbeing in order to streamline an effective
treatment regimen that would ensure both psychological and medical wellbeing.
For this to be realized there is an urgent need to clearly spell out the roles or functions
of illness perception and levels of religiosity and its influence on the mental
wellbeing among patients. To rule out or discredit the relevance of these two
actors will be a grave error and miscalculation on the part of health care
providers and can lead to more serious complications. So far, very limited
studies have been conducted on the perception and religiosity on the mental
health patients’ mental health. This study however, extends the scope to
include mental health.
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