SStt.. CCaatthheerriinnee UUnniivveerrssiittyy SSOOPPHHIIAA Master of Social Work Clinical Research Papers School of Social Work 5-2013 TThhee IInnccoorrppoorraattiioonn ooff IInntteeggrraattiivvee MMeeddiicciinnee ttoo AAsssseessss aanndd AAddddrreessss DDiiaabbeettiicc PPaattiieennttss’’ PPssyycchhoossoocciiaall NNeeeeddss Jennifer E. Ranallo St. Catherine University Follow this and additional works at: https://sophia.stkate.edu/msw_papers Part of the Social Work Commons RReeccoommmmeennddeedd CCiittaattiioonn Ranallo, Jennifer E.. (2013). The Incorporation of Integrative Medicine to Assess and Address Diabetic Patients’ Psychosocial Needs. Retrieved from Sophia, the St. Catherine University repository website: https://sophia.stkate.edu/msw_papers/250 This Clinical research paper is brought to you for free and open access by the School of Social Work at SOPHIA. It has been accepted for inclusion in Master of Social Work Clinical Research Papers by an authorized administrator of SOPHIA. For more information, please contact [email protected]. Running head: INTEGRATIVE MEDICINE & DIABETICS’ NEEDS The Incorporation of Integrative Medicine to Assess and Address Diabetic Patients’ Psychosocial Needs by Jennifer E. Ranallo, B.A.S. MSW Clinical Research Paper Presented to the Faculty of the School of Social Work St. Catherine University and the University of St. Thomas St. Paul, Minnesota In Partial fulfillment of the Requirement for the Degree of Master in Social Work Committee Members GRSW 682 Katharine Hill, Ph.D., MSW, MPP, LISW (Chair) Lynn Manning, M.D. Carissa Morris, M.A., MSW, LGSW The Clinical Research Project is a graduation requirement for MSE students at St. Catherine University/University of St. Thomas School of Social Work in St. Paul, Minnesota and is conducted within a nine-month time frame to demonstrate facility with basic social research methods. Students must independently conceptualize a research problem, formulate a research design that is approved by a research committee and the university Institutional Review Board, implement the project and publicly present the findings of the study. This project is neither a Master’s thesis nor a dissertation. INTEGRATIVE MEDICINE & DIABETICS’ NEEDS ii Abstract The purpose of this project was to increase the understanding of the assessment, implementation and referral of Complementary and Alternative Medicine (CAM) in order to meet psychosocial needs and decrease stress among diabetic patients. Using a mixed method design, both qualitative and quantitative research questions were incorporated into a survey distributed using a non-probability sample of healthcare professionals working in family medicine or general medicine practices within the metro area. The study attempted to answer the following questions: Is integrative medicine being conducted by healthcare professionals to address type 1 and type 2 diabetic patients’ psychosocial needs in family medicine and primary care settings? Is IM being assessed, referred and implemented in family medicine and primary care settings? Quantitative data was analyzed using both descriptive and inferential statistical analyses. Qualitative data was interpreted using the content analysis technique. Findings indicated respondents who ask about CAM use during clinic appointments are more likely to implement CAM during office appointments. Respondents that ask about CAM during office visits were more likely to refer to CAM for additional care. Next, there was an increased likelihood of putting psychosocial interventions in the treatment plan when respondents assessed for diabetic patients’ psychosocial needs. The respondents who endorsed practicing CAM personally were more likely than those who have not to refer diabetic patients’ to CAM for additional needs. Findings suggested that implementing CAM is not a standard practice. Findings related to barriers were consistent with previous literature. Respondents endorsed an increase in blood sugars are a result of stress among diabetic patients. These findings emphasize the importance of assessing and addressing psychosocial needs among diabetics in order to decrease the harmful effects of stress. Keywords: Complementary and Alternative Medicine (CAM), Integrative Medicine (IM), conventional medicine, Diabetes Mellitus, assessment, stress, psychosocial needs, assessment, implementation, referral, primary care, barriers, INTEGRATIVE MEDICINE & DIABETICS’ NEEDS iii Acknowledgements I would like to extend an enormous debt of gratitude to my research chair, Katharine Hill and to my committee members Dr. Lynn Manning and Carissa Morris for their time, expertise, and commitment to this project. Additionally, I want to thank my husband, family and friends for their support during graduate school; particularly over this past year. I would not have been able to do it without you! INTEGRATIVE MEDICINE & DIABETICS’ NEEDS iv Table of Contents Abstract ii Acknowledgments iii Table of Contents iv List of Tables & Figures v Introduction 1 Purpose Statement 7 Definitions 7 Conceptual Framework 11 Literature review 19 Research Question 45 Methods 45 Research Design 45 Sample 46 Data collection instrument and process 47 Protection of Human Subjects 47 Data analysis plan 48 Strengths and limitations 49 Findings 50 Discussion 84 Implications & Conclusions 94 References 99 Appendices Appendix A—Agency Approval Letter 113 Appendix B—Informed Consent Form 114 Appendix C—Survey 116 Appendix D—Additional Findings 124 INTEGRATIVE MEDICINE & DIABETICS’ NEEDS v List of Tables and Figures Figure 1. Percentage of Time Curricula Focused on CAM 53 Figure 2. Frequency of CAM Referrals for Psychosocial Needs 60 Table 3. Chi-Square for Implementation of CAM 62 Table 4. Chi-Square Tests for Educational Degree 64 Table 5. Chi-Square Tests for Professional Identity 68 Table 6. Chi-Square Tests for Asking about CAM in Office 69 Table 7. Chi-Square Tests for Frequency of Referral to CAM for Additional Care 71 Table 8. Chi-Square Tests Effects of Stress on Diabetic Control 74 Table 9. Chi-Square Tests for Similarity of Professional Values to IM 75 Table 10. Chi-Square Tests for Frequency of Psychosocial Needs 78 Table 11. Chi-Square Tests for Familiarity of CAM Interventions 81 Table 12 Chi-Square Tests for Inclusion of Psychosocial Needs on Treatment Plan 124 Table 13. Chi-Square Tests for IM as New Framework in Healthcare 125 Table 14. Chi-Square Tests for Stress as Part of Typical Approach to Treatment 126 Table 15. Chi-Square Tests for Familiarity of CAM Interventions 126 Table 16. Chi-Square Tests for Personal Practice of CAM 127 Table 17. Chi-Square Tests for Understanding IM Principles 81 Table 18. Years of Practice and CAM Curricula 83 Figure 19. Number of Years in Practice and Percentage of CAM Curricula 84 Running head: INTEGRATIVE MEDICINE & DIABETICS’ NEEDS INTEGRATIVE MEDICINE & DIABETICS’ NEEDS 1 Introduction According to the American Diabetes Association (ADA), “Diabetes Mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both (2006).” Diabetes is a prevalent and growing epidemic. As of 2011, almost 26 million people from birth to death were affected by diabetes (Centers for Disease Control (CDC, 2011). The CDC (2011) recently reported that diabetes affects approximately 4% of 20 to 44 year olds, 14% of 45 to 64 year olds and almost 27% of adults older than 65. These are alarming rates as is, however this epidemic has been estimated to increase in the future. Boyle and colleagues (2001) found that the amount of United States citizens diagnosed with diabetes is estimated to increase from 11 million individuals in 2000 to 29 million people in 2050. Not only is diabetes rampant in the United States of America but the World Heath Organization (WHO) and International Diabetes Federation (IDF) estimated that the international projection in 2030 will be approximately 366 million individuals affected by diabetes worldwide (2003). The ADA (2012) suggests a need for comprehensive care when treating diabetes; which should include meeting both physiological and psychosocial needs because addressing emotional health is necessary for optimum health and wellness. Jack (2003) further defined diabetics’ psychosocial needs to include interventions for stress reduction and mental illness. This reason is due to the consequences that stress and mental health have on individuals suffering from diabetes. First, stress has physical effects on the body. Surwit and Schneider (1993, p. 382) suggested that “diabetic individual’s glucose metabolism is compromised so these stress INTEGRATIVE MEDICINE & DIABETICS’ NEEDS 2 effects can be problematic.” To complicate matters, diabetics experience difficulties when stressors are ongoing and subsequent increased blood sugars occur over an extended period of time (Surwit & Schneider, 1993). Furthermore, Innes, Vincent and Taylor (2007) reported that “chronic psychosocial stress can lead to a destructive, self-perpetuating cascade of neuroendocrine, metabolic, inflammatory, and neuropsychological changes that promote the development of insulin resistance syndrome, atherosclerosis and cardiovascular disease” (p. 44). Second, it is suggested that the risks associated with the psychological suffering connected to diabetes is a considerable forecaster of depression (Connell, Davis, Gallant & Sharpe, 1994). Lloyd, Pambinco, and Orchard (2010) also reported findings that there was a strong connection among symptoms of depression and related suffering from diabetes, autonomous of additional control variables. However, there is also the potential for increased mental health concerns associated with unmet psychosocial and self care needs as well as the already increased rate of depression among diabetics. Depression associated with diabetic adults can also happen due to the interactions between psychological and social adversities as a consequence of internal psychological issues associated to diabetes (Lustman, 1992). Findings imply that self care is critical to meeting diabetics’ mental and emotional stability as research showed decreased self care activities was more prevalent among respondents with major depression (Lin, et al., 2004). Third, there are some findings that suggest a link between untreated mental health needs and poorer diabetic care. In fact, Rubin and Peyrot (1992) reported that poor INTEGRATIVE MEDICINE & DIABETICS’ NEEDS 3 diabetes control can originate from the physical effects of stress or inadequate psychosocial care. Additionally, Rubin and Peyrot (1992) concluded that psychological disorders are common among diabetics and may contribute to poor outcomes including diminished physiological and psychological comfort and wellbeing, hence there appears to be a need for psychosocial objectives to combat these difficulties. Similarly, Gonzalez and colleagues (2008) found that symptoms of depression forecasted succeeding noncompliance to essential facets of care in type 2 diabetics, despite controlling self care variables. The extensive psychosocial needs of individuals with diabetes, demonstrate a need to assess and implement psychosocial interventions; however this is one area that may fall short in diabetic care. Peyrot and colleagues (2005) reported that diabetics’ concerns about their diabetes-associated anguish were common among respondents and in fact their physicians typically were also familiar with these concerns. Concerns included worries related to weight, financial status, and diabetes complications among others. However, Peyrot and colleagues (2005) reported that the primary care providers consistently perceived fewer problems among their patients than other providers, such as nurses. Nurses and like providers likely have increased interactions with patients requiring more care and thus may be more aware of presenting symptoms (Peyrot, et al., 2005). However, this still presents a concern that primary care physicians are not as in tune with such concerns as they treat the greater part of diabetic patients. Klinkman (1997) also found that mood disorders were under-detected and undertreated in primary care due to multiple barriers within the current health care system such as lack of time,