www.elsevier.es/enfermeriaclinica
Pampering older people with diabetes in Sundanese culture: A qualitative study 夽
Siti Badriah
a,b, Junaiti Sahar
a,∗, Jajang Gunawijaya
c, Sabarinah Prasetyo
daFacultyofNursingUniversitasIndonesia,Depok,WestJava,Indonesia
bHealthofPolytechnicTasikmalaya,WestJava,Indonesia
cFacultyofSocialandPoliticalSciencesUniversitasIndonesia,Depok,WestJava,Indonesia
dFacultyofPublicHealthUniversitasIndonesia,Depok,WestJava,Indonesia
Received13November2018;accepted17April2019 Availableonline19July2019
KEYWORDS Diabetes;
Sundaneseculture;
Olderpeople
Abstract
Objective: ThepurposeofthisstudyistodetermineSundanesefamilyhabitsincaringforolder peoplewithdiabetesinTasikmalaya,WestJava,Indonesia.
Method: This study using a qualitativephenomenological method, via in-depth interviews, inwhichthesaturationpoint wasreachedatthetenparticipants.Theethicalprinciples of autonomy,beneficence,maleficence,andjusticewereapplied.
Results:Thisstudyidentifiedtwomaintopics:first,familyabilitytoperformfamilyhealthtasks andsecond,thedifferenttypesoffamilyculturesthatinfluencetakingcareofthehealthof olderpeople,whichwerereflectedthroughseveralsub-topics,namely,pamperingtheparents, doingeverythingtheyasked,andcontrollingalltheiractivities.Thehabitsofpamperingand assentingtothewishesofolderpeoplewithdiabetesarehighlyrisky,as,whentheyarefood- related,theycanincreasebloodglucose.
Conclusion: Thefindingsofthisstudyrevealthatthefamilyhabitswhichhighlyriskytoincrease bloodglucoseolderpeoplemustbechangedthroughnegotiationeffortsandculturalrestruc- turing,suchthatthetreatmentsprovidedareinaccordancewiththediabetes management pattern. The results ofthe present study areuseful in improving health services for older peoplewithdiabetesinthemulticulturalcountryofIndonesia.
©2019ElsevierEspa˜na,S.L.U.Allrightsreserved.
夽 Peer-reviewunderresponsibilityofthescientificcommitteeoftheSecondInternationalNursingScholarCongress(INSC2018)ofFaculty ofNursing,UniversitasIndonesia.Full-textandthecontentofitisunderresponsibilityofauthorsofthearticle.
∗Correspondingauthor.
E-mailaddress:[email protected](J.Sahar).
https://doi.org/10.1016/j.enfcli.2019.04.111
1130-8621/©2019ElsevierEspa˜na,S.L.U.Allrightsreserved.
Introduction
One of the indicators of the success of a country’s development is higher life expectancy. The Central Bureau of Statistics has reported an increase in the life expectancyofIndonesiansfrom70.1yearsin2010to70.9 yearsin2015.1Thishasresultedinayear-on-yearincrease intheproportionofolderpeople,leadingtoahigherriskof theemergenceofvarioushealthproblems,suchasdiabetes.
In older people,diabetes occursin the formof insulin resistance as a result of endocrine disorders, impaired insulin secretion, or both. In addition, lifestyle factors, suchaseatinghabits,physicalactivities,andinappropriate methodsofstresscontrolalsocontributetotheemergence ofdiabetesintheseindividuals.2InIndonesia,casesofdia- betesinolderpeopleincreasedfrom1.1%in2007 to2.1%
in2013.InTasikmalayaspecifically,theincidenceincreased from313casesin2013to570casesin2014,withthenumber of patients whoreceived inpatienttreatment due todia- beticcomplicationsrisingfrom64in2013to262in2014.3,4 Theincreaseinthenumberofpatientswithdiabetes,and withdiabetescomplications,hasrevealedtheneedformak- ing serious efforts in the treatment of the disease, with regardtoinstillingthehabitsorculturethatenablecontrol ofriskfactorsforincreasedbloodglucose,suchthatfurther complicationscanbeprevented,andtheprevalencewillnot increase.
Tasikmalaya is a city in West Java, Indonesia in which themajortribeisSundanese.InSundaneseculture,parents occupyahigh status,asstatedinan idiomatic expression inducingtunggulrahayubapatangkaldarajat(themother as the source of salvation and the father as the source ofsuccess).Thisimpliesthatparentsarehighlyrespected people who will be a source of happiness for their chil- dren. Therefore, in order to gain happiness, safety, and prosperity,thechildrenmustberespectfulof,andobedient to, theirparents, andtheydosoby makingtheir parents happyand pleased.However, ifa child meetsallof their parents’dietaryrequeststopleasethem,despite therisk ofincreasingtheir blood glucoselevels,itcouldbe arisk factor in triggering health problems in older people with diabetes.5---7
This phenomenon implies that the culture of parental devotion,whichisembodiedviatheactionofpleasingthem and making them happy, should be able to improve the healthcareofolder people,includingthosewithdiabetes.
However,therealityinTasikmalayashowsthattheincidence ofdiabetesisstillincreasing,alongwiththatofvariousdia- betescomplications.Therefore,anin-depthstudyoffamily habitsincaringforolderpeoplewithdiabetesinTasikmalaya isnecessary.Basedonthatphenomenatheresearchques- tionsis‘‘whataretheessentialaspectsofcaringforolder peoplewithdiabetesaccordingtotheexperiencesofSun- danesefamilyInTasikmalaya,Indonesia?’’
Methods
StudydesignThis qualitative study usedthe phenomenology approach, asitaimedtoexplorethephenomenonoffamilyhabitsin
familiescaringforolderpeoplewithdiabetesinTasikmalaya city.
Settingandparticipants
The participants were chosen using a purposive sampling techniquewithseveralcriteria,namely,amemberofaSun- danesefamilywhocaredforatleastoneolderpersonwith diabetes inTasikmalayacity,awillingness tobearespon- dent,andtheabilitytodescribethiscaringexperience.Of the 20 prospective participants, the saturation point was reached atthetenparticipants,fromthetenparticipants noonedroppedout.Thiswasinaccordancewiththerecom- mendationofDuke(1984inCreswell,2013),suchthatthe numberofpeopleinaqualitativeresearchsampleshouldbe between3and10.8
Ethicalconsideration
The study received approval from the UI Ethics Commit- tee,withthenumber105/UN2.F12.D/HKP.02.04/2017,and italsometthenecessaryethicalrequirements,inthatthe participantswereprovidedwithanexplanationofthepur- poseofthestudyanditspossiblebenefits,afterwhichthey gavewrittenconsenttotakepartinthestudy.Inaddition, theparticipantswerepermittedtochooseaninterviewtime and place that was most convenient to them, they were treatedfairly,withnodiscriminationbasedonage,gender, andreligion,andtheiridentity,aswellastheresultsofthe study,remainedconfidential.
Datacollection
Some nurses working at Puskesmas (Pusat Kesehatan Masyarakat, or Community Health Center) were involved as key informants in the participant selection process.
DatawerecollectedfromMaytoSeptember2017through in-depth interviews, using digital sound recordings, field notes,fromeach participantintheir homeapproximately 60---90min/sessions, with a total of 18 interview sessions for 10 participants. The experience of the participants determines the tiger family’s habitsof caringfor parents withdiabetes wasobtainedusinga semi-structured inter- view technique. The interview starts with twoquestions:
‘‘Can you tellme howyour experiencetook careof your parentwithdiabetes?’’andwhatisthemeaningofcaringfor yourparentsforyou?Furtherinterviewquestionswereasked frominterviewswithintervieweesandinterviewersasking questions based on the analysis of important data from previous interviews.The participantsareeffectivelylead- ing thedirection of the interview, andresearchersfollow thepatternandcontentsoftheparticipants’conversation.
Thishelpstoavoidbiasagainstareasofspecialinterestof researchers.
Dataanalysis
Data analyzed using Colaizzi’s seven steps phenomenolo- gical method. These steps consisted of reading interview transcripts, listening to interview transcripts, selecting
keywords,groupingcategories,narrating,validating inter- viewswiththeparticipants,andaddingnewdatafoundin thevalidationprocess,andallowedustoobtainanoverview ofthestudyresultsasawhole.
Trustworthiness
The principlesof credibility,dependability, confirmability, and transferability were applied to ensure that the data wereaccountable.The credibilityprinciplewasconducted by checking the data on the transcripts provided by the participants.Ifastatementwasconfusingorpoorlyunder- stood,it wasclarified withtheparticipant.Dependability and confirmability were shown by how the results were obtained duringthe processof data collectionand analy- sisby involving thepromoter or supervisorasan external reviewertocheckand examinetheaccuracy ofthe data.
Transferabilitywasappliedby selectinga Sundanesefam- ily caring for an older personwith diabetes fromanother regiontoassesswhethertheyunderstoodwhatparticipants feltaccordingtothethemefoundinthisstudy.9
Results
There were ten participants (one man and nine women), with an age range of 43---58 years. With regard to their occupation,twowereretiredcivilservants,andeightwere housewives. Their levels of education varied; four were seniorhigh,fourwerejuniorhigh,andtwowereelementary schoolgraduates.Threeparticipantslivedwiththeirnuclear family, andseven participants lived in extended families.
Thedurationofdiabetesinfamilymembersofthepartici- pantsvariedfrom2yearsto16years,andallparticipants wereSundanese.
Thepresentstudyhighlightstwomaintopics:theability offamiliestocarryoutfamilyhealthtasks,andthevarious familyculturesthatinfluencecaringforolderpeoplewith diabetes.
Theabilitytocarryoutfamilyhealthtasks
Afamily’sabilitytoperformfamilyhealthtaskswasiden- tified from the sub-topics of its capacity to recognize problems, make decisions, perform care tasks, modify the environment, and utilize health service facilities.
Afamily’sabilitytorecognizediabetesinolderpeoplewas alsooneofthecategoriesthatdemonstrateditscapacityto recognizehealthproblems,asrevealedbysomeparticipants whoperceiveddiabetesasbeingahereditaryandincurable disease:
‘‘... Ahereditary disease....thereis nomedicine that cancureit....’’(AR)
‘‘... A hereditary disease... the sugar in her blood is high...that’sallweknow’’(DR)
‘‘Sicknessduetosugarinthebloodbeinghigh,adisease thatcannotbecured.’’(ER)
Otherparticipantssaidthatdiabetesisadiseasecaused by taking the wrong medications and eating too many sweets:
‘‘.... It is caused by too much drinking and eating sweets’’(YC)
‘‘...Itiscausedbyconsumingtoomuchmedicine...for example,he should take only onetablet per day, but he takestwo.’’(SK)
Thesub-topicoftheabilitytomakeadecisionwasevi- dentfromsome familystatements relatedtotakingolder peoplewithdiabetestoseektreatmentwhentheywereill, asshowninthestatementsbelow:
‘‘...Ifsherelapses...andwehavenomoney,weusually takehertothehospital....’’(CS)
‘‘... First she got a fever, high temperature... the physicalstategotworse...weak...wetookherdirectlyto thedoctor’’(AM)
‘‘...Steppedonsomethorns...thenshekeptscrapingthe wound...itbecameulcers...gettingbigger...finallytookher tothehospitaltobetreated.’’(NS)
Anothersub-topicwastheabilityoffamiliestocarefor older people with diabetes, and this wasidentified from thecategoryof eatingarrangements,exercise,andmedi- cationsthathadbeengivenbythefamilyagainstthewishes ofthe older people.With regardtoeating arrangements, some participants revealed that the family put no limits onolder people withdiabetes, as shown in the following statements:
‘‘... Just normal meals every day, nothing is forbid- den...!’’(DR)
‘‘...Ourfathereatsnormally,thereisnospecialrule,he hasthesameastheothers...’’(EN)
‘‘...Now she can eat anything becausethere is apple vinegar...soanyfoodsareallowed.’’(YC)
However,somefamiliesselectedthefoodstobeeaten byolderpeoplewithdiabetes,asexpressedbythosecaring forpeopleaged70and68years,asfollows:
‘‘...Thefoodsthatareforbiddenaresweets,othersare not.’’(IS)
‘‘....Sweets consumption is reduced,drinkingsyrup is also not allowed, wait (a type of Sundanese traditional sweet)isalsoreduced.’’(ER)
Withregardtotheexercisesub-topic,someparticipants stated that family members always accompany the older personwithdiabetes whentheydoexercise,asshown by thefollowingstatements:
‘‘....Oftenaccompanyhertogojogging... afterevery dawnprayer...’’(AM)
‘‘....Every morning afterdawn prayer, we accompany heronamorningwalkintheneighborhood...’’(IS)
‘‘Hasawalkeverymorning,orsometimesonceaweek...
routinely...accompaniedbyfamilymembers.’’(EN) The nextsub-topic,caringcapability,relatedtotaking medicine.Someparticipantsassertedthattheolderperson withdiabetes had routinely taken blood-glucose-lowering medicationsforaslongastheyhadhadthecondition,while othersstatedthat this wasnotthe case, asshownin the followingassertions:
‘‘...TakesoneGlibentabletperday...’’(SK)
‘‘Takesthemedicineregularlyeveryday....nowwestill havethemedicine...’’(IS)
‘‘ThemedicineisGliben,everyday...untillater,untilhe passesaway...’’(AM)
‘‘....Oftenchangethetypesofblood-glucose-lowering drugs....’’(EN)
‘‘...Usuallyconsumesantlionlarvaeormahoganyseeds threetimesaday...’’(AN)
‘‘...Drinkstwotablespoonsofapplevinegareveryday, aftereatingtastymealslike meat,fish,orsweet foods.’’
(YC)
Thenextsub-topicintheabilitytoperformfamilyhealth taskscategory wastomodify theenvironment andutilize health services. The former wasreflected in the family’s effortstopreventinjury,asrevealedinthefollowing par- ticipantstatements:
‘‘...Always remind themother towearsandalsevery- where....’’(ER)
‘‘... Remind her tobe careful when cooking, carrying stuff...we’reafraidshewillslip,thenfall....’’(AM)
‘‘...Afraidof hersteppingonthethorns...remindher alwaystowearsandals.’’(SK)
Ineffortstoutilizehealthservicefacilities,thepartici- pantsdescribedtheblood-glucosecontrolactivitiesofthe olderpeoplewithdiabetes, asillustratedin thefollowing statements:
‘‘...Ifthereis extramoneyIusuallyaccompanyherto seethedoctor,butifthereisnotenoughmoney,weusually gotothePuskesmas...’’(CS)
‘‘....Do youwanttocheckthediseasewiththedoctor orgotothehealthcenter?Ialwaysaskmymotherfirst...’’
(EN)
‘‘...Fortheroutinechecks,mymotherusuallygoesto theclinic becausethereis Prolanis (ProgramPengelolaan Penyakit Kronis or Chronic Disease Management Program) oncepermonth...’’(NS)
‘‘....Ifthebodyfeelswell...we don’tcheckit,butif itfeelsnumb orthereistingling inthelegs, thenwewill checkitagain.’’(DR)
Differentfamilyculturesincaringforolderpeople withdiabetes
Thefamilycultureincaringforolderpeoplewithdiabetes wasshown via variousbehaviors. These were reflectedin thesub-topicofpamperingtheolderpeople,doingevery- thingtheywanted, andcontrollingalltheiractivities.The participantstatementsbelowdescribethesebehaviors;they wanttofulfillalltheneedsoftheolderpeopleandtodoas theyask.Theyalsodon’tallowthemtowork(andconsider itimpolite toask them todoso),sothat theydon’t feel tired:
‘‘All needs are fulfilled... food and clothes are pro- vided...justtellsmewhatisneeded.’’(AM)
‘‘Alldesires must besatisfied....if shewants durian or duriandodol(atypeoftraditionalcandy)...wewillsurely giveittoher,although Ioftenremind hernottoconsume toomuchofit...’’(DR)
‘‘... No food that I won’t giveher..., any food, ifmy mothersaysshewantsitthenIwillbuyit.’’(AR)
‘‘...There is noprohibition...soI servefoods accord- ing to my father’s request...it’s The same as the food served totheother familymembers... shedoes not want tobedifferentiated...’’(EN)
‘‘...Mymother’sfavoritefoodisdodolwithnut...ifmy motherwantsit,I’llgiveittoherthen’’(CS)
‘‘...Myfathercannotstopsmoking...ifheasksme,I’ll satisfyhisrequest...’’(ER)
‘‘...Ifmymotherissick....shedoesnotwanttogetany treatments,Idonotdaretoforceher...’’(AR)
‘‘...ThereisascheduledPosbindu(PosPembinaanTer- paduorTheProgramofIntegratedCoachingPost),Ioften askmymothertogothere....butmymotheroftenrefuses...
soshehasneverbeentoPosbindu...’’(YC)
‘‘... Just sweeping the yard, for example...it is prohibited...becauseit cancausehertobesickagain...’’
(DR)
‘‘....It’snotpolitetoletmymothercleanupthehouse.
Besides,Idon’twanttoseehertired...’’(NS)
‘‘....Shehasalreadybeenforbiddentodogardening,we worryshewillsteponathornagain.’’(SK)
Anotherhabitofthefamilieswastheexertionofcontrol byassistingtheolderpeoplewithdiabetesintheiractivities, asrevealedinthefollowingstatements:
‘‘....Wherevershegoes,Iaccompanyher...’’(DR)
‘‘...She alwaysgoestorecitationwithme.... Ialways accompanyheronamorningwalk,aswellas...’’(AM)
‘‘....Goestotherecitationwithme.’’(CS)
Discussion
An interesting finding of the present study is that, when caringforolderpeoplewithdiabetes,thebehaviorsofSun- danese families can lead to high blood glucose levels in theseindividuals. Therefore,thehabitsof pamperingand doingeverythingthatolderpeoplewantmustbealteredby negotiationorrestructuring.Relatedstrategiesincludethe preservationofculturalhabitsthatarenotatoddswithgood health practices,cultural negotiation,whichis conducted tohelp the older people withdiabetes andtheir families adopthabitswithhealthbenefits,andculturalrestructur- ing,whichiscarriedoutifthehabitsoffamiliesandolder people aredetrimental tohealth.10 In a study conducted in African-Americanfamilies inGeorgia andIowa, USA, it wasshown thatthe uniqueroleof thefamilyin theform ofthehabitofregulatingandchangingintensivelifestyles, particularly with regard to diet, exercise and stress con- trol, is effective in preventing and managing diabetes.11 Therefore,inessence,familieswithanoldermemberwith diabetes should be able to show sensitivity by control- linginner conflictstoprovideadequate care12; therefore, familiesshouldbeabletodirect,motivate,negotiate,and restructurehabitsthatcantriggerincreasingbloodglucose, withoutshiftingtheadoptedvaluesandinamannerthatis appropriatetoSundaneseculture.
The view that older people with diabetes should be prohibitedfromperformingsomeactivities toensure that theydonotgettired,whichemergedinthepresentstudy, is notin accordancewithdiabetes managementpatterns.
Overprotective responses from the familycan causeneg- ative effects for people with diabetes, because activity and/or exercise are very important in increasing muscle sensitivity to insulin, thereby decreasing insulin resistance.13,14 In addition, physical activities can also support the management of diabetes, improve blood circulation, reduce the need for medication, help lower blood glucose,and reducethe risk ofcomplications, such
as heart disease and stroke.15 Therefore, it is necessary to implement a negotiation and restructuring strategy to change the culture and the family’s view, by increasing theirawarenessoftheimportanceofphysicalactivitiesfor olderpeoplewithdiabetes.
Anotherhabitthatwasobservedinthepresentstudywas thatofthefamily’sinsistenceongrantingalltherequests of the older people with diabetes. The Sundanese peo- plebehaveina dutifulandobedientmanner toward their parents,bypleasingthemandmeetingalltheirrequests.7,16 Making parents happy is one form of emotional support that can affect the psychology of older people in the treatment of diabetes. The results of a study conducted in African-American people with diabetes demonstrated thatemotional supportandfamilytrustresulted ina pas- sion for good self-management.17 This implies that the family can direct the behavior of their parents, accord- ing to the appropriate pattern of diabetes management, in an enjoyable manner, using subtlelanguage andeffec- tivecommunicationinaccordancewithSundanesecultural manners.16,18 Therefore, the process of negotiation and the restructuring of inappropriatecultures can ultimately be executed without reducing the level of respect for parents.
Another interesting finding of the present study wasthe presence of familycontrol in the form of assist- ingalltheolderpeopleintheiractivities.Astudyofolder people withchronic disease in Chinashowed that 18% of the 428 people assessed had increased levels of physical activity after being accompanied by family members.19 Anotherstudy,conducted in 32people aged60years and over who lived in families of two or three generations in Bahia, Brazil, revealed some important findings: fam- ily assistanceandproximity resultedin harmoniousfamily relationships across the generations, and deep emotional relationshipsandaffectiverelationshipsinthefamilyenvi- ronment were significant in determining the health and welfareoftheolderpeople.20 Therefore,familyassistance isaculturethatmustbepreserved,asithaspositiveimpacts onthehealthofolderpeople.
Furthermore, the finding of the present study relating to the lack of family capacity to perform family health tasks,whichwasidentifiedviarecognizingproblems,making decisions,caring,modifyingtheenvironment,andutilizing healthservices,isanissuethatmustbeaddressed,because knowledge is the basis of the formation of behavior and culture,andacultureorhabitcanbeestablishedthrough increased knowledge.18 The results of the current study showedthatthereisapositiverelationshipbetweenknowl- edgeofdiabetesanddiabetesself-managementbehavior, medicationadherence,goodfootcarehabits,andeffective bloodglucosecontro.21Inaddition,adequateknowledgeof diabetescanensureavoidanceofriskyhabitsandlifestyles thatmayleadtocomplications.22 Thus,knowledgeofdia- betesinolderpeoplewiththediseasecanformthebasisofa newcultureandfamilyabilityincaringfortheseindividuals.
The family’s ability to take care of older people with diabetes,particularlywithregardtoeatingarrangements, didnotmeettherulesofeatingmanagementfordiabetes patientsinthepresentstudy.Mealplanningforpeoplewith diabetes should be tailored to the caloric needs of each patient.However,mealplanning in olderpeople withthe
diseaseshouldbeinaccordancewiththeircultureorhabits asmuchaspossible,inthesensethatgoodhabitsarecon- tinuedandunfavorablehabitsshouldbestopped.10,23
Anotherimportantfindingofthepresent studywasthe lackofutilizationofhealthservicefacilities.Intheeffortsto monitorbloodglucoselevels,suchutilizationisanimportant componentofthemanagementofdiabetesinIndonesia,in addition to education, diabetes drug administration, and examination of symptoms of complications.24 Thus, nego- tiationeffortsaimedat increasingvisits tohealthservices shouldbecarriedoutbythefamiliesof olderpeoplewith diabetes,consideringtheimportanceofbloodglucosecon- trolintheearlydetectionofpossiblecomplications.
Thestrengthofthisstudyisthatthedataprovidedsuf- ficientvariationandaccuracyaccordingtoaninternaldata analysisperformedbytheauthorbasedonreadingthefirst versions of the transcripts andchecking the participants’
descriptionsintheirlanguage(Sundaneselanguage). Limi- tationsof thisstudy werethe difficultyofcommunicating withsomeparticipantsofvaryingdegreesofeducationand age,sotheresearcherhadtoillustratequestionsthatwere notunderstoodbytheparticipants.
Conclusions
Family habits in caring for older people with diabetes in Tasikmalaya were illustrated via families’ ability to recognizeproblems, make treatment decisions, take care ofhealth,modifytheenvironment,andutilizehealthser- vices.Inaddition,thedifferenttypesofculturethatfamilies inTasikmalayahaveintheformofpamperingolderpeople with diabetes, doing everything they want, and control- lingalltheiractivities,showedthatsomehabitsorcultures requiretheattentionofhealthofficers,particularlycommu- nitynurses,becausetheycanresultintheincreaseofblood glucose.Negotiation andculturalrestructuring effortsare requiredtoalignthebehaviorsoftheolderpeoplewithdia- betesandtheirfamilies,suchthattheSundanesecultureof consideringparentsashighlyrespectedpeoplecanformthe basisforsupportingthecreationofadequatemanagement of diabetes in older people. The recommendation of dia- betestreatmentforsuchanindividualinTasikmalayashould be based on the approach of Sundanese culture. There- fore, the Sundanese family culture-based nursing model, whichdescribesthemanagementofdiabetesinolderpeople withintheframeworkofSundaneseculture,isrequired.
Conflict of interests
Theauthorsdeclarenoconflictofinterest.
Acknowledgements
ThisworkissupportedbyHibahPITTA2017fundedbyDRPM UniversitasIndonesiaNo.381/UN2.R3.1/HKP.05.00/2017.
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