INTRODUCTION:

Diabetes mellitus is one of the major health problems. It is a disease known to the medical world since time immemorial. Its incidence is however much higher than it had been ever in the past. More than 50 million of people in the world suffer from diabetics. Estimates that by next 20 years the occurrence of diabetics will be 366, 000, 000 (WHO).⁴ Each year about 150, 000 people die from diabetes and its related complication. India is the diabetes capital of the world. One in every 5 diabetics in the world live in India. Studies of 2007 shows that in India the amount of people diagnosed with diabetes was 40.9 million. By 2025 the number will grow to 70 million.⁵ Stress plays a more direct role in the blood sugar than it does in any other disease. People with diabetes, both physical and emotional stress may affect on health. DM, is a metabolic diseases in which a person has high blood sugar, because the body does not produce enough insulin. This high blood sugar produces polyurea, polyphagia, polydypsia. Stress causes blood sugars to rise. This is due to the fact that hormones, such as epinephrine and cortisol, boost energy by raising blood sugars whenever the body requires extra exertion. Any stress-related event raises these hormones, thus causing Stress blood sugars to rise.⁶ Stress is a central theme in the program, and has been important in life and care because of known and suspected effects of stress and coping on biological system involves. Researchers at the University of Toronto's Quality of Life Research Unit define quality of life as “The degree to which a person enjoys the important possibilities of his or her life”. Their Quality of Life is based around three categories “being”, “belonging”, and “becoming. QOL is used to evaluate the general well-being of individuals. Standard indicators of the QOL include not only wealth and employment, but also the built environment, physical and mental health, education, recreation and leisure time, and social belonging. Individual with diabetes have the greatest burden on diabetes treatment and fear of long term consequences have an impact on QOL.⁷ Guided Imagery is a convenient and simple relaxation technique that helps quickly and easily to manage stress which help to reduce tension from the body. With practice, this technique will help individual to better access their inner wisdom. Guided Imagery, It takes less time to practice. But this is a great way to leave stress behind and relax our body. It is easier to practice Guided imagery through playing natural sounds in the background. Guided Imagery is simple, low cost and effective technique for stress reduction and to promote quality of life among the diabetic patients.⁸

STATEMENT OF THE PROBLEM:

“A study to determine the effectiveness of Guided Imagery Technique on Stress and Quality of Life among diabetic patients in a selected rural area, Bangalore”.

OBJECTIVES:

1. To assess the stress before and after the guided imagery technique among diabetic patients in a selected rural area.

2. To assess the quality of life before and after the guided imagery technique among the diabetic patients in a selected rural area.

3. To test the association between mean difference in stress and demographic variables among diabetic patients in a selected rural area.

4. To test the association between mean difference in quality of life and demographic variables among diabetic patients in a selected rural area.

HYPOTHESES:

H1. There will be a significant difference in stress scores before and after the guided imagery technique.

H2. There will be a significant difference in quality of life before and after guided imagery technique.

H3. There will be a significant association between the stress among diabetic patients and selected demographic variables.

H4. There will be a significant association between the quality of life among diabetic patients and selected demographic variables.

METHODOLOGY:

The research methodology presents the research approach and the research design. The design of the study describes about the setting of the study, population, the sample and sampling technique, the data collection technique, content validity and reliability of tools, pilot study and the method of data analysis based on the statement, objectives.⁹

RESEARCH APPROACH:

A quantitative research approach was adopted for the study, since the investigation was aim to determine the effectiveness of Guided Imagery Technique on stress and Quality of Life among the diabetic patients in a selected rural area, Bangalore.

RESEARCH DESIGN:

The purpose of a Quasi- experimental research design is to describe the variables and examine relationships among these variables. A Quasi-Experimental research design with one group Pre-test and Post-test design.

E=O1 O1 X O2 O2

E = Experimental group

O₁= Pre test stress score

O₁= Pre test quality of life score

O₂= Post test stress score

O₂= Post test quality of life score

X = Intervention (Guided Imagery Technique)

Setting:

Data Collected from Anugondanahalli Village, Bangalore.

Sample and sampling technique:

30 diabetic patients were selected by a quasi experimental approach with one group Pre-test and Post-test design

Data collection:

A pre-test was conducted by using structured interview schedule of stress and structured questionnaire on quality of life. On the same day the guided imagery technique was implemented to the diabetic patients. After 7 days, post test was conducted with the same structured interview schedule on stress and structured questionnaire on quality of life questionnaire for the same group of diabetic patients to assess the effectiveness of Guided imagery technique.

Analysis and interpretation of data:

The collected data were analyzed in terms of both descriptive and inferential statistics.

RESULTS:

In this study (6.7%) of the subjects were between the ages of 26 to 35 years, 5 (16.7%) between the ages of 36 to 45 years, 12 (40.0%) between the ages of 46 to 55 and 11 (36.7%) between the ages of 56 to 65 years. 23 (76.6%) of the subjects were males and 7 (23.3%) were females. In the whole group 17 (56.7%) were Hindus, 10 (33.3%) were Muslims and 3 (10.0%) were Christians. 13 (43.3%) has completed primary education, 8 (26.7%) has completed high school education, 6 (20.0%) has completed PUC, 2 (6.7%) were graduates and 1 (3.3%) has not attended school. Majority 18 (60.0%) were earning 1501 to 5000 monthly, 23.3% (7) were earning 5001-10, 000, 10% (3) were earning 10, 001-20, 000 and only 6.7% (2) were earning 1500 and below. All the subjects 30 (100%) were married. In this study the majority of the subjects 25 (83.3%) were non -vegetarian and 16.7% (5) were vegetarian. Out of 30 samples 27 (90%) were has family history of diabetics and 3 (10%) were has no family history of diabetics. The subjects 13 (43.3%) were have a duration of 6 to 10 years of illness, 11 (36.7%) were has 6-10 years of duration and 6 (20%) were has a duration 11-15 years of illness. The majority of the subjects 24 (80%) were taking oral diabetic drugs and 6 (20%) were taking insulin. The majority i.e; 28 (93.3%) subjects were have a previous history of other disease and non of the subjects 30 (100%) were not practicing any other alternative therapies.

Stress level before and after the guided imagery technique among the diabetic patients of the rural area:

Among 30 diabetic patients 10 (33.3%) were had severe stress and 20 (66.7%) were had moderate stress during test, before giving guided imagery intervention. After the intervention of Guided Imagery Technique, the stress level of 19 (63.3%) subjects were reduced to mild and 11 (36.7%) were come to normal.

Table 1 representing mean percentage of pre and post stress level of the respondents.

Sl. No	Test	No. of items	Mean	S. D	Mean%
1	Pre stress	30	114.67	9.400	76.45
2	Post stress	30	42.80	4.080	28.53

	Pre test		Post test		t value	DF	P value Inference
	Mean	SD	Mean	SD
Stress	114.67	9.400	42.80	4.080	34.965	29	P<0.05*

The above table shows that, during pre test the stress level of the subjects were 76.45% with mean value of 114.67 after the Guided Imagery intervention the stress level is reduced and the post test level shows 28.53% with mean value 42.80. This shows that there was a significant difference between pre and post stress levels of diabetic patients before and after administration of Guided Imagery Therapy.

Fig.01. The bar diagram representing mean percentage of pre and post stress levels.

QOL level before and after the guided imagery technique among the diabetic patients of the rural area.

Table 2 representing mean percentage of pre and post test QOL level of the respondents.

Sl. No	Area wise	No. of items	Mean	S.D	Mean %
1	Physical State	8	20.2667	4.33855	63.33
2	Mental or Emotional State	8	22.6333	3.83705	70.73
3	Social Interaction	5	15.2333	2.20788	76.17
4	Life Enjoyment	8	23.0667	4.05933	72.08
5	Overall Quality of Life	11	33.4333	4.64375	75.98
	Total QOL	40	114.6333	14.35626	71.65

Mean% score for the post QOL level

Sl. No	Area wise	No. of items	Mean	S.D	Mean %
1	Physical State	8	10.9000	2.00603	34.06
2	Mental Or Emotional State	8	10.4667	1.81437	32.71
3	Social Interaction	5	7.2667	1.74066	36.33
4	Life Enjoyment	8	10.9333	1.92861	34.17
5	Overall Quality Of Life	11	14.7667	2.12835	33.56
	Total QOL	40	54.3333	5.57292	33.96

The above table No.02, shows that, The mean percentage of total pre test quality of life is 71.65, and mean percentage of total post test quality of life is 33.96.

Fig. No-02

Fig. No.02, shows the value of quality of life after administration of Guided Imagery Technique. The Quality of Life of the 30 (100%) samples was come to good. The mean percentage of total pre test quality of life is 71.65, and mean percentage of total post test quality of life is 33.96.

Abstract of chi-square results of stress and socio demographic characteristics among diabetic patients in a selected rural area.

Table No.03

Sl. No	Characteristics	Chi-square value	Df	P – value	Result
1.	Age	9.8	3	p<0.05	Sig
2.	Sex	14.4	1	p<0.05	Sig
3.	Religion	3.404	3	p>0.05	NS
4.	Educational Qualification	2.244	5	p>0.05	NS
5.	Monthly Income	15.56	4	p<0.05	Sig
6.	Marital Status	0.00	3	p>0.05	NS
7.	Dietary Habits	2.160	1	p>0.05	NS
8.	Family History of Diabetics	3.333	1	p>0.05	NS
9	Duration of Illness	14.06	3	p<0.05	Sig
10	Treatment undergoing	0.00	2	p>0.05	NS
11	Previous history of disease	2.143	1	p>0.05	NS
12	Participating any alternative therapies	0.00	3	p>0.05	NS

From the table No.03- shows that the chi square value for stress and age, sex, monthly income, duration of illness, are significant. The remaining characters are not significant.

v NS – Not significant at 5% level (i.e., P > 0.05)

v Sig – Significant at 5% level (i.e., P < 0.05)

Association between mean difference in quality of life and demographic variables among diabetic patients in a selected rural area:

The chi square value for quality of life and age of the samples was 3.018 with the DF 3 which shows that there is no statistical association between the quality of life score and age of the respondents. The chi square value of the gender of the respondents and quality of life was 1.667 with the DF-1, this shows that there is no statistical association between the quality of life and gender of the respondents. The chi square value of the quality of life and religion of the subjects was 1.263 with the DF-3, this shows that there is no statistical association between the quality of life with the religion of the respondents. The chi square value of the quality of life and educational qualification was 19.5 with the DF-5, this shows that there was a statistical association between the quality of life level and educational qualification of the subjects. The chi square value of the quality of life with monthly income of the subjects was 15.56 with the DF-4. This shows that there is a statistical association between the quality of life with the monthly income of the respondents. The chi square value of quality of life with the marital status of respondents was 0.00 with DF- 3, this shows that there is no statistical association between the quality of life with the marital status of the respondents. The chi square value of the QOL with the dietary habits was 0.240 with the DF-1, this shows that there is no statistical association between the QOL and dietary habits of the respondents. The chi square value of the QOL with the family history of diabetics was 0.370 with the DF-1. This shows that there is no statistical association between the QOL level with the family history of diabetics. The chi square value of the QOL with duration of illness was 11.9 with the DF-3, this states that there was a statistical association between the QOL level with duration of illness. The chi square value of QOL with the treatment undergoing was 0.833 with the DF-2, this shows that there is no statistical association between the QOL and the treatment undergoing by the study subjects. The chi square value of the QOL with the previous history of other diseases to the study sample was 0.000 with the DF-1, this shows that there is no statistical association between the QOL with previous history of other disease. The chi square value of quality of life with the respondents were practicing any other alternative therapies was 0.00 with DF- 2, this shows that there is no statistical association between the quality of life with the respondents were practicing any other alternative therapies.

DISCUSSION:

Objective 1: To assess the stress before and after the guided imagery technique among diabetic patients in a selected rural area.

This study results shows that among 30 diabetic patients 10 (33.3%) were had severe stress and 20 (66.7%) were had moderate stress during pre test, before giving guided imagery intervention. After the intervention of Guided Imagery Technique, the stress level of 19 (63.3%) subjects were reduced to mild and 11 (36.7%) were come to normal. Therefore, there was a significant reduction in stress after the guided imagery intervention among the diabetic patients.

This study finding was consistent with the findings of Carole Holden et.al (2007) a study which showed that the effects of an audiotape series employing Relaxation with Guided Imagery stress response and wound healing in surgical patients. Twenty-four patients undergoing cholecystectomy were randomly assigned to either RGI or control conditions and measured against three indexes of recovery: state anxiety, urinary cortisol levels, and wound inflammatory responses. An analysis of variance for repeated measures revealed that the RGI group demonstrated significantly less state anxiety, lower cortisol levels one day following surgery, and less surgical wound erythema than the control group. Thus, the RGI tapes demonstrated stress-relieving outcomes.¹⁰

Objective 2: To assess the quality of life before and after the guided imagery technique among the diabetic patients in a selected rural area:

Study results showed that among 30 subjects 15 (50%) were has poor quality of life and 15 (50%) were has satisfactory quality of life. After administration of Guided Imagery Technique the Quality Of Life of the 30 (100%) samples were come to good. Hence, there was a significant improvement in the quality of life among the diabetic patients after the guided imagery intervention.

The study finding was consistent with the findings of Hanninen JA et.al (1999) a study that showed the quality of life of people with diabetes; people with diabetes have a worse quality of life than people with no chronic illness. Intensive treatment does not impair quality of life, and having better glycemic control is associated with better quality of life. Complications of diabetes are the most important disease-specific determinant of quality of life. Studies of clinical and educational interventions suggest that improving patient health status and perceived ability to control their disease results in improved quality of life. Methodologically, it is important to use multidimensional assessments of quality of life, and to include both generic and disease-specific measures. Quality of life measures should be used to guide and evaluate treatment interventions.¹¹

Objective 3: To test the association between mean difference in stress and demographic variables among diabetic patients in a selected rural area:

There was a significant association found between the demographic variables such as, age, sex, monthly income, duration of illness, and the stress among diabetic mellitus patients.

The current study finding was consistent with the findings of Parameshwari Krishna (2018), a study shows how stress can make a negative impact in diabetic patients. The present study was undertaken to observe the depression, anxiety, and stress levels in diabetic patients. The study included 30 type 2 diabetic patients and 30 age- and gender-matched healthy participants. The following criteria were used in the selection of cases. To assess the depression, anxiety, and stress levels, DASS 42 scale was used. Results: There were significantly higher scores of depression, anxiety, and stress in the diabetics when compared to healthy controls. This study also suggests that there are higher levels of depression, anxiety, and stress symptoms in diabetic population when compared with healthy controls. There were significantly higher scores of depression, anxiety, and stress in the diabetics when compared to healthy controls.¹²

Objective 4: To test the association between mean difference in quality of life and demographic variables among diabetic patients in a selected rural area:

There was a significant association found between the demographic variables such as, educational qualification, monthly income and duration of illness with the quality of life of diabetic patients.

The study finding was consistent with the study findings of Lewko J et.al (2007). This study Assess the quality of life, the aim of this study was to determine the relationship between quality of life and the history of illness in diabetic patients. 59 patients with diabetes were included in the study. Quality of life in people with diabetes was reduced and related to their levels of illness acceptance. Factors affecting illness acceptance in patients with peripheral diabetic neuropathy included feelings of being a burden to their family and friends (p≤0.05) and the belief that people in their company are made anxious by the patient’s illness (p≤0.05). These patients also defined their health status as being worse than that of diabetic patients without additional disease complications. Quality of life and illness acceptance were found to be strongly related. In general, patients with chronic peripheral diabetic neuropathy express lower degrees of acceptance of their illness than diabetic patients without peripheral diabetic neuropathy. Their subjective assessment of health status is also significantly worse than that of diabetic patients without neuropathy. ¹³

CONCLUSION:

This study concluded that, guided imagery technique is a good and effective way to improve quality of life by reducing stress in diabetic patients. Result shows that there was a significant difference between stress level before and after the GIT intervention among 30 diabetic patients. Study results reveal that there is a significant difference between total quality of life score before and after the GIT intervention in certain demographic variables such as educational qualification, monthly income and duration of illness with the quality of life of diabetic patients. So it indicates that the guided imagery technique was effective to improve the quality of life of diabetic patients. Guided imagery is a useful technique for managing stress and thus by improving the quality of life. Guided imagery technique is a cost effective method, can be applicable to the any individual irrespective of any disease. it is an effective stress management technique and can quickly calm your body and simultaneously relax your mind. It just takes less than 10 minutes to reduce stress, it's pleasant to practice, and not overly difficult or intimidating to learn. The study demonstrating the health benefits of imagery are so numerous that many hospitals can apply this technique to help with treatment.

IMPLICATION FOR NURSING PRACTICE:

The result of the study shows that the elevated stress level and poor quality of life of the diabetic patients were corrected by giving guided imagery intervention. So, the study has several implications for nursing education, nursing practice, nursing administration and nursing research.

Nursing Service:

Guided imagery significantly reduces the stress and improves the quality of life. So in future nurse can incorporate guided imagery as a part of nursing intervention treating diabetes mellitus with stress and poor quality of life patients.

Nursing Education:

Ÿ Guided imagery is an important topic in classical and modern philosophy, as they are central to the study of knowledge.

Ÿ As guided imagery is an easy way to practice, it should be included in training.

Nursing Administration:

The nurse administrator having an important role for diabetes educator for the prevention and management of diabetes and guided imagery had been found to be very effective for the treatment of stress, she can plan very well and organise guided imagery technique to the nurses.

Nursing Research:

Ÿ Nursing research to be done to find out the various innovative methods to reduce stress and to improve quality of life.

Ÿ Research can be conducted on various populations at various settings.

SUGGESTIONS:

· The nurse educators should improve knowledge of diabetic patients.

· Guided imagery technique helps in reducing stress and improving quality of life, this technique should be taught to the diabetic patients.

· Adequate knowledge about how to reduce stress will help the diabetic patients to avoid complications and it should help them to lead a better life.

RECOMMENDATIONS FOR FURTHER RESEARCH:

1. A longitudinal study to find out the guided Imagery Technique for long lasting therapeutic effect on blood sugar level.

2. A study to determine the effectiveness of Guided Imagery Technique among diabetic patients in a rural area and diabetic patients in an urban area.

3. A comparative study can be done with guided imagery and alternative therapies on stress among diabetic mellitus patients.

4. A study to determine the cost effectiveness of Guided Imagery Technique for stress reduction and improving quality of life.

5. A similar study can be done through true experimental approach.

6. A similar longitudinal study can be done in hospital setting.

7. A similar study can be done with the help of video assisted guided visualization.

REFERENCES:

1. India Today(November 2018) URL: https://www.indiatoday.in/education-today/gk-current-affairs/story/98-million-indians-diabetes-2030-prevention-1394158-2018-11-22

2. Jeffrey S. Gonzalez, et.al (January 2011) Depression in Diabetes: Have We Been Missing Something Important?. American Diabetes Association. Daiabetes Care. URL: http://care.diabetesjournals.org/content/34/1/236.full

3. Diabetes.co.uk the global diabetes community. URL: https://www.diabetes.co.uk/alternative-treatment/Relaxation-Therapy-guided-imagery-and-diabetes.html.

4. Lawrence JM, Contreras R, Chen W, Sacks DA (May 2008). "Trends in the prevalence of preexisting diabetes and gestational diabetes mellitus among a racially/ethnically diverse population of pregnant women, 1999–2005". Diabetes Care 31 (5): 899–904. doi:10.2337-2345.

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6. Diabetes Statistics: India is the diabetic capital of the world. Health Savvy. 25 Feb 2008; URL:http://health.savvy-cafe.com/diabetes-statistics-india-is-the-diabetic-capital-of-the-world-2008-02-25/

7. Diabetes mellitus. Diabetes .co.in. URL: http://diabetes.co.in/

8. Diabetes. Diabetes information hub. 16 Dec 2010; URL: http://diabetesinformationhub.com/

9. Polit D F, Hungler B P. “Nursing research principles and methods”. 6^th edition. Philadelphia: Lippincott; 1999. 155.

10. Carole Holden and Lund. Effects of relaxation with guided imagery on surgical stress and wound healing. Research i nursing and health. Jan 2007; 10: 1002

11. Hanninen JA, Takala JK, Keinanen-Kiukaanniemi SM. Depression in subjects with type 2 diabetes. Predictive factors and relation to quality of life. Diabetes Care. 1999; 22:997–8.

12. National Journal of Physiology, Pharmacy and Pharmacology. 25 August 2018; URL:https://www.ejmanager.com/mnstemps/28/28-1536743371.pdf?t=1550898753

13. Advances in Medical Sciences 20 April 2007; URL:https://www.researchgate.net/profile/Jolanta_Lewko/publication/5621554_Quality_of_life_and_its_relationship_to_the_degree_of_illness_acceptance_in_patients_with_diabetes_and_peripheral_diabetic_neuropathy/links/09e41509696bb167cb000000/Quality-of-life-and-its-relationship-to-the-degree-of-illness-acceptance-in-patients-with-diabetes-and-peripheral-diabetic-neuropathy.pdf

Received on 25.02.2019 Modified on 16.04.2019

Int. J. Nur. Edu. and Research. 2019; 7(3):373-378.

DOI: 10.5958/2454-2660.2019.00084.X