Stress in mothers of diabetic children in riyadh city, saudi arabia.

OBJECTIVES: The purpose of this study was to determine the presence of physical, social, financial and marital stress on mothers of diabetic children and the possible relationship of this stress to the epidemiological characteristics of the mothers.
METHOD: It was a case-control study in which 125 mothers of diabetic children were selected randomly from 10 general and private hospitals in Riyadh city. A control companion group of 110 mothers who were free of chronic illness, was drawn from primary health care centers in the same city. Mothers in both groups were interviewed using a structured questionnaire.
RESULTS: In the study group, 110 mothers were interviewed. Physical, social and financial stress was more common in mothers of diabetic children than in mothers in the control group. With the exception of marital stress, the differences were statistically significant. Physical stress was correlated positively with the frequency of blood tests and the working status of mothers. Social stress was correlated positively with the frequency of blood tests; but negatively with child's knowledge of diabetes mellitus. Financial stress was correlated positively with the presence of chronic illness but negatively with family income.
CONCLUSION: Mothers of diabetic children are at risk of being under various kinds of stress. Certain epidemiological factors are associated with the development of the stress. These factors have to be taken into consideration in the management of the disease.

INTRODUCTION

Diabetes mellitus (DM) is a chronic disease of wide prevalence varying from one place to another.12 The prevalence of DM in children in the Kingdom of Saudi Arabia (KSA) has not been determined yet, although it is believed to be high.2–10 Psychological and psychiatric disturbances are common in DM.11 Much stress is expected in families where there is a diabetic child to be taken care of.11 The cost of a new modality of treatment required by the chronic disease in a dependent child, the demand of a constant supply of insulin, the difference in types and strengths of insulin and the strive for adequate control are likely to create much stress in the family, particularly in mothers.1–3 Hence, insulin dependent diabetes mellitus (IDDM) is considered to be a major health problem in children and adolescents which creates a challenge for the treating clinicians.14 The chronic illness also makes the afflicted individual more vulnerable to the stresses of life but not necessarily cause any maladjustment.15 To the best of the investigator's knowledge, no study has been published on the detrimental effects of the physical, social, financial and marital stresses on the health of the caring mothers, and the association of these stresses with certain epidemiological characteristics of the mothers of diabetic children.

METHODS

This was a case control study. It was conducted in Riyadh city, the capital of KSA. The investigator visited all ten hospitals (including Ministry of Health, University, Military and Private Hospitals), which had provided care to DM in Riyadh city. All their admissions and outpatient clinic notes were reviewed. A final list of 358 patients comprising all Saudi diabetic children up to 12 years of age was obtained. A sample size of 125 mothers of diabetic children was randomly selected from the list. The investigator and 6 Arabic-speaking female nurses conducted the interviews. This was done in the pediatric clinic, diabetic centers and at home. The instrument used was a structured questionnaire developed by Kovacs et al16 that had been previously used in Saudi Arabia to determine stress in the parents of the handicapped in Dammam city.10

The questionnaire had been previously validated and found appropriate for use in the present study. The independent variables included the following: demographic data of the mothers, such as age, marital status; socio-economic status, such as income, level of education and work; and epidemiological characteristics, such as diabetes duration, frequency of insulin injections, previous admissions, etc.

The controlled group was randomly selected from patients who attended primary health centers but had no chronic illness. The matching criteria included child's age, gender, father's education, job, income, family size, and mother's age.

The dependent stress variables were investigated by means of the following questions as in the questionnaire: Maternal Physical Stress Index (MPSI) by Q16-17 &19; Maternal Social Stress Index (MSSI) by Q20-21 & 30; Maternal Marital Stress Index (MMSI) by Q22-24; and Maternal Financial Stress Index (MFSI) by Q25-29.

SPSS package was used in the analysis of the data obtained. Guturman split-half was used to test reliability of the questionnaire. T-test and multiple regression were used for data analysis.

RESULTS

Only 110 mothers of diabetic children could be traced and they all responded to the interview. The coefficient of reliability using Gutumann split – half was .8765, indicating a total reliability of about 87%.

Epidemiological characteristics of the diabetic children and their mothers

The mean age and standard deviation (±SD) of diabetic children was 8.54 ± 2.7 years. Diabetes was found more in girls (61.8%) than in boys (38.2%). The mean ± SD of the duration of the disease was 2.8 ± 2.08 years (Table 1). Most of the diabetics received insulin twice daily. The mean ± SD of frequency of blood tests was 8.33 ± 6.25 times. About 66% of them did not do the urine tests. The mean ± SD of frequency of admission for the preceding year was 1.08 ± 1.4 times.

Table 1

Diabetes mellitus duration in diabetic children

The mean ± SD of mothers with diabetic children and the control group were 33.5 ± 7.8 and 33.1 ± 6.2 years respectively with no significant statistical difference. Seventy-five percent of the mothers of diabetic children were housewives. Twenty-six (23.6%) of the mothers of diabetic children were illiterates as against 17 (15.5%) of mothers in the controls who were illiterates. The mean ± SD of the duration of education of the mothers of diabetic children and control group was 7.5 ± 5.5 years, and 7.4 ± 4.6 years respectively, with no significant statistical difference. Forty-five (41%) families with diabetic children belonged to the low social class, 54 families (49%) to the middle social class, and 11 families (10%) belonged to the high social class. The mean yearly income ± SD was 6984 ± 4612.4 Saudi Riyals.

Physical, social, financial and marital stresses

Table 2 shows the significant differences found between the study and control groups in the maternal physical, social and financial indices but not in the marital indices when the t-test was used.

Table 2

Stress indices among mothers of diabetic children and control group

Analysis of the relationships between maternal stress indices and epidemiological characteristics

Among the other factors studies, multiple regression showed statistically significant associations between the MPSI and the frequency of blood tests, income and mother's job (Table 3); between the MSSI and the frequency of blood tests and child's knowledge (Table 4); and between the MFSI and presence of chronic illness and higher income (Table 5).

Table 3

Multiple regression of physical stress index

Table 4

Multiple regression of maternal social stress index

Table 5

Multiple regression financial stress index

DISCUSSION

Physical impact

The higher maternal physical stress index observed among mothers of diabetic children compared to their corresponding controls might indicate that the mothers of diabetic children put more effort in the care of their children as compared to the control group (p=0.000) (Table 2). After controlling the possible confounding factors (family size, maternal age, child gender, and age) it was evident that the mothers of diabetic children appeared not entrust the care of their children to other people. Accordingly, they were under greater physical stress. Dawood, in a study on mothers of mentally retarded children in Dammam area16 found a similarly high degree of physical stress.10 This study showed a positive connection of the important role mothers play in diabetic management with their stress.17 The physical stress index also correlated positively with increased frequency of blood tests (p=0.009) (Table 4).

Physical stress index was more significant in the working mothers (p=0.0238). The demand of IDDM on the caring mother is great and may become an intolerable source of stress particularly for a working mother. This factor should be taken into consideration in any new project concerning the management of diabetes, as tight control is required. It is thus mandatory to have a psychotherapist and a diabetic educator in any management program that is designed.

Higher income was positively correlated with physical stress index (p=0.001). It was impossible to explain why mothers with high income have difficulty in tolerating the extra physical effort required for the care of their children.

Social impact

Mothers of diabetic children had less social life probably because of their involvement in the care of their children. Hence the social stress index was significantly correlated with the frequency of blood tests (p=0.15) (Table 5). Since a mother is expected to be near her child especially if she/he has frequent blood test, the mother is prevented from leaving home to make social calls and therefore feels isolated from the community. Social contacts alleviates mental stress, therefore, mothers, who are deprived of this present with a form of anxiety rejection17 or a community withdrawal.1

The level of the children's knowledge about diabetes was inversely related to the social status index (Table 5). One expects that the knowledgeable diabetics will take better care of themselves. It is envisaged that the social stress will diminish with the improvement of the child's knowledge.

Financial impact

The financial stress index was high in families of diabetic children compared to the families of the control group (p=0.000) (Table 3).

Simells’ study confirms that insulin treatment, diabetic diet which is expensive, home monitoring of blood glucose and ketonuria increased the direct costs as well as the indirect costs such as loss of working time, the cost of employing a baby-sitter or a housekeeper. In his study of mentally retarded children, Al-Dawood10 did not find a significant financial stress on their families. This may be because the cost of caring for the two conditions is different and that mentally retarded children do not require as much continuous daily monitoring as is the case with diabetics.

In this study, the presence of diabetes was found to increase the financial stress index (p=0.012). Another factor, which also helped to increase financial stress on the mother, was low family income (p=0.026) (Table 6). In fact, families in which any chronic illness was present had financial difficulties as a result of repeated outpatient visits and hospital inpatient admissions etc. It seems that the financial stress is particularly severe when the illness was diabetes mellitus.

Marital impact

In this study, no statistically significant difference was found between mothers of diabetic children and mothers of the controls in the marital stress index. This may reflect the positive impact of the presence of the disease on the family in raising the level of awareness between both parents and in encouraging them to share in the responsibility of caring for the child. Although on such sensitive issues, one cannot exclude the possibility that some mothers, particularly those who were interviewed in the presence of the father, were not completely open about their marital problems.

CONCLUSION

This study revealed that mothers of Saudi diabetic children are under different kinds of stress. Some epidemiological factors are related to the development of these stresses. These factors should be taken in consideration for the comprehensive management of diabetic children. The treating physician, the diabetic health educator and the psychotherapist should work together as a unit in the management of the patient.