The Efficacy of Optimism: Benefit Finding in the Treatment of Diabetes in Iranian Patients

The incidence of diabetes mellitus is on the rise around the world. Middle Eastern countries will be facing a vast increase in the number of diabetes mellitus cases by 2030. Diagnosis of a chronic disease such as diabetes mellitus can be a shocking and life-altering event. Conversely, a diagnosis of a chronic illness can also offer the patient opportunities to change unhealthy behaviors such as poor diet, smoking, and lack of exercise, making them healthier than before their diagnosis. This is referred to as “benefit finding”. This study reveals the many benefit findings of Iranian patients who have been diagnosed with diabetes mellitus and illustrates how benefit finding can be an integral part of long-term patient care.


Introduction
Diabetes mellitus is one of the most challenging and burdensome chronic diseases of the 21st century, and it is a growing threat to the world's public health [1]. Diabetes mellitus currently affects about 285 million adults worldwide and this figure is expected to rise to over 400 million adults by 2030 [2]. Type 2 diabetes mellitus is responsible for over 90% of all cases of diabetes [3]. Most new patients with diabetes are from developing countries and it seems that the Middle East is among the regions that will have the largest increase in the prevalence of diabetes by 2030. According to the research results, the prevalence of diabetes is about 8.7% in Iranians aged 25-64 years (9.2% in women and 7.5% in men). More than 1% of the Iranian urban population older than 20 years develops diabetes mellitus each year [4]. Diabetes mellitus can lead to serious complications and premature death [5]. Consequences of chronic diabetes include eye disease, circulatory problems and kidney failure, decreased quality of life, and increased use of health services [6]. The diagnosis of a life-threatening illness, such as diabetes, can be an extremely stressful and traumatic experience [7]. Studies have showed that living with diabetes has a negative impact on many aspects of daily life and the quality of life for people with diabetes [8].
Although negative outcomes of having an acute or chronic illness have received the most attention, studies can be found elucidating possible positive effects of serious illness [9]. However, some emerging evidence has shown that experience with life-threatening adversity can be an accelerator for personal growth and transformation. For example, research has found that patients may change the way they view themselves, their priorities, and their interactions with others in response to a health-related trauma [10].
The manner in which patients perceive positive of negative implications of their illness can influence various psychological consequences [11]. Posttraumatic growth could be one of the cognitive strategies used to deflect the negative effects of illness. When diagnosed, individuals may change their internal standards of what constitutes good health or other aspects of quality of life (recalibration), adjust their values and priorities (reprioritization), or redefine what they think is important (reconceptualization) to maintain an acceptable quality of life in the face of declining health [12]. Benefit finding has been associated with better psychosocial well-being and lower affective distress in numerous chronic illness populations. A review of the literature showed that the benefit findings are typically investigated in diseases such as cancers, spinal cord injuries, multiple sclerosis, and rheumatoid arthritis with only a few studies conducted among myocardial infarction and HIV/AIDS patients [13,14]. On the other hand, several studies have been conducted on type 2 diabetes patients [15]. Available literature is based on studies conducted in western societies that differ in terms of cultural and social backgrounds from the Iranian society. Moreover, the studies have shown that sociocultural context could influence illness and outcome of the process of adaptation to disease [16,17].
An understanding of benefit finding is significant in the proper provision of health care, such as nursing, as it appears that benefit finding aids in dealing effectively with illness and plays a prominent role in the cognitive process that facilitates adjustments to adversity [18]. The aim of this study is to explore positive change experiences of patients with diabetes in the Iranian population.

Materials and Methods
A purposive sample of fifteen patients was recruited. Patients were selected on the basis of the following inclusion criteria: a confirmed diagnosis of type 2 diabetes mellitus for at least two years; awareness of their diagnosis; cognitive and physical ability to participate; and a willingness to participate. Data were collected via in-depth, semistructured, and face to face interviews conducted between September 2011 and August 2012. All interviews were private and conducted at the participant's discretion with regard to place and time by the Diabetes Association of Iran, Tabriz branch. The interviews were conducted in Persian by corresponding author. Each participant was interviewed only once. The analysis was conducted in Persian and, for the purposes of this paper, translated into English. The interviewer asked the participants about their experiences of living with diabetes. The interviews were tape-recorded and transcribed verbatim. The first set of interviews lasted 60-80 minutes and the next set of interviews lasted 40-50 minutes (mean time of each interview is 45 minutes). Data collection continued until data saturation was achieved. That is, data collection had gone on up to when no new code emerged from analysis of the data. The analysis of the interview texts began once the first interview had been conducted and transcribed. Data were analyzed using qualitative content analysis techniques inspired by Graneheim and Lundman [19]. The analysis began by reading through each interview several times to obtain a sense of the whole of the participants' experiences. Then, the meaning units, which were words, sentences, or paragraphs that depicted important aspects of participants' experiences, were highlighted. These meaning units were then condensed to shorten the text but retain the content. In the next stage, these condensed meaning units, or codes, were abstracted from each interview transcript. Finally, using comparison, reflection, and interpretation, these codes were grouped into categories and subcategories by the first three authors. Criteria for enhancing the rigor of qualitative studies have been proposed by Lincoln and Guba and include credibility, transferability, dependability, and confirmability [20]. In the research process, researchers allocated sufficient time for data collection and retained close communication with study participants. The interviews were returned to the participants for verification of the accuracy of the results and to validate the congruity of the interpretive findings with their experiences. This ensured that researchers were correctly representing the ideas of the patients.
The data were coded and categorized independently by the authors and emergent themes were compared. Opinions of experts and also three Ph.D. candidates of nursing in data analysis as peer reviewers were used and cases were discussed over a two-week period. Regarding rigor, the research team discussed and interpreted the findings until an agreement was reached, wherein one author collected and analyzed the data (Hossein Namdar Areshtanab) and two researchers (Hossein Karimi Moonaghi, Leila Jouybari), who had expertise and were interested in conducting qualitative research, discussed, checked, and verified the meanings which were being emerged. These reviews enhanced the credibility of the data. To increase the dependability, one of the researchers collected and analyzed the data and other researchers checked and verified the results. Based on data collected from participants and memos taken after reading each of the interviews, participants were selected by considering maximum variation in terms of age, gender, previous experience with illness, family economic status, educational level, job background, and requirement of daily injectable insulin to provide transferability. Following the approval by the Ethics Committee of the Mashhad University of Medical Sciences, informed consents were obtained from all participants who met inclusion criteria for the study. All participants were assured that their personal data would remain confidential. Time and location were chosen by the agreement of the participants. Examples of interview questions are as follows.
(1) Can you tell us about your experiences of living with diabetes mellitus?
(2) Can you describe some things you did or experienced that were helpful in the management of your disease?
(3) What positive effects/changes do you feel may have occurred in your life due to diabetes mellitus?

Finding
Of the participants, 9 (60%) were males and the average age was 47.8 ± 12.0 years and 13 (86.7%) were married. Six (40%) had a lower educational background (illiterate to high school) and 6 (40%) had higher education backgrounds (college graduates). Females had a lower educational background than males. Most females were unemployed while most males were employed and three of them were retired. Participants  (Table 1).
During the data analysis, three main themes emerged as the positive experiences of Iranian patients with diabetes: lifestyle modification; promotion of interpersonal interactions; and appreciating health ( Table 2).

Lifestyle Modification.
The participants considered their diseases as an agent in changing unhealthy lifestyle behaviors. This refers to positive changes in knowledge, behavior, self, and spiritual dimensions of participants. The category has four subcategories: promotion of knowledge; modification of behaviors; promotion of self; and promotion of spiritual aspects. The research findings are shown in Table 2.

Discussion and Conclusion
Until now, there have been no studies conducted in Iran on posttraumatic growth following type 2 diabetes mellitus. This study shows that the participants have realized positive changes following type 2 diabetes mellitus depending on what meaning they ascribe to it. Studies have shown that how the individual cognitively processes information plays an essential role in coping with illness [21].
In this study, one of the positive changes after a diagnosis of type 2 diabetes mellitus was promotion of lifestyle. It was evidenced in knowledge, behavior, self-, and spiritual dimensions of participants. The present study found promotion of spiritual aspects as the most significant dimension of benefit finding. Considering the dominant religious culture in Iran and special role of religion and spirituality in facing stressful events, predominance of the spiritual promotion subtheme is quite justified. Thus, taking into account existing studies, it seems that promotion of lifestyle is one of the positive outcomes to chronic illness [15,[22][23][24][25].
In this study, the illness may not only influence the patients to change their lifestyles, but also affect the interpersonal interactions in relation to positive changes in relationships between family members, participation in group activities, and empathy with other patients with diabetes.
Thus, taking into account existing studies, it seems that positive changes in relationships are one of the positive outcomes to chronic illness [15,18,[26][27][28].
Another positive change in the aftermath of the illness was appreciation of life. Thus, taking into account existing studies, it seems that appreciation of health is one of the positive outcomes to chronic illness [18,23,29]. In this study, length of time with the disease, high family support, low severity of illness, high educational level, high economic status, religious beliefs, and no underlying disease had positive impacts on posttraumatic growth in diabetes. Thus, taking into account existing studies, it seems that these factors have a positive effect on diabetes mellitus [30].
It can be concluded that, despite the difficulties of having diabetes, it may also have positive effects for those diagnosed. Consideration of the effects of the disease on patients' life experiences and understanding of their thoughts about the disease as well as the disease's impact on adaptation to disease are important elements in nursing care and education.

Limitations and Recommendations
In this study, the sample size is small and was carried out in one national context. Also, the findings reflect only the view of patients regarding positive effects of type 2 diabetes mellitus. Thus, as with other such qualitative studies, caution is needed in generalizing the findings to either Iran as a country or other countries around the world. Also, future study requires input from both health care providers and families. We believe that it is necessary to conduct a population-based survey to confirm these findings.