MEASUREMENT OF PSYCHO-EMOTIONAL CONSTRUCTS AND SELF-MANAGEMENT IN HEALTH OF PATIENTS WITH INFLAMMATORY BOWEL DISEASES

: This study intended to measure the scores of psych-emotional constructs and self-management in patients with inflammatory bowel diseases (IBD), compare those scores according to the type of IBD, and verify the influence of these measures on self-management in health. This is a cross-sectional study performed at the outpatient clinic of a public Hospital. The patients were adults and diagnosed with IBD; they answered instruments of measure of self-esteem, anxiety and depression, health status and of activation. Pearson’s correlation test and Student's t test evaluated the variables of interest. The level of significance was 0.05. We evaluated 65 patients (average age = 40.71; SD = 14.26). We found high score of activation (average = 57.5; SD = 13.38) and high score of self-esteem (average = 31.58; SD = 4.98), moderate score of anxiety (average = 8.24; SD = 4.38) and low score of depression (average = 5.47; SD = 3.53). Significant correlations were observed, from low to moderate magnitude, between the other measures and activation (p < 0.05). There were weak correlations between activation and time since diagnosis; anxiety and number of comorbidities (p < 0.05). We have concluded that patients with IBD presented high self-esteem, moderate levels of anxiety, low levels of depression and a high level of activation. Longer time since diagnosis was related with better self-management in health.


INTRODUCTION
Chronic diseases are seen as public health problem, because they present high rates of mortality, a reduced of quality of life, limitation and disability, besides being responsible for major economic impact both in the families and in the public health (WORLD HEALTH ORGANIZATION, 2011).
Among the many chronic diseases are Inflammatory Bowel Diseases (IBD), which are inflammatory conditions that affect the gastrointestinal tract (BARBIERI, 2000). The major and most prevalent IBDs are Crohn's Disease (CD) and Ulcerative Colitis (UC). Even though they present peculiar pathophysiological and clinical characteristics, they are both idiopathic (FILHO, 2011) in nature.
CD and UC generally have symptoms such as diarrhea with blood in stool or not, cramping, abdominal pain, fever, weight loss, fissures, urgency and fecal incontinence, and may also evolve and present symptoms outside gastrointestinal tract (MARANHÃO; VIEIRA; CAMPOS, 2015). It has prolonged clinical evolution and recurrence generating strong impacts in several aspects of the life of its patients (BARBIERI, 2000;FILHO, 2011;MARANHÃO;VIEIRA;CAMPOS, 2015).
These chronic conditions affect patients not only physically, but also from psycho-emotional and socioeconomic point of view, since it limits their social, educational, professional activities, their mobility, their eating habits and daily activities (FRIEDMAN, 2004). The therapy includes changes in health behaviors, high-cost treatment, the use of medicines for continuous use and change in the eating habits and of living (FREITAS; MENDES, 2007).
These negative repercussions in the life of these individuals are highly favorable to the development of psychological disorders (SERAFIM; COSTA, 2009;BOING et al., 2012) and distortions in the perception of the body selfimage (BARROS, 2016). These disorders can considerably compromise the patient's willingness and ability for the self-care and self-management of his or her health. The theoretical relationship of these constructs (self-esteem, anxiety and depression with self-management in health) has been noticed in individuals with chronic diseases (CUNHA, 2016), but until now, those aspects of the IBDs have been little studied.
In order to achieve better results in health, it is critical that healthcare professionals help IBD patients adapt to the lifestyle changes required by their health status, through the use of individualized approaches that aim self-care and self-management of health. On the other hand, it is also important, that they pay attention in the psycho-emotional aspects and of the self-esteem of these individuals.
The present study aimed to evaluate the scores of self-esteem, anxiety and depression and of self-management of health (activation) in a group of patients with IBDs, as well as verify the influence of the different characteristics social, demographic and clinical in these measures.

MATERIAL AND METHODS
This is a cross-sectional, analytical and descriptive study, with a quantitative approach. The data collection was performed at the gastroenterology outpatient clinic of The Hospital de Clínicas of Universidade Federal de Uberlândia (UFU), in the city of Uberlândia, Minas Gerais state, Brazil.

Participants, Procedures and Ethical Considerations
A non-probabilistic sample for convenience and of the consecutive type was formed by followup patients in the gastroenterology outpatient clinic. Those who met the previously established criteria were invited to participate: patient diagnosed with inflammatory pathologies of the gastrointestinal tract -ulcerative colitis and Crohn's disease -for at least 6 months, age between 18 and 80 years old, patients who are under regular clinical follow-up in the UFU gastroenterology outpatient clinic and with preserved cognitive function -evaluated by a questionnaire that estimates discriminatory capacity and the capacity of psychic and mental orientation of this individual in time and space, according to Pfeiffer's proposal (1975). In this evaluation, the participant must answer correctly to at least three of the questions, in order to be included on the study (PFEIFFER, 1975).
To the patients who were considered cognitively qualified through this evaluation, we performed the other methodological steps of this study. We adopted as exclusion criteria, the history of previous hospitalization within a period of up to one month right before this evaluation.
After the presentation of the objectives of the study and with due clarifications, it was requested of the participants their consent in order to start the methodological protocol of the project. We applied a sequence of evaluation instruments: characterization of the socio-demographic and clinical data, the validated versions for use in Brazil of the Rosenberg Self-Esteem Scale (RSES), the "Hospital Anxiety and Depression Scale" (HADS) and the Patient Activation Measure (PAM13). This research was approved by the Ethics in Research Committee. The data collection period occurred between July and September of 2014.

Sociodemographic and clinical information questionnaire
The information on socio-demographic characteristics collected was: gender, age (full years), marital status, level of education (total of years of study) and monthly family income (in Brazilian currency). The clinical data investigated were: medical diagnosis (reason for visit to the outpatient clinic where the interview was performed), time elapsed since the diagnosis of the chronic disease, and number of comorbidities. For the categorization of participants, according to the nature of the chronic disease, we considered the medical diagnosis recorded at the visit to the outpatient clinic.

Patient Activation Measure (PAM 13)
To evaluate the self-management in health of the patients we used the Brazilian version of the Patient Activation Measure (PAM13) (CUNHA, 2016). This instrument assesses the level of activation of individuals for self-management in health. The instrument is composed of 13 items evaluated by an ordinal scale, with five answers option: totally disagree (1 point), disagree (2 points), agree (3 points), totally agree (4 points) and Not applicable (0 points). The gross score is obtained by the sum of the values indicated in the responses to the items and can range from 13 to 52 points. The gross score is later converted into an activation score (from 0 to 100 points). Higher scores correspond to a greater activation for the care in health (HIBBARD et al., 2005).

Evaluation of the perceived health status by the Visual Analogue Scale (VAS)
A visual analogue scale (VAS) of 100 millimeters was used to evaluate the perceived health status of the participants. They were instructed to indicate, in the drawn line, the position of their health status at that time, being zero as the worst health status imaginable, and 100 as being the best one possible.

Hospital Anxiety and Depression Scale (HADS)
The presence of symptoms of anxiety and depression was evaluated by the adapted and validated version for Brazil (BOTEGA et al., 1995) of the Hospital Anxiety and Depression Scale (HADS), composed of 14 multiple choice questions, with values ranging from zero to three. Seven of the items evaluate anxiety symptoms (HADS-Anxiety) and the other seven evaluate symptoms of depression (HADS-Depression). The sum of each subscale can range from 0 to 21 points and the higher the value, the greater the presence of evaluated the symptom.

Rosenberg Self-Esteem Scale (RSES)
To evaluate the self-esteem, we used the Rosenberg Self-esteem Scale, on its adapted version for Brazil (AVANCI et al., 2007). It has ten items that evaluate the positive and negative feelings that the individuals have of themselves. The answers are obtained by an ordinal scale of four points, ranging from one to four. In order to obtain the total score is performed the sum of responses to the items, after the inversion of the values of the five negative items. The possible range can vary from 10 to 40, where higher values indicate greater self-esteem.

Data Analysis
The collected data was processed using the IBM Statistical Package for Social Sciences (SPSS) version 21.0, running in a Windows ® environment. For all analyzes we have adopted the significance level of 0.05.
We performed descriptive analysis for categorical variables (gender, level of education, marital status, monthly income etc.), of measures of central tendency (average) and of variability (standard deviation) for the continuous variables. For the measurement and analysis of the scores of the constructs: self-esteem, anxiety and depression and activation, we used the descriptive statistics (simple frequency, central tendency and variability).
And for their interpretation, we used the recommendations cited by the authors in their validation studies for the Brazilian population. To evaluate the correlation between the variables (age, level of education, time since diagnosis, income and number of comorbidities) with the measures of selfesteem, anxiety and depression and activation, we used the Pearson correlation test between the variables of interest (PEARSON, 2004). And to compare if there is difference between the measures of self-esteem, anxiety and depression and activation between the groups (gender, age range [18 to 30 years old, 31 to 59 years old and older than 60 years old] and time since diagnosis [up to 2 years and over 2 years]) we used the Student's t-test and ANOVA. We adopted the magnitude of the obtained correlations as recommended for Ajzen and Fishbein: correlation values below 0.30 are of little clinical applicability, even with statistical significance; Values between 0.30 and 0.50 indicate moderate correlation and values higher than 0.50, strong clinical correlation (AJZEN; FISHBEN, 1980).

RESULTS
In this study, we address 65 participants with inflammatory bowel diseases, 42 (64.6%) of them were women. The average age of the participants was 40.71 years (SD = 14.26), with age range predominant of 30 to 59 years (45; 69.2%). Most of the participants (32; 49.2%) were married or living in common law marriage. 41 (63.1%) of the participants reported having some occupational activity. The average time of formal education was 10.28 years (SD = 3.95) and the household income average was 2.97 minimum wages (Table 1). Most of the evaluated participants (40; 61.53%) had Crohn's disease as diagnosis and average time of diagnosis of 8.31 years (SD = 6.74). We observed great disparity between the numbers of comorbidities diagnosed and the number of self-reported comorbidities, being this last one with much higher values than the first one (Table 2). We verified that the patients evaluated presented high score of activation (average = 57.5 points) and high score of self-esteem (average = 31.58 points). Concerning the presence of symptoms of anxiety and depression in the evaluated group, we found that the anxiety scores revealed a moderate presence of symptoms of anxiety (average = 8.24), but with no presence of symptoms of depression. The health status index of this population was considered high (average = 78.78) ( Table 3). In the comparison between the means of the average scores of self-esteem, anxiety and depression, activation and health status we can observe that the scores obtained between patients with Crohn's Disease and UC showed statistical differences concerning self-esteem and the presence of symptoms of Anxiety (p < 0.05) (Table 4).  Regarding the evaluation of the existing relationship between the measures of self-esteem, health status, anxiety and depression and activation with some sociodemographic and clinical variables, we observed a weak and significant correlation only between the activation and the time since diagnosis (r = 0.241) and between the measures of anxiety and the number of comorbidities (r = 0.297 and r = 0.283) (p < 0.05). In relation to the other variables and measuring instruments, we did not observe any other significant correlation (p > 0.05). We also evaluated the performance of measuring instruments, according to some supposedly wellknown groups (gender, age range [18 to 30 years old, 31 to 59 years old and over 60 years old] and time since diagnosis [up to 2 years and more than 2 years]). Our intention was to evaluate if the instruments used were able to discriminate the measures according to some specific and predetermined groups (called known groups). In this evaluation, we did not find statistically significant differences in the comparison of the averages between the groups (p> 0.05).

DISCUSSION
The present study measured some subjective constructs, such as the measures of self-esteem, of anxiety and depression, health status and of activation in a group of patients with Inflammatory Bowel Disease (IBD), as well as it correlated and compared these measures with different social, demographic and clinical characteristics.
The results of this study showed in young adults, ranging in age between 30 to 59 years old. These data are similar to those described in the Pearson says that the most susceptible age group is between age 10 and 40 years of age and that there is no gender predominance, but a possible association with specific ethnic groups (PEARSON, 2004). Another study argues that IBD affects both men and women in similar proportions, with Chron's disease (CD) being present in a higher prevalence in women. The age range can vary between 15 to 30 years old and with a second peak between 60 to 80 years old. Regarding Brazilian data, the Zaltman study mentions that the rates of prevalence, incidence and mortality of IBDs in Brazil are still unknown, although regional reports have described an increase in the number of new cases of CD when compared to ulcerative colitis (UC) (ZALTMAN, 2007).
The IBDs have as a characteristic the occurrence in young adults who comprise the economically active population, showing the importance and repercussion of these diseases on work capacity, social life and on quality of life (VICTORIA; SASSAK; NUNES, 2009). And with regards to gender, studies suggest that CD is more frequent in women, with a ratio of about 3:2, and this may be linked with the use of oral contraceptive and female hormones (CORNISH, 2008).
Concerning to the type of IBD, the majority of our participants presented Crohn's disease as a diagnosis. Studies have warned to the rapid increase of this disease in comparison to others IBDs (SOUZA et al., 2002;ZALTMAN, 2007;LIMA, 2012;MARANHÃO;VIEIRA;CAMPOS, 2015) The literature has mentioned that the rapid increase and prevalence of IBD in developing countries is due to the Western lifestyle linked to the environmental factor of the IBDs genesis (ZALTMAN, 2007). Besides, Shanahan, 2002, points out that in addition to family history and predisposing environmental factors, other factors such as antigens derived from the microbiota, degree of exposure to intestinal pathogens, smoking, and use of nonsteroidal anti-inflammatory drugs appear to be linked to the development of the IBDs (SHANAHAN, 2002).
It is important to emphasize that some studies affirm that the delay of diagnosis of IBDs is quite frequent, due to the fact that these diseases do not present a specific characteristic that alone is able to close the diagnosis, being necessary for that, the sum of all the data from the clinical history plus other findings from different exams. In this study we found that the average time for diagnosis was around 8 years, finding similar to the results of other studies (BARROS, 2016;COHEN;BIN;FAYH, 2010;FALCÃO;MARTINELLI, 2016).
In our study, we found that the patients had a average family income, slightly above two minimum wages. Besides that, their average level of education was considered high, around 10 years. The study by Souza et al., 2013 demonstrated the correlation between higher levels of education with better income (SOUZA et al., 2013). This information corroborates our findings. The fact that the participants of this study have average family income and average level of education is important information, since these patients need sufficient financial resources due to the high expenses with health services (OLIVEIRA; EMERICK; SOARES, 2010). In addition, the patients with higher level of education present greater knowledge about their health condition and because of that, they may be more collaborative in order to maintain their condition stable.
We also found that more than half of our patients had occupational activities. The literature shows us that there is a concordant relationship between IBD and disability, whether for work, domestic or even daily activities (BÜSCH, et al., 2014). The factors that determine incapacity for work activities are uncertain, with some emphasis on the severity of the disease. Of the various predictive factors of disability due to IBD, the time elapsed since diagnosis showed special relevance, supporting the progressive pathological character of IBD. Another point to be considered is the progress in disease control provided by recent therapeutic measures (RAMOS et al., 2015).
The measurement of the subjective constructs is relatively recent in the scientific community, with the development and the progressive use of measuring instruments, especially since the 90s, of the last century (PASQUALI, 2009). The instruments of measurement used in this study present all the characteristics of validity and reliability, in order to be used in the Brazilian population, since all were submitted to a rigorous process of cultural adaptation and psychometric validation. In the present study we verified that all instruments presented adequate levels of reliability, with Cronbach's alpha values greater than 0.7. And concerning validity, we verified that these instruments showed good validity of convergent construct between the measures evaluated, since we obtained significant correlations, from low to moderate magnitude, between all the measures evaluated, which confirms the existence of theoretical relationship between the measures used, evaluated on individuals with IBDs.
The Self-esteem scores, measured by the Rosenberg Self-Esteem Scale, in the patients with IBD revealed a high average score, reflecting a high self-esteem, result consistent with the results of other studies (MENEZES, 2008;BARROS, 2016) performed a study in patients with IBD evaluating their self-esteem with the RSES and found that almost all the patients presented high self-esteem.
The literature describes that, in the middle of the several studies that evaluated self-esteem in patients with IBD, people with low self-esteem are rare (MENEZES, 2008), strengthening the results of our study. We can conclude that self-esteem interferes in several aspects of the patient's life, as learning and autonomy. When elevated, self-esteem is an influential factor on coping with complicated moments and overcoming difficulties, it influences the individual in his / her perception mode and especially in his / her behavior, when facing the challenges of life (BRANDEN; GOUVEIA, 1998).
Our study verified that the patients presented high self-esteem, and this is justified by the fact that, although they often live with physical impacts, they still manage to maintain their selfesteem high, mainly because they are young and they have the willingness to fight to live with quality. On the other hand, our study also showed a statistical difference in scores of the self-esteem between patients with CD and UC, in which the scores of self-esteem of patients with CD were significantly lower than the scores of patients with UC, in other words the self-esteem of individuals with CD is lower. This can be attributed to the fact that the CD is characterized by a more severe evolution, with more complications, and greater need of hospitalizations and surgical interventions than UC (SOUZA et al., 2002). Therefore, people with CD suffer more from the multidimensional impacts imposed by the disease.
Regarding the symptoms of anxiety and depression, we verified that the index of symptoms of anxiety in patients with IBD was considered moderate, while the index of symptoms of depression was considered low, being the index of symptoms of depression similar to index of healthy individuals. These data are corroborated by other studies, which suggested separately that anxiety would be more prevalent than depression in patients with IBD (MIKOCKA-WALUS et al., 2008). The numerous concerns that such patients are subjected to, along with the awareness of their incurable condition and uncertainties of its course and prognosis, the fear of undergoing surgery or develop cancer contribute to the development of anxiety in people with IBD (GRAFF; WALKER; BERNSTEIN, 2010).
The literature emphasizes that there are controversies about the development of anxiety and depression in patients with IBD (BARROS, 2016;FALCÃO;MARTINELLI, 2016;LIMA, 2012;(SERAFIM;COSTA, 2009;BOING, et al., 2012. Some researchers (FALCÃO;MARTINELLI, 2016;LIMA, 2012) have found no evidence of association between these comorbidities, while others (BARROS, 2016;(SERAFIM;COSTA, 2009;BOING, et al., 2012) have confirmed that depression and anxiety are common in patients with IBD, however, anxiety and depression are more prevalent in patients who experience exacerbations than in patients in remission (MITTERMAIER et al., 2004). Kurina et al. found that both depression and anxiety are more present in Ulcerative Colitis than in Crohn's disease (KURINA et al., 2001).
We believe that the fact that this study found low rates of symptoms of depression may be related to the high self-esteem of our patients. Selfesteem is a relevant characteristic of the individual that can result in motivation for care in health. Such motivation is an effective condition for positive changes of self-management in health (CUNHA, 2016).
In our study, we found that patients diagnosed with UC are more symptomatic for anxiety than patients with Crohn's disease; there was no significant correlation between depression and ulcerative colitis or depression and Crohn's disease. Both Crohn's disease and ulcerative colitis presented high rates of self-esteem in our sample, highlighting in significant way, greater rates of self-esteem in patients with ulcerative colitis. In our study, we verified that patients with UC presented better selfesteem when compared to patients with Crohn's disease. On the other hand, although they have greater self-esteem, we found that in those patients, the symptoms of anxiety are more present compared to the group of patients with Crohn's Disease.
Concerning health status, we noted scores from moderate to high on the patients with IBDs, with average values greater than 78 points, according with another study (COHEN; BIN; FAYH,2010). The study by Campolina et al. found averages of VAS smaller than ours (67.30 points), and even then, the authors consider as being good those quality of life results (CAMPOLINA, et al., 2011). Other studies argue that the health status of patients with IBD may be compromised, especially when they are going through the period of exacerbation of the disease (SOUZA et al., 2011).
In our study, the score obtained from PAM13 by patients with IBD showed a high level of activation, with an average of 57.5 points. This score corresponds to level 4 of activation, which means that these patients can maintain their health and cope with their health problems resulting from Crohn's disease or ulcerative colitis. This demonstrates that these patients have extensive knowledge about their health condition, the confidence to act and the skills necessary to conduct behaviors and healthy changes in their lifestyle. In addition, they believe that they can maintain their health, considering that they present behaviors of self-management and they know how to deal with their health problems (and not just the symptoms) in an independent way (CUNHA, 2016).
The teaching of self-care for selfmanagement in health is an important process and should be practiced continuously by health professionals, because it helps the individual to increase knowledge of the process, health / illness, improving the self-perception and promoting the change of habits necessary (LEOPARDI, 2006). Self-management includes skills that help people successfully manage their chronic conditions on a day-to-day basis (LORIG; HOLMAN, 2003). As the individuals effectively adapt strategies to their own conditions, their perceptions of self-efficacy, control, and ability increase, and they are more likely to apply and diffuse the skills and techniques they have learned in their daily lives (WALKER; SWERISSEN;BELFRAGE, 2003).
Concerning the existing relationship between the measures of self-esteem, anxiety and depression, activation and some variables sociodemographic and clinical, we observed a significant correlation only between activation and time since diagnosis (r = 0.241); the measures of anxiety and number of comorbidities (r = 0.297 and r = 0.283) presented correlations of low magnitude but statistically significant (p < 0.05). Therefore, it is essential take into account these variables when evaluating patients with IBD.

CONCLUSION
The findings evidence that the health professionals may include the evaluation of these subjective constructs in the clinical evaluation of patients with IBD, so that they may seek strategies in order to detect and reduce symptoms of anxiety and that way improve the self-esteem of those patients. All these strategies aim to improve the activation of the individuals with IBD, based on self-care, in the ability and greater disposition of the individual to self-manage their chronic condition in order to obtain better outcomes in health.