Abraham Maslow, the American psychologist, is best known for his theory of hierarchy of needs.1 Maslow’s theory highlights the positive potential of humankind and tries to understand how motivating factors relate to individual behaviour. The nature of these factors is vital to diabetes care as well. Healthcare professionals and family members report frustration at people with diabetes for not taking adequate care of themselves.2,3 The lack of self-motivation and self-care is a source of irritation for care providers,4 and of ill health for person with diabetes. In recent years, diabetes care has embraced the concept of responsible patient-centred care, delivered in a salutogenic (rather than pathogenesis-oriented) manner.5,6 This Insight article on Maslow’s theory, creates a hierarchy of diabetes-related needs to inform diabetes care-related strategies, tools and targets.
Maslow proposed a multi-layered, yet fluid and dynamic, hierarchy of needs to explain what motivates human behaviour. He stated that man is a perpetually-wanting animal whose needs progress upwards as basic ones are met. Until simple or physiological needs are fulfilled, ‘higher’ or psychological needs cannot be addressed.1 The physiological needs include breathing, food, water, sleep, homeostasis and excretion. Once achieved, the individual craves for safety, including security of body, employment resources, morality, family, health and property. Later, the person moves on to satisfying the needs for belonging and love, such as friendship, intimacy and love.1
Once these d-needs (deficiency needs) are taken care of, b-needs (being needs) appear. This, the final level of Maslow’s hierarchy, implies the “desire to accomplish everything that one can, to become the most that one can be”. This understanding of one’s potential, and its achievement, is what Maslow terms as self-actualisation. Self-actualisation can also be defined as an individual’s motivation to reach his or her full potential.1 However, these needs are not absolutely compartmentalised, wherein the higher need appears only after the earlier one has been completely met. On the contrary, Maslow emphasised on fluidity and dynamic nature of these stages and how external and internal cues from the human experience affect where a person is along the hierarchy at a given point of time.
We invert the pyramid of Maslow’s hierarchy of needs, and list some of these needs in Table 1, which can then be used to discuss diabetes-oriented hierarchy as well.
Table 1: Hierarchy of needs in diabetes care – the Maslow-based model
|Level of hierarchy||Maslow’s need||Diabetes-related need||Patient-centred description||Diabetes care tools|
|1||Physiological||Symptomatic benefit||Relief from symptoms/sickness||Drugs with fast onset of action|
|2||Safety||Metabolic benefit||Euglycemia without hypoglycaemia or other side-effects||Safe and effective drugs with low risk of hypoglycaemia|
|3||Love/belonging||Psychosocial relief (euthymia)||Psychological health, along with biomedical health||Diabetes therapy by the ear|
|4||Esteem||Social benefit||Social acceptance||Biopsychosocial assessment and redressal|
|5||Self-actualisation||Outcomes benefit||Comprehensive fitness, including heart and kidney||Therapy with proven vascular safety and benefit|
|6||Self-transcendence||Peer benefit (helping others)||“Others shouldn’t undergo what I had to”||Therapeutic patient education and communications training|
Maslow’s theory and life with diabetes
The diabetes care provider expects that every person living with diabetes demonstrates self-actualisation and experiences the full potential of diabetes care. What we do not realise, however, is that self-actualisation is extremely difficult to achieve. If this is true for life in general, it must be much tougher in a life complicated by diabetes. If self-actualisation requires the fulfilment of all basic desires – physiological, safety, love/belonging and self-esteem – a similar logic should prevail in life with diabetes.
Each person is unique, and driven by different and dynamic motivating factors7, which operate singly or in conjunction with each other, in varying degrees. Motivation is influenced by multiple internal and external factors. Education and health literacy, an understanding of one’s body, and functional limitations due to symptoms of disease are examples of internal variables which modulate motivation. External variables include exposure to disease in the family and community, comfort with the health care system and health care team, and availability of resources.
All these factors merge together to create a hierarchy of attitudes towards health. We propose a pyramid, similar to Maslow’s hierarchy, to help describe and identify the key motivating factors in patients with diabetes. This blueprint, as depicted in Table 1 and Figure 1, helps the diabetes care team understand the people they care for, decide the most optimal approach to therapy, choose the most appropriate tools for diagnosis, treatment and monitoring and reach across to the individual and influence behaviour.
Level 1 – physiological needs
At base level, a person has simple needs. They expect symptomatic relief from their physician and may not be concerned about ‘healthy numbers’ or long-term outcomes. Engagement with the healthcare system aims to ensure functional adequacy, and enjoy reasonably good quality of life. It is important for the healthcare team to ensure that the leading complaints of the individual are addressed before proceeding further. For instance, when a person presents with symptomatic hyperglycaemia, therapy should focus on amelioration of osmotic symptoms. In such, glucose lowering drugs with rapid onset of action should be chosen.8 Subjective cues should be chosen to encourage the person to accept therapy and provide reassurance that they have been heard:
“I understand you are bothered by body aches and fatigue. Let us begin this treatment as it will help increase your energy and wellbeing, and allow you to do gardening that you enjoy so much”.
Level 2 – safety needs
Once primary concerns have been addressed, focus of care shifts to safety. This is reflected in our version of Maslow’s model. Significant emphasis has been placed on choosing pharmacological treatments to attain therapeutic goals while avoiding side-effects. Drugs with a low risk of hypoglycaemia9 and less glycaemic variability10 are preferred in high-risk individuals. People who voice concerns about safety of treatment, must be reassured of the tolerability of prescribed medication, to ensure adherence.
“It is natural to have concerns about the side effects of medicines and I am glad you brought that up. This drug has a low risk of hypoglycaemia and doesn’t damage kidneys. In fact, it helps the kidneys and the heart.”
Level 3 – love and belonging
The need for love and belonging is evident in patients with diabetes as well. People with diabetes require a warm and close relationship with their health team, family and society at large. Inter-personal discord is a significant stressor, and can be both a cause and consequence of poor control. Diabetes care should, therefore, lay equal emphasis on biomedical and psychosocial health, including assessment of domestic and societal discrimination. The ‘diabetes therapy by the ear’ model is suited for these persons.11
“While we are using the best possible medication, is there any emotional issues I can help you with? Are there any issues that particularly upset you?”
Level 4 – esteem
The fourth level, esteem, finds resonance in diabetes care. While many people are happy accepting physician-driven therapy, others appreciate active involvement in their care. This is a means of maintaining their self-esteem . Such people need self-management, education and skill enhancement, and welcome shared decision-making.12 Discussion should specifically include challenges to self-esteem faced by the patient, including social challenges such as self-injection at work or in public. Flexible insulin regimens and preparations, using discreet delivery devices, may be welcome in such persons.
“I understand you are worried that insulin injections will interfere with your freedom to move about and may create social embarrassment. This pen can fit in your pocket; you can inject as convenient, and do not have to disclose diabetes.”
Level 5 – self-actualisation
Self-actualisation is the pinnacle of needs. The self-actualised person is one who achieves his or her full potential. This is the ‘dream patient’, who has mastered self-care, can treat and monitor oneself, and works with the medical team to ensure optimal outcomes. Self-actualised patients appreciate the diabetes care team’s efforts, and work towards further improvement once long-term goals are explained.13 They are more likely to become true partners in the shared decision-making process.
“How well you are controlled today will impact your health over the long term, like karma. The treatment we suggest will improve your metabolic karma and reduce the risk of cardiovascular disease.”
Level 6 – self-transcendence
Maslow later added another motivational level, termed self-transcendence.14 This can be applied to self-actualised patients with diabetes, who wish to make a difference in diabetes care, beyond their individual management. These people wish to improve health of others, or contribute towards preventing the diabetes epidemic, and may appreciate training and employment as diabetes care providers.
“Thank you for offering support. Once trained, you will be able to help lots of people.”
The three-step model
The six steps discussed are concordant with Maslow’s original structure. Our choice of two biomedical parameters, interspersed with two psychosocial parameters, and capped by a comprehensive marker of success, highlights the integrated nature of health. A three-step model (Figure 2) helps simplify Maslow’s relevance to diabetes care. This lists three successive needs: symptomatic, metabolic, and outcomes benefit. Psychosocial health is an essential component of this biomedical stepladder. We name this model the TRIDENT (TRIpod of DiabEtes Needs and Therapy).
These three compartments are not watertight, unidirectional or static in nature. A person with diabetes can have multiple and dynamic permutations and combinations of needs. However, TRIDENT does allow a psychological triage of persons seeking diabetes care. This helps establish and plan effective physician–patient communication, which allows the diabetes care jigsaw puzzle to fall into place.
Improvement in healthcare accepting behaviour can be achieved step-by-step, and our rubric provides a useful framework for this. There is no point discussing outcomes or metabolic benefit in a person whose symptoms have not been addressed properly. Similarly, an asymptomatic person with diabetes must be counselled emphatically about the need for metabolic health, to improve their healthcare-seeking behaviour.
Trident as a tool for success
The TRIDENT is a clinical decision-making tool, which allows categorisation of the patient into a ‘psycho-type’, based upon expectations from healthcare. This facilitates planning and execution of a patient-centred management strategy, based on communication and motivation. We hope that TRIDENT finds widespread acceptance as a clinical and teaching tool, to spread the essence of patient-centred diabetology.
- Maslow AH. A theory of human motivation. Psychological Review. 1943;50:370–96. Available at: http://psycnet.apa.org/doiLanding?doi=10.1037%2Fh0054346. Last accessed on 15 January 2019
- Kovacs Burns K, Nicolucci A, Holt RI, et al. DAWN2 Study Group. Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross‐national benchmarking indicators for family members living with people with diabetes. Diabet Med. 2013;30:778–88.
- Holt RI, Nicolucci A, Kovacs Burns K, et al. Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross‐national comparisons on barriers and resources for optimal care—healthcare professional perspective. Diabet Med. 2013;30:789–98.
- Boyle DA. Compassion fatigue: The cost of caring. Nursing 2018. 2015; 45(7):48-51.
- Kalra S, Baruah MP, Unnikrishnan AG. Responsible patient-centered care. Indian J Endocrinol Metab. 2017;21:365–7.
- van Dam HA, Van der Horst F, Van den Borne B, et al. Provider–patient interaction in diabetes care: effects on patient self-care and outcomes: a systematic review. Patient education and counseling. 2003; 51(1):17-28.
- Stewart M. Towards a global definition of patient centred care: the patient should be the judge of patient centred care. BMJ. 2001;322:444.
- Kalra S, Gupta Y. Choosing an insulin regimen: a developing country perspective. African Journal of Diabetes Medicine. 2014;22:17–20.
- Seaquist ER, Anderson J, Childs B, et al. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society. Diabetes care. 2013 Apr 22:DC_122480.
- Hirsch IB. Glycemic variability and diabetes complications: does it matter? Of course it does!. Diabetes care. 2015;38(8):1610-4.
- Kalra S, Baruah MP, Das AK. Diabetes therapy by the ear: A bi-directional process. Indian J Endocrinol Metab. 2015;19(Suppl 1):S4–5.
- Kalra S, Sridhar GR, Balhara YP, Sahay RK, Bantwal G, Baruah MP, et al. National recommendations: Psychosocial management of diabetes in India. Indian J Endocrinol Metab. 2013;17:376–95.
- Barry MJ, Edgman-Levitan S. Shared decision making—the pinnacle of patient-centered care. New England Journal of Medicine. 2012; 366(9):780-1.
- Maslow AH. Health as transcendence of environment. J Humanist Psychol. 1961;1:1–7.