submitted to the university of gezira in fulfillment of
TRANSCRIPT
1
The Effect of Self-Management Telecare Educational Program on
Knowledge, Attitude and Practice among Saudi Type-2 Diabetic
Patients at Sultan Bin Abdulaziz Humanitarian City ، Kindom of Sudia
Arabia (2015-2017)
Fatima Mohammed Ibrahim
B.A. In Psychology, Faculty of Arts, University of ALNilain (2010)
A Thesis
Submitted to the University of Gezira in Fulfillment of the
Requirement for the Award of the Degree of Master of Science
in
Community Health
Primary Health Care and Health Education Center
Faculty of Medicine
July ،2018
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The Effect of Self-Management Telecare Educational Program on
Knowledge, Attitude and Practice among Saudi Type-2 Diabetic
Patients at Sultan Bin Abdulaziz Humanitarian City ، Kindom of Sudia
Arabia (2015-2017)
Fatima Mohammed Ibrahim Hassan
Supervision Committee:
Name Position Signature
Prof. Magda Elhadi Ahmed Yousif Main Supervisor ……………….
Dr. Salwa Saad Awad Co-supervisor ……………….
Date: July , 2018
3
The Effect of Self-Management Telecare Educational Program on
Knowledge, Attitude and Practice among Saudi Type-2 Diabetic
Patients at Sultan Bin Abdulaziz Humanitarian City ، Kindom of Sudia
Arabia (2015-2017)
Fatima Mohammed Ibrahim Hassan
Examination Committee:
Name Position Signature
Prof. Magda Elhadi Ahmed Yousif Chair Person ……………….
Prof. Yousif Abdelhameed Elsisi External Examiner ……………….
Prof. Mawia Albalal Alhabob Internal Examiner ……………….
Date of Examination: 29 /8 /2018
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DECLARATION
I hereby declare the work embodied in the dissertation “A Qualitative and Prospective Study of
The Effectiveness of Self-Management Educational Program on Knowledge, Behavior, Attitude
and Practice among Saudi Type-2 Diabetic patients At Sultan Bin Abdulaziz Humanitarian City
(SBAHC)”was carried out by me
5
Acknowledgements
I would like to express my deep thanks and sincere appreciation and gratitude to Prof. Magda
Elhadi Ahmed, Director of Primary Health Care and Health education center , for her
supervision, support, assistance and guidance throughout the research period..
I would like to express my sincere thanks to my committee members, Dr.Sadi AL Zahrani and
my greatest shanks goes to Gezira University .
I am very grateful for their direction and guidance, which allowed me to successfully complete
this project. Co-Supervisor: Dr. Salwa Saad Awad Assistant Professor of Psychology, College of
Health and Rehabilitation Sciences Princess Nourah Bint Abdulraman University.
My sincere thanks go out to all the patients who completed questionnaire and provided their
support.
Special thanks go to Dr. Yaser ELTayeb Consultant Internal Medicine, Dr. Enas El Sayed
Shaine consultant physiatrist and my family and friends for their support during this long
journey. This project wouldn’t have been possible without him.
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The Effect of Self-Management Telecare Educational Program on Knowledge,
Behavior, Attitude and Practice among Saudi Type-2 Diabetic Patients At Sultan Bin
Abdulaziz Humanitarian City ،Kindom of Sudia Arabia (2015-2017)
Fatima Mohammed Ibrahim
Abstract
Diabetes is a lifelong chronic disease that requires daily management. Diabetes is the leading cause
of blindness, kidney failure, and non-traumatic lower limb amputations. Studies have proved that
Saudi nationals are more likely to suffer from diabetes related complications than any other
nationality. The purpose of this study was to decide whether a diabetes educational program would
be operative in altering Saudi patients’ behavior specifically their knowledge, attitudes, and
practices about managing the disease. The study was aiming at determining if patients would
enhance their capacity to perform management skills for their disease, physical activities, increase
their knowledge of health topics after completing the program that included educational and activity
components for a period of 12 weeks. Data was collected using a pre- and post-test in addition a
socio-demographic questionnaire .The program lasted for six-months. The program was based on
the American Diabetes Association (ADA) guidelines: (a) introduction to diabetes, (b) healthy
eating, (c) being active, (d), medications, (e) glucose monitoring and complications, and (f)
symptom management. 93 Saudi adults ’patients with type 2 diabetes have participated in the study
protocol. Participants’ age ranged between 20-65 years who attended the outpatient clinic in Sultan
Bin Abdulaziz Humanitarian City. The patients’ biomarker (HBA1C) was measured at a baseline
there was statistically significant decrease with P<0.05. The Diabetic Care Profile, the Diabetic
Knowledge scale, Diabetes Attitude Survey, Understanding and Practicing Scales were measured at
the baseline and post intervention. At baseline, many patients had poor diabetes knowledge,
negative attitude about self-care adherence and diabetes self-management activities. The findings at
the end of the study revealed statistically significant positive improvements in diabetes knowledge,
behavior, attitude and practice. The study participants gained awareness of the need of diabetes self-
management. The studies recommend designing and implementing telecare communication to
enhance diabetes self-management among Saudi patients with Type2diabetes. The study
recommends social networks should inspected by medical professionals as means of improving
communication and outcomes with individual patients. The study recommends people with DM
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should have a close relationship with their healthcare professional or team; they are more likely to
follow their diabetes care plan. The study recommended closed the gap between knowledge and
practice among diabetics which is highly needed for good diabetes management such as, adherence
to diabetes self-care tasks, as well as self-efficacy.
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باستخدام الرعاية بواسطة الهاتف على السلوك المعرفي التعليمي العناية الذاتية برنامج مدى تأُثير
لعزيز لخدمات , بمدينة سلطان بن عبدا من النوع الثانيوالممارسات التطبيقيه لدي مرضي السكري
(2017-2015الانسانية ، الممكة العربية السعودية )
فاطمة محمد ابراهيم
الدراسة ملخص
مرض السكري مرض مزمن يحتاج الى العلاج بصفة يومية. يعتبرمرض السكري من أكثرالأمراض التي تؤدي الى العمى،
عرضة لمرض السكري ومضاعفاته من باقي الجنسيات. الفشل الكلوي، وبتر الأقدام. أثبتت الدراسات أن السعوديين أكثر
الغرض من هذه الدراسة معرفة تأثير التعليم في تغيير نمط العادات والسلوك والممارسات لدى المرضى السعوديين ومدى
هدف هذه تأُثيرها على قدرتهم على العناية الذاتية وذلك عن طريق اجراء برنامج تعليمي على المرضى عينة الدراسة. كما ت
الدراسة الي معرفة استطاعة هؤلاء المرضى على تطبيق أسس العناية الذاتية بأنفسهم وذلك بالتعرف أكثرعلى مرضهم
وأهمية العناية الذاتية وزيادة وعيهم الصحي ، لتمكينهم من اكمال هذا البرنامج اللذي استغرق اثني عشر اسبوعا. تم جمع
قبل وبعد البرنامج بالاضافة الى Diabetes Care Profile (DCP)ة بالسكري( ـــــــــنايالبيانات باستخدام إستبيان )الع
العناية الذاتية على تعبئة استبيان الحالة الاجتماعية. البرنامج أخذ فترة ستة أشهر لاكماله.يرتكز هذا البرنامج على أهمية
كري، التغذية السليمة، ممارسة الرياضة، التقيد حسب توصية الجمعية الأمريكية للسكري ويشمل مقدمة عن مرض الس
من البالغين والذين مريضا سعوديا 93بالأدوية، فحص السكر، معالجة الأعراض ان وجدت. وأجريت هذه الدراسة على
سنة وهم مراجعين في العيادات الخارجية 65-20يعانون من مرض السكري )النوع الثاني(، وتراوحت أعمارهم ما بين
نة سلطان بن عبدالعزيز للخدمات الانسانية . تم فحص عينة الدم للسكر التراكمي عند بدء الدراسة كمقياس ضبط السكربمدي
، مقياس المهارات المعرفية، مقياس السلوك تجاه السكر، مقياس الفهم P <0.05كان هناك انخفاض ذو دلالة إحصائية مع
ليمي ، لم تكن لدى المرضى عند بدء الدراسة معلومات كافية وكذلك كان سلوكهم والممارسة التطبيقيه قبل وبعد التدخل التع
سلبي تجاه العناية الذاتية بمرض السكري. نتائج الدراسة أوضحت تحسن كبير في معرفة مرض السكري وتحسن في سلوك
ج العناية الذاتية عن بعد بطريقة الى تصميم وتطبيق برنام توصيالمرضى وممارستهم للعناية الذاتية بأنفسهم.هذه الدراسة
ينبغي الاستفادة منها من الاجتماعية التواصل شبكاتتوصي الدراسة ان التواصل مع مرضى السكري في المجتمع السعودي.
السكري يجب ان تكونالأشخاص المصابين بمرض اه ، وان كوسيلة لتحسين الاتصالات والنتائج مع مرضكادر الطبي القبل
توصي الدراسة كما .علاجهم هم أكثر احتمالا لمتابعة خطةو ة وثيقة مع أخصائي الرعاية الصحية أو فريقهلديهم علاق
لوصول الى التحكم الجيد مرضى السكري ، وهي حاجة ماسة التطبيقيه لدي المعرفة والممارسة السلوك بإغلاق الفجوة بين
الكفاءة الذاتية رفع رعاية الذاتية ، بالإضافة إلىالسكري مثل التمسك بمهام ال ىضيلمر في ادارة الذات
9
LIST OF CONTENT
Dedication ………………………………………………………….……………………..iii
Acknowledgment………………………………………………….………………………iv
English Abstract ………………………………………………………………….……….v
Arabic Abstract……………………………………………………………………………vi
List of contents……………………………………………………………………………vii
List of Tables ……………………………………………………………………………..viii
List of Figures……………………………………………………………………….……. ix
LIST OF ABBREVIATIONS……………………………………………………..…… x
CHAPTER I INTRODUCTION
1.1 Background of the Problem………………………………………………….. 1
1.2 Statement of the Problem……………………………………………………. 2
1.3 Nature of the Study…………………………………………………………… 3
1.4 Justification of the Study……………………………………………………… 3
1.5 Research Objectives…………..………………………………………………. 6
1.6 The Knowledge Gaps, Relationship with Diabetes Self-Care Management 6
CHAPTER II. Literature Review and Theoretical background
2.1 Diabetes Mellitus………………………………………………………………… 8
2.1.1. CLASSIFICATION OF DIABETES…………………………………………. 9
2.1.1.1 Type 1 diabetes……………………………………………………………. ….. 9
2.1.1.2 Type 2 diabetes……………………………………………………………. …. 9
2.1.1.3 Impaired Glucose Tolerance………………………………………........... …. 9
2.1.1.4 Gestational diabetes………………………………………………….…. …. 9
2.2 Diagnostic Tests…………………………………………………………………. 9
2.2.1 Hemoglobin HbA1C…………………………………………………………. ….. 10
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2.3. Prevalence of Diabetes……………………………………………………….. 10
2.3.1 Prevalence of Diabetes in the Arab Region………………………………… 10
2.3.2 Prevalence of Diabetes in Saudi Arabia and its Economic Impact……… 10
2.4. Morbidity and Mortality……………………………………………………. 11
2.5. Global Economic Impact of Diabetes………………………………………. 12
2.5.1 Diabetes Economic Impact in Arab Countries……………………………… 12
2.6. Psychosocial Care for Diabetic patients and Health Practiced………………. 13
2.7 Cognitive Variable………………………………………………………….. 14
2.7.1 Diabetes Knowledge and Self-Efficacy Attitude………………………… 14
2.8 How does social Media Effect Diabetes Self-Management……………….. 15
2.9 Diabetic Care Profile (DCP), the Diabetic instruments…………………… 17
CHAPTER III. METHODOLOGY
3.1. Research Philosophy……………………………………………………… 20
3.2 Purpose of the Study…………………………………………………………… 20
3.3. Research Ethical Considerations…………………………………………… 20
3.4. Research Questions…………………………………………………………….. 21
3.5 Variables………………………………………………………………………… 21
3.6 Assumption……………………………………………………………………… 21
3.6.1 Telecare Procedure………………………………………………………………... 21
3.7 Research Design………………………………………………………………….. 22
3.8 Limitation………………………………………………………………………… 22
3.4.1. Data Collection Procedure…………………………………………………… 22
3.4.2. Research Setting……………………………………………………………… 23
3.4.3. Recruitment sample of the study..…………………………………….……… 23
3.4.4. Inclusion and Exclusion Criteria……………………………………………. …… 23
3.4.5. Non participant’s profile…………………………………………………….. …… 24
3.4.6. Reliability and Validity……………………………………………………….. 24
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3.4. Variables of the Diabetes Care Profile (DCP) Instrument……………………. ….. 24
3.4.1. The items of the Diabetes Care Profile (DCP) are distributed as follows …. 26
3.4.2. Haemoglobin HbA1c……………………………………………………….. …. 27
3.5. The Intervention Diabetes Education Program………………………………. 28
3.5.1 Phase 1: Pre-assessment……………………………………………… ……… 29
3.5.2 The Major Components of the Intervention Program………………….. 29
3.5.2.3 Phase 3Post-intervention……………………………………………….. 29
CHAPTER IV. RESULTS
3.6 Data Analysis………………………………………………………………………33
CHAPTER IV. Discussion Chapter
5.1 Characteristics of the study population………………………………………….. 34
5.1.2. Clinical Characteristics…………………………………………………………. 36
5.2 Knowledge and its Effect on Adherence………………………………………… 41
5.3 Attitudes towards the Disease……………………………………………………. 44
5.4 The practice………………………………………………………………………. 47
5. 5 Barriers……………………………………………………………………………. 47
5. 6 Understanding of diabetes……………………………………………………….. 50
5.5.1 The Social Cognitive Theory (SCT) and Behavioral Change………………… 48
CHAPTER Vii Conclusion………………………………………………………….. 60
Recommendations for Future Research……………………………………………… 61
REFERENCES………………………………………………………………………. 62
APPENDIX A. CONSENT FORM.....................................................................................
APPENDIX B. SUPPORT LETTERS.................................................................................
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List of Tables
Table (1): Characteristics of the study population………………..…………… 27
Table (1a): Age and diabetes duration……………………………………….. 34
Table (3): Knowledge Score…………………………………………………… 37
Table (5): Distribution of Patient’s Attitude Before the intervention…………. 37
Table (6): Comparison of the mean Attitude score before and after the intervention 42
Table (7): Comparison of practice of DM patients before and after the intervention 44
Table (8): Barriers towards DM management before and after the intervention `
47
Table (9): Comparison of barriers towards DM management before and after the
Intervention…………………………………………………………….. 47
Table (10): Patients understanding of DM before and after the intervention …………….. 50
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LIST OF ABBREVIATIONS
SBAHC Sultan Bin Abdulaziz Humanitarian City
ADAS American Diabetes Association Standards of care
MDKT Michigan Diabetes Knowledge Test
DCP Diabetic Care Profile
UPS Understanding and practice scales
D K T Diabetes Knowledge Test
SM Social media
HbA1C Glycosylated Hemoglobin
IDF International Diabetes Federation
WHO World Health Organization
PHCs Primary Health Centers
DM Diabetes Mellitus
SMBG Self-Monitoring Blood Glucose
DCCT Diabetes Control and Complications Trial
SCT Social Cognitive Theory
EMR Electronic Medical Records
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Thesis
Submitted in partial fulfillment for
The requirements of M.Sc degree
In Primary Health Care and Health Education Center
University of Gezira
By
Under the supervision of:
Main Supervisor: Prof. Magda Elhadi Ahmed Yousif
Professor of Community Heath
Faculty of medicine
AlGezira University, Sudan
Co-Supervisor: Dr. Salwa Saad Awad
Assistant Professor of Psychology
College of Health and Rehabilitation Sciences
Princess Nourah Bint Abdulraman University, KSA 201
15
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Chapter 1
INTRODUCTION
1.1. Background of the Problem:
Diabetes Mellitus (DM) is characterized by the high levels of blood glucose resulted from
defects in insulin secretion, insulin action or both and belongs to a group of metabolic diseases
(American Diabetes Association Standards of Medical Care in Diabetes2017). It has been
estimated that 415 million or 8.8% of adults aged 20-79 have diabetes in the world with an
increase of 642 million or 10.4% by 2040. This significant increase has caused an outbreak, as
well as cost the health-care services remarkable amount of money (Nadir et al. 2011).
According to the 2013 International Diabetes Federation report, an estimated 382 million people
aged between 40 years and 59 years had the highest number of diabetes (World Health
Organization Updated November (2017). The outline associated death caused by diabetes to
be 5.1 million deaths, of which half of the people were <60 years of age.
The number of people with type 2 diabetes in the countries of the Gulf Cooperation Council
(GCC) the Kingdom of Saudi Arabia (KSA), Kuwait, Qatar, Oman, Kingdom of Bahrain, and
United Arab Emirates (UAE) has dramatically increased in the past two decades (Abuyassin
and Laher 2016), and is expected to increase by 96.3% by 2035 (IDF 2015). In 2015, the
estimated prevalence of diabetes in adults (20±79 years) in each of the GCC countries was
higher than the global prevalence of 8.8% (IDF 2015). In KSA, it was 17.6%; Kuwait, 14.3%;
Qatar, 13.5%; Oman, 9.9%; Kingdom of Bahrain, 15.6%; and UAE, 14.6% (IDF 2015). Studies
have shown that diabetic control is poor amongst adults with type 2 diabetes living in the GCC
countries (Omar & et al. 2016). In GCC countries an inappropriate figure of 40±70% of diabetes-
related foot amputations occurs as type 2 diabetes complication (IDF 2015).
There are more than three types of diabetes Type 1, Type 2, gestational diabetes and impaired
glucose tolerance. Type 2 diabetes (formerly called non-insulin-dependent or adult onset
diabetes) results from the body’s ineffective use of insulin. Symptoms may be similar to those of
type 1 diabetes, but are often less marked or absent. As a result, the disease may go undiagnosed
for several years, until complications have already arisen. For many years type-2 diabetes was
seen only in adults but it has begun to occur in children. In type2 the body is able to produce
insulin but it is not sufficient enough. Ideally, the symptoms are usually less noticeable compared
17
to type1. People with type 2 condition may take years before they recognize and seek
consultation. It is reported by the International Diabetes Federation (IDF) Atlas global 7th
193
million diabetic persons of which more than 46% are unaware of their condition. In year 2015 it
was reported world-wide that approximately 5.0 million people died from diabetes. A number of
disabled people such as blind and lower limb amputations were among the highest reported. The
Saudi population has witnessed an increase of 50% in the cost of the healthcare and treatment
of diabetes in the last two decades; In fact it was documented in 2014, with an approximate 25
billion (Saudi Riyal) was spent on the entire Saudi diabetic population (Dawish. MA., Robert.
AA., Braham. R., Al Hayek. AA., (2016)
Diabetes mellitus (DM) has become an increasing epidemic and a health challenge worldwide in
the 21st century predicting 642 million people living with DM by 2040 (IDF 2016). By 2040, the
Middle East and North Africa (MENA) are expected to have a leading rise in the total number of
adults with DM correspondingly (96·2%) (IDF 2016). Certain demographic and socio-behavioral
health determinants influence the Type 2 diabetes mellitus (T2DM) epidemiology (IDF 2016).
Socio-demographic factors include globalization, urbanization, and increased life expectancy,
whereas behavioral risk factors include obesity (BMI >30 kg/m2) and physical inactivity among
others smoking (Willi and Pan 2015).
1.2 Statement of the Problem:
Type2 diabetes rates are escalating in the Saudi community. Encouraging Saudi citizens to
search for early diagnosis and cure is a challenge. The depth of diabetes education that is needed
to attain the positive change in attitudes toward diabetes treatment was not fully practiced by
practitioners. In 2012 more than 9% of the population had diabetes, costing 2.3 times higher in
annual healthcare than costs for non-diabetic people in accordance with the Centers for Diseases
Control (CDC, 2014). Much of the budget of treating diabetes comes from the long-term effects
of the disease on the individual’s body. Poor management of the disease and the disease
comorbidities lead to an increase in the frequency of hospitalization, which results to more than
40% of costs to cure diabetes (American Diabetes Association 2012). The Saudi nationals seem
to have difficulty learning the necessary lifestyle changes to either avoid or control the disease. If
Saudis with Type 2 diabetes are able to recognize the obstacles that prevent them from changing
their lifestyle that are essential to control their blood glycemic levels and receive education on
how to overcome and manage their disease, then they can be able to control their blood sugar
18
levels. This progress will strongly decrease the undesirable diabetic complications that they
presently encounter.
Diabetes is a long term disease that demands self-care management practices among patients
with diabetes. Diabetic patients need to construct proper adherence to strict diet and exercise
plans that result in a beneficial care and health (Senécal, C.,Nouwen, A.,White, D.et al 2000).
Diabetes self-management education (DSME) empowers patients with the skills, knowledge, and
essential information for self-care, and has been shown to have a positive impact on the health of
patients Holt RIG, Nicolucci A, Kovacs Burns K, Escalante M, Forbes A, Hermanns N et
al2013)Due to the lack of knowledge and resources, diabetic patients often experience poor
glucose control, amputation, renal disease, cardiovascular disease, and retinopathy for shortage
of knowledge and resources (Lee, and Young-Shin et al. (2015).
1.3 Nature of the Study:
A quantitative study framework utilizing three instruments was selected for this investigation.
The study was designed to measure four items:
patients’ level of knowledge about diabetes
Their attitudes toward the control DM
Psychosocial impacts, and seriousness of diabetes
Their beliefs about their own susceptibility to the disease; and their perceptions of the
severity, barriers, and benefits of diabetes self-management.
This research specifically investigated Saudis’ attitudes and beliefs about self-management and
sought to determine whether socioeconomic factors have an effect on adopting positive lifestyle
changes related to diabetes.
1.4 Justification of the Study
The most significant challenge in managing and controlling diabetes is self-care through
adequate health education (Niroom Niroomand .M., Ghasemi .SN., Karimi-Sari. H., et
al2107). There are evidences supporting that people with diabetes often have a lack of
information regarding the nature of disease, its risk factors and associated complications
attributed to the person’s attitude and practices towards its care (Enza Gucciardi a, Vivian
Wing-Sheung Chan ,et al 2013). Due to an increasing prevalence of diabetes and its
complications in Saudi Arabia consider it necessary to apply a diabetes educational program,
minimizing the governmental cost to treat diabetes and hence decreasing the incidence of
19
complications related to untreated diabetes cases (Asiri SA(2015). More importantly diabetic
patients benefit from the educational programs. Likewise, programs can be accredited when
patients fully understand the nature of diabetes through intensive education from diabetic
educators, thus enhancing their quality of life. Literature studies of patients with diabetes type 2
or cardiovascular disease found a varying connection between adherence and health literacy,
identifying patients’ needed understanding of the information to properly manage their disease
(Juutilainen A., Lehto S., Ronnemaa T. et al. (2005)). As a result, diabetes self-management
education is invaluable for patients with type 2 diabetes (ADA ,2015). There are limited studies
in Saudi Arabia studying the efficacy of self- management program on knowledge,behavior,
attitude and practices of diabetic patients. Saudi Arabia is having the second highest rate
of diabetes in the Middle East, 7th highest in the world with an estimated population of 7 million
living with diabetes and more than 3 million with pre-diabetes. Challenges like micro-and
macro-vascular complications, lifestyle changes, late diagnosis, poor awareness and high
treatment costs need to be managed in diabetes (A. Boutayeb1, andMohamed E. N, 2014).
Researches have concluded that many patients with diabetes do not have sufficient information
and awareness regarding risk factors, complications in handling diabetes. Yet to the best of the
researcher’s knowledge there are no studies conducted in a rehabilitation setting in Saudi Arabia,
wherein diabetes is one of the most common comorbidities among adult patients whether in the
inpatient or in the outpatients clinics. Sultan Bin Abdulaziz Humanitarian City (SBAHC) is
considered the biggest rehabilitation facility in Saudi Arabia, where the researcher is currently
working as a diabetes educator for more than 14 years. It is the researcher’s conviction that
without active participation of patients in education and self-care, that will lead to more
expensive health care costs, and will lead to further decline to the patient’s quality of life.
Therefore, the need of a diabetes educator is essential to increase patients’ knowledge about
various issues including diabetes self-care principles, continuous control of blood glucose levels,
and prevention of early as well as late complications of the disease. Educating the patient is the
first step towards moving diabetes out of the top ten diseases plaguing the Saudi nationals. It
should be made a priority for every treating physician and healthcare facility.
20
1.5.Difinition of terms:
Diabetes Knowledge was defined in this study as knowing the diagnosis, symptoms, and
management of diabetes )Haas, Maryniuk and Beck , 2017).
Behavior,how confident a person feels about his ability to perform a given task Behavior
was defined in this study as diabetes self-
management(Bandura,A.Badran,1995,p.10Attitude,Inclinations to react a certain way to
certain situations to see and interpret events according to certain predispositions; or to
organize opinions into coherent andinterrelated structures (Bandura, A. Badran, 1986, p.10)
Practice, a daily practice of monitoring blood sugar using a tool to indicate the better blood
glucose control. The application of rules and knowledge that leads to action (Bandura, A.
Badran, 1995, p.11)
Diabetes Self-Management, DSME According to the American Diabetes Association, is the
process of obtaining knowledge, skill, and capability necessary for diabetes self-care DSME
was defined in this study as increased physical activity, daily foot checks, and blood glucose
monitoring and medication adherence. Healthy eating, preventing low blood glucose,
diabetes related complications and problem solving (ADAS, 2017).
Barriers to Taking Action: action may not take place, even though an individual may
believe that the benefits to taking action are effective. This may be due to barriers. Barriers
relate to the characteristics of a treatment or preventive measure may be inconvenient,
expensive, unpleasant, painful or upsetting. These characteristics may lead a person away
from taking the desired action (Godfrey Hochbaum & Born,Public Health Rep 71, no 4
(1956):377–380)
The Empowerment model: is defined as “the process of assisting individuals, acting
separately and collectively, to make informed decisions about matters affecting their personal
health and that of others”. The long choice goal of health education, therefore, is to prepare
persons with the needed means to work toward their life objectives because they possess
optimum organic health and the vitality to meet emergencies, mental well-being to meet the
stresses of modern life, adaptability and social awareness of the requirements of group living,
attitudes and values leading to optimum health behavior, and moral and ethical qualities
contributing to life in a democratic society(Leviton, D, 2002).
21
1.10.Research Objective:
1.11. General objective:
Of this study was to evaluate the effect of self-management telecare educational program on
knowledge, behavior, attitude and practice among Saudi type-2 diabetic patients
1.12 specific Objectives:
a. Assess self-management behavior of diabetic patients
b. To evaluate the effect of the telecare self-management educational program before and
after its implementation.
c. To examine the participants’ knowledge, attitudes and practice of diabetes management
skills before implementing the self-management educational program and after its
implementation.
1.13 The Knowledge Gaps, Relationship with Diabetes Self-Care Management
According to literature review the diabetes self-management education is challenging (Parisa A.,
and R. Karbalaeifar, 2016). There is sufficient evidence to question whether methods of DSME
are appropriate for Saudi Arabia. This is based on documented differences in complications of
health outcomes where negligible research studies exist in Saudi Arabia which focuses mainly on
the effectiveness of self- management program on knowledge, attitude and practices of diabetic
patients (Al-Hamrani, 2009)( K. Aldossari1, 2015). Thus, a study delivering (SBAHC) based
intervention is needed to accommodate the patients of Saudi Arabia experiencing diabetes. The
goal of study is to implement relevant diabetes self-management programs in SBAHC. These
DSME programs emphasize and focus on diabetes knowledge, self-management and problem
solving skills, diabetes complications, physiological (blood test A1Cs,). They have provided
DMSE with contents that include: (a) healthy eating, (b) preventing low blood glucose, (c)
physical activities, (d) diabetes related complications, (e) problem solving, and (f) glucose
monitoring. Within this study, designed interventions tend to improve health knowledge and
outcomes among Saudi patients with DM. The psychosocial and cultural practices of Saudi
patients with DM were integrated into DSME. The curriculum focused on healthy eating, being
active, glucose monitoring, and medication adherence .The Saudi adult patients with type 2 DM,
aged 20-65 years who were referred by the inpatient/outpatient were allowed an opportunity to
interact directly with patients. This study demonstrated the need of importance of integrating
22
DSME into spiritual practices. Thus addressing the whole needs of individuals where designing
educational based diabetes self-management programs may have positive effects on diabetes
self-care practices and improve overall health. Based on the review of the literature, it is
reasonable to view diabetes self -management education delivered to individuals establish an
effective background to improve diabetes outcome indicators. There were a number of variables
evaluated within the studies reviewed. First, diabetes knowledge was an outcome indicator
examined in several diabetes self-management studies. The findings indicated significant
improvements in diabetes knowledge. The second variable was that significant improvements
were documented in many studies (Al Slamah T1, Nicholl BI1, Alslail FY2, Melville CA,et al
(2017), that lifestyle modifications were noted as consequence indicator. Few studies in diabetes
self-management as an outcome measure for Saudi adult (Fadia Megeid and Mervat
Mohamed, 2017). However, more studies are needed to examine the effectiveness of
educational programs on Saudi adults with DM based on interventional programs.
23
Chapter 2
Literature Review and Theoretical background
Literature reviews of the present research were based on the databases from Web of Sciences
which made some literature available through the PUBMED search engine at the local university
library in King Saud University. Other articles were retrieved from Google Scholar, the World
Health Organization website and IDF website that link to several American Diabetes Association
Standards of medical care in diabetes (ADA, 2017). Agencies such as the Central Department of
Statistics and Information (CDSI) websites provided access for statistical information. Keywords
used to find the literature in this study included diabetes mellitus, diabetes self-management,
diabetes knowledge, behavior, attitudes, and practice. A majority of the articles had publication
dates between 2003 and 2017. However, older articles were obtained for appropriate references.
Results of keywords narrowed to the full text provided journals from PsycINFO database, from
CINAHL database, and references from MEDLINE database and Google scholar.
2.1 Diabetes Mellitus:
Diabetes Mellitusis characterized by the high levels of blood glucose resulting from defects in
insulin secretion, insulin action or both and belongs to a group of metabolic diseases. Diabetes is
a complex chronic illness requiring continuous medical care with multifactorial risk-reduction
strategies beyond glycemic control (IDF, 2016). Ongoing patient self-management education
and support are critical to preventing acute complications and reducing the risk of long-term
complications. Significant evidence supports a range of interventions to improve diabetes
outcomes. Due to modern demographic transitions from accustomed to westernized and
urbanized lifestyles, there has been notable increase in diabetes occurrence in developing
countries(SusanL Norris, andMichaelM. Engelgau20014).It has led to an epidemic status,
thereby costing health-care services directly and indirectly significant amounts of money.
24
2.1.1. CLASSIFICATION OF DIABETES
Diabetes can be classified into the following general categories:
2.1.1.1 Type 1 diabetes:
This type of Diabetes is due to autoimmune β-cell destruction, usually leading to absolute insulin
deficiency, accounting to about 5% -10% of diagnosed cases (IDF, 2016). Usually patients with
Type 1 diabetes have lean body and most often are children and young adults.
2.1.1.2 Type 2 diabetes:
Type 2 diabetes is due to either insulin resistance with relative insulin deficiency or to insulin
secretion defect with or without deficiency. It is associated with overweight. Although it is most
common among those above 30 years old, yet, it is increasingly seen among younger people.
Type 2 diabetes accounts for about 90-95% of the diagnosed diabetes cases (WHO, 2017).
2.1.1.3 Impaired Glucose Tolerance:
It is not a category of diabetes but it is an intermediate metabolic stage between normal glucose
homeostasis and diabetes. It indicates a high risk for diabetes and cardiovascular diseases (IDF,
2016). It is diagnosed if fasting plasma glucose is 100 <126 mg/dl and 2 hours post glucose load
is 140 and < 199 mg/dl (ADA, 2017). Individuals with blood glucose levels in the range of
impaired glucose tolerance and impaired fasting glucose are at increased risk for developing type
2 diabetes, heart disease and stroke (Kardas P, Lewek P, 2014) Physical inactivity and sedentary
lifestyle can contribute to diabetes where one third of deaths in the developed countries have
been attributed to sedentary lifestyle and lack of physical activity (Kent D, D’Eramo Melkus G,
2013).
2.1.1.4 Gestational diabetes:
It is a temporary condition that occurs in pregnancy and carries long term risk of type 2 diabetes.
The condition is present when blood glucose values are above normal but still below those
diagnostic of diabetes (IDF, 2016).Women with gestational diabetes are at increased risk of
some complications during pregnancy and delivery, as are their infants. On the other hand,
gestational diabetes is determined through prenatal screening, rather than reported symptoms
(WHO, 2017).
25
2.2 Diagnostic Tests:
Diabetes may be diagnosed based on plasma glucose criteria or the fasting plasma glucose, two-
hour plasma glucose value after a 75-g oral glucose tolerance test, HbA1C. The same tests are
used to screen and diagnose diabetes and to detect individuals with pre-diabetes (ADA, 2017).
Table 1
Diagnostic
Criteria
Fasting Glucose
mg/dl
2-h oral glucose
tolerance test
mg/dl
Random
Glucose
mg/dl
HbA1C
Normal less100 less140 less200 Less5.7%
Pre-diabetes 100–125 140–199 More 200 5.7-6.4%
Diabetes More 126 More200 More 200 6.5%
American Diabetes Association Standards of Medical Care in Diabetesd2017
2.2.1 Hemoglobin HbA1C
Tight glycemic control or blood sugar values that remain within a specific range can prevent or
slow the progression of diabetes complications (American Diabetes Association). The adequacy
of diabetes therapy is determined by Hemoglobin HbA1C value (Diabetes Care, 2017Volume
p51).
2.3. Prevalence of Diabetes
The IDF Diabetes Atlas Eighth Edition of 2017 estimates 366 million people have diabetes and
is expected to rise to 552 million by 2030. Most of them (80%) live in low and middle-income
countries. Diabetes is undoubtedly one of the most challenging health problems in the 21st
century. It is rapidly getting worse; leaving the biggest impact on adults of working age in
developing countries (IDF, 2017). Undiagnosed diabetes accounts for 212 million or 1 in 2
adults. And 1 in 6 births is affected by DM.
2.3.1 Prevalence of Diabetes in the Arab Region
According to the last figures released by the (IDF, 2016)a rising trend of incidence and
prevalence is seen in every country around the world. However, the Arab region appears to have
a higher prevalence of diabetes than the global average. The Middle East and North Africa
region has the highest comparative prevalence (11%). Six of the top 10 countries with the highest
prevalence of diabetes (in adults aged 20 to 79 years) are in the Arab region: Kuwait (21.1%),
26
Lebanon (20.2%), Qatar (20.2%), Saudi Arabia (20.0), Bahrain (19.9%) and UAE (19.2%). For
the 20 Arab countries for which data is available, nearly 20.5 million people are living with
diabetes and another 13.7 million are in the pre-diabetes stage, having impaired tolerance
glucose. While in developed countries most people with diabetes are above the age of retirement.
In the Arab region 73.4% of diabetics are under 60 years of age and in the peak of their
productive years, making the burden in terms diabetic disability heavier (CDS, 2017).
2.3.2 Prevalence of Diabetes in Saudi Arabia and its Economic Impact
Saudi Arabia is ranked as the second highest rate of diabetes in the Middle East and seventh
highest in the word, with an estimated population of 7 million living with diabetes and more than
3 million with pre-diabetes (WHO, 2017). Several challenges in diabetes management need to
be tackled in Saudi Arabia, including the growing prevalence among children and young adults,
micro-and macro-vascular complications, lifestyle changes, late diagnosis, poor awareness and
high treatment costs. Over the last two decades, the Saudi population saw an increase in the
expenses in healthcare and treatment of diabetes by more than 50%. In 2014,
the health care budget was 180 billion (Saudi Riyal) with an approximate 25 billion(Saudi Riyal)
on the entire Saudi diabetic population. This implies that the direct expense of diabetes is costing
Saudi Arabia around 13.9% of the total health expenditure. Therefore, unless a comprehensive
epidemic control program/ multidisciplinary approach are stringently enforced, the DM
burden on Saudi Arabia will probably increase to very serious levels. Improving health and
health-related quality of life is essential to minimize social as well as personal expenses for
diabetes care in Saudi Arabia (Al Dawish MA, & Robert AA, 2016). This reflects an increase in
associated risk factors such as being overweight or obese. Over the past decade, diabetes
prevalence has risen faster in low- and middle-income countries than in high-income countries.
2.4. Morbidity and Mortality
Globally, an estimated complication cause’s blindness, kidney failure, lower limb amputation
and other long-term consequences that have an impact on quality of life is at least 10 times more
common in diabetic patients in developed countries (WHO, 2017). This estimated that the
number of deaths is equivalent to one death every seven seconds. Almost 48% of deaths due to
diabetes are “among people under the age of 60. The highest number of deaths due to diabetes is
in countries with the largest numbers of patient with diabetes like India, China, United States of
America, and Russian Federation. More than 80% of diabetes deaths occur in low and middle
27
income countries. The number of deaths attributable to diabetes in 2016 shows a 14.3% increase
over the estimates for the year 2017. This increase is largely due to increase in the number of
deaths due to diabetes in the South and Central America, Western Pacific, North America and
Caribbean, Middle East and North Africa Regions. This can be explained by a rise in diabetes
prevalence in some highly populated countries in each region. There has been a documented
decline of the mortality due to some non-communicable diseases in few countries, but there was
no such reported decrease of mortality for diabetes (Diabetes Care, 2017 Volume p51). CDC
rated the Kingdom of Saudi Arabia second highest death rate due to diabetes equivalent of 7%.
2.5. Global Economic Impact of Diabetes
Increasing prevalence around the world, reached the status of an epidemic costing health-care
services significant amounts of money in direct and indirect costs. The global health expenditure
on diabetes is expected to total at least USD 376 billion or ID 418 billion in 2010 and USD 490
billion or ID 561 billion in 2030. Globally, 12% of the health expenditures and USD 1330 (ID
1478) per person are anticipated to be spent on diabetes in 2010. The expenditure varies by
region, age group, gender, and country's income level (CDS, 2017).
2.5.1 Diabetes Economic Impact in Arab Countries:
In the Arab region, the number of adult deaths attributed to diabetes is about 170,000 people,
representing more than 10% of all deaths in the region. Complications of diabetes such as
blindness, amputations, and kidney failure and cardio vascular diseases contribute to temporary
and permanent disabilities (Haas L1, and Maryniuk M, 2014). Consequently, diabetes causes
an important economic burden due to the cost of treatment and the loss of productivity.
According to IDF estimates, the Arab region was expects to spend USD 8.7 billion as (WHO,
2017) expenditure for diabetes in 2017. However, the total healthcare expenditures due to
diabetes in the region account for less than 2% of the total global figure, whereas the number of
diabetics in the region (20.5 million) represents 5.6% of the world total number of diabetes (366
million). Treatment costs of a diabetic patient without complications (US$ 1605) were 3.2 times
higher than the per capita expenditure for health care in the UAE (US$ 497). The cost increased
notably with the presence of micro-vascular complications (2.2 times) and macro-vascular
complications (6.4 times). In patients with both micro and macro-vascular complications, the
treatment cost was 9.4 times higher (ABoutayeb & Mohamed 2012).
28
2.6. Psychosocial Care for Diabetic patients and Health Practiced
Psychosocial factors like complex environmental, social, behavioral and emotional influence
living with diabetes, both type 1 and type 2, and achieving satisfactory medical outcomes and
psychological well-being (CDC, 2017). Thus, individuals with diabetes and their families are
challenged with complex, multifaceted issues when integrating diabetes care into daily life. The
health mandate implies the concept and approach of holism. WHO defined health as “a state of
complete physical, mental, and social well-being and not simply the absence of disease .The
holistic concept, which is the directive of the WHO, means unity in the wellness states of the
“spirit, mind, body, and environment (WHO, 2017). This view of holism provided a foundation
to find the different correlation between behaviors and factors that influence diabetes self-
management practices among Saudi diabetic patients who have type 2 DM to promote optimal
medical outcomes and psychological well-being. Patient-centered care is vital and is defined as
“providing care that is respectful and responsive to individual patient preferences, needs, and
values thus assuring that patient values guide all clinical decisions(Nadir K., , William G,
2011). Practicing personalized, patient-centered psychosocial care requires that communications
and interactions, problem identification, psychosocial screening, diagnostic evaluation, and
intervention services take into account the context of the patient with diabetes and the values and
preferences of the patient with diabetes. (Kent D, D’Eramo Melkus G, 2013). As lifestyle,
includes a personal commitment to be directed toward the right end of the wellness continuum.
No matter what their current status of health, patient can improve their level of well-being. Even
when there are temporary setbacks, movement is always headed toward wellness. Whilst
preventing illness is important, Holistic Health emphasizes on reaching higher levels of wellness
(Sakraida .Robinson 2009). The right half of the wellness continuum invites patients to
constantly explore which everyday actions work for them and discovering what is appropriate to
move them toward maximum well-being. Patients are motivated by how good it feels to have lots
of energy and awareness for life, knowing that what they are doing that day will allow them to
continue to feel this great for years to come. Holistic Health principles can also be applied even
when disease and chronic conditions take place. The term is usually referred to as holistic
medicine, and additional factors are added (Jocelyn B., and Sonsona 2014). The healthcare
professionals using the holistic approach work in partnership with their patients. They
recommend treatments that support the patient’s natural healing system putting into
29
consideration the whole patient as well as the whole situation (Jocelyn B,and Sonsona 2014).
Factors influencing health behavior, peoples’ behavior is affected by what they think, believe,
and feel. The cognitive process is considered the most external influence affecting
behavior,wherein, self-efficacy is the most effective predictor of health behavior and is a critical
link between knowledge application and actual behavioral( Bandura, A. and Badran, 1995,
p.8) also postulated that social support is an effective tool to get through the barrier and stresses
people experience in the paths they take. Spiritual factors and well-being provided a positive
connection (Goode,and Pandora, 2016).
2.7 Cognitive Variable:
2.7.1 Diabetes Knowledge and Self-Efficacy Attitude:
Diabetes knowledge has been reported by researchers as a factor affecting diabetes self-
management and encouraging healthy behaviors (Jocelyn B,and Sonsona 2014). Diabetes
education was identified as leading an important role in managing diabetes and building skills to
empower patients in assuming daily responsibilities in controlling the disease (Al-Maskari F,
and El-Sadig M, ,2013).
A Previous study measured the relationship between medication knowledge and blood glucose
control by giving the 44 patients in an ambulatory care practice consumer guide questionnaires
and by drawing blood samples to measure their HbA1C. The findings were that knowledge score
predicted 40% of HbA1C levels variation; whereas knowledge score of 5 had 2.3 HbA1C level
points lower (Davies MJ, Heller S, Skinner TC, et al 2008). In another study, the Michigan
Diabetes Knowledge Test was tested on 77 participants with diabetes along with measuring
HbA1C(Kathleen Colleran, Brian StarrPuttinget al 2013). It was found that better scores
were inversely associated to HbA1C (r = -0.337, P <0.003), indicating a positive influence on
glycemic levels. However, diabetes knowledgeguarantees the achievement of good glycemic
control. In a cross-sectional study among 40 inpatients and 60 outpatients with type 2 DM in
Shanghai, China, it was found that there is no difference in the overall diabetes knowledge
among Chinese people who have good glycemic control or suboptimal glycemic control.
Nevertheless, there was a negative correlation (r = -0.208, P=0.038) between diabetes knowledge
with age (Jie Hu, Kenneth J GruberHuaping Liu, Hong Zhao, et al 2013) Attitude is the
individual’s ability to exercise control over events that will likely affect one’s life. The
application of attitude as a health behavior framework was well documented(Khaled
30
Aldossari1, and Mohamed Abdelrazik22015). A study of 570 older women with heart disease
anticipated that self-efficacy enhanced the use of prescribed medicine, engagement in adequate
exercise, stress management, and adherence to recommended diet, which asserted that Self-
Efficacy Attitude was a critical link between knowledge application and actual behavioral
change and is one of the most effective predictors of health behavior (Jocelyn B.and Sonsona
2014). Researchers showed considerable evidence that diabetes self-care is a consistent predictor
of diabetes self-management behaviors. For example, (LI Aljasem, M Peyrot, L Wissow2001)
found that the variance accounted for self-efficacy is 35% in the overall self-care, 42% in diet
self-care, 14% in exercise self-care, and 7% in blood testing self-care of young adults with
diabetes. In another cross-sectional study that investigated the relationship between self-efficacy
and self-care behaviors of 309 individuals with diabetes, the variance accounted in diabetes self-
care behavior was from 4% to 10%, explaining beyond what characteristics and health beliefs of
the patients about barriers had been accounted. A survey to 408 ethnically diverse participants
found that increased diabetes self-care was related to increased optimal diet (14 day more
weekly), exercise (0.09 day more weekly), blood glucose monitoring (16% increased daily), and
foot care (22% increased daily) but not to medication adherence. In a previous study, (Kardas P,
Lewek P, Matyjaszczyk et al 2014) found that self-efficacy had a significant association with
adherence to dietary self-care. Johnston-Brooks et al (Senécal, C., Nouwen, A., & White, et al
2000) also reported that self-efficacy would likely increase the relationship between diabetes
knowledge and diabetes self-management. A healthy lifestyle is important to prevent the
progression and complications of diabetes. However, modification of long-term health habits
may not be very easy. To implement healthy lifestyles pre-diabetic patients require a substantial
increase in self-care to overcome difficulties (Al Slamah T1,and Nicholl BI1, 2017).
2.8 How does social Media Effect Diabetes Self-Management:
These technologies encompass globally, social networks, video- and photo-sharing sites, and
many other media, and are pervasive around the world indeed. In 2015, Facebook surpassed a
billion users worldwide, or nearly 1/7th of humanity (IDF, 2016). Social media are not only
shaping peoples’ personal lives, they are also influencing professional environments, within
healthcare, the social media usage has risen dramatically from 41% to 90%in 2015.The use of
social media have been found to be above 90% for medical students, furthermore, a growing
majority of modern patients with chronic conditions are seeking out social media (SM) as well as
31
other online sources to acquire health information, connecting with others affected by alike
conditions (Tompsett L, and Moorhead T. 2013) . And thus play a more active role in their
healthcare decisions despite the supported benefits of diabetes self-management education by
literature (Heisler M,and andPietee JD, , 2005) . It is imperative to develop novel diabetes
patient education programs and to assess the effectiveness of them in order to ensure that limited
health resources are being spent effectively. Relatively new methods based on mobile phone
educational interventions are potentially shifting the focus from the clinic to patients’ daily lives,
where changes in behavior and attitude is actualized (Jan-Mar Karbalaeifar R, Kazempour-
Ardebili S, et al 2016). So this can be translated into more favorable clinical outcomes and
better self-care skills, as well as reducing costs involved and patient referral to specialists. The
number of mobile phone subscribers in Saudi has sharply increased since its introduction two
decades ago. Among different mobile services available in Saudi, WhatsAPP, a text messaging
application is increasingly popular, reportedly reaching a peak of 80 million messages per day
(Alireza Jozi2016). This service allows for instantaneous delivery of short messages directly to
individuals at any time, place, or setting. Customized SMS messages and WhatsAPP can be
tailored to individuals, which is important given that personally tailored messages are more
effective in health behavior changes than untailored messages. Communication with SMS and
WhatsAPP is also very affordable and cost effective. All these features have led to the increasing
popularity of this service among educated population as well as illiterate specially
WhatsAPP.Subsequently, the availability of voice messages(forouzan tonkaboni, Alireza
Yousefy &Narges Keshtiaray,et al 2014) has been the focus ofattention of many researchers
and a considerable number of studies have been carried out regarding utilization of this
technology for improving the quality of care for diabetic patients (MA Powers and J Bardsley,
2015 ) . For example, a study in United Kingdom has developed a novel support network, based
on a unique text-messaging system designed to deliver individually targeted messages and
general diabetes information (Maryam Peimani a, Camelia Ramboda, Maryam Omidvar et
al 2016).
Another study in Korea has assessed the impact of a nurse short message service intervention on
HbA1c levels and adherence to treatment control recommendations in patients with diabetes
(Kim HS, and Kim NC, 2006). In Bahrain, a study demonstrated effectiveness of mobile phone
short message service on diabetes mellitus management (Maryam Peimania & Camelia
32
Ramboda, et al 2016). In addition, a study was done by Mulvaney et al. in the USA to
determine whether a tailored messaging system according to individually-reported barriers to
diabetes self-care would be effective on glycaemia control (Parker, and Jill2017). Integrating
this type of messaging system with online educational programming could prove to be beneficial.
It is noteworthy, moreover, that another study done by Ramachandran et al. assessed
effectiveness of mobile phone messaging in prevention of type 2 diabetes by lifestyle
modification in men in India. The findings of study was that mobile phone messaging is an
effective and acceptable method to deliver advice and support towards lifestyle modification to
prevent type 2 diabetes in men at high risk.(Mellitus, 2011)(B Nagrajui, and GV Padmavathi
2013).Therefore, social networks should not be inspected by medical professionals as means of
improving communication and outcomes with individual patients as described above, but also
generating a potential change in changes among a huge network of people (Collin A. Ross
2016). Observable behavioral changes within a social network, both by medical professionals
and the lay public, can trigger larger, more profound effects.
The use of WhatsApp messaging can improve engagement of type 2 DM patients. This virtual
community allows patients to share information and expertise in self-management to improve
motivation, self-care and knowledge, and also bridging gaps between appointments. Social
media is an unexploited gigantic resource where people worldwide have access to mobile phones
than toothbrushes (Al Slamah T1and Nicholl BI1, 2017). Other study among Egyptian
diabetics shows SMS education is a viable and acceptable method for refining glycemic control
and self-management behaviors (Haitham Abaza and and Michael Marschollek 2017).
2.9 Diabetic Care Profile (DCP), the Diabetic instruments
The DCP was developed as an instrument to assess social and psychological factors related to
diabetes and its treatment. The questionnaire is self-administered and consists of 234 items
including demographic information, self-care practices, and 116 questions divided into 16 profile
scales with 4 to 19 questions per scale. It takes approximately 30 to 40 minutes to complete
(Fitzgerald, 1996). The 16 profile scales assess control problems, social and personal factors,
positive attitude, negative attitude, self-care ability, importance of care, self-care adherence, diet
adherence, medical barriers, exercise barriers, monitoring barriers, understanding management
practice, long-term care benefits, support needs, support, and support attitudes. In an initial study
involving 1,017 patients in Michigan, internal reliability, was good to excellent, ranging from
33
0.60 to 0.95 for the profile scales. Significant differences were found between types 1 and type 2
diabetics for 6 of the 14 scales. Three scales (control problems, self-care ability, and self-care
adherence) were significantly correlated with HA1c level. A second study involving 576 patients
again measured the reliability and validity of the DCP. Cronbach’s ranged from 0.66 to 0.94 in
this set of patients. Significant correlations were found between many of the DCP profile scales
and independent psychological and social measures. There was a study conducted at King
Abdulaziz Medical City in Riyadh. This study showed that the Arabic version of Michigan
diabetes knowledge test is a reliable and valid tool to measure the diabetes knowledge of Saudi
diabetic patients, which can be used in clinical practice (William H. and Rodney Hayward,
2016).
34
Chapter 3
Methodology
This chapter provides details of the research methods that utilized for this study. It contains a
description of the research methodological procedure with reference to the research boundaries,
research methodology, available data resources, sample, techniques and tools of data collection,
procedure, and statistical procedures.
3.2. Research Philosophy
The exploration of philosophical concepts usually assists in specifying research design and
strategy, which further defines the way of proceeding from research questions to the conclusions.
This includes decisions about the type of empirical data collection, analysis, interpretation of the
analyses, and ideas of presenting the conclusions (Easterby-Smith, Thorpe and Jackson 2008).
The philosophy of the science underlying the current research here is positivistic. It is an attempt
to find out the answer to the research questions by gathering the data objectively. It further aims
to eliminate the factor of researcher bias and provides observation of external reality and facts.
By using standardized survey questionnaires, it was possible to have quantitative evidence to test
the hypotheses (Creswell and Creswell 2018). The researcher belongs to a rehabilitation
organization that concerned of people with disabilities. She observed that studies in diabetes self-
management are still in a phase of testing the theories because of the lack of evidence-based
diabetes education studies. So, this study is adopting a positivist position to test the educational
program. The primary goal of this study was to evaluate the level of knowledge, attitude and
practice of patients with diabetes and its relationship with self-management of the disease and
quality of life. This goal will be achieved by the administration of a survey method (standardized
questionnaires) and by the analysis of quantitative data. The results will help to explain
underlying mechanisms or identifying causal effects. Therefore, there will be an opportunity for
facilitating the generalization (Easterby-Smith et al., 2008) of findings regarding the relationship
between knowledge, practice, attitudes and education.
This research is organized as an embedded survey research method within the broader context of
correlational research (by conducting structured questionnaires). Data is collected through survey
method using structured quantitative questionnaires with standardized scales.
35
Three standardized questionnaires were used in order to answer the research questions of this
study. To explore on the participants’ background a sociodemographic questionnaire was
administered, for measuring knowledge, Practice and Attitudes a Scale Diabetes Care Profile was
used. Participants were selected through the outpatients’ clinic referral system. That an internal
medicine physician refers a patients to the diabetes education unit for patients/family education.
Ninety three participants who regularly visit the clinic were chosen and a survey was utilized to
ensure the objectivity. The study was not affected by any bias from the researcher’s side due to
the objectivity of standardized scales and scoring. It was decided that the survey to be
administered to a sample of 100 participants. But due to the withdrawal of seven (7) participants
the study sample stayed to be 93 participants. A brief structured sociodemographic information
form to get the demographic information was also provided, and administration of standardized
scales was ensured through the instructions given to the participants. Data was gathered by
sparing some time from the patients’ visit to the clinic. Phone calls were used in cases where it
was not possible to have the respondents physically come to the clinic.
3.2. Research Ethical Considerations
All the ethical considerations were fulfilled before conducting the study. Consent was taken from
the authors of the scales. Written permission from the Institutional Review Board (IRB) of
SBAHC’s was sought before the initiation of data collection process (see Appendix 1)A consent
form was given to all the respondents to obtain their consent to participate in the study and to
express their willingness (see Appendix2). Some patients refused to participate in the study for
different reasons (social, health and time reasons). Participants were assured about the
confidentiality of the information sought from them, and they were assured that they are free to
withdraw from the research data collection process at any time during the research, in case they
feel any undue pressure or unwillingness to participate. The researcher explained to respondents
that she will be in a continuous direct contact with the patients through their phones and
WhatsAPP messages to answer any question for three months before starting the post-test
3.3. Purpose of the Study
The purpose of this study was to determine the effect of a comprehensive self-management
diabetes telecare education program on the compliance of patients with diabetes for their
treatment programs. Another purpose of this study was to decide whether a diabetes educational
36
program would be operative in altering Saudi patients’ behavior specifically their knowledge,
attitudes, and practices about managing the disease.
The potential benefits of identifying factors that can increase in effectiveness of self-
management telecare educational program of diabetes are profound, thus enhancing their quality
of life. Important evidence exists that supports a range of interventions to improve diabetes
outcomes throughout their life. Through this study, we may increase knowledge that was useful
for health intervention developers, educators, health psychologists, physicians, nurses, and other
clinicians who are searching for trend in improving diabetes self-management for the Saudi
diabetic population with type 2 DM. This research study is specially contributing to the research
in the area of effecte of self-management telecare educational program.
3.3. Variables
The independent variable for the purpose of this study was the diabetes telecare educational
program. The dependent variable was patients’ self-reported behavior and action to manage their
diabetes; this includes taking insulin or diabetes pills, testing blood glucose, recognizing signs
and symptoms of hypo and hyperglycemia, eating balanced meals, and performing body
exercises, .
3.4.Assumptions:
For the purpose of this research study, the following were assumed to be true:
1. All patients would honestly answer the pre and post survey questions.
2. There are individual differences in the perception of and need for health care.
3. Telecare education can improve behaviors related to health.
Research Questions:
1. Is the diabetes telecare educational program effective in changing patients’ self-reported
current practices in managing diabetes?
2. What are the barriers that hinder the adherence to the diabetes regimens?
Is perceived self-efficacy related to diabetes self-management behaviors predictive of better
disease control among persons with DM .
3.4. Research Design
The study used a pre- and post-test design consisting of pre- and post-survey with a convenient
selection of 93 diabetic patients to participate in the two phases of the data collection procedure.
The participants have received educational program through one-to-one educational sessions.
37
The pre-test and post-test was used to test type2 diabetic patients for a period of 6-months. The
test was based on a self-management educational program. The telecare educational program
was aiming at helping patients to acquire conducive diabetes behavior, attitudes, and practice
skills that could result in improving their diabetes self-management.
The data collection phase took place during the period 26th
of August 2016 to the 25th
of
February 2017 at SBAHC based on the educational intervention program. The research
employed a correlational research design to measure the effect of the educational program on the
knowledge, attitudes and practice of diabetic patients.
3.4. Limitations
The following limitations were identified for this study.
1. The study utilized a small convenience sample.
2. The study was conducted in Riyadh city which represents only one geographical area.
3.5.1. Telecare Procedure:
It is agreed that participants are to be available for educational sessions and to be contacted by
the researcher -who was the assigned diabetes educator- for follow up via phone calls or the
social media using the WhatsApp massages during the intervention period. Each patient recruited
to this study was asked to give their mobile number immediately after the session or through
their routine visits to the diabetic clinic. The researcher in diabetic clinic asked patient follow-up
via telecare and WhatsApp. The researcher had established a rapport with the patients to
guarantee a trustworthy relationship to facilitate the education program that to be implemented.
4. 3.5.1. Data Collection Procedure
Data collection methods were interview, questionnaire, and observation. The Informed consent
was obtained from each patient at the time of their visit to the hospital. Literate patients filled out
the questionnaires themselves while illiterate participants were interviewed by the researcher.
Data was collected by the researcher over the period of August 2016 up to February 2017 during
the patient’s routine visit, administration of the questions are multiple choices was collected over
six months. Respondents were able to complete the background socio-demographic questions
about Saudi adult patients aged 20-65 years with DM type 2 and who were referred by the
inpatient/outpatient physician for diabetes education either on insulin or oral medications was
included in the study and HbA1c measurement was extracted from Patients Electronic Medical
38
Records (EMR) via Hospital Information System as baseline data collection and was divided into
pre-intervention, and post intervention. Clinical data, including HbA1c (within six months prior
to the survey) of participants were retrieved from medical records. Glycemic control was
considered good, acceptable or poor when HbA1c levels were less than 7%, 7 to 8% and greater
than 8, respectively, according to the American Diabetes Association’s recommended guidelines
(ADA, 20017).
A verbal consent was obtained from the patients after explaining the purpose of the study and
reassuring about the strict confidentiality of any obtained information and that the study result
was used only for the purpose of research.
3.3.2. Research Setting:
The study was carried out at the outpatient department of Prince Sultan Humanitarian City which
is a rehabilitation hospital which serves approximately 510 beds three quarters of the patients’
population coming from all over the Kingdom of Saudi Arabia.
3.3.3. Recruitment Sample of study:
Eligible Saudi adult patients aged 20-65 years with DM type 2 and HbA1c ≥ 8% during the
period between August 2016-February 2017) have agreed to get involved in the study for a
period of 6 months. Patients usually are referred to the diabetes education clinic by the
inpatient/outpatient physicians. Referred patients are usually with poor control blood glucose
levels and are either put on insulin or oral medications patients. It was decided that the survey to
be administered to a sample of 123 participants. But due to the withdrawal of seven (30)
participants the study sample stayed to be 93 participants.
3.3.4. Inclusion and Exclusion Criteria
The sample was comprised of Saudi nationals with type 2DM. All the participants were male and
female patients of age 20 to 65 years of age who were referred to the diabetes education clinic.
All the participants were registered patients who paid frequent visits to the outpatient clinic. The
exclusion criteria included those patients who were less than 20 years old, over 65 years old and
those who failed to attend one or more educational sessions and those who are not Saudi
nationals.
3.3.5. Non participant’s profile
39
Seven (7) patients declined to participate in the study for personal reasons (can’t continue with
the program due to lack of interest.
3.3.6. Reliability and Validity
The Diabetes Care Profile (DCP) was the main instrument that was used for this study. In
addition, the researcher collected socio-demographic data that included gender, age, occupation,
marital status, educational level, income, family history of diabetes, duration of diabetes and
medications. The questionnaire was translated into Arabic separately by two bilingual
translators. The two versions were combined and revised and then back translated into English
by another bilingual translator. The translation was refined after back translation until agreement
was achieved among the four people involved in the translations. Two internal medicine
physicians have examined and approved the Arabic version of the questionnaire for content and
construct validity. In addition to the translation process that was made, a great consideration was
made to the patients’ needs and their cultural background. All the questions of the instrument
were used in the evaluation of the rating process. Out of a total of 54questions, the rattersagreed
on 44 questions and disagreed on 10 questions. The agreement percentage was 81.5%. This
result determined the reliability of the tool that used in the study.
The questionnaire was then piloted among 20 outpatients with type2 diabetes, who have been
excluded later from participating in the study. The outcomes of the piloting process added minor
paraphrases of the questionnaire. This piloting was conducted in order to identify the feasibility
of the questions and the time that was needed to fill up the questionnaire and to give an idea
about the process of carrying out health educational program. It was conducted on 20 patients
who attended diabetes outpatient clinic and inpatient units. Then these 20 participants were
excluded from the main study sample.
3.4. Variables of the Diabetes Care Profile (DCP) Instrument
The DCP is a tool that used to measure the Diabetes Self-Management of diabetic patients. The
questionnaire measures the following variables:
a. Age, gender, family member, marital status, level of education, smoking status, regain,
duration of diabetes (demographic)
b. Diabetic Care Profile the Diabetic Knowledge Test (DKT),
c. Diabetes Attitude Survey (DAS) Positive Attitude, Negative Attitude, Care Ability,
importance of Care, and Self-Care Adherence
40
d. Understanding and Practice Scales (UPS) .
This research utilized the Understanding Practice Scale (UPS) in order to evaluate the
relationship between diabetic patients and compliance to self-management. This decision was
supported by (Harris et al 1982) who determined that the UPS is an appropriate theoretical
framework to use in such a type of study. The DKT is a 12-item instrument that tests the general
knowledge of diabetes. The questions are multiple choices in nature and appropriate for both
insulin dependent and noninsulin dependent diabetics. The DKT took on average 15 minutes to
complete with some patients asking longer to complete the survey. The DKT is a valid and
reliable general measure of knowledge relating to diabetes managed with or without insulin. The
DAS is a 14 question instrument that examines the respondent’s attitudes toward control,
psychosocial impacts, and the seriousness of diabetes. Using a 5-pointLikert scale ranging from
Strongly Agree to Strongly Disagree, the respondents were asked to complete general belief
statements about diabetes. The DAS took approximately15 minutes to complete with some
patients taking longer to respond. The UPS is a 28 question survey. Using a 5-point Likert scale
ranging from Strongly Agree to Strongly Disagree, the respondents are asked to complete
general belief statements about diabetes. The questionnaire has four questions each that
operationalized perceived susceptibility, perceived severity, perceived barriers, and perceived
benefits for patients with Type 2 diabetes. Patients indicated their beliefs in statements regarding
diabetes and its management. High scores were equated with the intent to take appropriate health
modifications to manage the disease. The (UPS) took approximately 15 minutes to complete with
some completing it in less time. The participants also provided information on demographics,
Age, gender, family member, marital status, level of education, smoking status, regain, duration
of diabetes,. The strength of using the DAS, UPS and DKT was that these instruments have been
tested for validity and reliability (Al Qahtani1, Alqarni1,and Mohamud, Masuadi, 2016). The
DAS-3 is a valid and reliable general measure of diabetes related attitudes and is most suitable
for comparisons across different groups of patients. a study done by Daniel and Messer (William
H. Herman, Rodney Hayward, 2016) .The strength of using the UPS is that it has been tested
for validity and reliability with diabetes patients in a number of studies. The construct validity
was tested, and reliability by internal consistency was also confirmed in the Daniel study The
data from three surveys, (Fitzgerald, et al, 1998). Diabetes Knowledge Test (Michigan Diabetes
Research & Training Center, 1998), and Diabetes Attitude Survey (Michigan Diabetes Research
41
& Training Center, 1998) were scored using the protocols developed by the authors. The UPS
was scored based on the Likert Scale and 5 were given the highest weight. The DKT was scored
based on the correct answer to the question. The DAS was scored utilizing the MDRTC
protocols. The UPS, DKT and DAS were created by the Michigan Diabetes Research and
Training centre (MDRTC) at the University of Michigan (MDRTC, 1998).
3.4.1. The items of the Diabetes Care Profile (DCP) are distributed as follows
Eight demographic questions: age, Gender, marital status, level of educational, Duration
of Diabetes (onset of diabetes), Region, Smoke and how many people live with you (size
of the family).
Sixteen question(s) that assess about the knowledge and understanding of the following:
overall diabetes care, coping with stress, diet for blood sugar control, role of exercise in
diabetes care, medications, use of the results of blood sugar, prevention and treatment of
high blood sugar, prevention and treatment of low blood sugar, prevention of long term
complications of diabetes, benefits of improving blood sugar, foot care.
Fourteen questions that assess attitude towards diabetes scales: I am afraid of my
diabetes, I find it hard to believe that I really have diabetes, I feel unhappy and depressed
because of my diabetes, I feel satisfied with my life, I feel I'm not as good as others
because of my diabetes, I can do just about anything I set out to do, I find it hard to do all
the things I have to do for my diabetes, Diabetes doesn't affect my life at all, I am pretty
well off, all things considered, Things are going very well for me right now, I am able to
keep my blood sugar in good control, I am able to keep my weight under control, I am
able to do the things I need to do for my diabetes (diet, medicine, exercise, etc.), I am
able to handle my feelings (fear, worry, anger) about my diabetes, I think it is important
for me to, keep my blood sugar in good control, I think it is important for me to keep my
blood sugar in good control, I think it is important for me to keep my weight under
control , I think it is important for me to do the things I need to do for my diabetes (diet,
medicine, exercise, etc.), I think it is important for me to handle my feelings (fear, worry,
anger) about my diabetes, I keep my blood sugar in good control, I keep my weight under
control, I do the things I need to do for my diabetes (diet, medicine, exercise, etc.), I feel
dissatisfied with life because of my diabetes, I handle the feelings (fear, worry, anger)
about my diabetes fairly well.
42
Eight questions that assess practice score
Eleven questions that assess Barriers score
3.4.2. Haemoglobin HbA1c
All available HbA1c measurements were extracted from Patients Electronic Medical Records
(EMR) via Hospital Information System as baseline data.Tight glycemic control values that
remain within a specific range can prevent or slow the progression of diabetes complications
(American Diabetes Association ADA, 2017). Hemoglobin HbA1c is a value that determines
the adequacy of diabetes therapy. According to the American Diabetes Association (ADA 2017)
a target value for hemoglobin HbA1c of less than 7% is desirable for adequate blood sugar
control. A hemoglobin HbA1c level was obtained by laboratory examination.
Expected values of Glycosylated Hemoglobin
Diabetic Non Diabetic
Good Control : 5.5 6.8 %
Fair Control : 6.8 7.6 %
Poor Control : > 7.6 %
Normal range: 4.2 6.23 %
The reference range was established by (ADA2017)
43
3.5. The Intervention Diabetes Education Program
Initially 123 patients with type
2DM were decided to
participate in the study in
database
Attended the diabetes
education clinic
26/08/2016 to
25/02/2017
93
patients
30
patients
No further action
"Would you like
to participate?" None
All agreed Pre-Test
* Diabetic care profile, a self-
administered questionnaire with
informed consent were filled in.
* Blood samples for lab tests
(GHA1C) were drawn.
Intervention
Knowledge evaluation
questionnaire distributed at
the beginning and the end
Intervention session components:
* Perform self-blood glucose monitoring at
home
* The importance of the patient's role in
self-management.
* Provide information about behaviour
change and problem solving strategies.
* Educate about diabetic foot, hypoglycemia
and hyperglycemia management and
complications.
* Educate about diabetes mellitus symptoms,
risk factors, types, complications, main
aspects of self-care of the disease and main
aspects of diet and physical activity.
Follow-up weeks 1 through 12:
Repeat education session throughout in
tele-care clinic in outpatient during
working days and via phone and
whatsApp to review patient's SBGM
record as well to raise any concern of
the patients
No Yes
No
Yes
Pre-Intervention
Source: Researcher
44
3.5.1 Phase 1: Pre-assessment
The pre-assessment includes involved using the Diabetic Care Profile which is a self-
administered questionnaire specific for diabetes that was adapted after approval from the
University of Michigan .The DCP is an instrument designed to measure the social and
psychological factors important in a patient’s adjustment to diabetes and its treatment. These
factors are related to a patient’s self–care behavior and thus may influence an individual’s ability
and willingness to provide diabetes self-care (Powers, Bardsley, and Cypress, Duker
2015) .The results of previous studies indicated that the DCP is a reliable and valid instrument
for measuring the psychosocial factors related to diabetes and its treatment (Fitzgerald, Davis,
and Connell, Hess, 1996). As mentioned earlier in this chapter; prior to use this method in the
current study, the DCP instrument was translated from its original English version into Arabic
version to accommodate the official language used by the Saudi patients. In addition, it was
modified based upon the patients’ needs and cultural considerations (see appendix 3 ).
3.5.2 The Major Components of the Intervention Program
3.5.2.2 Phase 2:
First visit
One-to-one -based educational intervention session about diabetes was conducted by the
researcher (who is the assigned diabetes health educator at SBAHC). It was presented once the
patients referred by the inpatient units or attended an appointment at the clinic. This session was
a 45 minutes education program carried out using videos, computer for power point presentation,
oral discussion was used as a teaching aid in the session (see appendix 5). Patients have received
health education information after tested their blood sugar. The education program was
concerned about including the definition of diabetes mellitus in terms of the symptoms and
complications of diabetes, importance of diabetic self-management education (DSME), patients
role in self-management, support system in self-management decision making, progress towards
metabolic and behavioral goals, benefits of therapeutic and behavior options, treatment of
diabetes and the importance of adherence to treatment, Behavioral change and problem solving
strategies were also part of the components of the program. The importance of regular check-up
and measurement of blood sugar and how to do self-measurement, prevention and management
of diabetic complications were highlighted as major issues, besides smoking, home monitoring
45
and importance of physical activity. At the beginning of the session a pre-test knowledge
evaluation questionnaires was implemented to the diabetic respondents , and at the end of the
session colored educational materials printed in Arabic language were distributed (Appendix 5)
as references. The educational materials were developed and approved by the Health Promotion
Department of (SBAHC).
Contents of the Educational Materials used in the intervention program
Flip Chart about dietary management for diabetic patients.
Booklets, videos, power point presentation, brochures and handbooks about
definition, types, symptoms and risk factors of diabetes mellitus, complications,
diabetic foot, diabetic eye and self-management of diabetes, importance of exercise
and investigations especially glycosylated hemoglobin. In addition, diabetic patients
were allowed to ask questions about the topic being presented.
Patient was requested to perform self-blood glucose monitoring (SBGM) at home.
The first health education session was repeated throughout the week in the telecare
clinic in the outpatient clinic during the working days, via phone, by sending
WhatsApp messages to review patient SBGM record as well to discuss any concern
that might be raised by the patients. The researcher was in a continuous direct contact
with the patients through their phone and via WhasAPP to answer any question at any
time for three months before starting the post-test (see appendix 6).
Second visit
Patients who attend the second sessions were informed about the results of laboratory
tests and the time of the next visit (8-weeks after the first visit). Laboratory results and
time of next visit were also recorded in their follow-up EMR. Patients were reminded
with the contents of the first session then they were given information about diabetes the
seriousness of diabetes, as well as the importance of DSME, the importance of the
patients role in self-management, how to support and facilitate patients in their roles as
self-management decision makers, progress toward metabolic and behavioral goals,
provide ongoing information about the benefits of therapeutic and behaviors options, the
importance and seriousness of SBGM , provide information about behavioral changes
and problem solving strategies .
46
Table 2 Description of Intervention Sessions during 12 weeks
Contents of the education Sessions Sessions by weeks
Pre- data collection
investigations especially glycosylated haemoglobin
First visit to clinic
Goals and Objectives Diabetes self-management behaviors includes
Educational Session via phone or WhatsApp
Educated about behavioral goal-setting is an effective strategy to support
self-management behaviors by coping with stress. Patient was requested
to perform self-blood glucose monitoring at home. Patient was
information about diabetes the seriousness of diabetes. Patient was
educate about healthy eating, dietary management for diabetic patients.
Patient was educated about physical activity, medication taking, diabetes
self-care related problem solving.
Week 1- Week 2
Perform self-blood glucose monitoring at home.
the importance of the patient’s role in self-management. Provide
information about behavior change and problem solving strategies .
Educate about diabetic foot. Educated about hypoglycemia and
hyperglycemia management, complications
Week 2 - Week 3
Perform self-blood glucose monitoring at home.
Support and facilitate patients in their roles as self-management decision
maker. Patient was educating about healthy eating, dietary management,
and medication taking. Importance of exercise
Week 3 -Week 4
Perform self-blood glucose monitoring at home.
Educate about the outcomes and quality of life, at least in the short-term.
Importance of exercise, medication taking
Patient was educated about healthy eating, dietary management for
diabetic patient.
Week 5- Week 6
Patients was reminded with the contents of the educational session Second visit
47
Provide information about behavior change and problem solving
strategies.
Educate about diabetic foot
Patient was educated about healthy eating, dietary management for
diabetic patient.
Patient was educated about physical activity, medication taking, diabetes
self-care related problem solving.
Week 6- Week 7
Perform self-blood glucose monitoring (at home).
Importance of body exercise.
Educated about Behavioral goal-setting was an effective strategy to
support self-management behaviors for coping with stress.
Week 8- Week 9
Perform self-blood glucose monitoring (SBGM) at home.
importance of exercise
Educated about Behavioral goal-setting is an effective strategy to support
self-management behaviors by coping with stress
Week 10- Week 11
Post data collection
investigations especially glycosylated haemoglobin
Week 12 last visit
to clinic
3.5.2.3 Phase 3Post-intervention
To evaluate the impact of the intervention education program on knowledge, Attitudes and
Practice which was implemented by the researcher to measure the degree of self-management
educational program on their diabetes. Evaluated 3 months later by asking the patients the same
questions used in the pre-intervention and blood sample was taken for measuring HbAlc.
A Knowledge evaluation questionnaire (Appendix 4) was implemented by the researcher to
measure the degree of knowledge and understanding of patients in managing their diabetes, after
applying the education program. The questionnaire was filled by the patients before starting the
session and after three months at the end of the study. The questionnaire DCP consists of
34multiple choice questions covering different aspects of diabetes including definition, types,
48
risk factors, symptoms, complications, main aspects of self-care, and main aspects of dietary
management and importance of physical activity for diabetic patients.
3.9. Data Analysis
The data obtained from the basic information questionnaire and diabetic care profile. These data
were statistically analyzed and represented using Statistical Package for Social Science (SPSS
15.0.1 for windows; SPSS Inc, Chicago, IL, 2001). Descriptive statistics for quantitative
variables as; Mean, Standard deviation (±SD), Minimum and maximum values (range) were
done, number and percent for qualitative variables.
Analytical statistics: Quantitative data were tested for normality to select either a parametric
analysis as Paired “t” test; that was used for parametric data follow-up; as in clinical outcome,
knowledge, attitude, barrier and understanding.
Non-parametric analysis as Wilcoxon-rank sign test; that was used for non-parametric
quantitative data follow-up; on comparing the practice of DM patients before and after the
intervention.
Chi-square test was used for analyzing qualitative data; as in Knowledge score, Barrier score and
Understanding score.
P-value was considered significant if less than 0.05; highly significant if less than 0.001.
Data were graphically represented using Harvard Graphic under Windows program (HGW-
program).
49
Chapter 4
Result
Ninety three diabetic patients were recruited for this study. The findings of the diabetes self-
management educational program in this study is presented Pre-test and post-test design was
used to examine the effectiveness of self-management educational program on knowledge,
attitudes and practice among Saudi Type-2 diabetic patients, Lifestyle behaviors and knowledge
about self-management through measurements prior to starting the program and after completion
of the program for Saudi Type-2 adult diabetic patients. The sample description, the analysis for
each hypothesis and statistical tests are presented in this chapter. Results are reported with
measures of central propensity and statistical significance. Reliability numbers for the scales
were computed. The data were collected from all regions in the kingdom of Saudi Arabia.
Table (1): Characteristics of the study population:
Table (1a): Age and diabetes duration
Mean +SD Range
Age (years) 52.05 +10.71 20-65
Duration of Diabetes (Years) 12.31 +7.77 1-30
From the previous table, our results showed that: The age ranged from 20 to 65years, with mean
= 52.05+10.71. The disease duration was ranged from one year to 30 years with mean
12.31+7.77.
50
Table (1b): Characteristics of the study population.
Gender N (%)
Male 48 51.61%
Female 45 48.39%
Educational Level N (%)
Illiterate 15 16.13%
Primary 28 30.11%
Elementary 18 19.35%
High School 12 12.90%
College 13 13.98%
Professional 7 7.53%
How many people live with you N (%)
One person 10 10.75%
Two persons 7 7.53%
Three persons 21 22.58%
Four persons 44 47.31%
Five persons or more 11 11.83%
Marital Status: N (%)
Single 12 12.90%
Married 58 62.37%
Separated 12 12.90%
Widow 11 11.83%
Area N (%)
Center 31 33.33%
North 25 26.88%
East 11 11.83%
West 10 10.75%
South 16 17.20%
Smoker: N (%)
Yes 26 27.96%
No 67 72.04%
N= Number
Regarding gender distribution: There were 48 males representing 51.61%, and 45 females
representing 48.39%.
Regarding the level of educational distribution: There were Illiterate 16.13%, Primary 30.11%,
Elementary 19.35%, High School 12.90 %, College 13.98% and Professional 7.53%.
51
Regarding how many people live with the patient: There were 44 cases presented with four
persons living with him (representing 47.31%).
Regarding Marital Status distribution: There was Single 12.90%, Married 62.37%,
Separated12.90% and Widow 11.83%.
Regarding Area distribution there was Central region 33.33%, North region 26.88%, East region
10.75%, West region 10.75% and South region 17.20%.
Regarding Smoker distribution there was none smokers representing 72.04% and smokers
representing 27.96%.
Table (2): Clinical Outcome.
Mean+SD Paired “t” test P-value (Sign.)
HbA1C (Before) 10.14+6.42
2.57
<0.05
(S)
HbA1C (After) 8.42+1.68
S= Significant
Fig. 1) HbA1c before versus after education:
Table (2) and figure (1) the mean value of HbA1c before the intervention program was
10.14+6.42, while after our intervention program became 8.42+1.68. There was statistically
significant decrease with P<0.05.
52
Table (3): Knowledge Score
P-value
(Sig.)
Chi-
squar
e
After Before
(%) N (%) N Overall diabetes care 1
<0.001
(HS)
87.32
73.12
%
68 10.75
%
10 Excellent
24.73
%
23 38.71
%
36 Good
2.15% 2 50.54
%
47 Poor
<0.001
(HS)
40.90
5
(%) N (%) N Coping with stress 2
62.37
%
58 18.28
%
17 Excellent
31.18
%
29 52.69
%
49 Good
6.45% 6 29.03
%
27 Poor
<0.001
(HS)
50.06
1
(%) N (%) N Diet for blood sugar control 3
69.89
%
65 21.51
%
20 Excellent
23.66
%
29 37.63
%
35 Good
6.45% 6 40.86
%
38 Poor
<0.001
(HS)
40.29
5
(%) N (%) N The role of exercise in diabetes care 4
62.37
%
58 24.73
%
23 Excellent
35.48
%
33 43.01
%
40 Good
2.15% 2 32.26
%
30 Poor
<0.001
(HS)
24.59
2
(%) N (%) N Medications you are taking 5
77.42
%
72 43.01
%
40 Excellent
18.28
%
17 36.56
%
34 Good
5.38% 4 20.4319 Poor
53
%
<0.001
(HS)
34.50
5
(%) N (%) N How to use the results of blood sugar
monitoring
6
76.34
%
71 36.56
%
34 Excellent
18.28
%
17 39.78
%
28 Good
5.38% 5 33.33
%
31 Poor
<0.001
(HS)
36.59
5
(%) N (%) N How diet, exercise, and medicines
affect blood sugar levels
7
76.34
%
71 35.48
%
33 Excellent
21.51
%
20 30.11
%
37 Good
2.15% 2 24.73
%
26 Poor
<0.001
(HS)
34.39
3
(%) N (%) N Prevention and treatment of high
blood sugar
8
76.34
%
71 38.71
%
36 Excellent
21.51
%
20 39.78
%
31 Good
2.15% 2 27.96
%
26 Poor
<0.001
(HS)
34.93
2
(%) N (%) N Prevention and treatment of low
blood sugar
9
80.65
%
75 41.94
%
39 Excellent
19.35
%
18 39.78
%
37 Good
0 0 18.28
%
17 Poor
<0.001
(HS)
36.61
7
(%) N (%) N Prevention of long-term
complications of diabetes
11
68.8% 64 32.26
%
30 Excellent
29% 27 36.56
%
34 Good
2.1% 2 31.1829 Poor
54
%
<0.001
(HS)
34.24
6
(%) N (%) N Foot care 12
78.26
%
72 38.04
%
35 Excellent
21.74
%
20 44.57
%
41 Good
1.09% 1 17.39
%
17 Poor
<0.001
(HS)
53.26
5
(%) N (%) N Benefits of improving blood sugar
control
13
91.30
%
84 40.22
%
37 Excellent 14
7.61% 8 39.13
%
36 Good
1.09% 1 20.65
%
20 Poor
HS= Highly significant
Table (4): Knowledge Total Score.
Mean+SD Paired “t” test P-value
(Sign.)
Knowledge (Before) 24.4+5.8 11.86 <0.001
(HS) Knowledge (After) 32.6+3.3
HS= Highly significant
55
24.4
32.6
Before After0
5
10
15
20
25
30
35
40
Fig. (2): Knowledge score before versus after education
Fig. 2) Knowledge score before versus after education
Table (4) and figure (2) show the mean Knowledge scores. The increase of the mean scores of
knowledge before versus after education intervention was statistically highly significant
(P<0.001). Score indicating increase knowledge as a result of this short-term intervention was
considered to be due to patient’s knowledge more positive attitudes and the importance of the
patient making the primary decisions about their daily self-management care.
Table (5): Distribution of Patient’s Attitude Before the intervention:
Strongly
disagree
Disagree Neutral Agree Strongly
Agree
N (%) N (%) N (%) N (%) N (%)
1 I am afraid of my
diabetes
6 6.45
%
4 4.30% 19 20.43
%
30 32.26
%
3
4
36.56
%
2 I find it hard to believe
that I really have
diabetes
9 9.78
%
35 38.04
%
25 27.17
%
10 10.87
%
1
3
14.13
%
3 I feel unhappy and
depressed because of my
1
4
15.05
%
17 18.28
%
22 23.66
%
21 22.58
%
1
9
20.43
%
56
diabetes
4 I feel satisfied with my
life
2 2.15
%
5 5.38% 19 20.43
%
22 23.66
%
4
5
48.39
%
5 I feel I'm not as good as
others because of my
diabetes
7 7.53
%
7 7.53% 17 18.28
%
22 23.66
%
4
0
43.01
%
6 I can do just about
anything I set out to do
1
1
11.83
%
25 26.88
%
13 13.98
%
27 29.03
%
1
7
18.28
%
7 I find it hard to do all
the things I have to do
for my diabetes
1
1
11.83
%
21 22.58
%
19 20.43
%
26 27.96
%
1
6
17.20
%
8 Diabetes doesn't affect
my life at all
4 4.30
%
16 17.20
%
13 13.98
%
31 33.33
%
2
9
31.18
%
9 I am pretty well off, all
things considered
6 6.45
%
17 18.28
%
18 19.35
%
36 38.71
%
1
6
17.20
%
1
0
Things are going very
well for me right now
8 8.60
%
20 21.51
%
13 13.98
%
35 37.63
%
1
7
18.28
%
1
1
keep my blood sugar in
good control
1
4
15.05
%
22 23.66
%
21 22.58
%
23 24.73
%
1
3
13.98
%
1
2
Keep my weight under
control
2
1
22.58
%
33 35.48
%
18 19.35
%
15 16.13
%
6 6.45%
1
3
Do the things I need to
do for my diabetes (diet,
medicine, exercise, etc.)
1
0
10.75
%
16 17.20
%
19 20.43
%
37 39.78
%
1
1
11.83
%
1
4
Handle my feelings
(fear, worry, anger)
about my diabetes
8 8.60
%
17 18.28
%
20 21.51
%
31 33.33
%
1
7
18.28
%
57
Table (6): Comparison of the mean Attitude score before and after the
intervention:
Mean+SD Paired “t” test P-value
(Sign.)
Mean attitude (Before) 31.39+3.9
7.80
<0.001
(HS)
Mean attitude (After) 35.23+2.7
HS= Highly significant
31.39
35.23
Before After0
10
20
30
40
Fig. (3): Attitude score before versus after education
Fig. 3) Attitude score before versus after education
Table (8) and figure (3) show the mean Attitudes scale scores. The increase of the mean scores of
attitudes before versus after education intervention was with a P value of (P<0.001). This score
indicates there are more positive attitudes and shows the importance of enabling patients to take
their primary decisions about their daily diabetes self-management care.
58
Table (7): Comparison of practice of DM patients before and after the intervention
Before After
N % N %
Do you keep a record of your blood sugar
test results?
Yes 26 27.96% 93 100.00%
No 49 52.69% 0 0
Not Sure 18 19.35% 0 0
Has your health care provider or nurse ever
told you to take special care of your feet?
Yes 37 39.78% 93 100.00%
No 35 37.63% 0 0
Not Sure 21 22.58% 0 0
Has your health care provider or nurse ever
told you to follow an exercise program?
Yes 37 39.78% 93 100.00%
No 36 38.71% 0 0
Not Sure 20 21.51% 0 0
Has your health care provider or nurse ever
told you to follow a meal plan or diet?
Yes 44 47.31% 93 100%
No 28 30.11% 0 0
Not Sure 21 22.58% 0 0
Have you ever received diabetes education?
(For example: attended a series of classes or
series of meetings with a diabetes educator?
Yes 30 32.26% 93 100%
No 47 50.54% 0 0
Not Sure 16 17.20% 0 0
59
Table (8): Comparison of practice of DM patients before and after the intervention
Mean+SD Z-test
P-value
(Sign.)
How many days a week do you test your blood
sugar? (Before)
2.50+2.22
14.9
P<0.001 (HS) How many days a week do you test your blood
sugar? (After)
6.44+1.26
HS= Highly significant
2.5
6.44
Before After0
1
2
3
4
5
6
7
8
Fig. (4): Practice score before versus after education
Fig. 4) Practice score before versus after education
Table (11) and figure (4) show the mean practice scale scores the results indicate that education
program improved practice of the patients after intervention. The increase of the mean scores of
practice before versus after educational program was found to be statistically highly significant
(P<0.001).
60
Table (9): Barriers towards DM management before and after the intervention:
Before After
Chi-
Square
P-
value
(Sig.)
1 You forgot? N (% ) N (% )
Often 34 36.56% 0 0
75.31
<0.001
(HS)
Sometimes 39 41.94% 17 18.28%
Rarely 20 21.51% 76 81.72%
2 You don't believe it is
useful?
38.354
<0.001
(HS) Often 9 9.68% 1 1.08%
Sometimes 27 29.03% 1 1.08%
Rarely 57 61.29% 91 97.85%
3 The time or place wasn't
right?
42.456
<0.001
(HS) Often 26 27.96% 0 0
Sometimes 34 36.56% 22 23.66%
Rarely 33 35.48% 71 76.34%
4 You don't like to do it?
41.078
<0.001
(HS)
Often 31 33.33% 0 0
Sometimes 24 25.81% 22 23.66%
Rarely 38 40.86% 71 76.34%
5 You ran out of test
materials?
23.321
<0.001
(HS) Often 12 12.90% 0 0
Sometimes 11 11.83% 1 1.08%
Rarely 70 75.27% 92 98.92%
6 It costs too much?
39.767
<0.001 Often 14 15.05% 1 1.08%
61
Sometimes 23 24.73% 1 1.08% (HS)
Rarely 56 60.22% 91 97.85%
7 It's too much trouble?
35.136
<0.001
(HS)
Often 26 27.96% 2 2.15%
Sometimes 40 43.01% 30 32.26%
Rarely 27 29.03% 61 65.59%
8 It's hard to read the test
results?
19.777
<0.001
(HS) Often 14 15.05% 0 0
Sometimes 17 18.28% 9 9.68%
Rarely 62 66.67% 84 90.32%
9 You can't do it by
yourself?
13.064
<0.001
(HS) Often 14 15.05% 1 1.08%
Sometimes 6 6.45% 4 4.30%
Rarely 73 78.49% 88 94.62%
1
0
Your levels don’t change
very often
10.398
<0.001
(HS) Often 19 20.43% 39 41.94%
Sometimes 37 39.78% 30 32.26%
Rarely 37 39.78% 24 25.81%
1
1
It hurts to prick your
finger?
18.684
<0.001
(HS) Often 39 41.94% 18 19.35%
Sometimes 19 20.43% 45 48.39%
Rarely 35 37.63% 30 32.26%
HS= Highly significant
62
Table (10): Comparison of barriers towards DM management before and after the
intervention
Mean+SD Paired “t” test P (Sign.)
Mean barrier (Before) 19.09+4.2
10.06
<0.001
(HS)
Mean barrier (After) 14.29+1.9
HS= Highly significant
Fig. 5: Barriers score before versus after education
Table (13) and figure (5) show the mean Barriers scale scores. The results indicate that education
program improved Barriers of the patients after intervention the difference between mean scores
of barriers before and after educational was found statistically highly significant (P<0.001).
63
Table (11): Patients understanding of DM before and after the intervention:
Before After Chi-
Square
(P-value)
P-
value
(Sig.)
N % N %
1 Diet and blood sugar
control
66.808
<0.001
(HS)
Excellent 20 21.51% 71 76.34%
Good 40 43.01% 22 23.66%
Poor 33 35.48% 0 0
2 Weight management
16.885
<0.001
(HS)
Excellent 24 25.81% 35 37.63%
Good 31 33.33% 45 48.39%
Poor 38 40.86% 13 13.98%
3 Exercise
3.942
<0.05
(HS)
Excellent 29 31.18% 40 43.48%
Good 36 38.71% 35 38.04%
Poor 28 30.11% 18 18.48%
4 Use of insulin/pills
43.419
<0.001
(HS)
Excellent 45 48.39% 85 91.40%
Good 28 30.11% 8 8.60%
Poor 20 21.51% 0 0
5 Sugar testing
29.551
<0.001
(HS)
Excellent 38 40.86% 58 62.37%
Good 30 32.26% 35 37.63%
Poor 25 26.88% 0 0
6 Complications of diabetes
41.258
<0.001
(HS)
Excellent 34 36.56% 66 70.97%
Good 28 30.11% 27 29.03%
Poor 31 33.33% 0 0
64
7 Foot care
39.290
<0.001
(HS)
Excellent 31 33.33% 68 73.91%
Good 40 43.01% 25 26.09%
Poor 22 23.66%
8 Eye care
70.103
<0.001
(HS)
Excellent 19 20.43% 62 67.39%
Good 27 29.03% 31 32.61%
Poor 47 50.54% 0 0
9 Combining diabetes
medication with other
medications
Excellent 39 41.94% 73 78.49%
44.321
<0.001
(HS)
Good 20 21.51% 20 21.51%
Poor 34 36.56% 0 0
HS= Highly significant
Table (12): Comparison of patient understands score before and after the
intervention
Mean+SD Paired “t” test P-value
(Sign.)
Mean understanding (Before) 18.01+4.15
11.94
P<0.001 (HS) Mean understanding (After) 23.68+1.96
HS= Highly significant
65
Fig. 6) : Understanding score before versus after education
Table (15) and figure (6) shows the mean understanding scale scores. The increase of the mean
scores of understanding before versus after education program was found statistically highly
significant (P<0.001). Understanding the benefits of controlling their diabetes is important by
changing their behavior.
66
Chapter 5
5. Discussion
5.1 Characteristics of the study population
This study found that the number of male participants is higher than the number of females The
age ranged from 20 to 65 years, with mean = 52.05+10.71.; this reflects the fact that the males,
attendance to diabetic clinic is higher than females attendance, additional to, 30+% of the
sample their educational levels is the primary level mostly compared to 13+% College levels,
the majority of the sample were with low educational level which is associated with the
participants knowledge of the disease. This finding is supported by a study that conducted by
(Al-Adsani AM1, Moussa MA, Al-Jasem LI, Abdella NA, .,et al 2009)in Kuwait that
confirmed the lack of knowledge and the poor practice of diabetes management skills are
associated with the low educational level of diabetic patients. Another study conducted by
(William H. Herman, and Rodney Hayward2016); confirmed this finding. The disease
duration was ranged from one year to 30 years with 12.31+7.77. This duration of time requires a
continuous medical care with multifactorial risk-reduction strategies beyond glycemic control
with link of social support from family that offers patients with practical help.
5.1.1. Social Support and its effect on Adherence:
Social support from families also helps patients to minimize the level of stresses of living with
illness. In a study conducted by (DiMatteo 2004) it stated that the care from friends and family
helps adherence by enhancing confidence and self-esteem, which can minimize the stress of
being ill and reduce patient depression. While social support can influence the ability to adjust
and live with illness, some empirical studies have reported opposite findings, that social support
can act as a significant barrier to patients’ self-management (Gherman. 2011 and Rosland,
1999). However, for the current study participants, the social practices by which social support
had negatively affected patient adherence, such as the emotional support that linked to coffee
time, dietary habits, social gatherings that require the patient to eat what is offered to him/her.
More family support and better family perception have been associated with better glycemic
control (Diego García and Huidobro 2011).
The urbanized living style is characterized by having access to variety of food, cultural inputs
like coffee time, habits, gatherings that resulted in greater sample of the urban population
67
(33.37%) with diabetes than those coming from the rural areas which was (10.5%). The study
has also explored the unhealthy behavior that associated with smoking and the results showed
that among the sample only 27.96% were smokers while 72.04% were none smokers.
5.1.2. Clinical Characteristics
Table (2) in the previous chapter showed the clinical outcomes of the respondents. The HbAc1
was significantly changed between the pre-and post-intervention. This change reflects the effect
of the intervention program using the pre-intervention measures as quantitative data that
examined normality to select either a parametric analysis as paired “t” test; that was used for
parametric data follow-up. For clinical outcome, it was demonstrated that after three months
were the mean value of HbA1c before the intervention program was 10.14+6.42, while after our
intervention program became 8.42+1.68. There was statistically significant decrease with P<0.05
that indicates an improve in the level of HbAc1 between the pre-and post-intervention in
comparison with the baseline levels.
Respondents showed significant improvement from pre- to post- intervention in the diabetes
knowledge self-efficacy diabetes symptoms management. This result showed the change by
increasing knowledge of diabetics about the disease, and the importance of changing their life
style. Moreover it closed the gap between knowledge and practice among diabetics which is
highly needed for good diabetes management such as, adherence to diabetes self-care tasks, as
well as self-efficacy. This finding is supported by a study that conducted by Hu and others in
2013 that revealed the difference in pre- and post- test diabetes knowledge that determined by
the clinical trials and had provided strong evidence for a decrease in the HbA1c–value. This
finding also supports the fact that when there are more chances of exposure to information this
helps the patients to acquire the knowledge which ultimately boost the disease management
practice skills. Many studies had also shown that diabetic patients with poor level of knowledge
about the disease and self-care management are with high levels of HbA1c. Another study in
Korea has assessed the impact of a nurse short message service intervention on HbA1c levels
and adherence to treatment control recommendations for patients with diabetes (Fadia Abdel
Megeid and Mervat Mohamed,(2017)(Al-Maskari F1, El-Sadig M, Al-Kaabi JM,(2013).
5.2. Knowledge and its Effect on Adherence:
The findings of this study showed that the participants’ level of knowledge with regards to the
overall care of the disease was (55%) before attending the education program which is
68
considered as poor. But this percentage has been changed to (73.1%) after getting involved in the
education program. This shows the positive effect of the diabetes educational intervention
program on their overall knowledge. These results indicate that education is effective in
improving knowledge of patients which is supported by the previous study (Zhuang R, Xiang Y
and Han T, 2016). That knowledge can be improved through training and education, especially
the use of telecare, including social media for communication with patients such as “WhatsApp”
and the weekly follow-up telephone calls as part of the educational program and reinforcement,
motivation and active involvement.
About (40.86%) of the participants reported that their knowledge of diet and blood sugar
monitoring was poor prior to the intervention. While the same issue was investigated after the
participants were involved in the intervention program and the percentage had changed to
(33.33%). This proves the high significant reduction which was 6.46% after the intervention.
Patients provided weekly blood sugar monitoring and were provided with telecare support to
discuss their diet and to implement self-management strategies related to diet. This is supported
by across sectional survey that conducted in Saudi Arabia for a research that was related to self-
management in a similar population (Yousif, and El-Sayed 2017)(Al-Hamrani, 2009). where it
found that 18.26% of patients reported poor knowledge regarding how to manage their low blood
sugar and the poor knowledge of this population have significantly reduced to 0% after the
intervention. Similarly knowledge about foot care was found to be poor amongst 17% of
participants prior to the study and was reduced to 0% after the intervention. Almost a third of the
participants (32%) reported poor knowledge about the benefits of exercise in managing diabetes.
This was significantly reduced to 2.15% after the intervention. Similar studies (Aldossari and
Abdelrazik, 2015). However, the results of this current study indicate a positive self-reported
rating which is (70.97) to cope with stress prior to the educational program. For this finding no
similar results were found in other studies for coping with diabetes (Aljasem, Peyrot, &
Wissow, 2001) . In this study the disease duration was ranged from one year to 30 years, with an
average of 12.31 years of living with diabetes. For this finding the possible factor that can be
justified that a high number of participants believe that the disease translates the God’s will
which leads to accepting the fact that they need to cope with the disease. The personal beliefs,
spiritual or cultural beliefs that held by individuals can influence their self-care ability (Cattich
and Knudson-Martin 2009).The increase of the mean scores of knowledge before versus after
69
education intervention was statistically highly significant which was with a p value (p<0.001).
This score indicates the increase in knowledge as a result of this short-term intervention which
considered being due to the participant’s knowledge which lead to more positive attitudes
towards the importance of enabling the patients to make the primary decisions about their daily
self-management care.
5.3 Attitudes towards the Disease:
In this study there was a focus on three factors that establish the attitudes of the participants
which are the knowledge and beliefs, the participants’ feelings and emotions and participants’
actual behavior towards the disease. The findings of the attitudes showed there is a statistical
high significance of a (P<0.001) which indicates more positive attitudes which will help the
patients in making the primary decisions about their daily diabetes self-management care. Prior
to applying the educational program; the study participants were exhibiting negative feelings and
knowledge that lead to incorrect disease management practices. This fact can be justified by the
definition of attitudes as a learned predisposition toward a target (object or person) that has been
formed from previous experiences. For better understand the attitude concept, the Triadic Model
of Attitudes, which is commonly used in social psychology has been considered (Allport, 1954).
The purpose of using this model is to elaborate more on participants’ attitudes. In the model,
attitude consists of three components: Cognition (knowledge and belief), affect (feelings and
emotion), and behavior. In the model, accuracy of knowledge and beliefs (cognition) is important
because incorrect beliefs could lead to unpleasant consequences. Although cognition is most
often aroused to explain an attitude, all three components are interdependent. People develop
pre-positioned views toward a their disease through social constructs and life experiences; these
views remain relatively consistent over time and throughout various situations (Erwin, 2001).
Positive attitudes towards the disease facilitate well-adjusted behaviors, while negative attitudes
may lead to inappropriate behaviors.
Triadic Model: Components of attitudes. Adapted from Lee & t. al 2015
The perceptions toward the disease involve beliefs, cognitive and emotional representations or
understandings that patients have about their illness (Lin, et. al, 2012). These perceptions have
been found to be associated with health behaviors and clinical outcomes, such as treatment
adherence and functional recovery (American Diabetes Association, 2007). Illness perceptions
constitute beliefs on the chronicity of the illness, locus of control of the illness 3and efficacy of
70
treatments; it includes an assessment on the perception of understanding the patient has of the
illness; illness perception evaluates the emotional impact of the illness directly and indirectly
from the aspects of symptoms experience and concern for the illness’s consequences.
5.4 The practice
The percentage of the practice of self-care of the participant patients of this study before the
intervention program was 49%. Participants reported they do not keep the records of the history
of blood sugar and they do not adopt this important step as a daily practice. This practice is a
principal step for the follow-up with their primary physician. Not being able adopting this
practice is expected to lead to poor knowledge regarding how to manage their blood sugar. After
the intervention there was a high significant reduction which was 0%. Similarly knowledge about
foot care was found to be poor amongst 38% of participants prior to the study and was reduced to
0% after the intervention. 38% of patients reported they are not following an exercise program
which lead to poor control of their blood levels due to lack of exercise to decrease insulin
sensitivity. After the intervention there was a considerable change which was a reduction of 0%.
Several studies show how exercise plays a great role in decreasing blood surge levels (Goode,
Pandora ,2016, Meyrick Chow The, 2014, Gucciardi E, Chan VW, Manuel L and Sidani
S.A 2013 Heisler M, Pietee JD, Spencer M, et al. 2005, Wichit .N., and Mnatzaganian. G.,
2017). 28+% of patients reported they are not following a meal plan or diet prior to the
intervention program. This was significantly reduced to 0% after the intervention again many
studies show how exercise is crucial in decreasing the blood sugar levels (Kent D, D’Eramo
Melkus G, Stuart PM, McKoy JM2013, Meyrick ChowThe 2014). Fifty (50+%) of
participants reported they have not received diabetes education neither attended series of classes
or meetings with a diabetes educator. In the intervention program that conducted for the
participants of this study there were series of educational sessions. The primary goal of this
diabetes education was to provide knowledge and skill training to help individuals identify
barriers and to facilitate problem-solving and coping skills to achieve effective self-care behavior
and behavior change. These educational elements have proved to receive a high significant
reduction to 0% after the intervention. Studies show the vital importance of knowledge and skill
training by empowering individuals through identifying barriers (Jan Koetsenruijtera, ,
Nathalie van 2016 S, Peeples M, T, 2001). The interaction between diabetes educator and
patient could enhance the patient’s communication which can influence DSM through changing
71
knowledge, self-efficacy and behavior. Patients communication may help build trusting
relationships between the patient and the educator and promote the patient’s DSM (Haitham
Abaza, and Michael Marschollek, et al 2017). Therefore, the communication between the
educator and the patient may play a vital role in building knowledge, enhance the belief about
treatment, and increase the confidence in the management of their disease. This finding is in
consistence with previous researches (Xu Y, Toobert D, Savage C, Pan W, Whitmer Ket al
2008). Also, regular follow-up support via whatsApp or phone calls was very helpful in
achieving this goal. It was considered as a source of closing the gaps in this study, knowledge
and practice have directly leaded to behavior change. The positive knowledge gained by the
participants affected their skills of managing.
5. 5 Barriers
Barriers were grouped together into two main categories (personal and resources). Personal
barriers were related to attitude, behavior and self-efficacy such as usefulness, suitability of time
and place etc. Resource barriers referred to the availability and accessibility of supplies and
materials. Interventions included problem solving self-management strategies that are related to
individualized modification of typical cultural practices related to social and family time,
involving dietary patterns such as eating dates and coffee. Family support was addressed in terms
of the amount of food presented to participants. The results show that personal barriers such as
usefulness, forgetfulness, do not like to do it and too much trouble appear to be more significant
in comparison to resource related barriers. 36.2% of participants’ patients reported that they
often or sometimes forgot to do their monitoring. This was significantly reduced by having
81.7% of the participants’ patients who declared that they rarely forget to monitor their blood
sugar. With regards to monitoring of blood sugar; patients were required to send their weekly
monitoring blood sugar reading to the researcher for discussion and reinforcement of problem
solving and self-management strategies. Although this study showed that the patients’ education
is one of the most influential factors on practice; decisions regarding diabetes management had
used key daily practice guidelines produced by (whatsApp). The same result was found in one
study conducted in assessing the levels of knowledge, attitude and practice about DM ( Enza
Gucciardi a , Vivian Wing-Sheung Chan2013). 40+.8% of patients reported that time was a
barrier to perform the blood sugar monitoring. This was changed to 76+.3%, who were able to
follow the positive reinforcement. 29+% of patient indicated that the blood sugar monitoring was
72
too much trouble. The percentage has changed to 61+%, through the weekly positive
reinforcement and availability of the diabetes educator who is the researcher; to provide support
through telecare, using whatsApp voice message. This approach had enabled in filling up the gap
and resulted in improving diabetes care outcomes by answering the question about the
progression of their diabetes, providing motivationfor change, and for future follow-up. A study
in the United Kingdom has developed a novel support network, based on a unique text-
messaging system that designed to deliver individually targeted messages and general diabetes
information (Collin A. Ross, 2016). Another study in Korea, conducted by Kim and others in
year 2006, has assessed the impact of a nurse short message service or texting or telephone call.
These researchers have found that 60% of patient indicated they do not like to do the blood sugar
monitoring. This correlates with the findings of this study of experiencing pain by 60+%. The
findings indicate that 15+% of the patients found the results hard to read. This correlates with the
illiteracy rate of 16% of the participants of this study. With regards to the accessibility and
availability of resources, the study findings indicated that diabetes educational materials and
resources such as strip tests and glucometers for monitoring are available to the participants and
they are not causing any barriers to the participants.
5.5.1 The Social Cognitive Theory (SCT) and Behavioral Change:
The investigations done in this study were to consider the strategy of empowering participants to
seek and critically assess information about their treatment which lead to motivating participants
in changing behavior which is resulted by learning (Shrivastava & et.al, 2013). The educational
program that delivered to the participants proved education and training empowered patients and
changed their behavior. People undergo various changes during their lives, and many theories
have been established over the years to explain the change. The human behavior about
continuous reciprocal interaction among the behavioral, environmental and cognitive influence is
explained by the Social Cognitive Theory (Martin et al. 2017). Individuals rather than merely
responding to environmental influences, they try to seek and interpret information (Boateng et
al. 2016). According to (SCT) theory, individual act as the contribution of their motivation,
behavior, and development in a network where there are reciprocally interacting influences.
Social cognitive theory not only covers the response of individuals based on environmental
influence but topics such as physiological and moral judgment. This theory takes individuals like
perspective for a change and adaptation and these individuals are those who intentionally
73
influence functioning. Although the behavioral change is incredibly complex and includes many
inputs and dimensions, the cognitive, behavioristic, and social cognitive theories can be used to
develop an overall framework for an evidence-based approach (Martin et al. 2017).
In this study it has been noticed that the participant patients have been affected by the three-
factors which are the environment, individual behavior and personal factor which affect each
other. In the social cognitive theory, there is the explanation of the environment as a factor that
affects the person’s behavior; there may be the social and physical environment. Situation and
environment provide the outline to understand the behavior of the individual. There are not one,
but several factors which play a crucial role in deciding human behavior and they are not of
equal strength. For example, the social strategies (environmental factors) affect the people
(cognitive factors) which in turn affect the individual’s performance (behavioral factors) as
explained earlier by the Triadic Model of attitudes (figure1). According to social cognitive
theory, if diabetic patients have been trained through competency development, they can be more
self-efficient, self-regulated and have more control of behavior. It, further, provide bases to
interact with the social/cultural environment with better decision-making skills and to facilitate
others for learning through modeling.
74
Chapter 6
Conclusion
The management of diabetes and achievement of blood glucose goals for patients is complex due
to numerous variables, including various factors such as the environmental/cultural factors, the
cognitive factors and the behavioral factors. Overcoming the barriers and cultivating the
facilitators to change can improve care processes, provider effectiveness, and patient outcomes.
This project aimed to empower the diabetes educators or clinic nurses to implement the DSME
program with patients with diabetes. To increase their self-management and self-efficacy and to
enable them to adhere to the self-management plan, to improve the effectiveness of the diabetes
self-management program and expand it beyond the current group of participants of patients,
diabetes educators, nurses and other clinic personnel who must deliver care based on best
practices and hold the social responsibility for the holistic welfare of the patients.
In this study the researcher identified areas of opportunity for additional staff and patient
education as well as processes that can be improved, such as providing a guide that must include
the diet, exercise, and glucose management instructions. The study outcomes and resulting
recommendations can help clinicians in providing organized and efficient diabetes care. The
outcomes of this study were useful in developing content and skills for the staff members to use
in conducting interactive preventive care with the key beneficiaries of the clinic in order to
influence their attitudes and increase and maintain their self-efficacy and self-management
behavior.
The positive effect of the telecare educational program that was found from the subjects of this
study showed the significance of the interaction between the patients and the healthcare
providers. The patients’ adherence to the medications and to any instructions can enhance their
treatment were very much related to the close relationship with their health care providers. This
have been supported by many studies that assure when people with diabetes feel they have a
close relationship with their healthcare professional or team, they are more likely to follow their
diabetes care plan (Jan-MarKarbalaeifar R., Kazempour-Ardebili S., Amiri P. et al. (2016).
The outcomes of the study also suggest that demographic, psychological, social dynamics and
other factors, such as communication, diabetes education and family support affect diabetes self-
management and adherence.
75
Recommendation
1. The study recommends designing and implementing telecare communication to enhance
diabetes self-management educational program among Saudi patients with Type2
diabetes.
2. The study recommends patients having a close relationship with their healthcare
professional or team, they are more likely to follow their diabetes care plan.
3. The study recommends social networks should inspected by medical professionals as
means of improving communication and outcomes with individual patients.
4. The study recommends people with DM should have a close relationship with their
healthcare professional or team; they are more likely to follow their diabetes care plan
5. The study recommended closed the gap between knowledge and practice among diabetics
which is highly needed for good diabetes management such as, adherence to diabetes
self-care tasks, as well as self-efficacy
76
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Appendix 1
Dear sir
Good morning
I will provide your good office with translated copy after I done with translation
I appreciated your support and consideration
Fatima Ibrahim
Sultan Bin Abdul-Aziz Humanitarian City
K.S.A
From: [email protected]
87
Subject: RE: DIABETES QUESTIONNAIRES
Date: Wed, 19 Aug 2015 14:38:14 +0000
Thank you for the information regarding your workplace. If you are translating any of our survey
instruments, we would very much appreciate the translated version, along with the back
translated copy, for our files.
Best,
Sandy
~~~~~~~~~~~~~~~~~~~~~~~~~
Sandy Hardy, MBA, Administrator
University of Michigan
Michigan Diabetes Research Center (MDRC)
Michigan Center for Diabetes Translational Research (MCDTR)
From: fatma Ibrahim [mailto:[email protected]]
Sent: Tuesday, August 18, 2015 4:04 PM
Subject: RE: DIABETES QUESTIONNAIRES
I work in Sultan Bin Abdulaziz Humanitarian city
K.S.A
Thank you
From: [email protected]
Subject: RE: DIABETES QUESTIONNAIRES
Date: Tue, 18 Aug 2015 22:53:46 +0300
88
From: [email protected]
Subject: RE: DIABETES QUESTIONNAIRES
Date: Tue, 18 Aug 2015 18:18:36 +0000
Dear Fatima,
Thank you for your inquiry regarding the survey instruments. Please feel free to use any of our
survey instruments on the website. We just ask that you cite our center as appropriate with a
statement such as: “the project described was supported by Grant Number P30DK092926
(MCDTR) from the National Institute of Diabetes and Digestive and Kidney Diseases.” Should
you have any additional questions, please let me know.
Also, with which institution or organization are you affiliated as a diabetes educator?
Best,
Sandy
~~~~~~~~~~~~~~~~~~~~~~~~~
Sandy Hardy, MBA, Administrator
University of Michigan
Michigan Diabetes Research Center (MDRC)
Michigan Center for Diabetes Translational Research (MCDTR)
1000 Wall Street
Brehm Tower Room 6107
Ann Arbor MI 48109-5714
(tel) 734.764.6103
(fax) 734.647.2307
89
From: fatma ibrahim [mailto:[email protected]]
Sent: Tuesday, August 18, 2015 11:05 AM
Subject: DIABETES QUESTIONNAIRES
Dear Sir
Good afternoon
I would like to request for your good office allow me to use your DIABETES
QUESTIONNAIRES for my research purposes.
Thank you for your support
Fatima Mohammed Ibrahim
Diabetic educator
Kingdom of Saudi Arabia
المملكه العربية السعودية
Sultan Bin Abdulaziz Humanitarian City
مدينة سلطان بن عبدالعزيز للخدمات الإنسانية
PATIENT CONSENT FORM
INFORMED CONSENT ( CLINICAL STUDY ) ) موافقة خطية ) لدراسة إكلينيكية
TITLE The Effectiveness of Self-
Management Educational Program
on Knowledge, Attitudes, and
عنوان الدراسة
90
Practice among Saudi Type 2
Diabetic patients. (2015 – 2016)
PRINCIPAL INVESTIGATOR الاساسيالباحث
FATIMA IBRAHIM
Having discus ed this research project with ة مع : بعد مناقشة بحث هذه الدراس
and re iewed the OPEN LETTER, which is
attached, I agree, voluntarily to the
participation in this study:
ومراجعة المعلومات المفصلة عن الدراسة المرفقة فأنني أوافق
طوعاً على المشاركة في هذه الدراسة .
Patient’sname اسم المريض
Relationship العلاقة بالمريض
1. I understand that I will be participating in a
study, which may, or may not benefit me
directly, but will provide new knowledge,
w ich could benefit other patients with
similar conditions to mine in the future.
م بأنني سوف أشارك في هذه الدراسة ومن المحتمل أن أنا أعل -1
تكون ذات فائدة بطريقة مباشرة أو غير
مباشرة ولكنها سوف توفر معلومات يمكن أن تفيد مرضى آخرين
بمثل حالتي في المستقبل.
2. I also understand that I do have the right to
withdraw from this study at any time, by
tel ing my dentist. My decision to withdraw,
or to decide not to participate, will in no way
affect my ongoing treatment, to my
relationship with my th rapist.
بالإضافة إلى ذلك فإنني أعلم بأنه لي الحق في الانسحاب في -2
أي وقت من هذه الدراسة وذلك بإخطار الاخصائي المعالج بأنني
قررت الانسحاب أو قررت عدم المشاركة ولن يؤثر ذلك على
علاجي أو علاقتي بالاخصائي.
3. I give permission for the principal
investigator to read my medical records, and to
publ sh or report the findings of this study at
scientific meetings in the future, knowing that
إنني قد فوضت الباحث الاساسي بمراجعة ملفي الطبي ونشر -3
دم أو تقديم نتائج الدراسة في المؤتمرات الطبية في المستقبل مع ع
ذكر اسمي. وفي نهاية الدراسة سيشرح لي الاخصائي نتائجها.
91
my identity will not be revealed. The therapist
will explain the results of this study at the end.
Signature توقيع المريض
Witness شاهد
Investigator/
FATIMA
IBRAHIM
الباحث / الاخصائي
92
Diabetes Care Profile
Michigan Diabetes
Research and Training Center
DCP2.0
1998 The University of Michigan
1. Q1. MRN- Age: ______ year - Weight: _________ Kg - Height: ___ cm- BMI:
____ kg/m2,
.Duration of Diabetes……..Years
2. Clinical Data:
Date(month & year) HbA1c level FBS
Section I – Demographic
الجنس:
نثي ذكر أ
مستوي التعليم :
متوسط امي أبتدائي جامعي ثانوي
Q5.: الحالة الجتماعية
ارمل مطلق متزوج اعزب
نوع السكن ما
في منزل مع العائلة /مع لاصدقاء ا منزل بالايجار
_______________ أخرى 7
هل تسكن لوحدك
لا نعم
Q8.) كم عدد الاافراد الذين يعيشون معك بالسكن
اربع افراد 4 ثلاث افرادفردين مع فرد واحد 1 وحيد 0
خمسة افراد واكثر
93
Section 2- Knowledge
How do you rate your understanding of: (circle one answer for each line)
ما مدي معرفتك بالتالي ضع دائرة حول اجابة واحدة
ضعيف
1السؤال ممتاز جيد
1 العنايةالعامة بالسكر 1 2 3
2 قدرتك على التعامل مع الضغوط 1 2 3
مناسبة للسكريالحمية ال 1 2 3 3
3
2
1
4 ور التمارين في علاج السكري
5 الادوية التي تتناولها 1 2 3
6 كيف تستخدم نتيجة فحص السكر 1 2 3
3 2 1
كيف تؤثر كل من الحمية و التمارين الادوية في مستوى السكر لديك
7
3 2 1
الوقاية والعلاج في حالة ارتفاع السكر
8
3 2 1
ة والعلاج في حالة انخفاض السكرالوقاي
9
3 2 1
الوقاية من المضاعفات المزمنة للسكري
10
11 الوقاية من المضاعفات المزمنة للسكري 1 2 3
12 العناية بالقدم 1 2 3
13 فؤائد تحسين مستوى السكر 1 2 3
94
Q2. Section 3- Attitudes Toward Diabetes Scales
(Positive Attitude, Negative Attitude, Care Ability, Importance of Care, and Self-Care
Adherence)
For the following questions, please circle the appropriate response. (Circle one answer for each
line)
أوافق أوافق طبيعي لا اوافق لا اوافق بشدة
بشده
2الاسئلة
1
انا خائف من مرض السكري 5 4 3 2
1
1 2 3 4 5
في تصديق اني مصاب بالسكري أنا اجد صعوبة
2
1 2 3 4 5
اشعر بالاكتئاب وعدم السعادة لإصابتي بالسكري
3
أنا أشعر بالرضا في حياتي 5 4 3 2 1
4
1 2 3 4 5
أنا لا اشعر اني على ما يرام كالأشخاص الاخرين بسبب
السكري
5
أنا استطيع ان افعل كل ما أريد 5 4 3 2 1
6
1 2 3 4 5
أنا اجد صعوبة في التعامل مع كل ما يخص مرض السكري
7
السكري لا يؤثر على حياتي اطلاقا 5 4 3 2 1
8
95
المناسبة لكضع دائرة حول الاجابة
أنا لدي القدرة لفعل كل ما هو مطلوب 5 4 3 2 1
9
10 كل الامور تجري في مجراها الصحيح حاليا بالنسبة لي 5 4 3 2 1
لدي القدرة على الحفاظ على المستوى الطبيعي للسكر 5 4 3 2 1
11
احافظ على وزني المطلوب 5 4 3 2 1
12
أستطيع التعامل مع مشاعري من خوف قلق وغضب تجاه 5 4 3 2 1
إصابتي بالسكري
13
96
Q3 Section 4- Monitoring Barriers and Understanding Management Practice Scales
( هل تفحص السكر؟ 1
نعم لا
( ماهي عدد الايام التي تفحص فيها السكر في الاسبوع2
اسبوع /ايام ) _____
لفحص كم مرة تفحص السكر؟ ( خلال أيام ا3
يوم / المرات) _____
( هل تحتفظ بتسجيل نتائج فحص السكر؟4
□ليس دائما □ لا □ نعم
( هل مقدمى الرعاية الطبيه او التمريضيه اخبروك عن العناية بقدمك؟5
غير متاكد □ لا □ نعم
( هل مقدمي الرعاية الطبيه او التمريضيه اخبروك كيفية عن القيام بتمارين الرياضية ؟ 6
□ غير متاكد □ لا □ نعم
( هل مقدمي الرعاية الطبية او التمريضيه اخبروك عن اتباع نظام وجبات صحيه7
□ ليس دائما □ لا □ نعم
( هل تلقيت تثقيف صحي بخصوص السكر مع مثقف السكري او فصول تثقيفه بخصوص السكر8
□ ليس دائما □ لا □ نعم
97
عندما لاتفحص السكركما طلب منك من مقدمي الرعاية الطبية ماهي الاسباب؟
ضع دائره حول الاجابة الاقرب لك
نادرا
أحيانا
غالبا
الاسئلة
الارقام
3
2
1
نسيت
1
3
2
1
لاتؤمن باهميته
2
3
2
1
الوقت والزمن غير مناسب
3
3
2
1
لا تحب ان تفحص
4
3
2
1
فحصلاتوجد لديك ادوات
5
3
2
1
تكلف كثيرا
6
3
2
1
تسبب لك متاعب كثيره
7
3
2
1
صعوبة قرأة نتيجة الفحص
8
3
2
1
لاتستطيع القيام بها بنفسك
9
98
3
2
1
مستويات السكري لديك لاتتغير كثيرا
10
3
2
1
تؤلمك وخزة ابرة الفحص
11
3
2
1
13
99
For the following questions, please circle the appropriate response.(circle one answer for each
line)
ضع دائرة حول الاجابة المناسبة لك
كيف تقيم فهمك للتالي ممتاز جيد ضعيف
الارقام
الغذاء وضبط مستوى السكر
1
التحكم في الوزن
2
ارين الرياضيةالتم
3
استخدم حقن الانسولين /الاقراص
4
فحص السكر
5
العناية بالقدم
6
مضاعفات السكري
7
العناية بالعين
8
استخدام أدوية السكري مع الأدوية الاخرى
9
100
Section 2- Knowledge
How do you rate your understanding of: (circle one answer for each line)
ما مدي معرفتك بالتالي ضع دائرة حول اجابة واحدة
Q1. Poor
ضعيف
Good
جيد
Excellent
ممتاز
a) overall diabetes care العنايةالعامة بالسكر 1 2 3
b) coping with stress قدرتك على التعامل مع
الضغوط
1 2 3
c) diet for blood sugar control الحمية المناسبة
للسكري
1 2 3
d) the role of exercise in diabetes care
دور التمارين الرياضيه في علاج السكر
1 2 3
e) medications you are taking الادوية التي
تتناولها
1 2 3
f) how to use the results of blood sugar
monitoring يجة فحص السكر كيف تستخدم نت
1 2 3
g) how diet, exercise, and medicines affect
blood sugar levels
كيف تؤثر كل من الحمية و التمارين والعلاج في مستوى
السكر لديك
1 2 3
101
h) prevention and treatment of high blood
sugar
الوقاية والعلاج في حالة ارتفاع السكر
1 2 3
i) prevention and treatment of low blood
sugar
بالوقاية والعلاج في حالة انخفاض السكر
1 2 3
j) prevention of long-term complications
of diabetes
الوقاية من المضاعفات المزمنة للسكري
1 2 3
k) foot care 3 2 1 العناية بالقدم
l) benefits of improving blood sugar
control
فؤائد تحسين مستوى السكر لمستواه الطبيعي
1 2 3
102
Q2. Section 3- Attitudes Toward Diabetes Scales
(Positive Attitude, Negative Attitude, Care Ability, Importance of Care, and Self-Care
Adherence)
For the following questions, please circle the appropriate response. (Circle one answer for each
line)
ضع دائرة حول الاجابة المناسبة لك
Strongly
Disagree
لااوافق بشدة
Disagree
لااوافق
Neutral
طبيعي
Agree
اوافق
Strongly
Agree
اوافق بشده
a I am afraid of my diabetes.
انا اخاف من السكري
1 2 3 4 5
b I find it hard to believe that I
really have diabetes.
أنا اجد صعوبه في الاعتراف اني
مصاب بالسكري
1 2 3 4 5
c I feel unhappy and depressed
because of my diabetes
اشعر بالاكتئاب وعدم السعادة لاصابتي
بالسكري
1 2 3 4 5
d I feel satisfied with my life.
أنا أشعر بالرضا في حياتي
1 2 3 4 5
e I feel I'm not as good as others
because of my diabetes.
أنا لا اشعر اني على يرام كالاشخاص
الاخرين بسبب السكري
1 2 3 4 5
f I can do just about anything I
set out to do.
أنا استطيع ان افعل كل مااريد
1 2 3 4 5
103
g I find it hard to do all the
things I have to do for my
diabetes.
أنا اجد صعوبة في التعامل مع كل
مايخص مرض السكري
1 2 3 4 5
h Diabetes doesn't affect my life
at all. السكري لم يؤثر على حياتي
اطلاقا
1 2 3 4 5
i I am pretty well off, all things
considered.
ا لدي القدرة لفعل كل ماهو مطلوبأن
1 2 3 4 5
j Things are going very well for
me right now.
كل الامور تجري في مجراها الصحيح
حاليا بالنسبة لي.
1 2 3 4 5
Strongly
Disagree
لااوافق وبشده
Disagr
ee
لااوفق
Neutral
طبيعي
Agree
اوافق
Strongly
Agree
شدهاوافق ب
a) keep my blood sugar in
good control.
لدي القدرة على الحفاظ على المستوى
الطبيعي للسكر
1 2 3 4 5
b) keep my weight under
control.
احافظ على وزني المطلوب
1 2 3 4 5
104
c) do the things I need to do
for my diabetes (diet,
medicine, exercise, etc.). ع استطي
القيام بما يلزم من ناحية الحمية والدواء
والتمارين للمحافظة على مستوى
السكري
1 2 3 4 5
d) Handle my feelings (fear,
worry, anger) about my
diabetes.
استطيع التعامل مع مشاعري من خوف
وغضب تجاه اصابتي بالسكري
1 2 3 4 5
Q3 Section 4- Monitoring Barriers and Understanding Management Practice Scales
Q1a. Do you test your blood sugar? (Check one box) هل تفحص السكر
No لا 1 Yes 2 نعم
Q2b. How many days a week do you test your blood sugar
كر في الاسبوع ماهي عدد الايام التي تفحص فيها الس
_____ (day’s ايام/ week) اسبوع
Q3c. On days that you test, how many times do you testyour blood sugar?
كم مرة تفحص السكر
_____ (timesاوقات / day يوم
Q4d. Do you keep a record of your blood sugar test results? (Check one box)
هل تحتفظ بتسجيل نتائج فحص السكر
نعم No 1Yesلا 2 Only Unusual ليس دائما 3
Q5e. Has your health care provider or nurse ever told you to take special care of your feet?
(Check one box (
هل مقدمى الرعاية الطبيه او التمريضيه اخبروك عن العناية كيفية بقدمك
105
1 No2 لا Yes نعم 3 Not Sure ر متاكدغي
6e. .Has your health care provider or nurse ever told you to follow an exercise program (check
one box)
هل مقدمي الرعاية الطبيه او التمريضيه اخبروك كيفية عن القيام بتمارين الرياضيه
1 No لا 2 Yes 3 نعم Not Sure? غير متاكد
7f.Has your health care provider or nurse ever told you to follow a meal plan or diet? (Check one
box)
هل مقدمي الرعاية الطبية او التمريضيه اخبروك عن اتباع نظام وجبات صحيه
1 No2 لا Yes3 نعم Not Surغير متاكد
8g.Have you ever received diabetes education? (For example: attended a series of classes or
series of meetings with a diabetes educator) (Check one box)
هل تلقيت تثقيف صحي بخصوص السكر مع مثقف السكري او فصول تثقيفه بخصوص السكر
1 Noلا 2 Yes 3 نعم Not Sureغير متاكد
For the following questions, please circle the appropriate response.(circle one answer for each
line)
Q2.When you don't test for sugar as often as you have been told, how often is it because:
بية ماهي الاسباب؟عندما لاتفحص السكركما طلب منك من مقدمي الرعاية الط
ضع دائره حول الاجابة الاقرب لك
Rarely
نادرا
Sometimes
احيانا
Often
غالبا
a) You forgot?
نسيت
1 2 3
b) You don't believe it is useful?
لاتؤمن باهميته
1 2 3
106
b) The time or place wasn't right?
الوقت والزمن غير مناسب
1 2 3
c) You don't like to do it?
لاتريد ان تفحص
1 2 3
d) You ran out of test materials?
لاتوجد لديك ادوات فحص
1 2 3
e) it costs too much?
تكلف كثيرا
1 2 3
f) it's too much trouble?
تسبب لك متاعب كثيره
1 2 3
g) it's hard to read the test results?
صعوبة قرأة نتيجة الفحص
1 2 3
h) you can't do it by yourself?
لاتستطيع القيام بها بنفسك
1 2 3
j) your levels don’t change very
often?
مستويات السكري لديك لاتتغير كثيرا
1 2 3
k) it hurts to prick your finger?
تؤلمك وخزة ابرة الفحص
1 2 3
107
For the following questions, please circle the appropriate response.(circle one answer for each
line)
لسؤال التالي ضع دائرة حول الاجابه الاقرب لك
Q4.How do you rate your understanding of:
كيف تقيم فهمك للتالي
Poor
ضعيف
Good
جيد
Excellent
ممتاز
a) diet and blood sugar control
السكرالغذاء وضبط مستوى
1 2 3
b) weight management
التحكم في الوزن
1 2 3
c) exercise
التمارين الرياضية
1 2 3
d) use of insulin/pills
استخدم حقن الانسولين /الادويه بالفم
1 2 3
e) sugar testing
فحص السكر
1 2 3
f) foot care
العناية بالدم
1 2 3
g) complications of diabetes
سكريمضاعفات ال
1 2 3
h) eye care
العناية بالعين
1 2 3
i) combining diabetes medication with
other medications
استخدام أدوية السكري مع الأدوية الاخرى
1 2 3
108
questions: :ألاسئلة
How do you rate
your understanding
of: ل اجابة واحدةما مدي معرفتك بالتالي ضع دائرة حو
Rater
1 Rater 2 Agreement
a) overall diabetes
care العناية العامة بالسكر
b) coping with stress قدرتك على التعامل مع الضغوط
c) diet for blood
sugar control الحمية المناسبة للسكري
d) the role of exercise
in diabetes care دور التمارين الرياضية في علاج السكر
e) medications you
are taking الادوية التي تتناولها
f) how to use the
results of blood sugar
monitoring كيف تستخدم نتيجة فحص السكر
g) how diet, exercise,
and medicines affect
blood sugar levels
كيف تؤثر كل من الحمية و التمارين والعلاج في مستوى
السكر لديك
h) prevention and
treatment of high
blood sugar الوقاية والعلاج في حالة ارتفاع السكر
i) prevention and
treatment of low
blood sugar الوقاية والعلاج في حالة انخفاض السكر
109
j) prevention of long-
term complications of
diabetes الوقاية من المضاعفات المزمنة للسكري
k) foot care العناية بالقدم
l) benefits of
improving blood
sugar control فؤائد تحسين مستوى السكر لمستواه الطبيعي
m) pregnancy and
diabetes مل والسكري الح
For the following
questions, please
circle the appropriate
response. ضع دائرة حول الاجابة المناسبة لك
Rater
1 Rater 2 Agreement
a) I am afraid of my
diabetes. انا اخاف من السكري
b) I find it hard to
believe that I really
have diabetes. أنا اجد صعوبه في الاعتراف اني مصاب بالسكري
c) I feel unhappy
and depressed
because of my
diabetes اشعر بالاكتئاب وعدم السعادة لاصابتي بالسكري
d) I feel satisfied
with my life. أنا أشعر بالرضا في حياتي
e) I feel I'm not as
good as others
because of my
diabetes.
أنا لا اشعر اني على ما يرام كالاشخاص الاخرين بسبب
السكري
f) I can do just about
anything I set out to
do. أنا استطيع ان افعل كل مااريد
110
g) I find it hard to do
all the things I have
to do for my diabetes. أنا اجد صعوبة في التعامل مع كل مايخص مرض السكري
h) Diabetes doesn't
affect my life at all السكري لم يؤثر على حياتي اطلاقا
i) I am pretty well
off, all things
considered أنا لدي القدرة لفعل كل ماهو مطلوب
j) Things are going
very well for me right
now. .كل الامور تجري في مجراها الصحيح حاليا بالنسبة لي
I am able to: (circle
one answer for each
line) ضع دائرة حول الاجابة الاقرب
Rater
1 Rater 2 Agreement
a) keep my blood
sugar in good control ستوى الطبيعي للسكرلدي القدرة على الحفاظ على الم
b) keep my weight
under control. احافظ على وزني المطلوب
c) do the things I
need to do for my
diabetes (diet,
medicine, exercise,
etc.)
استطيع القيام بما يلزم من ناحية الحمية والدواء والتمارين
للمحافظة على مستوى السكري
d) Handle my
feelings (fear, worry,
anger) about my
diabetes.
استطيع التعامل مع مشاعري من خوف وغضب تجاه
اصابتي بالسكري
Monitoring Barriers
and Understanding
Management Practice
Scales
Rater
1 Rater 2 Agreement
111
Do you test your
blood sugar? (Check
one box)
□لا □ هل تفحص السكر نعم
How many days a
week do you test
your blood sugar
ماهي عدد الايام التي تفحص فيها السكر في الاسبوع
On days that you test,
how many times do
you test your blood
sugar? يا ماهي عدد ألاوقات كم مرة تفحص السكر يوم
Do you keep a record
of your blood sugar
test results? (Check
one box) □ No□
YesOnly Unusual □
□ لا □ هل تحتفظ بتسجيل نتائج فحص السكر نعم
□ليس دائما
Has your health care
provider or nurse
ever told you to take
special care of your
feet? (Check one
box)□ No□ Yes Not
Sure □
هل مقدمى الرعاية الطبية او التمريضيه اخبروك عن كيفية
□ غير متاكد □ لا □ العناية بقدمك نعم
Has your health care
provider or nurse
ever told you to
follow an exercise
program (check one
box) □ No□ Yes Not
Sure □
هل مقدمى الرعاية الطبية او التمريضيه اخبروك عن كيفية
غير متاكد □ لا □ القيام بالتمارين الرياضية نعم
□
Has your health care
provider or nurse
هل مقدمى الرعاية الطبية او التمريضيه اخبروك عن اتباع
□ غير متاكد □ لا □ نظام وجبات صحيه نعم
112
ever told you to
follow a meal plan or
diet? (Check one
box)□ No□ Yes Not
Sure □
Have you ever
received diabetes
education? (For
example: attended a
series of classes or
series of meetings
with a diabetes
educator) □ No□ Yes
Not Sure □
هل تلقيت تثقيف صحي بخصوص السكر مع مثقف السكري
غير □ لا □ او فصول تثقيفه بخصوص السكر نعم
□ متاكد
When you don't test
for sugar as often as
you have been told,
how often is it
because:circle the
appropriate response
ماهي الأسباب التى جعلتك لا تفحص السكرى حسب
تعليمات مقدمى الرعاية الطبية؟ ضع دائره حول الاجابة
الاقرب لك
Rater
1 Rater 2 Agreement
a) You forgot? نسيت
b) You don't believe
it is useful? ميتهلاأومن باه
c) The time or place
wasn't right? الوقت والزمن غير مناسب
d) You don't like to
do it? لاتريد ان تفحص
e ) You ran out of test
materials? عدم توفر ادوات فحص السكرى
f) it costs too much? تكلف كثيرا
g) it's hard to read صعوبة قرأة نتيجة الفحص
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the test results?
h) you can't do it
by yourself? لاتستطيع القيام بها بنفسك
j) your levels don’t
change very often? مستويات السكري لديك لاتتغير كثيرا
k) it hurts to prick
your finger? لفحصتؤلمك وخزة ابرة ا
How do you rate your
understanding
of:circle the
appropriate response كيف تقيم فهمك للتالي: ضع دائرة حول الاجابه الاقرب لك
Rater
1 Rater 2 Agreement
a) diet and blood
sugar control الغذاء وضبط مستوى السكر
b) weight
management التحكم في الوزن
c) exercise التمارين الرياضية
d) use of
insulin/pills استخدم حقن الانسولين /الادويه بالفم
e) sugar testing فحص السكر
f) foot care العناية بالقدم
g) complications
of diabetes مضاعفات السكري
h) eye care العناية بالعين
i) combining
diabetes medication
with other
medications أستخدام أدوية السكري مع الأدوية الاخرى
114
Agreement %
Total Number of questions were agreed between raters
Total Number of questions were disagreed between raters
Total Number of questions were agreed and disagreed between raters
Agreement %
أوفق
لا أوفق
أوفق مع التعديل
115
116
117
118
119
120
121
122
123
124
125
126
127
Figure 1. Triadic Model: Components of attitudes. Adapted from Lee & t. al 2015