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  • 1. Psychosocial Predictors Assessment and Mitigation of Problems Among Diabetes Clients A SAMPLE RESEARCH PROJECT Protocol Developed By: Ram Sharan Mehta Additional Professor Medical Surgical Nursing Department College of Nursing B.P. Koirala Institute of Health Sciences Dharan, Sunsari, Nepal Email: ramsharanmehta7@yahoo.com Phone: 9842040537, 025-525555-Ext. 3022 Fax No: 025520251 2012
  • 2. 1. Title of the Study:Psychosocial Predictors Assessment and Mitigation of Problems Among Diabetes Clients.2. Introduction:Background: Between 1995 and 2025 the number of the adult population affected by diabetesmellitus in developing countries is projected to grow by 170%, from 84 to 228 million people. By 2025,these countries will be home to 76% of all persons with diabetes, as compared with 62% in 1995. Inthe same period, the developed world will see a 41% increase, from 51 to 72 million people.Diabetes Mellitus (DM) is a chronic disease caused by inherited and/or acquired deficiency inproduction of insulin by the pancreas, or by the ineffectiveness of the insulin production. It is asyndrome caused by an imbalance between insulin supply and demand, characterized byhyperglycemia and associated with abnormal carbohydrate, fat and protein metabolism. Insulindeficiency results in increased concentrations of glucose in the blood, which intern damage many ofthe body’s systems, in particular the blood vessels and Nerves.DM is a major non-communicable disease affecting approximately 150 million people in world in2002,180 million in 2003 and expected to reach 330 million in 2025. The prevalence of DM is steadilyincreasing world wide, particularly in developing countries. It is projected to increase by 170%, out ofwhich 76% will be from developing countries. 310 patients were admitted in medical units of BPKIHSbetween 1-3-2003 to 29-2-2004.DM is a chronic disease that affects approximately 14 million people and among those 14 million, 7million were un- diagnosed. Among older people (>65 years) 8.6 had type-II DM. Type-I DMapproximately account for 10% and type-II 85-90% of all known cases of DM in United States. There is rising prevalence of the disease in the developing countries, which was rare before, is due toindustrialization, Socio-economic development, and urbanization and changing life style. Type-II DM ismore prevalent than type-I DM and constitutes nearly 90% of cases among the diabetes. Theprevalence of diabetes increases with age. The prevalence of type-II DM in female was relatively lower(5.57%) than males (6.73%).The high incidence (new cases) of type-II DM in Nepal was found due to lack of public awarenessregarding the problems and poor medical service in country2. From 28th oct.1997, to 27th Oct. 1998, inMedical OPD of B.P. Koirala Institute of Health Sciences, 1840 patients (1040 M & 800 F) attendedwith DM. Hence, the investigators tried to explore the various facts or problems of the admittedpatients suffering with DM.Diabetes: Facts: • At least 171 million people worldwide have diabetes; this figure is likely to be more than double by 2030. • Around 3.2 million deaths every year are attributable to complications of diabetes; six deaths every minute. • The top 10 countries, in numbers of sufferers, are India, China, USA, Indonesia, Japan, Pakistan, Russia, Brazil Italy and Bangladesh. • Overall, direct health care costs of diabetes range from 2.5% to 15% of annual health care budgets, depending on local diabetes prevalence and the sophistication of the treatment available. • The costs of lost production may be as much as five times the direct health care cost, according to estimates derived from 25 Latin American countries.Recent studies in China, Canada, USA and several European countries have shown that feasiblelifestyle interventions can prevent the onset of diabetes in people at high risk.2.1 Statement of the Problem:What are the Psychosocial Predictors of Diabetes Clients?
  • 3. 2.2 Null Hypothesis:Patients who do not benefit from education are more likely to have psychiatric problems or particularlyineffective coping styles.2.3. Aims of the study:The aim of this study will be to determine which psychosocial factors directly and immediately influencepatients ability to learn diabetic self-care and decrease the level of depression, anxiety and stress. Itwill also improve the quality of life.2.4 Objectives of the study: 1. Find out the psychosocial factors which influence patients’ ability to learn diabetes care. 2. Conduct education programme on the management of diabetes and minimization of the psychosocial problems. 3. Evaluate the effectiveness of education intervention programme on management of diabetes.2.5 Rational of the study:Diabetes mellitus (DM) is a major non-communicable disease affecting approximately 150 millionpeople in world in 2002,180 million in 2003 and expected to reach 330 million in 2025. The prevalenceof DM is steadily increasing world wide, particularly in developing countries. It is projected to increaseby 170%, out of which 76% will be from developing countries2.A study conducted by mehta3 in BPKIHS from 1-3-2003 to 29-2-2004 i.e. for 1 year among admitteddiagnosed cases of DM found that, about 60.7 % subject had hypertension, 39.3 % had ocularproblem, and 25 % had renal problems. Majority of subject (82.1 %) knows about the disease (DM)they were suffering but limited subject had the knowledge about, causes, curability, treatmentmodalities, diet, and other aspects. As the knowledge regarding various aspects of DM is very low,there is need for informational booklet in Nepali and health education programme among public will bevery useful.Very few booklets are available in Nepal in Nepali on diabetes. As the number of diabetes cases isincreasing very high and there is inadq2uate knowledge among the clients and their relatives to takecare of client and prevent complications it is urgency to publish s booklet on Nepali for those clients.Hence, the investigators decided to conduct study on or Effectiveness of information booklet ondiabetes among the admitted diabetes client in BPKIHS.Psychosocial factors can play an important role in diabetes care. For example, patients often feel highlevels of diabetes-related emotional distress, resulting in diabetes care "burnout". Depression isapproximately twice as high among people with diabetes compared with those without chronic disease,and >40% of patients have been identified as depressed in some studies. Depression can interfere withself-care and glycemic control and is associated with increased morbidity, morality, and functionallimitations as well as health care costs.Patients who experience emotional distress often want more emotional support than they receive.Despite high levels of distress, relatively small numbers of patients receive psychological treatment.Primary care providers do not identify all those in need of psychological treatment, and those identifieddo not necessarily receive appropriate treatment. This is unfortunate because research indicates thatpsychological treatment in primary care can be effective. Moreover, treatment by psychosocialspecialists can be effective for patients who are referred for care. For example, recent meta-analysesindicate that mental health treatment is associated with reductions in depression and HbA1c levels.Medications represent another effective method of treatment.
  • 4. Health care provider strategies for dealing with the psychosocial needs of patients with diabetes arenot well understood. The research cited here indicates that psychosocial factors are importantinfluences on diabetes outcomes, and subjective quality of life is a worthwhile outcome in its own right.Therefore, it is important to understand how health care providers deal with their patients’ psychosocialneeds.2.6. Implications of the study:Nurses and diabetes specialists used psychosocial strategies more than physicians andnonspecialists. Psychosocial strategies were used more when practitioners believed that more patientshad psychosocial problems and that these problems interfered more with diabetes control. Referral topsychosocial specialists was significantly more likely when practitioners perceived that professionalpsychological resources were more available.This research has examined two strategies for managing the psychosocial needs of patients withdiabetes. Both of these strategies have a place in the repertoire of the diabetes care provider. Allpatients are entitled to be treated by a provider who is sensitive to their psychosocial needs, and allproviders should receive the training necessary to attain the appropriate level of expertise.Yet, it is unreasonable to expect every diabetes care provider to be able to meet all of his/her patients’psychosocial needs, just as it is unreasonable to meet all other specialized care needs. For physicians,referral to nurses, who tend to provide greater levels of psychosocial support, may be an option. Butsometimes this option may not be enough, a fact that has resulted in the demand for increasedinvolvement of psychosocial specialists in diabetes care . In an ideal practice environment,psychosocial specialists are available on a routine basis as members of the diabetes care team. Thispermits the integration of psychosocial issues into regular multidisciplinary care. Research has shownthat consultations between primary care providers and psychosocial specialists can improve patientoutcomes and primary care provider satisfaction. Patients of nurses who monitor psychological statusand incorporate these factors into their care planning have better psychosocial outcomes. Anddiabetes education incorporating coping skills training produced improved clinical and psychosocialfunctioning. But when psychosocial specialists are not part of the multidisciplinary team, it is even moreimportant that providers have available a psychosocial specialist to whom patients can be referredwhen necessary.The availability of psychosocial specialists was positively related to physician and nurse referralpatterns, net of the perceived prevalence and severity of the problems for which patients are referred,and the referring provider’s own skills for managing psychosocial problems. This suggests thatincreased availability of psychosocial specialists might increase their use. Other related issues, notaddressed in this study, are whether the available psychosocial specialists are seen as competent todeal specifically with diabetes and whether providers’ perceptions of the competence of psychosocialspecialists play a role in their referral decisions.2.7 Limitations of the study:The study will be conducted at BP Koirala Institute of Health Sciences only.3. Review of Literature:Diabetes is a chronic disease that requires a lifetime of consistent and careful daily self-management.Failure to adhere to strict self-care regimens may lead over time to diabetic complications, such asretinopathy, nephropathy, neuropathy, and coronary heart disease.1,2The role of psychosocial factors in the long-term outcome of diabetes patients has been widely studiedand well documented.3–17 Previous studies have addressed a wide range of psychosocial factors at thepersonal, social, and community level, including the presence of psychiatric conditions3 (especially
  • 5. depression4,5), health beliefs and attitudes,6–8 stress and coping styles,9–11 social support,12–14 andfamily and social environment.15–17Education has been considered an important part of diabetic treatment. Education has been generallyeffective in increasing patients knowledge about the disease, but it has not been as effective inchanging self-care behavior.18 The research literature has shown that short-term and information-based educational programs are often ineffective in enhancing and sustaining treatment adherence, asthe behavior of recipients of such programs deteriorates over time.19A few studies have addressed the question of who benefits from diabetes education by examining therelationship between psychological factors and the effects of education. Wooldridge and associates7conducted a 12-month follow-up after a diabetes education program that included patients with bothtype 1 and type 2 diabetes. They found no significant correlation between health beliefs andhemoglobin AIc (HbAIc) (the major fraction of glycosylated hemoglobin) values (a measure of glycemiccontrol) or between self-reported compliance and HbAIc values. Rubin et al.,20 on the other hand,followed both type 1 and type 2 diabetes patients for 6 months and found that those with low levels ofemotional well-being, poor self-care patterns, or poor glycemic control benefited the most fromeducational programs. In a 3-year follow-up study, Bott et al.21 found that the following factors weresignificant predictors of glycemic control: HbAIc values before the educational intervention, smoking,diabetes-related knowledge, blood glucose monitoring in the home, age at onset of diabetes, perceivedcoping abilities, and insulin C-peptide levels. Their study, however, was limited to type 1 diabetespatients who participated in intensive treatment and teaching programs. OConnor and his researchteam22 found that patients who had diabetes for 2 years or less and who had poor baseline glycemiccontrol (HbAIc values greater than 10%) were more likely to have significant positive change in theglycemic index in response to educational programs. Their follow-up study, however, was based onHbAIc values obtained 2 months after the educational intervention, which reflect only the acute effectsof outpatient education. The study did not investigate whether the educational program helped patientsto maintain good glycemic control over longer periods.We have observed clinically that some patients have trouble assimilating what they are taught ineducational programs. In addition, other patients seem to assume responsibility for their self-care withrelative ease in the beginning of treatment but fail in the long run. A meta-analysis of the effect of self-management education for adults with type 2 diabetes23 showed that the net changes in glycosylatedhemoglobin values at the 1–3 month follow-up were particularly diverse. The authors noted that thisfinding may be partly explained by patient factors, such as psychosocial mediators. Also, Glasgow andEakin24 stated that patients who require particularly intensive intervention may include those with majorpsychological disorders, such as clinical depression. On the other hand, Glasgow25 also emphasizedthe role of social environment factors in diabetes self-management.The cost of diabetes: As the number of people with diabetes grows worldwide, the disease takes anever-increasing proportion of national health care budgets. Without primary prevention, the diabetesepidemic will continue to grow. Even worse, diabetes is projected to become one of the world’s maindisablers and killers within the next twenty-five years. Immediate action is needed to stem the tide ofdiabetes and to introduce cost-effective treatment strategies to reverse this trend4.The size of the problem: A diabetes epidemic is underway. An estimated 30 million people would-wide had diabetes in 1985. By 1995, this number had shot up to 135 million. The latest WHO estimate(for the number of people with diabetes, world-wide, in2000) is 177 million. This will increase to at least300 million by 2025. The number of deaths attributed to diabetes was previously estimated at just over800,000. However, it has long been known that the number of deaths related to diabetes isconsiderably underestimated. A more plausible figure is likely to be around 4 million deaths per yearrelated to the presence of the disorder. This is about 9% of the global total. Many of these diabetesrelated deaths are from cardiovascular complications. Most of them are premature deaths when thepeople concerned are economically contributing to society. This situation is increasingly outstretchingthe health-care resources devoted to diabetes 4.For WHO and the International Diabetes Federation (IDF), sponsors of World Diabetes Day, thisincrease can and must be prevented with the right measures.
  • 6. The burden of diabetes and its complications: The exact costs of diabetes are not easy topin down but estimations can be obtained according to three levels: 1. Cost directly related to the diagnosis and management of diabetes without complications. This includes the in-patient and out-patient care, means of treatment by insulin or tablets and the equipment of self control (blood and urine testing). 2. Costs generated by complications of diabetes. These are difficult to quantify because diabetes is linked to micro and macro vascular diseases such as heart disease, kidney failure, eye disease and amputation. Moreover, diabetes may add a cost of care by complicating other unrelated medical situations like infections, accidents and surgery. 3. Indirect costs correlated to the quality of life and the economic productivity which can be somehow estimated by the degree of disability.Prevention of diabetes: Effective prevention also means more cost-effective healthcare. This may bethe prevention of the onset of diabetes itself (primary prevention) or the prevention of its immediateand longer-term consequences (secondary prevention).Primary prevention protects susceptible individuals from developing diabetes. It has an impact byreducing or delaying both the need for diabetes care and the need to treat diabetes complications.Reliable examples of this measure come from studies undertaken among susceptible groups in China.Lifestyle modifications (appropriate diet and increased physical activity and a consequent reduction ofweight), supported by a continuous education programme, were used to achieve a reduction of almosttwo-thirds in the progression to diabetes over a six-year period. This type of measure is not easy, butis likely to be cost effective if it can be implemented on a population scale. It should be consideredparticularly in the poorest regions of the world where resources are severely limited. Similar resultshave also been achieved recently in Finland and the USA. Such preventive measures will havebenefits above and beyond diabetes since improvements in diet and day-to-day physical activity willreduce obesity, cardiovascular disease and some cancers.Secondary prevention includes early detection, prevention and treatment. Appropriate action taken atthe right time is beneficial in terms of quality of life, and is cost-effective, especially if it can preventhospital admission.Secondary prevention Measures: • The treatment of high blood pressure and raised blood lipids, as well as the control of blood glucose levels, can substantially reduce the risk of developing complications and slow their progression in all types of diabetes. • Another cost-saving strategy is the prevention of foot ulceration and amputation. Effective foot-care reduces both the frequency and length of hospital stays and the incidence of amputation in diabetes patients by as much as 50%. • Screening and early treatment for retinopathy is also very cost-effective, given the devastating direct, indirect and intangible costs of blindness. • Screening for protein in urine i8s another valid preventive measure to prevent or slow down the inevitable progression to kidney failure. Furthermore, there is evidence that screening for traces of protein is cost saving, as it allows even earlier intervention in the natural course of kidney disease. • Measures to reduce the consumption of tobacco will also assist in the management of diabetes. Cigarette smoking has been found to be associated with poor control of blood glucose and it is also strongly causally related to hypertension and heart disease in people with diabetes as well as those without.Complications associated with diabetes mellitus:Diabetes mellitus is a chronic disease caused by inherited and /or acquired deficiency in production ofinsulin by the pancreas, or by the ineffectiveness of the insulin produced. Such a deficiency results inincreased concentrations of glucose in the blood, which in turn damage many of the body’s systems, inparticular the blood vessels and nerves.
  • 7. Diabetic retinopathy is a leading cause of blindness and visual disability. Diabetes mellitus isassociated with damage to the small blood vessels in the retina, resulting in loss of vision. Findings,consistent from study to study, make it possible to suggest that, after 15 years of diabetes,approximately 2% of people become blind, while about 10% develop severe visual handicap. Loss ofvision due to certain types of glaucoma and cataract may also be more common in people withdiabetes than in those without the disease.Good metabolic control can delay the onset and progression of diabetic retinopathy. Loss of vision andblindness in persons with diabetes can be prevented by early detection and treatment of vision-threatening retinopathy: regular eye examinations and timely intervention with laser treatment, orthrough surgery in cases of advanced retinopathy. There is evidence that, even in developedcountries, a large proportion of those in need is not receiving such care due to lack of public andprofessional awareness, as well as an absence of treatment facilities. In developing countries, in manyof which diabetes is now common, such care is inaccessible to the majority of th4e population.Kidney failure: Diabetes is among the leading causes of kidney failure, but its frequency variesbetween populations and is also related to the severity and duration of the disease. Several measuresto slow down the progress of renal damage have been identified. They include control of high bloodglucose, control of high blood pressure, and intervention with medication in the early stage of kidneydamage, and restriction of dietary protein. Screening and early detection of diabetic kidney disease arean important means of prevention.Heart disease accounts for approximately 50% 0f all deaths among people with diabetes inindustrialized countries. Risk factors for heart disease in people with diabetes include smoking, highblood pressure, high serum cholesterol and obesity. Diabetes negates the protection from heartdisease which pre-menopausal women without diabetes experience. Recognition and management ofthese conditions may delay or prevent heart disease in people with diabetes.Diabetic neuropathy is probable the most common complication of diabetes. Studies suggest that upto 50% of people with diabetes are affected to some degree. Major risk factors of this condition are thelevel and duration of elevated blood glucose. Neuropathy can lead to sensory loss and damage to thelimbs. It is also a major cause of impotence in diabetic men.Diabetic foot disease, due to changes in blood vessels and nerves, often leads to ulceration andsubsequent limb amputation. It is one of the most costly complications of diabetes, especially incommunities with inadequate footwear. It results from both vascular and neurological diseaseprocesses. Diabetes is the most common cause of no traumatic amputation of the lower limb, whichmay be prevented by regular inspection and good care of the foot.Diabetic neuropathy is a heterogeneous disorder that encompasses a wide range of abnormalitiesaffecting proximal and distal peripheral sensory and motor nerves as well as the autonomic nervoussystems. For these reasons, it has been difficult to obtain precise estimates of the true prevalence andreports vary from 10 to 90% in diabetic patients, depending on the criteria and methods used to defineneuropathy. From patients attending a diabetes clinic 25% reported symptoms; 50% were found tohave neuropathy after a simple clinical test such as the ankle jerk or vibration perception test; almost90% tested positive to sophisticated tests of autonomic function or peripheral sensation 17.The need for more diabetes educators to serve the numbers of people with the disease is the firstmajor challenge in our country. In urban areas, at least in some metros, up to 30-40% of people can bereached through a diabetes education facility. However, in rural or less developed communities, thisnumber may drop to zero. People in rural areas may have to travel for hours or even days to accessspecialist services18.Diabetic neuropathy is a most common and troublesome complication of diabetes mellitus, leading tothe greatest morbidity and mortality and resulting in a huge economic burden for diabetes care. It is themost common form of neuropathy in the developed countries of the world, accounts for moreadmission to hospital than all the other diabetes complications combined and is responsible for50.75% of non-traumatic amputations. Diabetes neuropathy is a set of clinical syndromes that affectdistinct regions of the nervous system, singly or combined, It can be silent and go undetected, while
  • 8. exercising its ravages, or be present with clinical symptoms and signs that although non-specific andinsidious with slow progression also minic those seen in many other diseases. It is, therefore,diagnosed by exclusion17.Diabetes self management training, the process of teaching individuals to manage their diabetes hasbeen considered on important part of clinical management since 1930 s1. The goal of diabeteseducation is to optimize metabolic control, prevent acute and chronic complications, and optimizequality of life while keeping. Costs acceptable.A programme of patient information and education, as a primary tool of diabetes treatment, has beendeveloped during the past 5 years, aiming to an effective self-management of diabetes. The programis patient oriented, with an essential psychological approach, based on a realistic language andfollowing the concepts of a simple, or diabetes philosophy”. The diabetes is considered as a humancondition, not necessarily a disease 5.A study conducted by piette 4 on, “Impact of automated calls with nurse follow-up on diabetestreatment out comes in a department of veterans affairs health care system: a randomized controlledtrial”, mentioned, at 12 months, intervention patients reported more frequent glucose self-monitoringand foot inspections than patients recovery usual care and were more likely to be seen in podiatry anddiabetes specialty clinics. Intervention patients also were more likely than control patients to have hada cholesterol test”.How do we prevent and treat diabetes: Primary prevention, healthy diet and regular physical activity,protects susceptible individuals. It has an impact by reducing or delaying both the need for diabetescare and the need to treat diabetes complications. It should be emphasized particularly in the poorestrations of the would where resources are severely limited.Reduction in weight and half an hour of walking each day reduced the incidence of diabetes by morethan one half in overweight subjects with mild Impaired Glucose Tolerance (IGT).Because of its chronic nature, the severity of its complications and the means required to control them,diabetes is a costly disease, not only for affected individuals and their families, but also for the healthsystems. Studies in India estimate that, for a low-income Indian family with an adult with diabetes, asmuch as 25% of family income may be devoted to diabetes care. For families in the USA with a childwho has diabetes, the corresponding figure is 10%.In WHO’s Western Pacific region a recent analysis of health care expenditure has shown that: 16% ofhospital expenditure was for people with diabetes. In the Republic of the Marshall Islands, This figurewas 25%. And 20% of “offshore expenditure” on health by Fiji was for diabete3s-related complications– instances where facilities for care were not available in Fiji, so patients had to travel elsewhere.These represent considerable sums for countries that can ill afford such massive expenditure onpreventable conditions4.Diabetes education18: Education is not just a part of diabetes treatment; it is the treatment. The keyaims of diabetes education are to change behavior and promote self-management. Diabetes educationconsists of providing tools and support to patients as they learn to manage their disease therebycreating self-confidence. Education and imparting knowledge to diabetic patients is a complicatedprocess. Individuals affected by diabetes must learn self-management skills and make life stylechanges to effectively manage diabetes and avoid or delay the complications associated with thisdisorder. For these reasons, self-management education is corner stone of treatment for all peoplewith diabetes. Diabetes education has had had somewhat impressive results in reducing the frequencyof certain chronic diabetic complications in high-risks groups, notably foot ulceration and amputation.To deal with the great challenge of the global increase in diabetes prevalence, a diabetes educationteam has to intervene. A diabetes educator can provide support by encouraging patients to talk abouttheir concerns or fears about diabetes. When the patient is diagnosed for the first time, the diabeteseducator can actively teach the self-management skills and help them to live their life with diabetes.
  • 9. 4. Research Methodology:It will be Analytical cross sectional study conducted among the diabetes clients getting treatment indiabetes clinic and admitted clients in medical units of BP Koirala Institute of Health Sciences duringthe period of 2008 and 2009. Using purposive sampling technique about 300 clients’ clinicallydiagnosed diabetes (Type-I & Type- II) will be included in the study. The clients who give consent toparticipate in the study regularly will be only included. The standard tested tools on psychosocialanalysis of stress and coping inventory, profile of mode status along with socio-demographic andknowledge profile on diabetes used in Nepali tested version to evaluate the facts.4-5 focus group discussion will be also arranged before and after the education intervention toevaluate the programme. The tools will be prepared in Nepali and their validity and reliability will beestablished. Following tools will be used for data collection:1. Self Prepared Identification and demographic profiles2. Beck Depression Inventory-II to evaluate Depression level3. State Anxiety Inventory to assess stress level4. Quality of Life indexProcedure for data collection: On the diabetes clinic day (Once/Week) in medical OPD diabetesclinic and once per week in medical wards (unit - I, II, III) admitted diagnosed diabetes clients afterinformed written consent. The baseline information on psychosocial problems and knowledge profilewill be assessed and then education programme will be provided in small groups, using preparedprotocol and audio visual aids along with the information booklet.The regular follow-up will be made continuously during the study period and progress will be monitoredand evaluated. The collected data will be analyzed using SPSS- 10.5 and STATA software packageand available other appropriate statistical methods.Subjects: The subjects will be the patients with a diagnosis of type 1 or type 2 diabetes gettingtreatment in diabetes clinic or admitted in medical units of BPKIHSThe Inpatient Diabetes Education Program: The hospitals diabetes education program consists oflectures on the causes of diabetes, acute and chronic complications, treatment, diet, exercise,medication, and other aspects of self-management, including foot care. The lectures will be given bythe hospital staff, including physicians, nurses, a dietitian, and a pharmacist. In this comprehensiveprogram, this covers most areas involved in diabetic self-management. After the lectures, patients areinterviewed daily by a charge nurse to check their level of understanding, and the nurse providescomplementary information and training if necessary. The techniques for self-monitoring of bloodglucose and/or insulin injection are taught individually and supervised until each patient masters theseskills.Measures: The psychosocial measures used in the study included the Stress and CopingInventory,26,27 the Toronto Alexithymia Scale,28–30 the NEO Five-Factor Inventory,31,32 and the Profile ofMood States (POMS).33,34 All of the questionnaires had been translated and validated in Nepali.Statistical Analysis: The ultimate purpose of diabetic education is to enhance patients ability tomaintain good glycemic control over a long period of time, thus improving their quality of life. Length oftime as the number of months before relapse, and we estimated the rate of relapse using inferentialstatistics.6. Organization of the Study: (Time Schedule)SN Activities Duration/Time1. Literature review and finalization of the project 3 Months2. Pre-testing and finalization of tool 3 Months3. Data collection and education intervention 2 Years4. Analysis of Data 1 Months5. Report writing and Submission 5 Months ………………………. 3 Year
  • 10. References: 1. The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329:977–986. 2. UK Prospective Diabetes Study (UKPDS) Group: Intensive blood-glucose control with sulphonylureas of insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 1998; 352:837–853. 3. Haupt DW, Newcomer JW: Abnormalities in glucose regulation associated with mental illness and treatment. J Psychosom Res 2002; 53:925–933 4. Lustman PJ, Anderson RJ, Freedland KE, de Groot M, Carney RM, Clouse RE: Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care 2000; 23:934–942 5. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ: The prevalence of comorbid depression in adults with diabetes. Diabetes Care 2001; 24:1069–1078 6. Glasgow RE, Hampson SE, Strycker LA, Ruggiero L: Personal-model beliefs and social- environmental barriers related to diabetes self-management. Diabetes Care 1997; 20:556– 561 7. Wooldridge KL, Wallston KA, Graber AL, Brown AW, Davidson P: The relationship between health beliefs, adherence, and metabolic control of diabetes. Diabetes Educ 1992; 18:495– 500 8. Dunn SM, Beeney LJ, Hoskiins PL, Turtle JR: Knowledge and attitude change as predictors of metabolic improvement in diabetes education. Soc Sci Med 1990; 31:1135–1141 9. Delamater AM, Kurtz SM, Bubb J, White NH, Santiago JV: Stress and coping in relation to metabolic control of adolescents with type 1 diabetes. J Dev Behav Pediatr 1987; 8:136–140 10. Hanson CL, Cigrang JA, Harris MA, Carle DL, Relyea G, Burghen GA: Coping styles in youths with insulin-dependent diabetes mellitus. J Consult Clin Psychology 1989; 57:644–651 11. Peyrot M, McMurry JF, Kruger DF: A biopsychosocial model of glycemic control in diabetes: stress, coping and regimen adherence. J Health Soc Behav 1999; 40:141–158 12. Ruggiero L, Sppirito A, Bond A, Coustan D, McGarvey S: Impact of social support and stress on compliance in women with gestational diabetes. Diabetes Care 1990; 13:441–443 13. Garay-Sevilla ME, Nava LE, Malacara M, Huerta R, Dáaz de Léon J, Mena A, Fajardo ME: Adherence to treatment and social support in patients with non-insulin dependent diabetes mellitus. J Diab Comp 1995; 9:81–86. 14. Fukunishi I, Horikawa N, Yamazaki T, Shirasaka K, Kanno K, Akimoto M: Perception and utilization of social support in diabetic control. Diabet Res Clin Pract 1998; 41:207–211. 15. Anderson B, Finkelstein D, Laffel L: Parental involvement in diabetes management tasks: relationships to blood glucose monitoring adherence and metabolic control in young adolescents with insulin-dependent diabetes mellitus. J Pediatr 1997; 130:257–265. 16. Glasgow RE, Toobert DJ: Social environment and regimen adherence among type II diabetic patients. Diabetes Care 1988; 11:377–385. 17. Hanson CL, De Guire MJ, Schinkel AM, Kolterman OG: Empirical validation for a family- centered model of care. Diabetes Care 1995; 18:1347–1356. 18. Brown SA: Studies of educational interventions and outcomes in diabetic adults: a meta- analysis revisited. Patient Educ Couns 1990; 16:189–215. 19. Estey AL, Tan MH, Mann K: Follow-up intervention: its effect on compliance behavior to a diabetes regimen. Diabetes Educ 1990; 16:291–295. 20. Rubin RR, Peyrot M, Saudek CD: Effect of diabetes education on self-care, metabolic control, and emotional well-being. Diabetes Care 1989; 12:673–679. 21. Bott U, Jörgens V, Grüsser M, Bender R, Mühlhauser I, Berger M: Predictors of glycaemic control in type 1 diabetic patients after participation in an intensified treatment and teaching programme. Diabetic Med 1994; 11:362–371. 22. OConnor PJ, Crabtree BF, Abourizk NN: Longitudinal study of a diabetes education and care intervention: predictors of improved glycemic control. J Am Board Fam Pract 1992; 5:381– 387. 23. Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM: Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 2002; 25:1159–1171. 24. Glasgow RE, Eakin EG: Medical office-based interventions, in Psychology in Diabetes Care. Edited by Snoek FJ, Skinner TC. New York, John Wiley & Sons, 2000, pp 141–168
  • 11. 25. Glasgow RE: Using interactive technology in diabetes self-management, in Practical Psychology for Diabetes Clinicians, 2nd edition. Edited by Anderson BJ, Rubin RR. Alexandria, Va, American Diabetes Association, 2001, pp 51–6226. Rahe RH: Stress and coping in psychiatry, in Comprehensive Textbook of Psychiatry, vol. 6. Edited by Kaplan HI, Sadock BJ. Baltimore, William and Wilkins, 1995, pp 1545–155927. Fukunishi I, Nakagawa T, Nakamura H, Sone Y, Kaji T, Hosaka T, Rahe RH: Validity and reliability of the Japanese version of the Stress and Coping Inventory. Psychiatry Clin Neurosci 1995; 49:195–199.28. Bagby RM, Taylor GJ, Parker JDA: The twenty-item Toronto Alexithymia Scale-I: item selection and cross-validation of the factor structure. J Psychosom Res 1994; 38:23–32.29. Bagby RM, Taylor GJ, Parker JDA: The twenty-item Toronto Alexithymia Scale-II: convergent, discriminant, and concurrent validity. J Psychosom Res 1994; 38:33–40.30. Fukunishi I, Nakagawa T, Nakamura H, Kikuchi M, Takubo M: Is alexithymia a culture-bound construct? Validity and reliability of the Japanese versions of the 20-item Toronto Alexithymia Scale and modified Beth Israel Hospital Psychosomatic Questionnaire. Psychol Rep 1997; 80:787–799.31. Costa PT Jr, McCrea RR: Revised NEO Personality Inventory and NEO Five-Factor Inventory Professional Manual. Odessa, Fla, Psychological Assessment Resources, 199132. Shimonaka Y, Nakazato K, Gondo Y, Takayama M: Manual for the Japanese version of the NEO P-I-R and the NEO-FFI [Japanese]. Tokyo, Tokyo Shinri, 199933. McNair D, Lorr M, Dropplemann L: Manual for the Profile of Mood States. San Diego, Educational and Industrial Testing Service, 197134. Yokoyama K, Araki S, Kawakami N: Reliability and validity of the Japanese version of the Profile of Mood States [Japanese]. Japanese J Public Health 1992; 37:913–91735. Smelter SC, Bare BG. Text book of Medical – Surgical Nursing Lippincott. 8th edition 1996.36. Roman PG, maitra S. A comparative study of oral glucose tolerance test and glycated hemoglobin in high-risk patients for diabetes mellitus. INT.J. DIAB.DEV. Countries 2000; (1) 23-28.37. Mehta RS, Karki P, Sharma SK. Socio-demographic and knowledge profile among the diabetes clients admitted in medical units of BPKIHS. 2004.38. WWW.ncbi.nlm.nih.90v39. Karki P, Barel N, Lamsel M, Rijals, Koner BC, Dhungel S, and Koirala S. prevalence of NIDDM in urban areas of Eastern Nepal: A hospital based study. South East Asia J Trop. MED. Public health .2000; 31 (1): 163-166.40. Bruni B, Barbero PL, carlimim etal. Principles, means and evaluation of a programme for diabetes education Ann. Osp. Maria. Vifforia torino. 1981 JAN-JUN; 24 (1-6); 43-74.41. Nova Nordisk Education Foundation Consensus guidelines – Minimum basic care for persons with DM. INT.J.DIAB. DEV. Countries 2000; 20 (1): 1-7.42. Kapur A, Jorgensen LN. Diabcare Asia study- comparative status of current Diabetes cares in Asia. Nova Nordisk diabetes update. 2001; 3-13.43. Smith DM, Norton JA, weinberger M, Mc Donald C2, Kat2 BP. Increasing prescribed office visits: A controlled trial in patients with diabetes mellitus. Med. Care. 1986, mar; 24 (3): 189- 99.44. Funnel MM, Donnelly MB, anclerson RM, Johnson PD, Oh MS. Perceived effectiveness, cost, and availability of patient education methods and materials. Diabetes education 1992 MAR- APR; 18 (2): 139-45.45. Svoren BM, Butter D, Levine BS etal. Reducing a cute adverse outcomes in youths with type-I diabetes: a randomized controlled trial. Evi. Based Nurs. 2004. APR. 7 (2): 42.46. Pietfe JD, weinberger M, creamer FB etal. Impact of automated calls with nurse follow-up on diabetes treatment outcomes in a department of veterans affairs health care system: a randomized controlled trial. Diabetes care. 2001 feb; 24 (2): 202-8.47. Berg AO. Screening for type-2 diabetes mellitus in adults: recommendations and rationale. American Journal of Nursing (AJN). Mar 2004, 104 (3): 83-89.48. American association of clinical endocrinologist and the American college of endocrinology. The AACE system of intensive diabetes self-management 2000.49. Campbell IW. Management of type-2 diabetes mellitus with special reference to met formin therapy. Diabetes and metabolism (paris); 1991, 17: 191-196.50. Christian medical association of India, New Delhi, health dialogues. Issue no. 37, April-June 2004.
  • 12. 51. Vink AI. park TS, stansberry KB etal. Diabetic neuropathies. USA 2000.52. Soundarya M, Asha A, mohanV. Role of a Diabetes educator in the management of diabetes. J. DIAB. DEV. countries. 2004, 4: 65-74.53. Agrwal RP, Sharma S, shammo S etal. Pattern of obesity and abdominal adiposity in type-2 diabetic subjects of northwest India. INT. J. DIAB. DEN. Countries. 2004; 24: 79-82.54. Campbell IW. Management of type-2 diabetes mellitus with special reference to metformin therapy. Diabetes and metabolism (Paris); 1991, 17; 191-196.55. Funnel MM, Donnelly MB, Anclerson RM, Johnson PD, OH Ms. Perceived effectiveness, cost, and availability of patient education methods and materials. Diabetes Educ. 1992; Mar-Apr; 18(2): 139-45.56. Bruni B, Barbero PL, Carlini M et al. Principles, means and evaluation of a programme for diabetes education. Ann. Osp. Maria. Vittoria Torino. 1981; Jan-Jun,24(1-6): 43-74.57. Svoren BM, Butter D, Levine BS etal. Reducing acute adverse outcomes in youthys with Type-I diabetes: a randomized controlled trial. Evi. Based Nurs 2004, 7(2):42.58. Berg AO. Screening for type -2 diabetes mellitus in adults: Recommendations and Rationale. American Journal of Nursing ( AJN). Mar.;104(3): 83-89.59. Soundarya M, Asha A, Mohan V. roles of a Diabetes educator in the management of Diabetes. Ibt. J. DIAB. DEV. Countries. 2004, m4: 65-74.60. Susan L, Michael m, Venkat KM. Effectiveness of self-management training in type-2 Diabetes. Diabetes care. 2001;24(3):362-7.
  • 13. Tools of the study INTERVIEW SCHEDULE: A. IDENTIFICATION DATA. UNIT/WARD/OPD: IP NO/ OPD NO: CODE NO: 1. Name of patients: - 2. Age/Sex: - 3. Religion: 4. Ethnic group: 5. Occupation: 3. Education level; 4. Permanent address: District: VDC/NP: Ward No: Phone no: 5. Marital status: M/UM/W/D/S 6. Diet: veg/non-veg/ egg veg. 7. Frequency of admission: 8. Duration of disease: 9. Unit diagnosis: 10. Types of DM: IDDM / NIDDM B. RISK FACTOR 11. Weight (kg): 12. Height (cm) 13. BP: 14. Yearly saving: a. Deficit budget/loan b. No saving / balance c. < 5000Rs. d. 5000-25000 Rs. e. >250000RS 18. Economic status of patients? A. Poor b. medium c. high 19. Family history (sister/brother) of diabetes? A. Yes b. no 20. Parents with diabetes? A. Yes b. no 21. Female: (birth of large baby > 3.5 kg.) a. Yes b. no c. not sure22. Oral contraceptives? (Female) a. yes b. no23. Do you have following habits? Habits At Present In Pasta. Tobaccos chewing a. yes b. no a. yes b. nob. Betel chewing a. yes b. no a. yes b. noc. Guttka chewing a. yes b. no a. yes b. nod. Smoking (bidi/ cigarette/ hukka etc.) a. Yes b. no a. yes b. noe. Alcohol consumption a. yes b. no a. yes b. no24. Life style: a. Heavy physical worker (farmer/labour} a. Office worker c. Sedentary life style d. Others.25. Obesity: a. yes b. no26. History of stress (surgery/ trauma /others etc.) a. Yes b. noC ARE YOU ON FOLLOWING TREATMENTS/THERAPIES FOR DIABETES?TREATMENT/THERAPIES AT PRESENT IN PAST27. Oral hypoglycemic agent (OHA): a. yes b. No a. Yes b. No28. Insulin a. yes b. No a. Yes b. No
  • 14. 29. Diabetic Diet. a. Yes b. No a. Yes b. No30. Weight loss therapy. a. Yes b. No a. Yes b. No31. Quit smoking a. yes b. No a. Yes b. No32. Herbal/traditional remedy a. yes b. No a. Yes b. No33. Living situation Own living With relative Group home Missing34. Relationship between the caregivers and the clients Spouse Parent Child Sibling35. Frequency of occupation outside home One to 5 days every week Irregularly36. Burden Assessment Scale (BAS)Worried about what future holds for him/herDisturbed household routineUpset about patient change from former selfDifficulty concentrating on own activitiesCut down on leisure timeWorried that might make illness worseGuilty because not doing enough to helpLess time with friendsFamily friction and argumentsHad to change your personal plansNeglected other family members needsHad financial problemsStigma of illness upsettingFelt trapped by care giving roleEmbarrassed due to behaviourGuilty: felt responsible for causing problemResentful because too many demandsMissed days at work or schoolFriction with neighboursBAS Total
  • 15. 37. Item: Would you tell me to Factor I Factor II Factor III Communalitywhat extent you have had any (activity (feelings of (socialof the following experiences in limitation) worry and strain)the past 6 months guilt)Financial problemsMissed work/schoolDifficulty concentratingChange personal plansReduced leisure timeUpset household routineLess time for friendsNeglected familys needs Evaluation of the Education Programme on Diabetes: (Post test Only)38. Have you studied this type of information booklet earliar? A. Yes b. No39. Is this information booklet understandable? a. Easily understandable b. Understandable with little difficulty c. Not understandable40. Is the contents covered are appropriate? a. Very appropriate b. Appropriate c. All right d. Not appropriate41. Is this booklet useful / helpful to you? a. Very helpful b. All right c. Not useful42. How you evaluate this booklet? (a) Very good (b) Good (c) All right (d) Poor43. Do you recommend other people to read this booklet? A. Yes B. No C. Don’t know THANKS FOR SUPPORT AND CO-OPERATION
  • 16. Appendix - I Summary of Patient and Physician Responsibilities in Intensive Diabetes Self-Management SystemPatient Responsibilities:• Monitoring of blood glucose• Exercise program• Adherence to dietary guidelines• Blood pressure monitoring• Smoking cessation• Consistent use of aspirin• Overcoming psychologic and other barriers• Healthy expression of feelings• Foot and eye care• Understanding “targets” for control of blood glucose and blood pressure• Communication with physician and diabetes care team• Keeping appointments• Record keeping• Adherence to medication regimen• Evaluation of physician and diabetes care team• Treating and modifying “targets” in collaboration with physician• Knowledge of personal glycosylated hemoglobin value and its meaningPhysician Responsibilities:• Adherence to the system of intensive self-management of diabetes• Measurement of outcomes• Determination of patient satisfaction• Maintenance of communication with team• Development of evaluation programs; include safety in taking medication and identification of patient misconceptions• Listening to patient concerns• Establishing and maintaining follow-up schedule• Documentation of patient care• Supervision of the patient’s diabetes education• Encouragement of patient in use of preventive measures and risk reduction• Supervision of proper foot care procedures
  • 17. Appendix: - II Topics to be addressed during the overall course of treatment of the patient with diabetes1. Path physiologic features of diabetes.2. Rationale for the intensive treatment of diabetes mellitus a. Potential complications associated with diabetes. b. Relationship between control and complications.3. Self-monitoring of blood glucose. a. Use of blood glucose self-monitor. b. Schedule for use (minimum of twice daily) c. Instructions for record keeping.4. Medication. a. Description b. Dosing instructions c. Dosage adjustment algorithms. d. Suggestions for record keeping. 5. Nutrition a. Importance b. Prescribed meal plan c. Dealing with nutrition-related fluctuations in blood glucose levels. d. Suggestions for record keeping.6. Exercise. a. Importance b. Prescribed exercise plan c. Dealing with activity-related fluctuations in blood glucose levels. d. Suggestions for record keeping.7. Recognizing and managing potentially dangerous complications. a. Hypoglycemia. b. Diabetic ketoacidosis. c. Hypoglycemia unawareness. d. Infection e. Vascular disease.8. Instructions for special situations. a. Sick day rules. b. Travel instructions. c. Use of glucagons. 9. Preventive care. a. Foot care. b. Skin care. 10. Psychological aspects. a. Effect on relationships+ and family dynamics. b. Effect on self-image. c. Importance of support. d. Denial.11. Instructions for family members.