Abstract
Background
Diabetes type 2 is a chronic hyperglycemia, its control depends on the patient’s Self-efficacy and self-care activities. Therapeutic Patient Education (TPE) enhances the patient involvement and engagement in managing chronic diseases effectively by improving the health outcomes. It helps the patients developing competencies of self-care, coping with diabetes and controlling glycaemia.
Objective
The objectives of this study are to assess the effects of TPE in type 2 Diabetic patients in Lebanon on their glycemic control, Diabetes Management Self-Efficacy Scale (DMSES) and their self-care activities (Summary of Diabetes Self-Care Activities SDSCA).
Materials and methods
A total of 100 diabetic patients (50 experimental, 50 control) were recruited from a primary care center according to inclusion and exclusion criteria. The experimental group followed the TPE by a multidisciplinary team. Glycemic control, DMSES and SDSCA were measured at baseline and after three months. The experimental group (EG) was followed up by phone calls every two weeks after the TPE.
Results
The results revealed that the experimental group showed significant improvement at the level of self-efficacy in managing their disease concerning general nutrition, specific nutrition, control of glycaemia, physical activity, weight control and medical control (α<0.01); the total score of DMSES had significantly increased from 5.02 to 8.28 in the EG (α<0.01) compared to the control group (CG) that has decreased from 4.91 to 4.85 (α<0.05). Moreover, regarding the SDSCA of the EG, the results highlighted that the activities related to general diet, specific diet, physical exercise, foot care, the measurement of glycaemia and the medication-taking had significantly improved (α<0.05), whereas the CG didn’t improve his self-care activities (α>0.05). In addition, the glycemic control HbA1c had improved in the EG after the intervention compared to the CG.
Conclusion
The findings of this study demonstrated that Therapeutic Patient Education is efficient in contributing to better glycemic control, better DMSES and SDSCA. Health professionals are best suited to help diabetic patients improve their self-efficacy in managing diabetes, controlling glycemia and improving their self-care.
Keywords: Diabetes type 2, Diabetes self-efficacy, Self-care, Glycemic control, HbA1c, Lebanon
Background
Diabetes mellitus or type 2 Diabetes (T2D) is a chronic condition of hyperglycemia. T2D is a growing epidemic especially in the Middle East with an estimated prevalence of 15 to 20%. In Lebanon, a study conducted by Majeed et al. had estimated the prevalence at 14.99% for a population aged 20 to 79 years old [1]. This disease may contribute to many complications that can reduce the quality of life.
Researches had shown evidence that self-efficacy plays a major role in diabetes control and self-care activities [2]. The theory of self-efficacy (SE) first initiated by Albert Bandura, is defined as the belief of individuals in their abilities to carry out a successful practice. This theory emphasizes the fact that people will take action when they believe they are able to perform it and they will refrain from any action when they believe they will fail. Self-efficacy is helpful to determine and to predict the individual’s behavior changes. Therefore, SE has an important role in diabetes self-management and its control [3]. The results of the study conducted by O’hea et al. showed that eating behaviors of diabetic patients are associated with their self-efficacy [4]. The literature review had also shown that diabetes self-efficacy had an effect on glycemic control [3, 5]. The dimensions of diabetes self-care (i.e. healthy diet, appropriate physical activity, glucose control, foot care and appropriate medication use) are associated with the psychosocial factors specially self-efficacy [6].
In the Lebanese context, some studies showed that 73.3% of type 2 diabetic patients are treated by oral hypoglycemiants, however the endocrinologists noticed that a large number of patients had a bad glycemic control with a high level of HbA1c [7]. In a recent study conducted in Lebanon, the results revealed that the compliance rate was very low (32.4%) and most of diabetic patients had a low level of self-efficacy [8]. Moreover, the self-care activities didn’t meet 29.6% for the majority of the recommendations [9]. Therapeutic patient education through better provider-patient communication and having higher self-efficacy was related to performing diabetes self-care behaviors that were associated with glycemic control [10]. To date, despite the fact that the primary care centers offer Universal Health Coverage to patients with chronic diseases such as diabetes, they are not implementing the therapeutic patient education (TPE). Assessing the effects of this educational intervention on self-efficacy, self-care and glycemic control are very important to investigate.
Objectives
This study aimed to determine the effects of therapeutic patient education on glycemic control, the self-efficacy and the self-care activities among Lebanese patients diabetic type 2, consulting in the diabetes clinic in a primary care center in Lebanon.
Methods
This study followed an experimental design type before and after randomization by diabetic patients. A list of patients attending the primary care center was collected. The study population consisted of all patients with a positive type II diabetes mellitus diagnosis, visiting the primary healthcare center (PHC) diabetes clinic with active health records in Lebanon. The patients were selected according to the following criteria: the status of having an active clinical record at the diabetes clinic, the ability to communicate verbally, the fact of non-hospitalization during the last three months, at least 1 year from the diagnosis, the absence of history of mental retardation or other psychological disorders such as mood and anxiety disorders before the diagnosis of diabetes or severe psychological disorder after the diagnosis of diabetes and the absence of anemia.
Patients fulfilling the selection criteria were recruited. Then, they were contacted to request their consent to participate in the study. Those who accepted to follow the educational intervention, were considered as the experimental group. The control group was composed of patients who were after the experimental patient and fulfilling the selection criteria. In total, 100 diabetic patients (50 experimental, 50 control) were recruited from the PHC.
The educational intervention or the experiment was the therapeutic patient education (TPE) that was offered to the experimental group. The multidisciplinary team who delivered the intervention included a medical doctor, a nurse, a psychologist and a dietitian. The number of patients was 15 to 20 per workshop. The intervention session lasted for a period of 6 h. The topics were the travel of sugar, diabetes definition, types, causes, consequences and treatment; in addition to self-management in terms of medication compliance, glycaemia self-monitoring, dietetics, physical activity, foot care and stress management. The pedagogical methods were video, concept map, posters, demonstrations, role play and lectures. During the session, healthy snacks were distributed, a pedometer and an education kit were offered. Every two weeks, a phone call was done to the experimental group in order to check on their practices and verify if they have any question.
This study aimed to identify the causal relationship between the intervention and the improvement of the therapeutic compliance, the self-efficacy and the self-care. This research was practiced at open trial because the procedure of blindness was impossible based on the nature of the intervention.
Data collection was conducted from August 2015 to February 2016 in a PHC in Beirut city, Lebanon by research assistants. The questionnaire used contained the following data: socioeconomic, behavioral and clinical information, Diabetes Management Self-Efficacy Scale (DMSES) to measure the self-efficacy in diabetes type 2 self-management and the Summary of Diabetes Self-Care Activities (SDSCA) to measure the self-care behaviors. In this context, recruited patients were informed about the study objectives, and their written and oral consents to participate in this research were obtained. The questionnaires were completed in the presence of the research assistants. Clinical data including the BMI (Height and weight), the waist circumference, the diastolic and systolic blood pressure, the fasting blood sugar and HbA1c were measured before and after the intervention. Socioeconomic, behavioral and clinical data included subjects’ age, gender, marital status, level of education, presence of a paid job, work schedule, health insurance, family support, hobbies, perception of the socio-economic level and presence of a personal project. Data related to health behaviors included the actual smoking status, the practice of physical activity, and the Body Mass Index (BMI). The experimental group followed the TPE by a multidisciplinary team. Clinical data, DMSES and SDSCA were measured at baseline and after three months. The EG was followed up by phone calls every two weeks after the TPE.
Diabetes Management Self-Efficacy Scale (DMSES) is an instrument developed in 1999 by Van Der Bijl and Shortridge-Bagget in order to measure the self-efficacy in the self-management of diabetes type 2. The translation of the questionnaire was done and validated according to inverted translation of Haccoun (1987) in which the instrument is translated from English into Arabic then from Arabic into English by two different people [11, 12]. A pretest was performed, the questions were clear and understandable. This instrument was also validated by Sturt et al. [13].
This instrument consists of 20 items that are divided into 5 dimensions. The answers range from 0 to 10, zero signifies « surely no» or completely unable, and 10 « surely yes» or completely able; the participants determine their capabilities by drawing a circle on each question. These items are measured on an 11 Likert scale, the total score of self-efficacy is calculated in summing up the averages of all the answers of all dimensions varying from zero to 200 points, where the highest scores indicate a better self-efficacy. Based on a multifactorial analysis, five factors were identified: (1) general diet (2) specific diet (3) Blood glucose control (4) physical activity and weight control and (5) medical control. The Cronbach’s alfa coefficient varied from 0.70 to 0.95 for the different factors and was 0.93 for the DMSES, this verifies the reliability and the homogeneity of the instrument in the measure of self-efficacy (Table 1).
Table 1.
Cronbach’s alfa of DMSES total score and different factors
| Description | Number of items | Cronbach’s alfa |
|---|---|---|
| Factor 1: General diet | 5 | 0.88 |
| Factor 2: Specific diet | 5 | 0.95 |
| Factor 3: Blood glucose control | 4 | 0.86 |
| Factor 4: Physical Activity and weight control | 3 | 0.89 |
| Factor 5: Medical control | 3 | 0.70 |
| Total Score DMSES | 20 | 0.93 |
The second instrument, Summary of Diabetes Self-Care Activities (SDSCA) was developed in 2000 by Toobert et al.. It measures the following self-care activities: the general diet (2 items), the specific diet (2 items), the exercise (2 items), the medications (2 items), the foot care (2 items) and the blood sugar testing (2 items). The 12 items were evaluated with a scale ranging from de 0 to 7 which is equivalent to number of days per week during which the desired behavior was practiced by the participant during the week preceding the interview [14]. This questionnaire was validated in many languages especially the Arabic language [15, 16]. The Cronbach’s alfa was 0.62 for SDSCA total score and 0.98 for the general diet, 0.89 for the exercise, 0.99 for the medications, 0.77 for the foot care and 0.91 for the blood sugar testing (Table 2).
Table 2.
Cronbach’s alfa of SDSCA total score and self-care activities
| Self-care Activities | Number of items | Cronbach’s alfa |
|---|---|---|
| Factor 1: General diet | 2 | 0.98 |
| Factor 2: Specific diet | 2 | 0.14 |
| Factor 3: Exercise | 2 | 0.89 |
| Factor 4: Medications | 2 | 0.99 |
| Factor 5: Foot care | 2 | 0.77 |
| Factor 6: Blood Sugar testing | 2 | 0.91 |
| Total Score | 12 | 0.62 |
Statistical analysis
The data was analyzed for the patients who filled the inclusion criteria and who participated in the study from the beginning till the end using Statistical Package for Social Sciences (SPSS v.22). The descriptive statistical analysis included the description of the socioeconomic characteristics of the study population, and other behavioral and clinical data by using the frequency, percentage of the qualitative data and the mean and the standard deviation for quantitative variables. The inferential analyses were used to test the hypotheses with a statistical significance at α ≤ 0.05 and highly significant at α ≤ 0.01. The measurements of the socioeconomic, behavioral and clinical variables, the DMSES and the SDSCA for the experimental and control groups were done before the experiment to assess the comparability of the two groups with Chi-square and independent samples t-test. Then, they were measured after the experiment to test the evolution of the two groups with paired t-test, thus to test the efficiency of the therapeutic patient education in improving the self-efficacy, the self-care and the glycemic control.
Results
The socioeconomic data about the study population are presented in Table 3. The number of men participating in the study is equal to number of women but women participating in the experiment is higher than men. The mean age of the study population is 55.48 years among the experimental group (EG) varying from 34 to 64 years and 55.3 years in the Control group (CG) ranging from 36 to 64 years with α > 0.05. The majority of the participants (80%) are married and equally distributed between the EG and the CG. The level of education of the CG as well as the status of a paid job and the acquisition of a health insurance is higher than the EG. Almost two thirds of the experimental population have family support compared to 54% of the control group. The EG have more hobbies than the CG, but the CG perceive their socio-economic level better than the EG and they have more personal projects than the EG. The EG and the CG are comparable in terms of all the socioeconomic factors listed above with α > 0.05.
Table 3.
Socioeconomic profile of the study population
| Experimental Group | Control Group | Total | α | |
|---|---|---|---|---|
| n (%) | n (%) | n (%) | ||
|
Gender Men Women |
22 (44.0) 28 (56.0) |
28 (56.0) 22 (44.0) |
50 (50.0) 50 (50.0) |
NS* |
|
Marital Status Married Single or ever married |
41 (51.2) 9 (45.0) |
39 (48.8) 11 (55.0) |
80 (80.0) 20 (20.0) |
NS |
|
Level of education Knows to read and write Primary Intermediate Secondary University |
11 (55.0) 17 (56.7) 12 (48.0) 8 (50.0) 2 (22.2) |
9 (45.0) 13 (43.3) 13 (52.0) 8 (50.0) 7 (77.8) |
20 (20.0) 30 (30.0) 25 (25. 0) 16 (16.0) 9 (9.0) |
NS |
|
Paid Job Yes No |
14 (31.8) 36 (64.3) |
30 (68.2) 20 (35.7) |
44 (44.0) 56 (56.0) |
NS |
|
Work schedule (N = 44) Full time Part time |
12 (35.3) 2 (20.0) |
22 (64.7) 8 (80.0) |
34 (77.27) 10 (22.73) |
NS |
|
Health insurance Yes No |
15 (40.5) 35 (55.6) |
22 (59.5) 28 (44.4) |
37 (37.0) 63 (63.0) |
NS |
|
Family Support Yes No |
33 (55.0) 17 (42.5) |
27 (45.0) 23 (57.5) |
60 (60.0) 40 (40.0) |
NS |
|
Hobbies Yes No |
29 (52.7) 21 (46.7) |
26 (47.3) 24 (53.3) |
55 (55.0) 45 (45.0) |
NS |
|
Perceived socio-economic level Low Moderate High |
26 (56.5) 24 (47.1) 0 (0.0) |
20 (43.5) 27 (52.9) 3 (100.0) |
46(46.0) 51(51.0) 3(3.0) |
NS |
|
Presence of personal project Yes No |
17 (47.2) 33 (51.6) |
19 (52.8) 31 (48.4) |
36 (36.0) 64 (64.0) |
NS |
| m ± σ | m ± σ | m ± σ | α | |
| Age (in years) |
54.58 ± 6.58 Min 34 Max 64 |
54.30 ± 6.69 Min 36 Max 64 |
54.4 ± 7.07 Min 34 Max 64 |
NS |
*NS Not significant α > 0.05
Regarding the health behaviors of the participants, data was collected before the intervention. One third of the participants actually smoke, distributed into the EG (45.7%) and the CG (54.3%). Almost one third also practice physical activity and 47% are obese. No significant difference between the two groups (α > 0.05) (Table 4).
Table 4.
Data related to health behaviors and health status of the study population
| Description | Experimental Group | Control Group | Total | α |
|---|---|---|---|---|
| n (%) | n (%) | n | ||
|
Actual smoking status Yes No |
16 (45.7) 34 (52.3) |
19 (54.3) 31 (47.7) |
35 65 |
NS* |
|
Practice of physical activity Yes No |
16 (44.4) 34 (53.1) |
20 (55.6) 30 (46.9) |
36 64 |
NS |
|
BMI (Kg/m2) Normal Overweight Obesity |
7 (38.9) 16 (45.7) 27 (57.4) |
11 (61.1) 19 (54.3) 20 (42.6) |
18 35 47 |
NS |
*NS Not significant α > 0.05
Furthermore, data about clinical profile of the participants was collected before and after the intervention (Table 5). Concerning the Experimental Group, the mean BMI, the mean waist circumference, the mean systolic and diastolic blood pressure, the mean fasting blood glucose and the mean HbA1c were 30.5, 86.9, 132.0, 81.0, 181.1 and 8.4 respectively. After the TPE, the means BMI, the waist circumference, the systolic blood pressure, the diastolic blood pressure, the fasting blood glucose and the HbA1c dropped significantly to 30.1, 84.3, 125.6, 76.2, 140.3 and 6.8 respectively (α < 0.05). On the other hand, the Control group who didn’t follow the educational intervention; their mean BMI, their mean waist circumference, their mean systolic and diastolic blood pressure didn’t change significantly before and after the intervention (α > 0.05), unlike the fasting blood glucose and the HbA1c that changed significantly from 168.0 to 158.6 and from 7.7 to 7.5 respectively (α < 0.05). The first effect of TPE on glycemic control was tested by demonstrating that HbA1c improved very significantly in the experimental group after the TPE.
Table 5.
Clinical data before and after among the Experimental Group/ Control Group
| Description | Experimental Group (EG) | α* | Control Group (CG) | α* | EG-CG | EG-CG | ||
|---|---|---|---|---|---|---|---|---|
| Before | After | Before | After | Before | After | |||
| m ± σ | m ± σ | m ± σ | m ± σ | α* | α* | |||
| BMI | 30.5 ± 4.9 | 30.1 ± 4.6 | HS | 30.6 ± 6.8 | 30.6 ± 6.7 | NS | NS | NS |
| Waist circumference (cm) | 86.9 ± 17.4 | 84.3 ± 14.9 | HS | 86.3 ± 14.9 | 86.9 ± 20.4 | NS | NS | NS |
| Systolic Blood pressure (mm Hg) | 132.0 ± 15.4 | 125.6 ± 11.3 | HS | 129.0 ± 13.6 | 129.0 ± 11.3 | NS | NS | NS |
| Diastolic Blood pressure (mm Hg) | 81.0 ± 9.9 | 76.2 ± 6.7 | HS | 82.2 ± 8.4 | 81.2 ± 6.6 | NS | NS | HS |
| Fasting Blood Glucose (mg/dl) | 181.1 ± 60.8 | 140.3 ± 29.5 | HS | 168.0 ± 61.8 | 158.6 ± 52.5 | HS | NS | S |
| HbA1c | 8.40 ± 1.52 | 6.8 ± 0.7 | HS | 7.7 ± 1.8 | 7.5 ± 1.5 | S | S | HS |
*NS Not significant α > 0.05; S Significant α < 0.05; HS Highly significant α < 0.01
Second, in order to test the effect of TPE on T2D patients’ self-efficacy, a comparison between the EG and the CG before the therapeutic patient education was performed and revealed that the two groups have the same characteristics regarding the five factors, no significant difference between the two groups (Table 6). Then, DMSES was measured after three months. The mean factor 1 “general diet” is 5.16 and 4.99 among the EG and the CG respectively before the intervention (α > 0.05) and 8.01 and 4.93 among the EG and the CG respectively after the intervention (α < 0.01), this shows that there is a positive change after the intervention regarding the general diet among the EG, whereas the mean factor 2 “specific diet” is 4.0 and 3.99 among the EG and the CG respectively before the intervention with α > 0.05, and 8.43 and 3.96 after the intervention among the EG and the CG respectively with α < 0.01 revealing a significant improvement among the Experimental group after the intervention. Moreover, the mean factor 3 « glycemic control » is respectively 4.69 and 7.25 among the EG before and after the intervention with α < 0.01 and 4.51 and 4.47 among the CG before and after the intervention with α > 0.05; this result demonstrates that the Therapeutic patient education leads to significant positive change in self-efficacy regarding glycemic control among the EG. Whereas, the mean factor 4 “physical activity” and factor 5 « weight control” were 4.33 and 7.07 respectively among the experimental group before the intervention and changed significantly to 8.1 and 9.31 respectively after the intervention with α < 0.01; at the other side, the mean factor 4 and 5 were 7.02 and 4.91 among the CG before the intervention and changed to 6.97 and 4.85 after the intervention with α > 0.05. The mean average total score of the DMSES was 5.02 and 4.91 among the EG and the CG before the intervention respectively with α > 0.05, and it changed significantly to 8.28 among the EG with α < 0.01 and declined significantly to 4.85 among the CG with α < 0.05 after the therapeutic education. These results showed that the self-efficacy is significantly better among those who follow the therapeutic education.
Table 6.
Comparison of DMSES Experimental Group versus Control Group before and after Therapeutic Education
| DMSES Factors |
Experimental Group (EG) | α* | Control Group(CG) | α* | EG-CG | EG-CG | ||
|---|---|---|---|---|---|---|---|---|
| Before | After | Before | After | Before | After | |||
| m ± σ | m ± σ | m ± σ | m ± σ | α* | α* | |||
| Factor 1 | 5.16 ± 3.12 | 8.01 ± 1.16 | HS | 4.99 ± 2.65 | 4.93 ± 2.57 | S | NS | HS |
| Factor 2 | 4.00 ± 3.55 | 8.43 ± 1.08 | HS | 3.99 ± 2.71 | 3.96 ± 2.53 | NS | NS | HS |
| Factor 3 | 4.69 ± 3.05 | 7.25 ± 1.50 | HS | 4.51 ± 3.42 | 4.47 ± 3.22 | NS | NS | HS |
| Factor 4 | 4.33 ± 3.18 | 8.10 ± 1.18 | HS | 4.15 ± 3.01 | 4.06 ± 2.90 | S | NS | HS |
| Factor 5 | 7.07 ± 2.07 | 9.31 ± 0.45 | HS | 7.02 ± 2.18 | 6.97 ± 2.12 | NS | NS | HS |
| Total Score DMSES | 5.02 ± 2.45 | 8.28 ± 0.79 | HS | 4.91 ± 2.08 | 4.85 ± 1.96 | S | NS | HS |
*NS Not significant α > 0.05; S Significant α < 0.05; HS Highly significant α < 0.01
Third, in order to test the effects of TPE on diabetic patients’ self-care management, SDSCA was measured before and after TPE among the EG and CG. The results presented below show that there is a significant improvement in the self-care behaviors among EG compared to CG (Table 7). Before the experiment, the two groups were comparable in terms of the six factors and the total mean score of self-care behaviors (α > 0.05).
Table 7.
Comparison of Experimental Group versus Control Group according to SDSCA before and after the intervention
| Description | Experimental Group (EG) | α* | Control Group (CG) | α* | EG-CG | EG-CG | ||
|---|---|---|---|---|---|---|---|---|
| Before | After | Before | After | Before | After | |||
| m ± σ | m ± σ | m ± σ | m ± σ | α* | α* | |||
| General Diet | 3.47 ± 2.30 | 4.94 ± 1.3 | HS | 3.33 ± 2.28 | 3.05 ± 1.90 | HS | NS | HS |
| Specific diet | 3.99 ± 1.72 | 5.07 ± 1.12 | HS | 3.81 ± 1.80 | 3.01 ± 1.42 | HS | NS | HS |
| Exercise | 2.08 ± 2.50 | 3.34 ± 1.88 | HS | 1.99 ± 2.24 | 1.79 ± 2.01 | HS | NS | HS |
| Medications | 6.48 ± 1.46 | 6.85 ± 0.43 | S | 6.37 ± 1.50 | 6.20 ± 1.36 | HS | NS | HS |
| Foot Care | 0.75 ± 0.97 | 3.19 ± 0.73 | HS | 0.37 ± 0.59 | 0.33 ± 0.51 | NS | S | HS |
| Blood-Glucose Testing | 0.6 ± 0.67 | 3.99 ± 1.76 | HS | 0.16 ± 0.37 | 0.53 ± 1.07 | HS | HS | HS |
| Total Score SDSCA | 2.89 ± 0.78 | 4.56 ± 0.61 | HS | 2.67 ± 0.89 | 2.48 ± 0.77 | HS | NS | HS |
*NS Not significant α > 0.05 ; S Significant α < 0.05 ; HS Highly significant α < 0.01
After the therapeutic patient education, the mean total score of SDSCA and the mean of each factor showed a highly significant difference between the EG and the CG (α < 0.01). This highlights the importance of introducing a change by the therapeutic education to the Lebanese Experimental Group participating to this study. Concerning the EG, a statistical analysis before and after the intervention consisting of the comparison of the means of SDSCA score and of the six factors was performed. The mean score of SDSCA changed significantly from 2.89 before the intervention to 4.56 after the intervention. The same applies to general diet, specific diet, exercise, medications, foot care, blood glucose testing that changed very significantly from 3.47, 3.99, 2.08, 6.48, 0.75, 0.6 to 4.94, 5.07, 3.34, 6.85, 3.19, 3.99 respectively (α < 0.01). The experimental group of DT2 patients had progressed favorably from the pre-intervention to the post-intervention. However, the group of patients who didn’t follow the therapeutic patient education (CG), the mean SDSCA score changed from 2.67 to 2.48, while the general diet, specific diet, the exercise, the medication, the foot care and the blood glucose testing changed from 3.33, 3.81, 1.99, 6.37, 0.37, 0.16 to 3.05, 3.01, 1.79, 6.20, 0.33 and 0.53 respectively. All changes were not statistically significant except for the foot care that declined significantly and the blood glucose testing that increased very significantly unlike the experimental group that changed more significantly.
Discussion
The results of this study showed an improvement in diabetes self-efficacy, self-care activities and better glycemic control after the therapeutic patient education among the experimental group. On the contrary, the Control group didn’t experience positive changes. This result highlights the fact that patients specially uncontrolled should be followed closely and educated by their physician and the healthcare team in order to motivate them to increase their self-confidence in self-care.
The therapeutic patient education undergone by a multidisciplinary team in the primary healthcare center had permitted an improvement of the self-efficacy feeling among the participants compared to those who didn’t follow any type of education. The results highlighted that the self-efficacy of type 2 diabetic patients can improve through the therapeutic patient education that was conducted and through the phone calls follow-up. In this research, the multidisciplinary team, throughout the educational process, had utilized interactive pedagogical methods. In order to attain the acquisition of competencies, the patients have demonstrated their capacity to execute the tasks in front of others such as the self-monitoring of glucose, the choice of food and the utilization of the patient chart. In the framework of this study, many pedagogical methods were used such as the video, the concept map that helped the EG to succeed in managing their disease in adopting the self-care behaviors [17]. Concerning the verbal persuasion, the research assistants had encouraged and motivated the type 2 Diabetic patients to reinforce their positive behaviors. In the data collection, the patients had expressed their difficulties and their fears to follow the lifestyle modifications of the disease. The results of this study are consistent with other studies that have used the same methods to examine the effects of educational programs [18–21]. Mohebi et al. (2014) had mentioned that the self-efficacy is the basis of every initiative in Diabetes self-management by its effect on motivation. In fact, the more the patients feel capable of undertaking an action, the more they deploy all the efforts to succeed to perform the self-care behaviors necessary to manage appropriately their disease. Therefore, the self-efficacy is an essential component for the success of the patient in the disease self-management [22]. It needs to be integrated in the therapeutic education process by different workshops and follow-up phone calls. The Self-efficacy of T2D patients increased despite the Lebanese culture that considers that the T2D is difficult to manage due to Lebanese representations concerning diabetes and its treatment, and under the influence of myths relative to this disease and the lack of perceptions of potential complications. This particularity related to culture makes the patient feel destabilized, denying and ashamed which constitute a barrier to therapeutic compliance [6]. In fact, one of the EG patients expressed «despite the threatening risks of non-controlled diabetes, I am afraid to accept the disease and take care of myself by fear of failure».
Moreover, the results of this study demonstrate that the EG that have followed the TPE were engaged in a period of three months in self-care activities compared to the CG who followed regular care. These results are consistent with the observations of other authors who consider in their studies that the educational interventions with type 2 diabetic patients and the positive results of the cooperation of patients in the self-care behaviors are closely related to the short duration of the intervention and the voluntary engagement of the patients. This positive effect regresses with time based on the fact of lack of motivation to maintain self-care behaviors [23–26]. Most importantly, the results of the present study demonstrate that the most practiced self-care behaviors are the medications, then the general and specific diet, and afterwards the physical activity. The self-care behaviors the least practiced are foot care and the measurement of blood glucose. The findings of this study are in concordance with other studies that found that predisposing, reinforcing and enabling factors improved the self-care behaviors in DT2 [27, 28].
Conclusions
The results of this study showed that glycemic control, diabetes self-efficacy and self-care activities had improved significantly in the experimental group of diabetic patients type 2 who participated in therapeutic patient education workshops and were followed every two weeks by the research team compared to the control group who followed regular treatment. Diabetes management self-efficacy is a predisposing factor that can be deteriorated in chronic diseases such as Diabetes. Increasing in self-confidence levels of diabetic patients can help for better self-care behaviors and hence better glycemic control. Interventions especially therapeutic patient education are recommended for glycemic control of DT2 patients. The findings of this study confirm previous studies’ conclusions that self-care improves glycemic control [29, 30]. Health professionals are best suited to help diabetic patients improve their self-efficacy in managing diabetes and improve their self-care. The findings of this study revealed that Therapeutic Patient Education is efficient and can contribute to better DMSES and SDSCA and consequently to better diabetes control. Moreover, further studies are recommended to explore the factors that improve glycemic control in type 2 diabetic patients.
Study limitations and strengths
This study had obtained the consent of the director of the primary care center as well as the endocrinologist and the diabetic patients who signed an informed consent witnessing their voluntary approval. This latter contained clear data about the objectives of the research, the duration, the therapeutic intervention and the methodology used. The patients were assured that data collection is anonymous, confidential and their use is reserved for statistical analysis. At the same time, the patients were free to withdraw from the study at any moment. The permission from authors of the instruments was also obtained for the use of the questionnaires.
The reliability of the results is based on the randomized control trial design measuring the effects of the intervention. But likewise every research, there are limitations. The results concern only 100 patients from one primary care center and the study population doesn’t represent the total Lebanese population. The blind method was not possible because of the context of the study, it was performed overtly. The language used was the Arabic language though the level of proficiency was not evaluated. Finally, it is important to precise that the results of this study are limited to adults aged 25 to 64 years and without insulin therapy.
Acknowledgements
The author would like to thank the director and the staff of the primary healthcare center, the endocrinologist and the study participants, Johnson and Johnson, as well as the thesis advisor Pr. Marc Weisser Emeritus Professor at University Haute Alsace, Mulhouse France, and the administration of Faculty of Nursing and Health Sciences, Notre Dame University, Zouk Mosbeh, Lebanon, for their support.
Abbreviations
- BMI
Body Mass Index
- CG
Control Group
- DMSES
Diabetes Management Self-Efficacy Scale
- T2D
Type 2 Diabetes
- EG
Experimental Group
- HS
Highly Significant
- NS
Not Significant
- PHC
Primary Healthcare Center
- S
Significant
- SDSCA
Summary of Diabetes Self-Care Activities
- SE
Self-Efficacy
- SPSS
Statistical Package for Social Sciences
- TPE
Therapeutic Patient Education
Authors’ contributions’
The author is responsible for the design of the study, data collection, data analysis and manuscript writing.
Funding information
This research was funded by the researcher.
Availability of data materials
The data and materials are available with the author. Kindly contact her for data requests.
Compliance with ethical standards
Conflict of interest
The author declare that she has no competing interest.
Consent for publication
Oral and written consent were obtained from the patients.
Footnotes
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data and materials are available with the author. Kindly contact her for data requests.