Effect of Nursing Instructions on Adherence of Diabetic Patients to Treatment

Introduction:

Diabetes is a major cause of morbidity and associated mortality, type 2 DM is the most common type of diabetes and characterized by insulin resistance, which may be combined with relatively reduced insulin secretion, the defective responsiveness of body tissues to insulin is believed to involve the insulin receptor (Alkhatib, & Tuomilehto, 2019).

There is strong evidence that individuals who are educated and diligent with their diabetes self-care achieve better and durable diabetic control (Powers, et al., 2015). Furthermore, previous studies on knowledge, attitude and practice (KAP) on diabetes have supported the needs of greater awareness of prevention, diagnosis, and risk factor control in diabetes (Islam, et al., 2014). Even though, having better knowledge, good attitude and practices on diabetes could be helpful for better management (Herath, et al., 2017).    

Instructional programs that emphasize adherence to treatment regimens as a whole, especially to diet, to exercise and to regular follow up are of greater benefit in glycemic control as compared to compliance of medications alone. A significant role in diabetic patient instruction is played by the nursing staff, nurses provided patients with better information on diabetes than other studied staff. (MakkiAwouda, et al., 2014).

Patient instruction plays a crucial role the treatment and management of diabetes. Without proper instruction, people diagnosed with T2DM may ignore their symptoms, develop life- threatening complications and continue this trend amongst their family and peers. Instruction can help prevent serious complications as well as hospitalization. Instruction needs to be specific to the individual to have a basic understanding of his disease and for him to feel confident in managing his disease in a home setting when a provider is not present (Cardenas, 2019). Nurses have important educating roles and responsibilities to improve knowledge of diabetic patients (Aalaa, et al., 2012).

Significance of the Study:

Egypt is the nation with the ninth biggest population of diabetics in the world. According to IDF, there have been 8.2 million diabetic patients in Egypt in 2017, it is expected that this number will bounce up to 13.1 million by 2035. Among all diabetic cases, 90% are T2DM mellitus (Omar et al., 2018).The prevalence of T2DM is around 15.56% among adults with an annual death of 86,478 associated with diabetes (Hegazi, et al., 2015). In Egypt, the Demographic and Health Survey (DHS) 2015 estimated that around 4 in 10 of the individuals who had diabetes were eating a healthy diet, 13 percent of women and 15 percent of men were trying to lose weight or control their weight, and 2 percent of women and 7 percent of men were exercising. Only 2 percent of individuals who were diabetic (mainly men) said that they had stopped smoking in response to their condition (DHS, 2015). Diabetics need to have adequate knowledge, skills and positive attitudes to successfully manage diabetes every day(Parsons, et al., 2017& Escalada, et al., 2016).

Aim of the Study:

The aim of the present study was to evaluate the effect of nursing Instructions for diabetic patients on their adherence to treatment.

Research Hypothesis:

H1: Diabetic patients' Adherence to Treatment will be better for study group post instructions than control group.

Subjects and Methods:

Research Design: Quasi experimental research design (study and control) was utilized to fulfill the     purpose of the current study.

Study variables:

The independent variable in this study were the nursing instructions while the dependent variables were: patient's Adherence to Treatment

The present study was portrayed under topics as the following: technical design, operational design, administrative design, and statistical design.

I- Technical design:

Setting: This study was carried out at outpatient clinic for diabetic follow-up in Minia university hospital and Minia General Hospital.

Subjects: A purposive sample of 144 adult type II diabetic patients were divided in to two equal groups (study and control) the 1^st admitted patient for study group (n=72) and the 2^nd admitted patient for control group (n=72), all of them included in this study with the following criteria:

-          Inclusion criteria: male and female patient, patients age of (18 - 65) years, and with duration of diabetic disease more than one year.

-          Exclusion criteria: patients without comorbid disease, and without Cerebrovascular Accident (CVA).

Sample size:     

Sample size is calculated by using the Isaac, Bell, & Micheal (1982) formula which is computed as (N= n x 30 / 100(

N = sample size

n = Total number of diabetic patients admitted at Minia University Hospital during the period 2016:2017.

N = 240 x 30 / 100 = 72 patient

Study group 72 patient + control group 72 patient = 144 patient for total study sample.

Study duration: The data collection was continued over a period of ten months, starting from April 2018 to January 2019.

Tools of data collection:

Two tools were designed and used for collecting data:

Tool I: “Structured Interview assessment questionnaire sheet” (I): structured and developed by the researcher after a literature review, through clinical evaluation and examination, this tool includes two main parts:

Part 1: Patient socio-demographic characteristics: it includes items related to demographiccharacteristics of patient such as (age, sex, occupation, marital status, level of education, income, residence).

Part 2: Patient medical data: it includes details of the diabetes disease such as (duration of DM, treatment type, frequency of follow-up, had previous hospitalization for DM, smoker, previous instruction related to diabetic disease management, and source of knowledge about diabetic disease management).

Tool ІІ: Assessment of patient Adherence to Treatment by using of "Assessment Scale for Treatment Adherence in Diabetes Mellitus" which adopted and developed by Demirtaş and Akbayrak, (2017).This scale with 5 item Likert type, the participants reflect the degree of their attitude related to the statement content. The scale consists of these grades in the form of 1= certainly agree, 2 = agree, 3 = partially agree, 4 = disagree and 5 = certainly disagree, score of 5 was accepted as indication of an unfavorable attitude and 1 as a favorable attitude.    

The scale includes 13 items containing positive attitudes and 17 items containing negative expressions:

Items including positive expressions: item No.(1,3,5,8,13,15,16,17,19, 23,25, 26, 29 ).

Items including negative expressions: item No.(2,4,6,7,9,10, 11,12,14, 18,20, 21,22,24,27,28, and 30).

Scoring system:

• Good adherence: was considered if scoring= (13) grade in positive expressions items, and if scoring = (85) grade in negative expressions items.
• Moderate adherence:was considered if scoring = (14:64) grade in positive expressions items, and if scoring = (18-84) grade in negative expressions items.
• No Adherence: was considered if scoring = (65) grade in positive expressions items, and if scoring = (17) grade in negative expressions items.

Instructions about Diabetes "Booklet": The researcher was implementing the instructions about Diabetes "Booklet": that was formulated by researcher after extensive literature review (Phillips et al., 2015, Thom et al.,2013, Evert et al.,2013, Powers et al.,2013, Funnell et al.,2015, Raebel et al.,2014, and American Diabetes Association 2017) and revised by experts. This Booklet contain knowledge about diabetes (definition, sign and symptoms, causes, complication, how to prevent complication, medication, nutrition, exercise, and glycemic control). The researchers used simple language to suit the level of patients, with motivation and reinforcement to enhance learning. A copy of the handout booklet that was written in Arabic language offered for each study participant to use it as future reference. It was developed and supported with photos and illustrations to help patients and families to understanding the content of the booklet

II- Operational Design:

The study will carried out on three phases:

Phase I: Preparatory phase:

1- Thestudy tools were designed after extensive review of literature.

2- The content and validity were done to identify the degree to which the used tools measure what was supported to measured. The developed tools was tested by Jury committee consist of five academic experts in field of thesis (staff of medical and surgical nursing at faculty of nursing in Minia and Assiut university). Each of the experts is an active participant in their particular environment and together they offered a complete assessment of the content and face validity of the instruments. All jury members (100%) agreed that current study tools were valid and relevant with the aim of the study.

3- Pilot study: After having the ethical approval and permission to access the hospital, a pilot study was conducted on 10% of participants whom included in the study to test the clarity of tools and estimate the time required for fulfilling it. Based on result of the pilot study no modification or refinements were done and the participants included to the actual sample.

4- Tools Reliability: were designed in final format and tested for reliability by using, Cronbach’s alpha coefficient test (0.96, 0.71 and 0.68) respectively.

Ethical Consideration:

An official permission to conduct the study was obtained from the ethical committee in the Minia Faculty of Nursing, Dean of nursing faculty and the Manager of Minia University Hospitals, Minia General Hospital and agreement from Egypt academic for research center and technology at Minia University to carry out this study. Oral permission was obtained by the researcher from the patients and anonymity and confidentiality was applied by coding of all data and protecting the obtained data. Subjects were informed that obtained data will not be included at any further researches without a second oral consent. Each involved subject was informed about the purpose, procedure, benefits and nature of the study and that he/she had the right to withdraw from the study at any time without any rational, then oral consent were obtained.

III- Administrative design:

Phase II: Implementation phase:

1. Anofficial permission was obtained from the Manager of Minia University Hospitals and Minia General Hospital.
2. Oral permission for voluntary participation was obtained from the participants and the nature and the purpose of the study was explained.
3. Data was assured for confidentiality.
4. Each participant from the study and control group was assessed using tool I, II, in the first interview.
5. The researcher prepared the training places, teaching aids and media (computer, picture, handouts). Educational instructions were conducted   through discussion, demonstration and re-demonstration.
6. Study group were exposed to design nursing instructions in the form of small instructional sessions.
7. Knowledge was provided to the study group in 2 sessions, the duration of each session ranged from 30:45 minutes or according to the level of understanding of every patient. The first session started by theoretical part about knowledge related to meaning of DM, types, sign and symptom, causes, and complications. The second session concerning with the practical part about how to prevent complication, medication, nutrition, exercise, and glycemic control. One patient’s family member attended the sessions to help him/her follow the health instructions at home in addition every patient was given an illustrated booklet. 

Phase III: Evaluation phase:

In which the researcher was follow up for patients (study and control group) two times 1^st follow up(post 1^st 3 months) and 2^nd follow up (post 6 months) from the implementation of instructions to the study group using second tool to evaluate the impact of nursing instructions for diabetic patients on their Adherence to Treatment.

IV- Statistical design: 

Data were summarized, tabulated, and presented using descriptive statistics. Statistical package for the social science (SPSS), version (20) was used for statistical analysis of the data, quantitative data were expressed in the form of means and standard deviations as a measure of dispersion while qualitative data presented as frequency distribution. Chi square and fisher exact were used to compare qualitative data and One way ANOVA test and independent sample t test used for quantitative data. P value of less than 0.05 considered as cut off for significance, the test of significance, less than 0.05 was considered significant is the result (*), less than 0.001 was considered highly significant(**). Fisher's Exact test is a way to test the association between two categorical variables. When in case of small cell sizes (expected values less than5). Chi-square test is used when the cell sizes are expected to be large. If the sample size is small (or you have expected cell sizes<5.

Results

Table (1): Socio-demographic characteristics of the study & control group:-

     χ² Chi-square test                                                   * Statistical significant difference (P < 0.05)      

Table 1: Show that out of 144 of total study participants were their age around 50 years for study and control group, the majority of them were females and around half were live in rural area. Most of study participants were married and regarding to educational level about more than third (37.5%) were illiterate in the study group and (43.1%) were primary and secondary educated in control group. In addition more than half of the study participants were not working and with not enough family income according to subjects expression.

Table (2): Medical data of the study & control group:-                                                                  

        χ² Chi-square test                                                    * Statistical significant difference (P < 0.05) 

                                                                                        ** Highly statistical significant difference (P < 0.001)       

Table 2: Shows thatmore than half of the study participants in the study and control group have duration of disease 5-10 years, with oral diabetic treatment, with frequent follow up monthly, and with no previous hospitalization. Also less than quarter of participants had previous diabetic instruction and regarding to source of information was from physician in hospital. Most of study participants were not smoking with a statistical significant between study and control group regarding treatment of DM, previous hospitalization and smoking, and a highly statistical significant regarding previous training.

Part IІ: Comparison between the studied groups regarding to Adherence to Treatment pre-post application of nursing instructions (Table 3):

              χ² Chi-square test                                  ** highly Statistical significant difference (P <  0.001)

Table 4 Shows that all study and control group (100%)hadmoderate adherence to diabetic treatment pre application of instructions while in the 1^st and 2^nd follow up after application of instructions (40.3%and 54.2%) respectively of study group became good adherence. Also there is a highly statistically significant difference between study and control group in diabetic treatment adherence (positive expression) in the 1^st and 2^nd follow up after application of instructions (P < 0.001), and there is no statistical significant difference in diabetic treatment adherence (positive expression) pre and after application of instructions.

Part IV:Relation of Socio-demographic characteristics for study group with Adherence to Treatmentpre-post application of nursing instructions(Table 4):

   *Statistical significant difference (P <0.05)              ** highly Statistical significant difference (P < 0.001)

    F on-way-ANOVA test  t Paired sample T test

Table 9: It's clear from the above table that there was a highly positive significant relation between study participant's adherence to treatment and participant's age, residence, level of education, and occupation pre instructions except with family income pre and post 1^st follow up after application of instructions.