Rajiv Gandhi University of Health Sciences s101

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA ANNEXURE-II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

01. NAME OF THE MR. DANI PHILIP, CANDIDATE AND I YEAR M.Sc. NURSING, ADDRESS RATNA COLLEGE OF NURSING, B.M. ROAD, HASSAN.

02. NAME OF THE RATNA COLLEGE OF NURSING INSTITUTION

03. COURSE OF STUDY AND M.Sc NURSING SUBJECT MEDICAL-SURGICAL NURSING

04. DATE OF ADMISSION TO 30th JUNE 2008 THE COURSE

05. EFFECTIVENESS OF PLANNED TITLE OF THE STUDY TEACHING PROGRAMME ON HEALTH PROMOTING BEHAVIORS AMONG TYPE 2 DIABETIC PATIENTS.

5.1. STATEMENT OF THE A STUDY TO EVALUATE THE PROBLEM EFFECTIVENES OF PLANNED TEACHING PROGRAMME ON KNOWLEDGE REGARDING HEALTH PROMOTING BEHAVIORS RELATED TO DIABETES AMONG TYPE 2 DIABETIC PATIENTS IN THE SELECTED HOSPITALS OF HASSAN.

1 6. BRIEF RESUME OF THE INTENDED WORK

6.1. INTRODUCTION: Govern well thy appetite, lest sin surprise thee, and her black attendant, death. - John Milton Diabetes mellitus is a disorder which is resulted due to the abnormal metabolism of carbohydrates1 as a result of excessive consumption of the sweet tasted substances. There is one person in the world dying of diabetes every ten seconds. Also, there will be two cases of diabetes in the world being identified every ten seconds!!2 Diabetes mellitus is a chronic multi system disease related to the abnormal insulin production, impaired utilization of insulin or both3. Diabetes mellitus is a serious health problem in the world and its prevalence is increasing rapidly. According to statistics India is the diabetic capital of the world. Diabetes essentially affects 246 million people worldwide and it is expected to affect 380 million by 2025. Diabetes is the fourth leading cause of death by disease (3.8 million / year). At least 50% of all people with diabetes are unaware of their condition. In some countries, it may reach up to 80% (WHO diabetes unit and the international diabetes federation)4. Currently, India is the country with largest number of people having diabetes. In 2007, it was 40.9 million and it is expected to rise up to 79.4 million by the year 2030. Since, no cure of diabetes in sight, the control of the disease is the most efficient intervention which can be adapted. Self care is an important component of diabetes control programme. Self care includes the education of the patients regarding dietary compliance, medications, exercise, blood sugar monitoring etc. therefore, nursing interventions, like education is a necessity for diabetes management. These educational strategies collectively help in the development of health promoting behaviors among the diabetic patients.

2 6.2. NEED FOR THE STUDY: Diabetes mellitus is the fourth leading killer disease at present. The WHO states that death due to diabetes will increase all over the world by as much as 80% in some regions over the next 10 years, especially in the low and middle income countries. India is the example for the host to the larger diabetic population in the world with an estimated 40.9 million people, accounting to 8% of the adult population. WHO predicts, death from diabetes in India will increase by 35% over the next 10 years5. Hence it is important to promote awareness that every persons diabetes or at risk of diabetes deserves the best quality of education especially regarding dietary compliance, medications, exercise, blood sugar monitoring etc, because most of the clients are unaware of it. A study was conducted to find out the levels of awareness on diabetes in urban adult Indian population in a city of South India (Diabetes Research centre and M.V.Hospitals for Diabetes, Chennai). Details regarding the awareness of Diabetes in relation with healthy and unhealthy diet, physical activity, prevention, complications and measures to improve health were collected using a questionnaire. 50% of subjects scored less than 15 out of 65. The study highlights that the knowledge regarding the disease condition was significantly low among the general population and there is an urgent need for strategies to spread awareness about diabetes in the general population6. A cross sectional study was conducted among 100 patients attending the diabetic clinic at Klinik Kesihatan Seri Manjung which describes the knowledge, attitude and practice about health promoting behaviors regarding Diabetes mellitus by using a face to face interview. Only 56% of them practice all of the practices that were asked – healthy diet, regular exercise, monitoring blood glucose level, and monitoring body weight. The results indicate that the population need to have a better structured educational programme to increase the knowledge on diabetes and its preventive measures which improve their practice towards Diabetes7. In a cross-sectional study conducted at Chandigarh of the 60 diabetic individuals, only 18.3% were avoiding the sweets and fatty foods, even though they knew that they should be avoided. Oral anti-diabetic compliance rate was 62.9%,monitoring blood sugar was poor (46.7%) and none of them knew about insulin self therapy.

3 In another cross sectional study conducted in 150 diabetic residents of Pondicherry, 50% of them were modifying their diet, 97% of them were using the anti-diabetic agents, but many were using them wrongly. None of the patients had any formal education regarding Diabetes. The result shows that the diabetic clients need to be educated regarding the self promoting activities8.

Self-care is an important component of diabetes control programme. A cross- sectional survey was carried out in a resettlement colony of Chandigarh and 60 diabetics aged 20 years and above were identified. Their knowledge and practices regarding diet, genital hygiene, care of foot, wound, complications of diabetes and medication was assessed using a semi-structured interview schedule. Most of them (60%) opined that diabetic should consume whatever is cooked in the family. Forty eight diabetics knew that sweets and fatty foods should be avoided but only 18.3% were avoiding them. Genital hygiene was maintained by 51.7% and foot care was done by 63.3% through regular washing. Monitoring of blood sugar was poor (46.7%), only 3 knew and were continuing self testing of urine. Oral anti-diabetic drug compliance rate was 62.9%. None of the patients on insulin injections knew about self therapy. Knowledge regarding diabetic complications was partial. There is a need to reorient and motivate health personnel in educating diabetics about self- care9.

The concept of health promoting behaviors (HPB) are used to illustrate varied terms ranging from positive actions, taken by the individual to promote health, such as healthy nutrition, balanced diet, regular exercise, keeping fit, elimination of waste toxins, rest and sleep; to the avoidance of negative behaviors, such as alcohol, drug or tobacco use. Pender et al (1990) defined HPB as a “positive approach to living, having a multi-dimensional pattern of self initiated behaviors and perceptions that serve to maintain or enhance the level of wellness, self actualization and personal fulfillment of the individual”10. In this study, HPB is defined as the activities or practices for maintenance of life and health by adults with type 2 diabetes as measured by a structured questionnaire rating scale.

The investigator would like to take up the present study, as out of his own experience he found that many diabetic clients are suffering a lot, even though much of the complications could be controlled by the self care. Thus the investigator felt

4 that planned teaching programme would increase the knowledge towards the health promoting behaviors related to diabetes mellitus.

6.3. STATEMENT OF THE PROBLEM:

A STUDY TO ASSESS THE EFFECTIVENES OF PLANNED TEACHING PROGRAMME ON KNOWLEDGE REGARDING HEALTH PROMOTING BEHAVIORS SEEN AMONG TYPE 2 DIABETIC PATIENTS IN THE SELECTED HOSPITALS OF HASSAN.

6.4. OBJECTIVES:

The objectives of the study are:  To identify the existing knowledge of diabetic patients on health promoting behaviors.  To design and administer planned teaching programme on health promoting behavior for the type 2 diabetic patients.  To asses the level of knowledge on health promoting behavior after the implementation of planned teaching programme related to health promoting behaviors.  To compare the level of knowledge before and after the implementation of the planned teaching programme.  To associate the knowledge about the health promoting behaviors with selected demographical variables.

6.5. HYPOTHESIS:

There will be a statistically significant difference in the scores obtained on the pretest and the post test prior to and after the planned teaching programme on the health promoting behaviors of type 2 diabetic patients.

5 6.6. ASSUMPTIONS:

The study assumes that  The diabetic patients will have some knowledge on health promoting behaviors related to type 2 diabetes mellitus.  The diabetic patients would be willing to participate in the study to acquire knowledge on prevention of diabetes mellitus through a planned teaching programme.  Health promoting behaviors will be influenced by different variables.  Planned teaching Programme will enhance the knowledge of the diabetic patients on prevention of diabetes mellitus.

6.7. OPERATIONAL DEFINITIONS:

The terms used in this study are defined as follows: 1. Assess: It refers to the identification of the factors that influence the awareness regarding health promoting behaviors in diabetic patients. 2. Effectiveness: It refers to the improvement in knowledge of diabetic patients on health promoting behaviors as measured by gain in posttest knowledge score on the basis of a structured questionnaire. 3. Planned Teaching Programme: It refers to systematically organized teaching plan on awareness regarding health promoting behaviors in diabetic patients. 4. Knowledge: It refers to the correct responses of the patients to knowledge items in the closed ended questionnaires regarding health promoting behaviors. 5. Health promoting behaviors: It refers to activities or the practices for the maintenance of life and health by diabetic patients on selected aspects such as diet, exercises, hygiene, administration of the medications and prevention of the complications. 6. Type 2 diabetic patients: It refers to known cases of type 2 Diabetic patients diagnosed by the physician ,who are on with or without anti-diabetic therapy.

6 6.8. INCLUSION AND EXCLUSION CRITERIA:

I. INCLUSION CRITERIA:

Diabetic patients who are:  Diabetic patients belongs to the age group of 30 to 70 years.  Known diabetic patients associated with complications.  Available at the time of study  Willing to participate in the study.

II. EXCLUSION CRITERIA:

Diabetic patients who are:  Type 1 diabetic in nature.  Diabetic patients who are chronically ill, who are suffering with major diseases like HIV AIDS, cancer etc.  Have attended any structured teaching programme on diabetic health promoting behaviors.

6.9. DELIMITATIONS:

The study will be delimited to the diabetic clients who are:  Admitted in the selected hospitals of Hassan.  Known cases of type 2 diabetes mellitus.  Within the age group of 30 to 70 years.  Available during data collection.

6.10: SIGNIFICANCE OF THE STUDY:

This study signifies the effectiveness of the planned teaching programme on health promoting behaviors among type 2 diabetic patients.

6.11. CONCEPTUAL FRAMEWORK:

Health promotion model by N. J. Pender.

7 6.12. REVIEW OF LITERATURE:

Sharma (1998) conducted an evaluative research with a pre-test post-test control design on three groups of 50 diabetic clients, each were assigned to two experimental groups and one control group through systematic random sampling. The findings revealed significantly higher knowledge in the two experimental groups. The main findings of the study were the mean post-test knowledge, skill and attitude scores of the experimental group 1 and 2 were significantly higher than their mean pre-test scores11. This study shows that adults with diabetes in India need ongoing health education in the hospitals to help them improve their health behaviors.

An experimental study was conducted in Italy among 42 out patients (28 IDDM, 14 NIDDM) attending the diabetic clinic. The data was evaluated the outcome of a multiple choice questionnaire and fasting blood glucose, 24 hour urine glucose, before and 60 days after providing information about diet, physical exercise and hypoglycemic drugs or insulin therapy results were compared with those obtained in a group 57 age patients who did not receive individual teaching (control group). Knowledge concerning diabetes at the second evaluation was significantly higher in treatment group. Hence researcher concluded that individual teaching can improve the knowledge of patients without affecting metabolic control12.

A sample of 142 diabetic patients was interviewed twice, in 1984 and 1986, following an educational program administered to primary care staff. Positive changes were recorded regarding several aspects. (a) Process of care - the percentage of untreated patients decreased from 15% to 4%; the proportion of patients on diet only increased from 36% to 41%, while the insulin-treated proportion decreased from 12% to 8%; the percentage of patients treated with oral drugs went up from 36% to 46%. (b) Patient knowledge - an improvement in various aspects, such as diet and exercise. (c) Patient behavior - an improvement in adherence to diet and in compliance with medications13.

In the study done by Hampton et al, a structured two-session education programme was introduced for newly diagnosed 59 consecutive type 2 patients. When

8 patients were evaluated on the knowledge about diabetes, those who attended the education programme seemed to have a better knowledge than the non-attenders14.

Educational intervention was observed to have improved the diabetic patients' knowledge of the disease and self-care and the long term control of the disease according to the study by Tan et al. This study was carried out on an intervention group of 183 diabetic patients who completed the education programme and a control group of 95 diabetic patients who attended the clinic during the period of the study. When the patients were assessed regarding their knowledge of diabetes and its actual practice (dietary practice, compliance, home monitoring) the intervention group showed a significant and greater improvement in the knowledge of the disease and self-care and in the dietary practice compared to the control group15.

In a study conducted by Garcia and Suarez, when a five year follow up was done on an interactive educational programme established for diabetic patients above 60 years of age, it was found that there was a significant increase of knowledge among the patients who attended the educational programme. The results of another study conducted in Netherlands in which follow up was done after 12 months, indicated that primary care programs which integrated education into structured care were able to improve both the type 2 diabetic patient's knowledge about the disease and their self care behavior16.

Several studies have been done to determine whether attendance at the education programme had any effect on the patient's glycemic control. To assess the long term-effect of structured diabetes teaching and training programme (STTP) on metabolic control and knowledge of diabetes in patients with type 2 diabetes a study was conducted especially on diet in which 64 patients were included. Of the 52 patients who could be evaluated after 2 years, HbA1c was found to have decreased in all. This study revealed that STTP for patients with type 2 diabetes was found effective in improving the long-term glycemic control17.

Chandalia et al assessed the nutritional knowledge and control of diabetes in 43 non-ketosis-prone diabetic subjects. The patients were exposed to a 1-hour nutritional counseling program in groups of three to five. It was observed that the

9 patients' nutritional knowledge and the control of diabetes improved significantly after counseling in those patients in whom control had been inadequate18.

Many factors have an effect on glycemic control in diabetic patients. Diabetes knowledge, exercise, dietary habits, lifestyle, treatment regimens etc are some of the potential predictors of glycemic control in diabetic patients. Higher diabetic knowledge scores in a group of older type 2 patients was associated with better glycemic control when randomly assigned to diabetic education programs compared with those randomly assigned to usual care. Similarly, a study of 165 diabetic patients who received outpatient diabetes education for one week showed a significant increase in the knowledge score, which was associated with a significant fall in HbA1c at 6 months19

To demonstrate the advantages of behavior-modifying education on the metabolic profile of the type 2 diabetes mellitus patients, a quasi-experimental study was performed with the control group. The experimental group was made up of 25 type 2 diabetic patients and the control group consisted of 24. The education carried out was a behavior modification module. A reduction in serum glucose, total cholesterol and triglycerides was observed in the experimental group who received behaviour modifying education, whereas in the control group there was not much difference in any of the above mentioned studies. Thus introduction of an education programme was found to have a positive effect on the metabolic control of patients20.

7. MATERIALS AND METHODS OF STUDY: 7.1 SOURCE OF DATA: Data will be collected from type 2 diabetic patients of the selected hospitals, Hassan.

7.2. RESAERCH DESIGN: The research design for the study will be one group pretest and post test design (Quasi Experimental design)

10 PRE-TEST INTERVENTIONS POST-TEST

O1 X O2

KEY: O1 = Pre-test (Knowledge on health promoting behaviors before planned teaching programme)

O2 = Post-test (Knowledge on health promoting behaviors after planned teaching programme) X = Implementation of the planned teaching programme.

7.3. METHOD OF DATA COLLECTION: Data collection is planned through structured questionnaire on knowledge regarding health promoting behaviors among type 2 diabetic patients, and based on the following aspects. PART A: -Demographic variables include age, gender, religion and influence of mass media. PART B: - Structured questionnaire on knowledge regarding health promoting behaviors among type 2 diabetic patients. PART C: - Planned teaching programme regarding health promoting behaviors among type 2 diabetic patients.

7.4. SAMPLING PROCEDURE: 1. Population: In this study, the population consists of type 2 diabetic patients who are admitted in the selected hospitals of Hassan.

2. Sample: All the patients who had fulfilled the inclusion criteria.

3. Sample size: A sample of 50 type 2 diabetic patients will be selected.

11 4. Sampling Technique: In view of the nature of the problems and to accomplish the objectives of the study, purposive sampling technique will be used to select 50 type 2 diabetic patients.

5. Setting: Selected hospitals in Hassan.

6. Pilot study: The pilot study is planned with 10% of the population during the month of May 2009.

8. VARIABLES: 8.1. Dependant variable: Knowledge regarding health promoting behaviors.

8.2. Independent variable: Planned teaching programme.

9. PLAN FOR DATA ANALYSIS: 1. Descriptive statistics: To describe the demographical variables and knowledge through numbers, frequencies, percentages, mean and standard deviation will be used.

2. Inferential statistics: Inferential statistics such as Chi-square and Paired T tests are used for analyzing and computing data. 1. To describe the knowledge between the groups, independent t-test and to describe the knowledge within the groups, paired t-test is used. 2. To associate the socio-demographic variables with knowledge, Chi-square test is planned.

12 10. ETHICAL CONSIDERATION: 1. Does the study require any investigation or intervention on patients or other human or animals? Yes.

2. Has ethical clearance being obtained from your institution? Yes.

3. Has consent taken from the hospital authorities? Yes.

13 11. LIST OF REFERENCES: 1. Kumar, Abbas, Fausto, Robbins and Cotran Pathological basis of disease, 7th edition, Saunders publishers, Philadelphia, 2007, Chapter no: 24, Page no: 1190. 2. Did you know? http;//www.idf.org/home/index.cfm?unode. 3. Lewis, Heitkemper, Dirksen, O’Brien, Bucher, Medical Surgical Nursing, 7th edition, Mosby publishers,Missouri, 2007, Section no:10, Page no: 1253. 4. Diabetes Atlas, third edition, International Diabetes federation, 2007 and World Health Organization Diabetes Unit – www.who.int/diabetes. 5. World Health Organization Diabetes Unit – www.who.int/diabetes. 6. N. Murugesan, C. Snehalatha, R. Shobhana, G. Roglic, A. Ramachandran, “Awareness about diabetes and its complications in the general and diabetic population in a city in southern India”, Diabetes Research and Clinical Practice, Volume 77, Issue 3, September 2007, Pages 433-437. 7. Ranjini Ambigapathy, Subashini Ambigapathy, H. M. Ling, “A knowledge, Attitude and Practice study of diabetes mellitus among the patients attending Klinic Kesihatan Seri Manjung”, NCD Malaysia 2003, Volume 2, No 2. 8. A Asha, R Pradeepa, V Mohan, “Evidence for Benefits from Diabetes Education Program”, International journal of Diabetes in developing countries, Year: 2004, Volume: 24, Issue: 4, Pages: 96 – 102. 9. K Kaur, MM Singh, Kumar, I Walia, Knowledge and self-care practices of diabetics in a resettlement colony of Chandigarh, Indian Journal of Medical Sciences, 1998, Volume: 52, Issue: 8, Pages: 341 – 347. 10. N. J. Pender, S. N. Walker, K. R. Sechrist,, M. Frank Stromberg, Predicting health promoting lifestyles in the workplace, Nursing Research 39, 1990, Pages: 326 – 332. 11. A.Sharma, Effectiveness of auto and agent initiated instructions for developing self-care ability of NIDDM patients, Indian journal of Nursing and Midwifery 1, 1998, Pages: 39 – 46.

14 12. Alberto Piaggesi, Ottavio Giampietro, Luigi Picaro, Roberto Miccoli and Renzo Navalesi, Individual teaching as a first-step intervention for the education of diabetic subjects, Acta Diabetologica, September 1989, Volume 26, Number 3, Pages: 225 – 235. 13. L. newmann, S. Weitzman, J. Gross, “Improved knowledge of diabetic patients through education of the primary care staff”, Health policy, November 1989, Volume: 13, Issue:3, Pages: 103 – 108. 14. Hampton KK, Bodansky HJ, Stickland M. Audit of an education programme for recently diagnosed type 2 diabetic patients. Practical Diabetes 1998;5:166-7. 15. Tan AS, Yong LS, Wan S, Wong ML. Patient education in the management of diabetes mellitus. Singapore Medical Journal 1997;38:156-60. 16. Garcia R, Suarez R. Diabetes education in the elderly: A 5-Year follow-up of an interactive approach. Patient Education and Counseling 1996;29:87-97. 17. Fritsche A, Stumvoll M, Goebbel S. Long term effect of a structured inpatient diabetes teaching and treatment programme in type 2 diabetic patients: influence of mode of follow-up. Diab Res Clin Practice 1999;46:135-41. 18. Chandalia HB, Bagrodia J. Effect of nutritional counseling on the blood glucose and nutritional knowledge of diabetic subjects. Diabetes Care. 1979;2:353-6. 19. Jayendra H Shah, Glen H Murata, William C Duckworth, Richard M Hoffman, Christopher S Wendel, Factors Affecting Compliance in Type 2 Diabetic Patients: Experience from the Diabetes Outcomes in Veterans Study (DOVES), International journal of Diabetes in developing countries, 2003, Volume:23, Issue: 3, Pages: 75 – 82. 20. Pivaral CEC, Perez GG, Lopez GV et al. Effects of behaviour-modifying education in the metabolic profile of the type 2 diabetes mellitus patient. Journal of diabetes and its complications 2000;14:322-6.

15 12. SIGNATURE OF THE CANDIDATE

13. REMARKS OF THE GUIDE AN APPROPRIATE AND FEASIBLE STUDY FOR TYPE 2 DIABETIC PATIENTS TO BE AWARE OF POSITIVE HEALTH PRACTICES TO MAINTAIN THEIR HEALTH AND PREVENTS FURTHER COMPLICATIONS.

14. GUIDE: Mrs. H.N. SHANTHALA.

14.1 NAME AND DESIGNATION OF THE PROFESSOR AND H.O.D OF MEDICAL GUIDE SURGICAL NURSING

14.2. SIGNATURE

14.3. HEAD OF THE DEPARTMENT Mrs. H.N. SHANTHALA.

14.4. SIGNATURE

15 REMARKS OF THE PRINCIPAL

15.1. SIGNATURE