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Effect of an Empowerment Program on Self-Efficacy of Patients With Type 2 Diabetes


1 Kashan University of Medical Sciences, Kashan, IR Iran
2 PhD Candidate, Nursing and Midwifery School, Kashan University of Medical Sciences, Kashan, Iran
3 Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
4 Department of Nursing, Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, IR Iran
5 International Branch of Shahid Bbeheshti University of Medical Sciences, Tehran, IR Iran
6 Golabchi Diabetes Center, Kashan, IR Iran
*Corresponding Author: Neda Mirbagher Ajorpaz, Department of Nursing, Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, IR Iran. Tel/Fax: +98-315540021, E-mail: mirbagher_n@kaums.ac.ir.
Iranian Red Crescent Medical Journal. 19(1): e29252 , DOI: 10.5812/ircmj.29252
Article Type: Research Article; Received: Apr 18, 2015; Revised: May 20, 2015; Accepted: Jun 17, 2015; epub: Jun 21, 2016; collection: Jan 2017

Abstract


Background: Type 2 diabetes is a chronic disease that is spreading very quickly worldwide and is second in priority for investigation of chronic diseases. According to research, self-efficacy is low in diabetic patients.

Objectives: This study analyzes the effect of empowerment programs on self-efficacy in type 2 diabetes patients.

Patients and Methods: In this clinical trial, 100 patients with type 2 diabetes who had inclusion criteria were chosen randomly and divided into control and experimental groups by a randomized block method. Intervention was accomplished through educational sessions scheduled twice a week for four weeks. Diabetes self-efficacy questionnaires were completed before and two months after the intervention for each group. Data were analyzed using the SPSS 16 and the Mann Whitney U, chi-square, exact Fisher’s, and t-test statistical tests.

Results: Before intervention, the mean score of self-efficacy was 45 ± 14.49 and 39.61 ± 17.01 for the experimental and control groups, respectively, and the difference was not significant (P = 0.1). Two months after the intervention, the mean of self-efficacy was 55.71 ± 13.25 and 40.24 ± 17.55 for experimental and control groups, respectively; and the difference was significant (P < 0.001).

Conclusions: Using an empowerment program had positive effects on self-efficacy in patients with type 2 diabetes.

Keywords: Empowerment; Self-efficacy; Type 2 Diabetes

1. Background


Diabetes mellitus is a metabolic disorder resulting from defects in insulin secretion, insulin action, or both. It is classified into two major types, type one and type two diabetes (1). Type 2 diabetes is a chronic disease with an alarming rate of expansion throughout the world. Genetic and family history, environmental factors, lack of exercise, and inappropriate diet may all play roles in insulin resistance and/or dysfunctions in beta cells (2).


Evidence shows that only a small part of chronic disorders such as diabetes are being managed by health care professionals while the majority of patients or their families are managing the disorders by themselves. Therefore, it is important to improve the patients’ self-management behaviors (3). Empowerment programs play important roles in changing diabetic patients’ self-management behaviors (4). Such programs would affect the patients’ behaviors not only through education but also by improving their perception of their disease and increasing their motivation toward self-care. Then, self-management gradually would substitute for the absolute obedience to the physicians’ orders (5).


Most empowerment programs are based on behavior-change models. Self-efficacy is not only one of the most important factors in behavior-change programs (3) but also an important internal factor for long-term control of chronic diseases (6). Education and empowerment programs provide the basis for achieving optimal glycemic control and avoiding diabetes complications through increasing the patient’s knowledge of the treatment methods and also by teaching them some effective behavioral and self-management techniques (7, 8). However, some studies have shown that the level of self-efficacy in diabetic patients is low and there is a need to promote patients’ self-efficacy in self-care (9, 10). Steuten et al. (11) showed that a program for diabetes management not only can increase patients’ self-efficacy but also can improve their quality of life. A systematic review on the clinical effects of empowerment programs in type 2 diabetes patients has recently found that patient empowerment projects could significantly promote holistic diabetes management (12). In contrast, Kamimura et al. (13), in a study of the effect of education on knowledge, attitudes, self-care, and lifestyle in patients with type 2 diabetes, have reached the conclusion that empowerment programs have little effect on self-efficacy in diabetic patients. Tol et al. have also studied empowerment and its influential factors among patients with type 2 diabetes and reported that, with an increase in age and duration of the disease, diabetic patients show less readiness to change their behaviors. Therefore, empowerment programs that seek to change behavior would not be successful in these patients (14). Cinar and Schou (15) also have investigated the issue of self-efficacy in patients with type 2 diabetes and reported that traditional methods of patient education are more effective than the modern empowerment methods in enhancing the patients’ self-efficacy. In a study of the effects of two education methods on glycemic control and blood pressure in patients with type 2 diabetes, Molsted et al. (16) reached the conclusion that empowerment programs have little effect on glycemic control and blood pressure.


Due to the increasing prevalence of diabetic patients in Iran and around the world, the profound effects of this disorder on the self-efficacy of patients, and the lack of use of Anderson’s empowerment model in diabetic patients in Iran, we conducted this study to investigate the effect of a self-empowerment program on self-efficacy in patients with type 2 diabetic.

2. Objectives


The present study investigates the effect of a self-empowerment program on self-efficacy in patients with type 2 diabetic.

3. Patients and Methods


3.1. Design

This study was a clinical trial conducted on patients with type 2 diabetes who had files in the diabetes center of Kashan city in Iran in 2014. The center is a public outpatient clinic for the prevention and treatment of diabetes.


3.2. Participants and Setting

The sample size was calculated based on a previous study (17). The sample of 60 subjects was estimated to be needed in each group based on the following parameters: β = 0.20, α = 0.05, power = 0.80 and standard deviation = 10. Sampling was performed sequentially and then the patients were allocated to the experimental and control groups according to a randomized block method. According to the formula, the sample size in each group was 30 subjects.


Inclusion criteria were an age range of 30 - 65 years old, having a medical diagnosis of diabetes for at least one year, being physically and mentally able to participate in the study training sessions, being literate, and willing to participate in the study. Exclusion criteria were occurrence of any acute and chronic complications during the study and absence from more than two of the training sessions. Three patients in the intervention group were excluded due to absence from more than two sessions. Also, one patient was excluded from the control group due to incomplete response to the study instrument (Figure 1).


Figure 1.
The Sampling Framework of the Study

3.3. Measurement Tools

A two-part questionnaire was used in this study. The first part consisted of questions on the patients’ demographic information, including age, gender, marital status, number of children, education level, occupation, duration of disease, type of treatment, and other ailments. The second part included the Lorig questionnaire for measuring the self-efficacy of diabetic patients. This questionnaire was developed by Lorig at Stanford University, and Cronbach’s alpha of 0.82 has been reported. The Lorig questionnaire consists of eight items. Each item is scored on a scale of 1 (I am not sure) to 10 (I am pretty sure), with a total score from 8 to 80. The higher the score, the higher the level of self-efficacy. The Lorig questionnaire was used in Iran before, and its reliability and validity have been approved (Cronbach’s alpha 0.77 - 0.89) (18). The Lorig questionnaire was given to five patients, and five diabetologist confirmed the content validity of the instrument.


3.4. Procedure

Before the intervention, the research objectives were explained to the participants, and written informed consent was obtained. In addition to their routine treatments, patients in the experimental group participated in the empowerment program, which was adopted from Anderson’s empowerment model (19). This program consists of five steps (Table 1) and was conducted in eight 45-minute sessions that were held at Kashan’s diabetes center two days a week for four consecutive weeks (14, 15) . The control group received only their routine services at the diabetes center. All participants completed the demographic data forms and the questionnaire of “Self-Efficacy for Diabetes” at the beginning of the study. Two months after the last session, all the patients answered the self-efficacy questionnaire again. Research showed that the effects of the empowerment program on diabetic patients should be measured two months after the last session (14, 15).


Table 1.
The Content of the Empowerment Sessions, Adopted From Anderson’s Empowerment Model

3.5. Data Analysis

Data were analyzed using the SPSS software version 13. Descriptive statistics (frequency, percentage, mean, and standard deviation) were calculated for demographic variables. The Kolmogorov-Smirnov test was used to assess the normal distribution of variables. Nominal and categorical demographics of the two groups were compared using the chi-square and Fisher’s exact tests while quantitative demographic variables were compared using the Mann-Whitney U test. The mean self-efficacy scores of the two groups were compared using an independent sample t-test while a paired t-test was used for within-group comparisons.


3.6. Ethical Consideration

Ethical issues of the study were approved by the research ethics committee at Kashan University of Medical Sciences. The research objectives were explained to all participants. All participants signed a written informed consent and were assured about the voluntary nature of the study and the confidentiality of their personal information. This study has been registered at the Iranian registry for clinical trials with the registry number of 2014070818400.

4. Results


Most of the participants in the two groups were women (70.2% in the intervention group vs. 61.2% in the control group) and married (91.5% in the experimental group vs. 93.9% in the control group). No significant differences were found between the two groups in terms of variables such as age, gender, marital status, education level, job, and type of medical managements (P > 0.05) (Table 2).


Table 2.
Demographic Characteristics of Participants in the Study

Before the intervention, no significant difference was observed between the mean self-efficacy scores in the two groups (45.00 ± 14.46 in the intervention group vs. 39.61 ± 17.01 in the control group, P = 0.1). While the mean self-efficacy score of the control group remained relatively unchanged at the end of the study, this score significantly increased in the intervention group. Therefore, at the end of the study, a significant difference was observed between the mean self-efficacy scores in the two groups (55.71 ± 13.25 in the intervention group vs. 40.24 ± 17.55 in the control group, P = 0.001) (Table 3).


Table 3.
Comparison of Self-Efficacy in Two Groups Before and two Months After Intervention

5. Discussion


In the present study, the mean self-efficacy score of the experimental group significantly increased at post-test, while the mean self-efficacy score did not significantly change in either comparison with pretest or in comparison with the intervention group. These findings were consistent with the results of Zamanzade et al. (20), who studied the effect of an empowerment program on the psychosocial aspects of self-management in diabetic patients. The difference in this study and that of Zamanzade et al. is the type of empowerment program. This study used Anderson’s empowerment program. Coulter et al. (21) have shown that using empowerment programs in chronic patients can increase their physical and mental health. Nishita et al. (22) also have studied the effects of an empowerment program on self-efficacy of patients with type 2 diabetes. They reported that the implemented program not only could enhance the patients’ self-efficacy but also improved the diabetes control. Evidence shows that a reciprocal relationship exists between empowerment and self-efficacy (23). Moreover, studies confirm that culturally based empowerment programs not only may help diabetic patients decrease their levels of HbA1C, blood pressure and cholesterol (24) but also can improve all aspects of patients’ self-efficacy, self-care behaviors, and attitudes toward their diabetes (4, 19, 25). In a qualitative study of diabetes self-management strategies, Frost et al. reported self-management and supportive programs bring changes in patients’ health care behaviors that consequently would lead them to a better adherence to treatment and exercise regimens (26).


Moreover, in a study of 360 high school teachers, Asghari et al. (27) have shown that empowerment programs also could increase the levels of job satisfaction and self-efficacy in healthy people. In contrast, in a study of the effect of an empowerment program on self-management in diabetic patients, Sturt et al. (28) reported that intervention did not significantly affect patients’ self-efficacy. The latter study suggests that the empowerment programs might not be effective in all chronic conditions.


The weaknesses of this study include the following: 1. the research was carried out in a medical center; 2. there was a shortage of educational supplies in the Kashan diabetes center; and 3. the self-efficacy questionnaire was completed only once after intervention.


The strong points of this study were that 1. This study was a clinical research trial; 2. random sampling was used; and 3. Anderson’s empowerment program was used.


In conclusion, the results of the present study, along with the findings of previous investigations, revealed that empowerment programs are effective in enhancing the self-efficacy in self-care of patients with diabetes. The observed positive effects may not only be attributed to the nature of the intervention but also to the diabetic patients’ aspiration to be autonomous and independent in daily living activities and care needs. Given the positive effects of the empowerment program on self-care of patients with diabetes, the same programs are suggested to be integrated in the routine health care and education of patients with diabetes. In this study we implemented the empowerment program in a large group. We also re-assessed our participants after two months. Therefore, the long-term effects of the intervention could not be assessed. Perhaps small-group training or individual education might be more effective; therefore, duplication of the same program in small groups or an individual basis is suggested. Also duplication of the same study with a longer follow-up is suggested.

Acknowledgments

The research group would like to thank the Research Department of Kashan University of Medical Sciences for financial support of the project.

Footnotes

Authors’ Contribution: Neda Mirbagher Ajorpaz and Mohammad Aghajani participated in design, statistical analysis, and drafting of the manuscript. Maryam Moein participated in design and collected data. Leila Khorasanifar helped collect data. Neda Mirbagher Ajorpaz supervised the study. All authors read and approved the final manuscript.
Funding/Support: This project was supported by Kashan University of Medical Sciences.

References


  • 1. Van Dijk SEM, Pols AD, Adriaanse MC, Bosmans JE, Elders PJM, Van Marwijk HWJ, et al. Cost-effectiveness of a stepped-care intervention to prevent major depression in patients with type 2 diabetes mellitus and/or coronary heart disease and subthreshold depression: design of a cluster-randomized controlled trial. BMC Psychiatr. 2013;13(128):1.
  • 2. Ding D, Chong S, Jalaludin B, Comino E, Bauman AE. Risk factors of incident type 2-diabetes mellitus over a 3-year follow-up: Results from a large Australian sample. Diabetes Research Clin Practice. 2015;108(2):306-15.
  • 3. Robertson SM, Amspoker AB, Cully JA, Ross EL, Naik AD. Affective symptoms and change in diabetes self‐efficacy and glycaemic control. Diabetic Medicine. 2013;30(5):e189-96.
  • 4. Peña-Purcell NC, Boggess MM, Jimenez N. An Empowerment-Based Diabetes Self-management Education Program for Hispanic/Latinos A Quasi-experimental Pilot Study. Diabetes Educator. 2011;37(6):770-9.
  • 5. Sturt JA, Whitlock S, Fox C, Hearnshaw H, Farmer AJ, Wakelin M, et al. Effects of the Diabetes Manual 1:1 structured education in primary care. Diabet Med. 2008;25(6):722-31. [DOI] [PubMed]
  • 6. Shiu AT, Choi KC, Wong RY. The Chinese version of the Diabetes Empowerment Scale-short form. Patient Educ Couns. 2012;87(2):258-60. [DOI] [PubMed]
  • 7. Williams JS, Lynch CP, Knapp RG, Egede LE. Technology-Intensified Diabetes Education Study (TIDES) in African Americans with type 2 diabetes: study protocol for a randomized controlled trial. Trials. 2014;15(1):1.
  • 8. Xu WH, Rothman RL, Li R, Chen Y, Xia Q, Fang H, et al. Improved self-management skills in Chinese diabetes patients through a comprehensive health literacy strategy: study protocol of a cluster randomized controlled trial. Trials. 2014;15(1):1.
  • 9. Shimoda S, Iwashita S, Ichimori S, Matsuo Y, Goto R, Maeda T, et al. Efficacy and safety of sitagliptin as add-on therapy on glycemic control and blood glucose fluctuation in Japanese type 2 diabetes subjects ongoing with multiple daily insulin injections therapy. Endocr J. 2013;60(10):1207-14. [PubMed]
  • 10. Shearer NBC, Fleury JD, Belyea M. Randomized control trial of the Health Empowerment Intervention: Feasibility and impact. Nursing Research. 2010;59(3):203.
  • 11. Steuten LM, Vrijhoef HJ, Landewe-Cleuren S, Schaper N, Van Merode GG, Spreeuwenberg C. A disease management programme for patients with diabetes mellitus is associated with improved quality of care within existing budgets. Diabet Med. 2007;24(10):1112-20. [DOI] [PubMed]
  • 12. Lorenzo L. Partnering with patients to promote holistic diabetes management: changing paradigms. J Am Association Nurse Practitioners. 2013;25(7):351-61.
  • 13. Kamimura A, Christensen N, Myers K, Nourian MM, Ashby J, Greenwood JLJ, et al. Health and diabetes self-efficacy: A study of diabetic and non-diabetic free clinic patients and family members. J Community Health. 2014;39(4):783-91.
  • 14. Tol A, Baghbanian A, Mohebbi B, Shojaeizadeh D, Azam K, Shahmirzadi S, et al. Empowerment assessment and influential factors among patients with type 2 diabetes. J Diabetes Metabolic Disorders. 2013;12(1):6.
  • 15. Cinar AB, Schou L. The role of self‐efficacy in health coaching and health education for patients with type 2 diabetes. International Dental J. 2014;64(3):155-63.
  • 16. Molsted S, Tribler J, Poulsen PB, Snorgaard O. The effects and costs of a group-based education programme for self-management of patients with Type 2 diabetes. A community-based study. Health Education Research. 2012;27(5):804-13.
  • 17. Cleveringa FG, Minkman MH, Gorter KJ, van den Donk M, Rutten GE. Diabetes Care Protocol: effects on patient-important outcomes. A cluster randomized, non-inferiority trial in primary care. Diabet Med. 2010;27(4):442-50. [DOI] [PubMed]
  • 18. Shojaeezade DTA, Sharifirad G, Mohajeri Tehrani M, Alhani F. Evaluation of education program based on empowerment model on self efficacy promotion and communication with diabetes control in diabetic patient type 2. Iranian J Diabetes and Lipid Disorders. 2012;1(5):474-82.
  • 19. Anderson RM, Funnell MM, Butler PM, Arnold MS, Fitzgerald JT, Feste CC. Patient empowerment. Results of a randomized controlled trial. Diabetes Care. 1995;18(7):943-9. [PubMed]
  • 20. Zamanzade VSE, Jabarzade F. Effect of empowerment program on psychosocial aspects management of diabetic patient. J Nursing Midwifery. 2008;11:25-32.
  • 21. Coulter A, Entwistle VA, Eccles A, Ryan S, Shepperd S, Perera R. Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database Syst Rev. 2015;(3):CD010523. [DOI] [PubMed]
  • 22. Nishita C, Cardazone G, Uehara DL, Tom T. Empowered diabetes management: life coaching and pharmacist counseling for employed adults with diabetes. Health Educ Behav. 2013;40(5):581-91. [DOI] [PubMed]
  • 23. Tucker CM, Wippold GM, Smith TM, Desmond FF, Arthur TM, Butler AM, et al. Association of health self-empowerment with health-promoting behaviors among chronically ill African American and non-Hispanic White adolescents. J Health Care Poor Underserved. 2014;25(4):2019-31.
  • 24. Hernandez-Tejada MA, Campbell JA, Walker RJ, Smalls BL, Davis KS, Egede LE. Diabetes empowerment, medication adherence and self-care behaviors in adults with type 2 diabetes. Diabetes Technol Ttherapeutics. 2012;14(7):630-4.
  • 25. Sugiyama T, Steers WN, Wenger NS, Duru OK, Mangione CM. Effect of a community-based diabetes self-management empowerment program on mental health-related quality of life: a causal mediation analysis from a randomized controlled trial. BMC Health Serv Res. 2015;15(1):115.
  • 26. Frost J, Garside R, Cooper C, Britten N. A qualitative synthesis of diabetes self-management strategies for long term medical outcomes and quality of life in the UK. BMC Health Services Research. 2014;14(1):34.
  • 27. Asghari AKM, Salehsedghpoor B. Empowerment and self-efficacy relationship with job satisfaction. Journal of Psychol. 2008;12(2):227-39.
  • 28. Sturt J, Hearnshaw H, Farmer A, Dale J, Eldridge S. The Diabetes Manual trial protocol - a cluster randomized controlled trial of a self-management intervention for type 2 diabetes [ISRCTN06315411]. BMC Fam Pract. 2006;7:45. [DOI] [PubMed]

Table 1.

The Content of the Empowerment Sessions, Adopted From Anderson’s Empowerment Model

Session Content
First Introducing the sessions’ facilitator. Describing the purposes of the study. Obtaining the participants’ consent for taking part in the study. Answering the study instrument. Determining the problem. Patients expressing feelings, beliefs, and ideas in relation to diabetes. [First and second phases]
Second Understanding the nature of diabetes and threatening complications, such as retinopathy, nephropathy, neuropathy, hypo- and hyperglycemia, and diabetic ketoacidosis that can be perceived as threatening. [Third phase]
Third Making the patients familiar with the problems of people involved with diabetes complications. Showing some photographs and slides of diabetes complications. In this way, patients were motivated to prevent complications and to seek solutions and strategies for prevention and/or treatment. [Third phase]
Fourth Inducing group discussions on correct lifestyle (in terms of nutrition, diet, activity and exercises). Giving the patients educational pamphlets regarding an appropriate lifestyle in people with diabetes. [Fourth phase]
Fifth Explaining and exhibiting some practical procedures commonly needed by diabetic patients (using glucometer for measuring blood glucose level; where to store insulin; how to use insulin syringes; how to do insulin injections, etc.). Inducing group discussions on problems and the best practice in such procedures.
Sixth Practicing the practical procedures that have been taught until the patients reach the proficiency level. Using peer support to foster the participants’ motivation and learning. [Fourth phase]
Seventh Questions and answers. Appraising the patients’ efforts and their attitudes of the effectiveness of empowerment program. [Fifth phase]
Eighth Overcoming the patients’ weak points. Encouraging a healthy lifestyle in coping with diabetes. Summarizing and reviewing content of the previous sessions. Scheduling the evaluation session after two months. Giving patients a phone number for receiving more advice if needed.

Table 2.

Demographic Characteristics of Participants in the Study

Variable Control Group, No. (%) Experimental Group, No. (%) P Value
Gender aP = 0.19
Female 30 (61.2) 33 (70.2)
Male 19(38.8) 14 (29.8)
Marital status aP = 0.46
Married 46 (93.9) 43 (91.5)
Widowed 3 (6.1) 4 (8.5)
Education bP = 0.17, χ2 = 4.99
Under the diploma 34 (69.4) 41 (87.3)
Diploma 7 (14.3) 4 (8.5)
Bachelor’s degree or higher 8 (16.3) 2 (4.3)
Job bP = 0.81, χ2 = 0.4
Housekeeper 30 (61.2) 31 (66)
Employee & free 8 (16.3) 6 (12.8)
Retired 11 (22.4) 10 (21.3)
Treatment
Without treatment 3 (6.1) 8 (17.4) bP = 0.21, χ2 = 3.05
With tablet 33 (67.3) 26 (56.5)
With insulin 13 (26.5) 12 (26.1)
Other illness aP = 0.29
No 24 (49) 19 (41.3)
Yes 25 (51) 27 (58.7)
a Exact Fisher Test.
b Chi-square Test.

Table 3.

Comparison of Self-Efficacy in Two Groups Before and two Months After Intervention

Group Experimental, Mean ± SD Control, Mean ± SD Statistics Test P Value
Before intervention 45.0 ± 14.49 39.61 ± 17.01 T = 1.65 P = 0.1
After intervention 55.71 ±13.25 40.24 ± 17.55 T = 4.82 P = 0.001
Statistics test t = -4.66, P = 0.0001 t = -0.37, P = 0.71 - -

Figure 1.

The Sampling Framework of the Study