Keywords
nurse-led interventions - home care nursing - diabetes - visiting nurses - compliance
Introduction
Changes in human behavior and lifestyle over the last century have made dramatic increase
in the incidence of diabetes worldwide. The number of people with diabetic mellitus
(DM) is expected to reach 642 million by 2040. In South East Asia alone, 78.3 million
live with type 2 diabetes mellitus (T2DM), at a prevalence rate of 8.3%, of which
40.8 million (52.1%) are undiagnosed cases.[1] India stands second in the world with 69.2 million diabetics and accounts for one
million diabetes-related deaths every year.[2] The prevalence has increased over 10-fold in the last three to four decades.[3]
[4] Indian Council of Medical Research (ICMR-INDIAB) study reported an increase in prevalence
in urban (10.9–14.2%) and rural (3–8.3%) areas.[3] The prevalence of T2DM in Mangalore was 28.3% in 2017.[5]
T2DM evolves under the influence of environmental and behavioral factors such as sedentary
lifestyle, overly rich nutrition, and high stress.[1] Diabetes imposes a heavy burden on clients and their families. On an average, lower
income groups spend up to one-fifth of their income in direct and indirect costs of
managing the disease. Besides, intangible costs include pain, anxiety, inconvenience,
lower quality of life, and impact on family.[6] Studies have recommend creating awareness through health education.[7]
[8]
Diabetes management involves prevention of complications through the adoption of a
healthy lifestyle and careful self-management, including behavior change in terms
of diet, exercise, self-efficiency, social support, and self-monitoring. Comprehensive
and tailored interventions focusing on individual characteristics have also been emphasized.[9]
[10]
Diabetes is difficult to control in terms of self-management as motivation and support
is key. Self-care practices were found to be unsatisfactory in almost all aspects
except for blood sugar monitoring and treatment adherence. As prevention of complications
and better quality-of-life is the key, more efforts should be put to educate the people
with diabetes. Consistent, patient friendly, accessible systems based on levels of
patient knowledge, motivation, and cost effectiveness are necessary.[11]
[12] Prevention of diabetes and its control/management require integrated interventions
that aim to bring down the premature morbidity and mortality.[13] Researchers have found that visiting nurse service is more effective compared to
community-centered public health service.[12] This study is an attempt to study the effectiveness of nurse-led home care interventions
in management of T2DM.
Materials and Methods
This field-based descriptive evaluative study employed pre-experimental design. One
group repeated measures (time series). Altogether 624 adults aged 35 years or above
who resided in four community field practice areas (urban) were screened for DM from
January to September 2017, using the urine sugar test. All 103 subjects who presented
with sugar in urine and who met the inclusion criteria were inducted as study sample.
Sample size was calculated using G* power, estimated as 90. Official permissions were
obtained from public health authorities; ethical clearance and informed consent were
obtained.
Instruments/tools: Tools used were baseline proforma of the clients (questionnaire), Benedict test/Uro
sticks to screen for urine sugar, glucometer to monitor blood glucose level, and compliance
scale to identify the compliance status. Content validity of the tools was ascertained.
Compliance rating scale consisted of 31 items with domains such as dietary habits,
exercise, rest, sleep, symptom management, prevention of complications, medication,
and follow-up. The reliability of compliance tool was r =0.86. Instruments used for measuring blood pressure (BP), weight, and blood glucose
levels were calibrated. Inter-rater reliability was obtained. Audio visuals (10 sets
of standardized Flipcharts) were prepared for individualized health teaching and were
validated by experts. Required translation was done for the tool and the interventions.
Pretesting and pilot study were carried out to refine and make modifications.
Intervention and data collection procedure: Each subject was visited by a team of nurses and the interns at their homes. Baseline
measures like BP, weight, and blood glucose levels were obtained. Information on compliance
or lifestyle practices was collected. Individualized comprehensive nursing interventions
(education, testing, counseling) were provided, which was reinforced two times a week
for 4 weeks, with minimum seven home visits carried out by the researchers who are
registered nurses and teaching faculty along with 6 interns of BSc nursing program
who were trained and mentored by the researchers. Post-tests were obtained at second
and fourth weeks after start of intervention.
Results
Demographic profile: Nearly equal number of subjects (48; 47%) belonged to age group of 41 to 60 years
and those below 40 years were (6; 5.8%). More than half (69; 67%) patients were females.
Majority of patients were Hindus (88; 85.4%) and completed high school (77; 75%) and
nearly a quarter (23; 22%) had no formal education. Maximum were unemployed (67; 64%),
and 50% subjects had income ranging between Rs 5000 and Rs10, 000 and (17; 16.5%)
had less than Rs 5000 per month. All were married and majority of patients (63; 61%)
had one child. Fifteen patients (14.6%) had habits like smoking, (29%), chewing tobacco
(47%), and alcoholism (27%).
Profile of clients related to DM: Among 103 subjects (35; 34%) had family history of DM, out of which (22; 63%) had
two subjects with first-degree relatives with DM. Maximum subjects (40; 39%) were
diagnosed with DM from the last 6 months. Ninety-two (90%) patients consumed mixed
diet and majority of patients had three meals per day (87; 85%). However, 16 (15.5%)
patients consumed only two meals. Only two (1.9%) patients used home remedies, 14
(13.6%) patients practiced yoga, and 3 (2.9%) patients followed alternative systems
of medicine such as ayurveda and homeopathy. Majority of patients used private facilities
(68; 66%) for transportation. Only 51 (49.5%) patients claimed to have self-care information
received from friends/relatives (13; 25.5%), whereas, 37 (73%) from health team members
and 1 (2%) from the mass media.
Effect of nurse-led home care interventions on clinical variables: A significant improvement is found in blood sugar, systolic BP, and diastolic BP.
However, no change was found with BMI. Post-hoc analyses showed that the difference
was significant in the clinical parameters after the intervention between the time
periods of pre-, post1-, and post2- measures ([Tables 1] and [2]).
Table 1
Effect of nurse-led home care interventions on clinical profile of DM clients (n = 103)
|
Parameter
|
Mean ± SD
|
ANOVA
|
p-Value
|
|
Body mass index
|
Pre
|
24.91 ± 4.61
|
0.52
|
0.597
|
|
Post1
|
25.81 ± 3.92
|
|
Post2
|
24.84 ± 4.40
|
|
Diastolic BP
|
Pre
|
85.73 ± 9.86
|
14.13
|
0.001[a]
|
|
Post1
|
81.46 ± 9.74
|
|
Post2
|
82.82 ± 9.01
|
|
Systolic BP
|
Pre
|
137.28 ± 18.95
|
7.60
|
0.001[a]
|
|
Post1
|
133.79 ± 16.16
|
|
Post2
|
133.98 ± 14.71
|
|
Random blood sugar
|
Pre
|
199.03 ± 62.93
|
10.34
|
0.001[a]
|
|
Post1
|
178.07 ± 60.41
|
|
Post2
|
191.03 ± 58.25
|
Abbreviations: ANOVA, analysis of variance; BP, blood pressure; DM, diabetes mellitus;
SD, standard deviation.
a Significant values.
Table 2
Post-hoc analysis of significant parameters in ANOVA test (n = 103)
|
Parameter
|
(I) Factor 1
|
(J) Factor1
|
Mean difference (I–J)
|
SE
|
p-Value
|
|
Diastolic BP
|
Pre
|
Post 1
Post 2
|
4.27
2.91
|
0.89
0.80
|
0.000[a]
0.001[a]
|
|
Post 1
|
Post 2
|
− 1.4
|
0.77
|
0.240
|
|
Systolic BP
|
Pre
|
Post 1
Post 2
|
3.50
3.30
|
1.00
1.09
|
0.002[a]
0.009[a]
|
|
Post 1
|
Post 2
|
− 0.19
|
0.93
|
1.00
|
|
Random blood sugar
|
Pre
|
Post 1
Post 2
|
20.96
8.00
|
5.45
4.15
|
0.001[a]
0.171
|
|
Post 1
|
Post 2
|
− 12.96
|
4.25
|
0.009[a]
|
Abbreviations: ANOVA, analysis of variance; BP, blood pressure; SE, standard error.
a Significant values.
Effect of nurse-led home care interventions on compliance status: Improvement was seen overall and across all the five domains of compliance of diabetic
clients; there was a significant improvement with the nurse-led home care intervention
([Fig. 1]; [Tables 3] and [4]).
Table 3
Effect of nurse-led home care interventions on specific compliance parameters of DM
clients (n = 103)
|
Domain
|
Preintervention
|
Postintervention
|
t
|
p-Value
|
|
Mean ± SD
|
Mean ± SD
|
|
Dietary
|
9.76 ± 2.15
|
10.31 ± 2.32
|
2.44
|
0.016[a]
|
|
Habits
|
1.69 ± 0.611
|
1.76 ± 0.59
|
1.15
|
0.252
|
|
Exercise, rest, sleep
|
2.40 ± 1.023
|
2.70 ± 0.93
|
2.63
|
0.010[a]
|
|
Prevention and management
|
3.92 ± 1.46
|
4.40 ± 1.32
|
3.18
|
0.002[a]
|
|
Medication, follow-up
|
4.13 ± 1.27
|
4.39 ± 1.11
|
2.64
|
0.010[a]
|
Abbreviations: DM, diabetes mellitus; SD, standard deviation.
a Significant values.
Table 4
Effect of nurse-led home care interventions on overall compliance of DM clients (n = 103)
|
Domain
|
Mean ± SD
|
t
|
p-Value
|
|
Preintervention
|
21.89 ± 4.02
|
3.69
|
0.0001[a]
|
|
Postintervention
|
23.55 ± 4.13
|
Abbreviations: DM, diabetes mellitus; SD, standard deviation.
a Significant value.
Fig. 1 Description of compliance scores of clients with diabetes mellitus (DM) before and
after intervention.
Association of clinical parameters, compliance, and selected variables: No significant association was found between selected demographic variables with
clinical parameters except dietary habits and BMI (p = 0.043); dietary habits and diastolic BP (p = 0.041). No significant association was found between compliance scores and demographic
variables or clinical variables.
Discussion
Baseline Variables
Profile of subjects related to DM: Maximum subjects (40; 39%) were diagnosed with DM in the last 6 months. A study
among adolescents with T2DM found the average duration of diabetes was 2.0 years.[14] Another study in Jamaica found the median duration of DM was men, 7 years; women,
10.5 years.[15]
Subjects consumed mixed diet and majority had three meals per day (87; 85%). In another
study, however, 16 (15.5%) patients consumed only two meals. Majority of subjects
consumed more meals per day (80%) and did not include their regular sweetened food
intakes in their daily meal plan (80%), or were inactive in daily life (54%).[16] Patients reported frequent episodes of overeating, drinking sugary drinks, and eating
fast food. More than 70% of patients reported exercising ≥2 times a week, but 68%
reported watching ≥ 2 hours of television daily. Forty-six percent described diet
and/or obesity as contributing factor to their diabetes. Eighty-five percent had consulted
a dietitian but only 56.4% reported being on a “special diet.” Only 16.5% reported
not taking any sugar.[14]
[15]
Only 51 (49.5%) patients claimed to have self-care information that they received
from friends/relatives (13; 25.5%), 37 (73%) from health team members, and 1(2%) from
the mass media. Another study found most subjects receiving advice on the importance
of self-care in the management and recognized its importance. Sixty-seven subjects
(53%) scored below 50% in their diabetes-related knowledge.[16]
Clinical Variables
A significant improvement was found in the clinical parameters of diabetic clients
after the intervention in blood sugar (p < 0.05), systolic BP (p < 0.001), and diastolic BP (p < 0.001). However, no change was found with BMI (p >0.05). Post-hoc analysis showed there was a significant change in the clinical parameters
after the intervention between the time periods of second and fourth weeks. Another
study found self-care scores were inversely related to hemoglobin A1c % (HbA1c%) (p = 0.008), BMI (p = 0.001), sugar intake (p = 0.005), and were lowest in the area of weight control and exercise. Only 23% had
blood glucose controlled to HbA1c ≤ 6.5%. In women, HbA1c% levels were inversely related
to compliance with medication (p = 0.004). Glycemic control in adults with diabetes mellitus is related to their self-care
practices, especially weight control, exercise, and medication compliance.[15] Yet another study found patients in the intervention group significant improvement
in HbA1c, BP, body weight, efficacy expectation, outcome expectation, and diabetes
self-management behaviors.[17] Another study found subjects with medication nonadherence (46%) also tended to have
higher fasting blood glucose levels. Predictors of knowledge deficit and poor self-care
were low level of education (p = < 0.01), older subjects (p = 0.04) and T2DM subjects on oral antihyperglycemic medication (p = < 0.01).[16]
Compliance
Compliance improved from 29 (28.2%) to 47 (45.6%), partially compliant from 55 (53.4%)
to 45 (43.7%) and noncompliant from 19 (18.4%) to 11 (10.7%) with a clear improvement
in each of the domains of compliance. Another study revealed better compliance among
the clients.[18] A telephone survey of 103 diabetic adolescents found more than 80% of patients reported
≥ 75% medication compliance, and 59% monitored blood glucose > 2 times daily.[14] Another study among 106 study subjects with poor glycemic control in a tertiary
care hospital observed poor compliance was in 89.62% patients and 10.38% had good/acceptable
compliance. Compliance was better in above 60 years age group, in males, in married,
and educated persons. Noncompliance factors acted mostly in combination.[19] Another study in adults found only 45% reporting full compliance with medications.[15]
Another study found significant reduction in the average number of barriers to medication
adherence from pre (3.7) to post (2.2; p < 0.001) in those who completed the program.[20] Another study identified strategies for improving patient outcomes in T2DM, increasing
provider adherence to evidence-based management guidelines, streamlining practice
systems, and promoting patient lifestyle changes through intensive education.[18]
Conclusion
In diabetes self-management education, the close involvement of patients and care
givers is encouraged. Educated patients can positively affect the outcome of the disease
in multiple ways. Reinforcement of education ensures long-term blood glucose control,
as the person remains adherent to what has been taught, checks the accuracy of acquired
knowledge, has access to new data or even facilitates the development of new practices
and new behavior patterns.
Management of a disease like diabetes is more related to lifestyle and less related
to the quality of the provided health care and services. It is assumed that the home
visit component will enhance acceptability and readiness of clients, thereby improving
the acceptance of services by the nurses. Compliance status will help plan strategies
for improvement in health of clients. Standardized teaching/education materials and
approach help improve dissemination of information to clients in the community and
to provide comprehensive knowledge base for clients that will contribute towards health
and disease prevention. Coaching of behavior change through communication by nurses
and nurse practitioners is a feasible alternative for primary care towards improving
patient self-management of T2DM.
This study attempted to screen the communities for diabetes in their homes and deliver
nurse-led services at the doorsteps of clients. The nurse-initiated intervention at
home is a cost-effective strategy that can be emulated in community health nursing
practice for early detection and management. The success of the nurse-led home care
intervention will ensure the applicability of the concepts into health-care practices
in the community.
