INTRODUCTION:

Diabetes is a global epidemic and it is posing the biggest threat ever witnessed with devastating human, social and economic consequences¹.

Diabetes mellitus is defined as 'a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.^2,3 It is estimated that globally approximately 415 million adults have diabetes; to 120.9 million by 2030.⁴ The prevalence of diabetes in Kerala is 20%. Prediabetes is a wakeup call that we are on the path to diabetes. Prediabetes is the precursor stage before diabetes mellitus in which not all of the symptoms required to diagnose diabetes are present, but blood sugar is abnormally high. People with prediabetes have a higher risk of developing Type II diabetes mellitus and other health problems like stroke and cardiovascular diseases.⁵

NEED AND SIGNIFICANCE OF THE STUDY:

According to the American Diabetes Association (ADA), people who develop type 2 diabetes nearly always have prediabetes. This means blood glucose levels are elevated, but not high enough to be considered diabetes. The Centres for Disease Control and Prevention (CDC) estimates 84 million adult Americans have prediabetes, and 90 percent go undiagnosed. Studies in India have shown that nearly 40-55% of the people with prediabetes stage would develop to type 2 diabetes mellitus over a period of 3-5 years⁶. The prevalence of prediabetes is increasing worldwide and it is projected that >470 million people will have prediabetes in 2030. India is the diabetes capital of the world; 77.2 million people in India are said to have prediabetes. In the year 2012, Kerala reported a prevalence of diabetes at 20% and prediabetes at 11%. Considering the high cost and high visibility of the disease across all sections of the society, urgent research and intervention are required to alleviate the predicted calamitous increase in diabetes in the near future. In addition, an active personal awareness, improved lifestyle changes, proper dietary and exercise habits and regular check-ups are highly recommended to rule out the possibility of diabetes and support long-term health.⁷

PURPOSE OF THE STUDY:

The purpose of the study is to assess the effectiveness of the structured teaching programme on knowledge, attitude and practice regarding home care management of Type II diabetes mellitus among prediabetes patients.

STATEMENT OF THE PROBLEM:

Effectiveness of structured teaching programme on knowledge, attitude and practice regarding home care management of Type II diabetes mellitus among prediabetes patients in selected wards of Chunakkara Panchayat, Aleppey District.

OBJECTIVES OF THE STUDY:

1. Determine the effectiveness of structured teaching programme regarding home care management of Type II diabetes mellitus among prediabetes patients by comparing the pre-test and post- test knowledge, attitude and practice scores.

2. Find out the association between the pre-test knowledge, attitude and practice scores with selected demographic variables.

Assumptions:

Structured teaching programme may be effective in home care management of diabetes mellitus.

Hypothesis:

H1: There will be significant difference in pre-test and post-test knowledge, attitude and practice scores among prediabetes patients on home care management of Type II diabetes mellitus following structured teaching programme.

H2: There will be an association between pre-test knowledge, attitude and practice scores with selected demographic variables.

Conceptual Framework:

Roy’s Adaptation Model (1981)⁸

RESEARCH METHODOLOGY:

The research approach and design adopted for the study is quantitative research approach and a pre-experimental one group pre-test- post- test design. Population in this study consists of 50 prediabetes patients of 11th, 14th and 15th wards of Chunakkara Panchayath, Aleppey District who were selected using non-probability sampling technique.^9,10,11

Inclusion Criteria:

1. Persons whose postprandial blood sugar value is between 140-200 mg/dl.

2. Persons whose fasting blood sugar value is between 100-126mg/dl

3. Persons with family history of diabetes mellitus.

4. Persons between ages of 30-60 years.

5. Persons who are willing to participate.

Exclusion Criteria:

1. With associated diseases or complications of diabetes mellitus.

2. Persons who are diagnosed with other metabolic disorders.

Description of the Tool:

Part 1: Socio demographic data and checklist for screening prediabetes patients:

Section A: This part of the tool consisted of socio demographic data which includes age, sex, education, occupation, religion, marital status, type of family, and socioeconomic status.

Section B: This part of tool consisted of the checklist for screening the prediabetes patients which includes weight, height, BMI, Waist hip ratio of the patient, family history of Type II Diabetes mellitus or not, whether performing regular exercises or not, had gestational diabetes or not, whether having bad habits of smoking, alcoholism, presence of signs and symptoms of diabetes mellitus, fasting and post prandial blood sugar values and blood pressure.

Part 2: Structured Knowledge Questionnaire:

The knowledge questionnaire developed by the investigator consists of 30 multiple choice questions regarding diabetes mellitus, types, its causes, signs and symptoms, diagnostic measures, medical management, home care management regarding diet, exercises, self-glucose monitoring and prevention of complications of diabetes mellitus to assess the knowledge of the prediabetes patients.

Part 3: Likert scale:

Likert scale to assess the attitude statements of prediabetes patients regarding home care management of Type II Diabetes mellitus. It consists of 7 positive attitude and 3 negative attitude statements developed by the investigator related to home care management of Type II Diabetes Mellitus.

Part 4: Self- reported practice checklist:

A brief self-reported practice questionnaire of 10 questions regarding diabetes self-management that includes items assessing the following aspects of the diabetes regimen: diet, exercise, smoking, alcoholism, blood glucose testing and foot care.

Part 5: Intervention: Structured Teaching Programme:

Structured teaching programme to the prediabetes patients using appropriate audio-visual aids and an information booklet with detailed description about current scenario, prediabetes, diabetes mellitus, its types, causes, signs and symptoms, diagnostic evaluations, medical management, home care management related to diet, exercise, self-glucose monitoring and prevention of its complications.

Data Collection Procedure:

Phase I: After getting approval from the concerned authorities for the study, the questionnaires for the sociodemographic data, screening criteria for prediabetes patients, knowledge questionnaire, attitude scale, self-reported checklist and the lesson plan for structured teaching programme was designed and prepared.

Phase II: The researcher and the Panchayat with the help of Community Health Centre had conducted three medical camps in the 11th, 14th and 15th wards of Chunakkara Panchayat from 14th February to 16th February 2018. 250 people attended the camps and by preclinical examination using, the prediabetes screening checklist 50 samples whom all fulfils the inclusion criteria were selected by using non-probability purposive sampling technique. In this phase, the researcher explained about the study and its purpose to the samples and then obtained their informed consent for their participation in the study. The researcher collected the addresses and got the convenient date and time from the samples for the data collection.

Phase III:

The investigator visited all the houses of the samples with their prior permission. After assuring the confidentiality, the subjects were requested to participate in the study. Socio-demographic data was collected and the subjects were screened for prediabetes. The validated structured questionnaire, Likert scale and self-reported practice checklist were used to assess the pre-test knowledge, attitude and practice regarding the home care management of Type II Diabetes mellitus among the subjects. The information booklet and the self-reported practice checklist prepared were given to the samples. The researcher daily monitored the practice of the samples using the practice checklist.

Phase IV:

Post- test was done to assess the knowledge, attitude and practice of the samples regarding home care management using the same tool among the same subjects after 7 days following the teaching programme to evaluate the effectiveness of the structured teaching programme.

RESULT AND DISCUSSION:

Section A: Description of demographic variables of the sample

Table 1: Shows distribution of the subjects based on demographic variables (n=50)

Sl. No	Variable		Frequency (n)	Percentage (%)
1.	Age	30-40 years	12	24
		41-50 years	17	34
		51-60 years	21	42
2.	Sex	Male	21	42
2.	Sex	Female	29	58
3.	Education	Illiterate	0	0
		Primary	16	32
		High School	23	46
		College	11	22
4.	Occupation	Daily wages	12	24
		Government	4	8
		Private	8	16
		Home maker	26	52
5.	Religion	Hindu	29	58
		Christian	18	36
		Muslim	3	6
		Others	0	0
6.	Marital status	Married	50	100
6.	Marital status	Unmarried	0	0
7.	Family pattern	Nuclear family	49	98
7.	Family pattern	Joint family	1	2
8.	Income	<3000 Rs	7	14
		3000-5000 Rs	16	32
		5001-10000 Rs	16	32
		>10000 Rs	11	22

Fig 1: Pie diagram showing the distribution of prediabetes patients based on signs and symptoms reveals that the vast majority (96%) of the subjects not had any signs and symptoms of diabetes mellitus and less than one-tenth (4%) had the signs and symptoms of diabetes mellitus.

Fig 2: Bar diagram reveals that less than three fourth (72%) of subjects not performing exercises regularly and more than one fourth (28%) of the subjects performing exercises regularly.

Table 2: Comparison of the subjects based on pre-test and post-test knowledge regarding the complications of diabetes mellitus.

Sl. No	Complications of diabetes mellitus	Pre-Test		Post-Test
Sl. No	Complications of diabetes mellitus	N	%	N	%
1.	Major and minor complications of diabetes mellitus	15	30%	37	74%
2.	Prevention of diabetic foot ulcers	8	16%	45	90%
3.	Signs of hypoglycaemia	21	42%	45	90%
4.	Prevention of complications of diabetes mellitus	7	14%	37	74%

Section B: Effectiveness of structured teaching programme on home care management of Type II diabetes mellitus among prediabetes patients

Table 2: Shows the effectiveness of structured teaching programme on home care management of Type II diabetes mellitus among prediabetes patients (n=50)

Sl. No	Knowledge Score	Frequency In Pre-test(n)	% In Pre-test (%)	Frequency In Post Test (%)	% In Post Test (n2)
1	Good (21-30)	0	0%	42	84%
2	Average (11-20)	24	48%	8	16%
3	Poor (1-10)	26	52%	0	0%

Table 3: shows distribution of prediabetes patients based on knowledge regarding home care management of type II diabetes mellitus(n=50)

Parameter	Mean	S. D	Mean difference	Df	‘t’ value	‘p’ value
Pre-test	11.28	2.64	11.92	49	26.63	p<0.05*
Post-test	23.20	2.78	11.92	49	26.63	p<0.05*

Table value t49 = 2.0096 * P<0.05 Significance

Table: 4 Mean, Mean Difference, Standard Deviation and T Values of Pre-Test and Post Test Knowledge Scores (n=50)

Sl. No	Attitude Score	Frequency in Pre-test (n)	Percentage in pre-test (%)	Frequency in post test (n2)	Percentage in post test (%)
1	Good (38-50)	26	52%	38	76%
2	Average (26-37)	18	36%	12	24%
3	Poor (less than 25)	6	12%	0	0

Fig 3: shows the graphical representation of pretest attitude and post -test attitude scores

Comparison of pre- test and post -test attitude scores of prediabetes patients regarding home care management of Type II Diabetes mellitus:

Table 5: shows distribution of subjects based on pre-test and post-test attitude regarding home care management of type II diabetes mellitus. (n=50)

Parameter	Mean	Median	SD	Median Percentage
Pre-Test	28.88	29	4.855	57.76
Post-Test	42.74	42	3.69	85.48

Table 6: Mean, Mean Difference, Standard Deviation and T Values of Pre Test And Post Test Attitude Scores (N=50)

Parameter	Mean	SD	Mean Difference	‘t’ Value
Pre test	28.88	4.855	13.86	18.322
Post test	42.74	3.69	13.86

Table 7: shows distribution of subjects based on pre-test and post-test practice regarding home care management of type II diabetes mellitus.

Sl. No	% Score	Frequency in Pre-test (N)	% in Pre-test (%)	Frequency in Post Test (N2)	% in Post Test (%)
1	Good (51-70)	0	0	13	26%
2	Average (36-50)	13	26	37	74%
3	Poor (less than 35)	37	74	0	0%

Table 8: Comparison of pre- test and post- test practice scores of prediabetes patients regarding home care management of Type II Diabetes mellitus

Parameter	Mean	Median	SD	Median Percentage
Pre-Test	33.10	33	5.33	66.2
Post-Test	46.58	47	5.12	93.16

Fig 4: Graphical Representation of Pre- Test and Post Test Practice Scores

Section C: Association of pre- test knowledge score, attitude scale and practice score with selected demographic variables:

The study shows no significant association between knowledge, attitude and practice of subjects with selected demographic variable except practice score and the demographic variable sex with a significance of p<0.05. Thus, sex influences the practice of subjects.

DISCUSSION:

The findings of the present study were compared with the objectives of the study and findings of other studies are reviewed. The first objective was to determine the effectiveness of structured teaching programme regarding home care management of Type II diabetes mellitus among prediabetes patients by comparing the pre-test and post- test knowledge, attitude and practice scores. The major findings of the study were in pre-test out of the 50 prediabetes patients 52% had poor knowledge, 48% had average knowledge and none of them had good knowledge. Whereas in post- test after the structured teaching programme out of the 50-prediabetes patients 84% had good knowledge, 16% had average knowledge and none of them had poor knowledge. In the pre-test, majority (52%) of the prediabetes patients had a good attitude, 36% had an average attitude and 12% had a poor attitude; while in post-test majority had good attitude (76%), 24% had an average attitude and none had a poor attitude regarding home care management of diabetes mellitus. In pre- test, 74% had a poor practice, only 13% has a satisfactory level of practice and no one has a good practice regarding home care management of Type II diabetes mellitus. However, in post- test after the structured teaching programme, about 26% had good practice, 74% had satisfactory level of practice and no one had poor level of practice regarding home care management of Type II diabetes mellitus. The findings showed that there would be significant differences between the pre-test and post-test knowledge, attitude and practice regarding home care management of Type II Diabetes mellitus among the prediabetic patients. The second objective was to find out the association between the pre-test knowledge, attitude and practice scores with selected demographic variables. The findings showed that there is no significant association between pre-test knowledge and attitude with the demographic variables among the prediabetes patients. However, the pre-test practice score is associated with the demographic variable sex. No other significant association found.

The statistical analysis of the data revealed the following findings:

Knowledge level: In pre-test most of the prediabetes patients (52%) had poor knowledge, 48% had average knowledge and none of them had good knowledge. Whereas in post-test after the structured teaching programme most of the prediabetes patients had good knowledge (84%), some of them have average knowledge (16%) and none of them had poor knowledge.

Attitude level: In the pre-test, majority (52%) of the prediabetes patients had a good attitude, 36% had an average attitude and 12% had a poor attitude; while in post-test majority had good attitude (76%), 24% had an average attitude and none had a poor attitude regarding home care management of diabetes mellitus.

Practice level: In pre-test majority (74%) has a poor practice, only 13% has a satisfactory level of practice and no one has a good practice regarding home care management of Type II diabetes mellitus. However, in post-test after the structured teaching programme about 26% had good practice, 74% had satisfactory level of practice and no one had poor level of practice regarding home care management of Type II diabetes mellitus.

This study finding was supported by a cross-sectional study was conducted among 18,697 adults (aged 18 years and above; 7796 male and 10,901 female; 6780 non-DM and 11,917 T2DM) selected purposively from the OPD of 19 healthcare centres in and around Dhaka and in northern parts of Bangladesh. Knowledge, attitude and practice were assessed by a pre-structured, interviewer-administered questionnaire and categorized using predefined scores of poor, average and good. The proportion of poor, average and good knowledge scores among T2DM subjects were 17%, 68% and 15% respectively. The corresponding values for attitude score were 23%, 67% and 10% respectively. The knowledge, attitude and practice regarding diabetes were found to be better among people who were living with diabetes compared to their counterparts. DM males showed better knowledge and practice regarding diabetes, compared to non-DM counterparts females showed better attitude score compared to males. Overall knowledge, attitude and practice were found to be significantly higher (p < 0.001) in middle aged (31–50 years) participants in each group. Participants from urban residents, higher educational background and upper socio-economic class demonstrated significantly greater score in terms of knowledge, attitude and practice in both non-DM and T2DM groups (p < 0.001). On linear regression analysis, knowledge scores correlated strongly with education, income, residence, diabetic state, BMI and attitude. The researchers concluded that the overall level of knowledge and practice concerning diabetes among Bangladeshi population is average, but the overall level of attitude is good both in non-DM and in T2DM subjects. To prevent diabetes and its complications there is an urgent need for coordinated educational campaigns with a prioritized focus on poorer, rural and less educated groups.¹²

CONCLUSION:

Prediabetes is a serious health condition where blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes. Approximately 96 million American adults-more than 1 in 3-have prediabetes. Of those with prediabetes, more than 80% do not know they have it. Prediabetes puts you at increased risk of developing type 2 diabetes, heart disease, and stroke. In Kerala, there is a high burden of pre-diabetes also which in addition to leading a diabetes also increases the risk for heart disease. In the age group of 45 to 69 years nearly two third (67.7%) had either diabetes or prediabetes. The largest impediment against the prevention of diabetes is the attitude of the people. Healthy lifestyle can prevent diabetes in up to 70% population. The state has to ensure community participation, build infrastructure and bring in due legislation that helps in the fight against diabetes.

NURSING IMPLICATIONS:

The researchers have derived the following implications from the study which are of vital concerns in the field nursing service, nursing administration, nursing education and nursing research.

Nursing Practice:

· Community health nurse has to plan, implement and evaluate various teaching programmes regarding home care management of Type II Diabetes mellitus.

· Mass awareness programme can be conducted among prediabetes patients regarding importance of home care management of Type II Diabetes mellitus.

· The instructional media (information booklet) can be provided to the participants regarding.

Nursing Education:

· Importance of home care management of Type II Diabetes mellitus can be implemented in curricula GNM, BSc. (N) and MSc. (N).

· Nurse educator can teach community health nurses and student nurses regarding the importance of educating prediabetes patients about home care management of Type II Diabetes mellitus. Community health nurse in primary health centres can conduct in service education to “ASHA” workers and “Anganwadi” workers regarding home care management of Type II Diabetes mellitus.

· Nurse educator can develop brochures, leaflets or pamphlets regarding the importance of home care management of Type II Diabetes mellitus and it can be displayed in PHC and sub centres.

Nursing Administration:

· Public health nurse can think about the measures that can be adopted among the prediabetes patients to prevent Type II diabetes mellitus.

· In-service education programme can be conducted through the workshop or seminar to update the knowledge of staff nurses/community health nurses regarding home care management of Type II Diabetes mellitus.

· Public health should work with Panchayath to use maximum available resources to prevent Type II Diabetes mellitus and to develop public relations.

Nursing Research:

· A similar study conducted to identify the factors that prevent the prediabetes from effective home care management of Type II Diabetes mellitus.

· The finding of study can be communicated through the journal publication.

· The nurse researcher can further explore better ways to impart knowledge to nursing staff.

REFERENCES:

1. Sarah Wild, Gojka Roglic, Anders Green, Richard Sicree, Hilary King. Global Prevalence of Diabetes Estimates for the year 2000 and projections for 2030. Diabetes Care. 2004. May; 27(5) :1047–1053. Available from http: // www. who. Int / diabetes /facts/en/diabcare0504.pdf

2. Diabetes mellitus. Wikipedia. Available from: http://en.wikipedia.org/wiki/Diabetesmellitus

3. Smeltzer C Suzanne, Bare G Brenda, Janice Hinkle L, Kerry Cheever H. Brunner and Siddharth’s Textbook of Medical Surgical Nursing. 12th ed. II. New Delhi: Wolters Kluwer; 2011, 1377-1380.

4. International Diabetes Federation. Diabetes: Facts and Figures. Europe: The Federation; 2015; Available from: http://www.idf.org/about-diabetes/facts-figures

5. Maya C. Kerala has high rates of diabetes incidence. Ernakulam: The Hindu; 2016. Available from: http://www.thehindu.com/news/cities/Thiruvananthapuram/kerala-has-high-rate-ofdiabetes-incidence/article8457105.ece.

6. Prediabetes. Wikipedia. Available from: https://en.wikipedia.org/wiki/Prediabetes.

7. Prediabetes. Centres for Disease Control and Prevention. Available from: https://www.cdc.gov/diabetes/basics/prediabetes.html.

8. Adaptation model of nursing. Wikipedia. 12 October 2017; Available from: https://en.wikipedia.org/wiki/Adaptation_model_of_nursing.

9. Polit F D, Beck T C. Nursing Research: Principle and Methods. 9th edition; Philadelphia; Lippincott Williams and Wilkins Publications; 2011; 94-125.

10. Suresh S K. Nursing Research and Statistics. 2nd edition; Haryana; Elsevier Publications; 2015; 101-116

11. Shyamalan. Statistics in Medicine. 1st edition; Trivandrum; Global Education Bureau; 2006.

12. Shafiur R, Reza M, Kourosh H N, Owais R. Knowledge, Attitude and Practices (KAP) Regarding Chronic Complications of Diabetes among Patients with Type 2 Diabetes in Dhaka. International Journal of Endocrinology Metabolism. July 2017; 15(3); Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5702002/

Received on 17.03.2023 Modified on 02.04.2023

Asian J. Nursing Education and Research. 2023; 13(2):123-129.

DOI: 10.52711/2349-2996.2023.00027