Effectiveness of an educational intervention in the integral care of patients with diabetes mellitus

Introduction

Diabetes mellitus (DM) is a chronic metabolic disease with heterogeneous etiology and varied clinical presentation. Its microvascular and macrovascular complications affect various organs and systems and the patient’s quality of life due to the costs associated with it.¹ It has a high prevalence worldwide² and increasingly affects age groups under 40 years of age. It is related to overweight or obesity, sedentary lifestyle and consumption of processed foods. It is also reported that between 50 and 70% of DM cases are not controlled. DM was the sixth leading cause of death in Peru in 2018³ and in the American continent, it occupied the same place as a cause of death in 2019.²

Older adults with type 2 DM are at greater risk of presenting comorbidities and geriatric syndromes^4,5 and many live alone; factors that complicate the metabolic control of diabetes.⁴ There is a worldwide consensus that a decrease in the frequency of complications is achieved when the patient takes responsibility for the care of his/her disease and the best strategy to achieve this is education of both the patient and the family.^6–8 For this reason, research is oriented towards the study of programs that through the approach of clinical, educational, behavioral and psychosocial aspects, help to develop positive health behaviors in patients, to meet the treatment objectives, decision making and the guidelines required for optimal self-care of DM.^7,9

Adherence to pharmacological treatment can be influenced by the patient’s beliefs, culture and level of education, but also by the way in which the physician communicates and informs, so it is important to analyze these factors to contribute to metabolic control¹⁰: fasting glycemia between 80-130 mg/dL; HbA1c < 7%; blood pressure <130/80 mm Hg; LDL cholesterol <100 mg/dL; HDL cholesterol >50 mg/dL and triglycerides <150 mg/dL.¹¹

Health systems promote comprehensive care for people with chronic disease, which requires the participation of physicians, nurses, nutritionists, social workers, psychologists, as established in the family and community-based model of the Peruvian Ministry of Health.¹² Likewise, ESSALUD promotes the standardized and progressive health care model to guarantee the follow-up of people with chronic pathology. This model places the patients as co-responsible for their care, especially in their lifestyles, and as the center of a system for the delivery of comprehensive and interprofessional services over time.¹³

The integral care of a diabetic patient includes health education with emphasis on behavioral aspects such as daily exercise, healthy eating, glycemic control and medical check-ups. Preventive behaviors include a physical activity plan or a healthy diet, i.e., patients and their families should be aware of carrying out these activities and know how to do them, incorporating the new knowledge into their daily activities.¹⁴

We consider that the present study is important to understand the family and sociocultural context of patients with DM attending the I Albrecht Hospital and to identify the factors that favor or hinder compliance with treatment, namely: level of knowledge about DM and its complications, beliefs about diabetes, diet, physical activity, family support for food preparation, attendance to controls and level of therapeutic adherence. It is also of practical relevance to standardize educational interventions in workshops adapted to the existing reality in charge of the health team, so the general objective was to evaluate the efficacy of an educational intervention in the integral care of the patient with diabetes mellitus through the pre and post intervention analysis of knowledge about DM, dietary habits, type and frequency of physical activity, metabolic control, adherence to treatment and family support.

Methods

A quantitative, pre-experimental design study with pre-test and post-test was conducted. The population consisted of 580 outpatients with DM2 attended per month in family medicine at Hospital I Albrecht - Essalud during the second semester of 2024.

Patients of both sexes, aged 40-79 years, with a diagnosis of DM2, with physical and mental autonomy, treated with oral hypoglycaemic agents alone or in combination with insulin, who agreed to participate in the study by signing the informed consent form and who attended at least 80% of the scheduled sessions were selected. Patients with limiting chronic complications (blindness, amputations, heart failure, G4 chronic kidney disease) and patients with DM2 referred to other facilities were excluded.

The sample size was 150 participants and it was calculated with the formula for population proportions considering a confidence level of 95%, a test power of 80%.¹⁵ Forty-seven patients dropped out: 15 did not attend all the scheduled workshops, 10 because they did not have someone to accompany them to the analysis, 4 because they traveled, 7 because they did not perform the post-intervention analyses, and 7 because they withdrew their informed consent; for this reason, the results of 103 patients who completed the entire program are presented.

Consecutive non-random sampling was performed,¹⁶ since participants were invited to participate in the study on the day they came to the appointment and the sampling frame consisted of the lists of patients with DM2 scheduled for outpatient family medicine consultations, in morning and afternoon shifts, six days a week and until the sample was complete.

Pre and post educational intervention, the variables level of knowledge about diabetes, eating habits, glycemic control, adherence to treatment and family support were analyzed.

Regarding comprehensive care, the following variables were analyzed pre and post intervention: fasting glycemia, glycosylated hemoglobin, medical and nursing control attendance, pharmacological treatment compliance report, healthy eating report, physical activity and family support.

Results

Table 1 shows that 60.2% are women, the average age of the patients is 63.22 years, 68.0% are 60 years or older, 42.7% have higher education, 70.9% are married or cohabiting, 44.7% are employed or self-employed, 97.1% have type 2 diabetes mellitus and regarding the duration of the disease, 38.8% are less than 5 years. 72.8% were treated with metformin and the main comorbidity was arterial hypertension with 58.3%.

Table 2 shows a significant improvement in patients’ knowledge after the intervention. The mean knowledge improved with statistically significant difference (p < 0.001). With respect to family support there was a significant improvement in the level of support after the intervention. The difference between the means is statistically significant (p = 0.043), according to the Student’s t-test. The educational intervention not only increased average family support, but also homogenized the level of support among families, reducing the dispersion of scores. Regarding eating habits, it is evident that the educational intervention achieved a significant change as the percentage of patients with healthy eating habits increased from 3.9% to 12.6% (p = 0.022), indicating better adherence to a balanced diet (p = 0.022).

Table 3 shows that 51.5% of the participants stated that they did not comply with the prescribed treatment.

In Table 4, McNemar’s test shows a significant difference (p < 0.01) in the proportion of patients complying with treatment before and after the intervention, suggesting that the intervention had a positive impact on improving treatment compliance. 76.8% of patients who were compliant with treatment maintained that behavior after the intervention. However, the proportion of patients who were initially noncompliant with treatment and failed to improve their compliance remained.

Table 5 shows that there was no improvement in glycemic control with the educational intervention. The mean glucose went from 132.5 to 143.1 according to the Wilcoxon test. The proportion of patients with adequate glycemic control dropped from 60.19% to 48.54% post intervention.

In Table 6, we can see that 83.5% of patients have at least a quarterly follow-up with their physician and 44.7% with nursing, which indicates a regular frequency of follow-up according to EsSalud standards. Regarding Hba1c levels, the mean Hba1c is 7.54% for patients ≤ 69 years and 6.96% for patients ≥ 70 years. Only 33% of <70 years and 17.5% of >70, have good metabolic control.

Discussion

The population studied was predominantly female, with an average age of 63.22 years, higher education, married or cohabiting, and with a main occupation as an employee. Almost all patients had type 2 diabetes mellitus (DM2). As for the duration of the disease, the most frequent was less than 5 years. Two thirds of patients receive treatment with metformin and the main comorbidity was arterial hypertension.

With respect to the characteristics of the population, in a Peruvian study on family support and glycemic control, the predominant population was female, with a mean age of 63.5 years ±12.10 years, occupation housewife followed by independent worker and the most common level of education was secondary education followed by primary education,²⁴ data very similar to those recorded in this study. Other studies also report a predominance of women, mean age of 53.14 years ±8.99, marital status married,⁸ employed and with secondary education.⁶ Other studies reported that the average age was 63 years.^26,27 with a predominance of women (55.9%) but the majority of patients had only primary education (58.9%), followed by those with secondary education (20.5%).²⁶

Regarding the time of illness, 70.30% of the patients had a time of illness less than or equal to 15 years (n = 111), and in 29.70%, it was more than 15 years. The average time of illness was 11 years, with a standard deviation of 9.51.²⁶ While in a study carried out in Colombia, the average time since the diagnosis of DM was 11.3 ± 8.5 years.¹⁹ Regarding this variable, it is important to mention that it is referred by the patient and that many of them are not clear about the time of illness, they tend to deny the disease or say that it is of recent onset.

In the present study, we found a significant improvement in patients’ knowledge about Diabetes Mellitus (DM) and its complications after the educational intervention (p < 0.001) and the level of adequate knowledge increased from 83.5% to 95% after the intervention (p < 0.001). About this variable, it has been described that those educational interventions are useful to change a certain behavior and to facilitate adequate self-care²⁸ and that structured educational programs for patients with DM2, especially aimed at older adults, have great potential; however, there is still room for improvement.²⁹ In the present study, the DKQ-24 17 was used to identify the knowledge that patients with DM2 have of the disease, with the cut-off point of correctly answering ≥ 55% of the questions. The DKQ-24 is one of the most widely used questionnaires and the results indicate that more than 75% have adequate knowledge about their disease. Thus, a study conducted in ESSALUD with a population with similar characteristics in terms of sex, marital status and educational level, established a cut-off point of 75% for the results of the DKQ-24, and found that 17% of patients with DM2 had adequate knowledge.³⁰

In the present study, the educational intervention achieved a significant change in the dietary habits of patients with DM, with better adherence to a healthy diet (p = 0.022). The Health Belief Theory explains that in order for patients to change behavior, they must perceive and understand the seriousness of the disease and the benefits of changing behavior³¹ and adopting new habits.³² They must also understand the effects of not changing. In this way, patient self-care is encouraged.^31,32 From the health services, relevant and timely education, according to the Integrated Theory of Health Behavior Change, promotes knowledge and attitude change in patients as the only way to modify the behavior of the community. Both theories are applied in the case of patients with diabetes mellitus.

When analyzing treatment compliance, 51.5% of the participants reported noncompliance. This finding is consistent with the 35-50% non-compliance rate reported in patients with chronic diseases, which is even higher in developing countries.³³ A Peruvian study reported that 74.3% of patients were not adherent to DM treatment2³⁰ Patients are considered to be adherent to DM2 treatment when they have a compliance rate>=80% of pharmacotherapy and recommendations on diet, exercise and disease self-management, although in practice, less than 10% of patients with DM2 meet these criteria.³⁴

In this regard, a panel of 58 experts pointed out that lack of adherence to treatment in patients with DM2 leads to an increase in visits to emergency services, hospitalizations, failure to achieve therapeutic objectives, higher healthcare costs and a decrease in the patient’s quality of life. It also has negative consequences for the patient’s health and can mislead the treating physician as to the real effectiveness of the medication.³⁴

The educational intervention had a positive impact on improving family support, especially in families that initially had a high level of support. Research highlighted that family involvement is very important in the management of diabetes, as it resulted in a greater reduction in glycosylated hemoglobin HbA1c and a significant improvement in adherence to treatment. Intervention with family involvement is useful in diabetes management, especially when spouses or women are caregivers,³⁵ an effect that through multivariate analysis showed that family members who were spouses or women were strong predictors of better glycemic control.³⁶

The literature reviewed indicates that any educational intervention aimed at patients with DM2 should involve family, friends and organizations in the community in which the patient lives, ideally within the framework of a government policy that provides the patient with a social support network.⁶ It has also been described that the involvement of family members and caregivers is very important as one of the most influential factors in diabetes self-care practices and in the maintenance of long-term improvements.²⁹

The educational intervention had a positive impact on improving compliance with treatment. Of the patients who adhered to their treatment, 76.8% maintained this behavior after the intervention, although the proportion of patients who initially did not adhere to their treatment and did not manage to improve their adherence was maintained.

A patient with DM2 with good adherence to pharmacological treatment is more likely to also comply with adherence to the rest of the indications and change their eating, physical activity, and recreational habits.³⁴

Adherence to treatment has been shown to depend on several factors, including different individual and social levels, as most of them depend on the patient, the medication, the health care providers and the health care systems. Studies identified some of these factors for diabetes mellitus, such as depression, education level, gender, age, smoking status and employment status. Therefore, it is important to identify and pay attention to the effective factors involved in adherence to treatment in diabetic patients.³²

The educational intervention showed no improvement in glycemia values and the proportion of patients with adequate glycemic control dropped from 60.19% to 48.54% after the intervention. It is likely that the time of the educational intervention should have been longer to evaluate this variable, since in other studies it takes between 8 to 12 months to achieve favorable changes in metabolic control⁸ and maintaining them over time is more difficult. Therefore, follow-up periods of more than three years are recommended with periodic reevaluation of the patients at the end of the educational intervention.¹⁰

Regarding integral control, the majority of patients comply with the EsSalud standard by performing at least a quarterly control with a physician and less than 45% comply with nursing control. Regarding Hba1c levels, the mean Hba1c is 7.54% for patients ≤ 69 years and 6.96% for patients ≥ 70 years. Only 33% of <70 years and 17.5% of >70, have good metabolic control. This is similar to that reported in a study in which patients with an average age of 63.9 years had HbA1c of 7.5%.²⁷

It has been described that it is important to adapt the general glycemic control goal (HbA1c < 7%) to each patient. Thus, in people without frailty and without risk of hypoglycemia, the HbA1c goal is < 6.5% and in the presence of frailty, comorbidities and risk of hypoglycemia, a less strict glycemic control goal may be appropriate (HbA1c 8-8.5%).³⁷ Other authors suggest that the HbA1c goal should also be adapted according to the patient’s age, years of disease and presence of complications.²⁴

It is important to consider that there are seven variables that are significantly associated with good diabetes mellitus control (P < 0.05): self-reported medication adherence, number of medications to which patients did not adhere, medication knowledge, diabetes knowledge, education level, total self-efficacy, and anxiety.³⁷

Scientific studies that have examined the topic of education in diabetes mellitus have systematically demonstrated that structured educational programs represent a fundamental pillar in disease management. The fact that a diabetic assumes a proactive role in the care of their condition not only favors its metabolic control but also increases patient adherence to their monitoring, contributing to improved nutritional status and clinical parameters related to their disease.⁶

Among the limitations of the study is that the use of structured questionnaires with closed questions could contain biased responses and that the patients cannot express everything they think. It was not possible to implement physical activity workshops because most patients had medical restrictions for physical activity. The duration of the intervention did not allow us to see the change in glycemia and HbA1c values. Also, the generalizability of the results may be limited because the subjects were selected from a single diabetes care program.

It is concluded that structured educational programs are effective in improving the level of knowledge and lifestyles of patients with DM2, and that it is therefore necessary to strengthen these programs to improve the comprehensive care of these patients.

Authors’ contribution

Evelyn Goicochea-Ríos: Conceptualization, formal analysis, methodology, data collection, investigation, visualisation, writing – original draft preparation, writing – review & editing, funding acquisition.

Nélida Milly Otiniano: Methodology, data collection, formal analysis, writing – original draft preparation, writing.