Exploring the feasibility of implementing self-management and patient empowerment through a structured diabetes education programme in Yogyakarta City Indonesia: a pilot cluster randomised controlled trial.

Abstract

BACKGROUND Diabetes is a global public health problem which can cause serious disabling complications. Indonesia is among the top four countries with the highest numbers of diabetes. Diabetes self-management education (DSME) is widely recognized as an essential element of diabetes care. Patient empowerment has long served as the philosophical foundation for DSME. However, self-management and patient empowerment are largely unknown in diabetes education and care in Indonesia. The current traditional diabetes education found in hospitals and publicly funded community health centres (CHCs) does not incorporate these two concepts. Therefore, there is a particular need for research on DSME and patient empowerment for people with type 2 diabetes (T2D) in Indonesia. AIMS The main aims of this research project were to develop a pilot model of a structured diabetes education programme promoting diabetes self-management and patient empowerment for people with T2D in the primary care setting in Indonesia, and to evaluate its effectiveness on clinical outcomes and diabetes-related scores of knowledge, health beliefs, self-care behaviours, and self-efficacy. The research project also aimed to cross-culturally adapt the 24-item Diabetes Knowledge Questionnaire (DKQ-24), the Diabetes Health Belief Measure (DHBM), the Summary of Diabetes Self-Care Activities revised scale (SDSCA), and the Diabetes Empowerment Scale - Short Form (DES-SF); and to identify the perceptions of people with T2D and their family members, and health care providers (HCPs) towards the current diabetes education and/ or diabetes education intervention administered. METHODS This research project was undertaken in two studies. A convenience sample survey (n = 83) was used to test the internal consistency reliability of the final Indonesian versions of the DKQ-24, the DHBM, the SDSCA, and the DES-SF in an Indonesian population (Study 1). The internal consistency reliability of the adapted instruments were then reassessed among the participants of the main study (n = 101). A pilot cluster randomised controlled trial comparing a four-weekly structured diabetes education programme (intervention group = 51) and a three-hour diabetes seminar trial (control group = 50) in improving clinical outcomes and diabetes related scores of knowledge, health beliefs, self-care behaviours, and self-efficacy for patients with T2D was conducted at four community health centres (CHCs) in Yogyakarta City, Indonesia (Study 2, the main study). Both groups received a set of comprehensive diabetes leaflets. Outcome assessment was performed at baseline and 3 months after the research interventions were completed. Six scoping discussions were also conducted with four groups of patients with T2D and their family members (n=43), and two groups of health care providers working at the participating CHCs (n=18). Quantitative data were double-entered for verification, analysed and digitally stored using SPSS statistical software version 18. Descriptive statistics were used to examine sociodemographic characteristics and medical history outcome variables. Cronbach‘s alpha coefficients were performed to assess the internal consistency reliability of the Indonesian version of the DKQ-24, the DHBM, the SDSCA, and the DES-SF. T-tests were used to analyse differences on continuous data between mean scores for the intervention and control groups. Categorical data were analysed using Chi-square statistics to test the significance of different proportions. Repeated measures ANOVA were used to assess the group differences on clinical outcomes and diabetes-related scores of diabetes knowledge, health beliefs, self-care behaviours and self-efficacy. Scoping discussions were audiotaped and notes of important issues were taken during the discussions. Loose transcription of discussions and interview notes were combined to generate a summary of key findings. RESULTS Study 1 Using the main study population, the Indonesian versions of DKQ-24 (α = 0.723) and the DHBM (α = 0.718) demonstrated satisfactory internal consistency reliabilities. The Indonesian versions of 10-item SDSCA (α = 0.605) and the DES-SF (α = 0.595) showed adequate internal consistency reliabilities to be used as research instruments for a preliminary study. Study 2 (the main study) Participation in the structured diabetes education programme led to significant improvements only in diabetes knowledge (95% CI = 1.43 to 14.75; p = 0.004); 2-hour postprandial plasma glucose level (95% CI = -2.82 to 1.58; p = 0.02) and waist circumference (95% CI = -6.15 to 5.14; p = 0.04) at 3-month follow-up. The intervention group demonstrated improvements in HbA1c (primary outcome), fasting blood glucose, systolic and diastolic blood pressure, body weight, BMI, the SDSCA scores on general diet, specific diet, exercise, blood sugar testing and foot care, and the DES-SF score. However, these changes did not significantly differ to the changes in the control group. Findings from soping discussions suggested that there was inadequate provision of traditional diabetes education due to constrained resources and the characteristics of patients attending CHCs. Patients with T2D attending CHCs were ready and enthusiastic to engage with diabetes self-management and patient empowerment concepts. In contrast, the scoping discussions raised questions about the readiness of HCPs working at CHCs to embrace diabetes self-management education, particularly when they were reluctant to engage adequately in traditional diabetes education, let alone accommodate the patient empowerment concept. CONCLUSION A structured diabetes education programme for patients with T2D resulted in significant improvements in diabetes knowledge, 2-hour postprandial plasma glucose level and waist circumference at 3-month follow-up, but no significant difference in the primary outcome (HbA1c). The findings of this preliminary study can contribute to the development of DSME programmes based on patient empowerment approach in the primary care settings with limited resources, and will provide building blocks for an improved programme of diabetes education and care in Indonesia.