The Open Nursing Journal




ISSN: 1874-4346 ― Volume 13, 2019
RESEARCH ARTICLE

Effectiveness of the “Create Sensitivity” Caring Model on Blood Glucose/ Glycosylated Hemoglobin and Quality of Life in Patients With Type 2 Diabetes



Davood Hekmatpou1, *, Ali Poorgharahkhan2, Mahbobeh Sajjadi3, Amir Javaheri4
1 Nursing. Faculty member of Arak University of Medical Sciences, Arak, Iran
2 Master of Science in Nursing. Arak University of Medical Sciences,. Arak, Iran
3 Faculty member of Arak University of Medical Sciences, Arak, Iran
4 Endocrinologist. Kurdistan University of Medical Sciences. Kurdistan, Iran

Abstract

Objective:

This study aimed to determine the effectiveness of the “Create Sensitivity” caring model on blood glucose/ glycosylated hemoglobin and quality of life in patients with type 2 Diabetes.

Methods:

This study enrolled 70 patients from an educational hospital in Kurdistan, Iran. The model was implemented among the test group over a period of 3 months. Blood glucose/ glycosylated hemoglobin and patients’ quality of life were measured before and after intervention. Data were analyzed using version 21 of the statistical software SPSS.

Results:

After the intervention, significant differences existed between the test and control groups both in blood glucose levels (means, 146.4 ± 51.3 mg/dl and 175.6 ± 59.8 mg/dl, respectively; P=0.032) and in glycosylated hemoglobin (means, 67.89 ± 13.34 mmol/mol and 80.03 ± 17.234 mmol/mol, respectively; P= 0.002). Additionally, there was also a significant difference between the quality of life of the patients in test group (mean, 58.25 ± 5.3) and that in the control group (mean, 47.02 ± 4.5) (P= 0.0001).

Conclusion:

Use of this model was associated with reducing fasting blood glucose and glycosylated hemoglobin and increasing the total mean of quality of life in the patients in the test group. So, the application of this model is recommended.

Keywords: Blood glucose, Glycosylated hemoglobin, “Create Sensitivity” caring model, Quality of life, Type 2 diabetes, Endocrine disorder.


Article Information


Identifiers and Pagination:

Year: 2018
Volume: 12
First Page: 195
Last Page: 204
Publisher Id: TONURSJ-12-195
DOI: 10.2174/1874434601812010195

Article History:

Received Date: 26/5/2018
Revision Received Date: 7/8/2018
Acceptance Date: 27/8/2018
Electronic publication date: 18/09/2018
Collection year: 2018

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© 2018 Hekmatpou et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Faculty member of Arak University of Medical Sciences, Sardasht Sq. Arak, Iran, Tel: +9834173505; E-mails: dr_hekmat@arakmu.ac.ir; hekmatpou@yahoo.com




1. INTRODUCTION

Diabetes mellitus is the most common endocrine disorder and one of the most important health challenges to emerge in the 20th century due to sedentary lifestyles leading to more individuals acquiring diabetes or pre-diabetes (otherwise known as the metabolic syndrome) in middle age or even earlier [1American Diabetes Association. Diagnosis and classification of diabetes mellitus 2015; 33(1): 567-74. Diabetes Car Available at http://care .diabetesjournals.org/content/33/Supplement_1/S62.full.pdf+html]. In 2012, the number of patients with diabetes worldwide was about 371 million [2Jiao FF, Lam CL, Fung C, McGhee SM. Comparison of four cardiovascular risk prediction functions among Chinese patients with diabetes mellitus in the primary care setting. J Diabetes Investig 2014; 5(5): 606-14.[http://dx.doi.org/10.1111/jdi.12188] [PMID: 25411630] ], of which 70% lived in developing countries [3Khuwaja AK, Lalani S, Dhanani R, Azam IS, Rafique G, White F. Anxiety and depression among outpatients with type 2 diabetes: A multi-center study of prevalence and associated factors. Diabetol Metab Syndr 2010; 20: 2-72.[http://dx.doi.org/10.1186/1758-5996-2-72] ]. Four million people in Iran had diabetes as of 2010 [4Izadi A, Sepahvand F, Naderifar M, Mohammadipour F. The effect of an educational intervention on quality of life in patients with type 2 diabetes referring to Tamin Ejtemaei Hospital in 2013. J Diabetes Nurs 2014; 2(2): 18-28. [Persian].]. Recent studies have shown that 7.8% of the 25-56 year-old population has diabetes [4Izadi A, Sepahvand F, Naderifar M, Mohammadipour F. The effect of an educational intervention on quality of life in patients with type 2 diabetes referring to Tamin Ejtemaei Hospital in 2013. J Diabetes Nurs 2014; 2(2): 18-28. [Persian].]. At present, the disease is the fifth-leading cause of death in Western societies, and the fourth most-common cause of a visit to the physician [5Alhyas L, McKay A, Balasanthiran A, Majeed A. Prevalences of overweight, obesity, hyperglycaemia, hypertension and dyslipidaemia in the Gulf: Systematic review. JRSM Short Rep 2011; 2(7): 55.[http://dx.doi.org/10.1258/shorts.2011.011019] [PMID: 21847437] ]. Type 2 diabetes, as the most common type of diabetes, includes 90% of all cases of diabetes [6Smeltzer S, Brenda GB, Janice LH, Kerry HC. Brunner and suddarths textbook of medical-surgical nursing 12th ed. 12th ed.2014.].

Rapid economic development and urbanization have led to an increase in the number of patients with diabetes. Other factors in the development of this disease are changes in lifestyle that reduce physical activity; an increase in the consumption of refined carbohydrates; and obesity, aging of the population, and decreasing quality of life [7Abazari P, Vanaki Z, Mohammadi E, Amini M. Challenges of physicians’ training program on diabetes prevention and control. Iran J Med Educ 2012; 12(1): 32-7. [persion].]. The diverse and relatively common complications of diabetes are retinopathy, nephropathy, neuropathy [8Dyck R, Osgood N, Lin TH, Gao A, Stang MR. Epidemiology of diabetes mellitus among first nations and non-first nations adults. CMAJ 2010; 182(3): 249-56.[http://dx.doi.org/10.1503/cmaj.090846] [PMID: 20083562] ], and peripheral arterial diseases [9Fujiwara Y, Kishida K, Terao M, Takahara M, Matsuhisa M, Funahashi T, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: An uncontrolled before and after intervention study. J Advanc nurs 2011; 67(9): 1952-62.]. These complications cause a heavy economic burden and reduce patients’ quality of life [10Raaijmakers LGM, Hamers FJM, Martens MK, Bagchus C, de Vries NK, Kremers SP. Perceived facilitators and barriers in diabetes care: A qualitative study among health care professionals in the Netherlands. BMC Fam Pract 2013; 14: 114.[http://dx.doi.org/10.1186/1471-2296-14-114] [PMID: 23937325] ]. The ultimate objective in the treatment of diabetes is glycemic control in the normal range without hypoglycemia [6Smeltzer S, Brenda GB, Janice LH, Kerry HC. Brunner and suddarths textbook of medical-surgical nursing 12th ed. 12th ed.2014.]. One of the biggest challenges for these patients is learning how to live with diabetes, control blood sugar complications, and promote their quality of life [11Mertig IG. The nurse’s guide to teaching diabetes self -management 2007.]. To accomplish this aim, we selected the “Create Sensitivity” caring model, earlier developed and described by Hekmatpou et al. to control the symptoms of chronic diseases such as congestive heart failure [12Hekmatpou D, Mohammadi E, Ahmadi F, Arefi SH, Rafie M. The effectiveness of applying “Making sensitivity” caring model on controlling congestive heart failure complications among hospitalized patients in tehran cardiovascular centers, 2009. J Iran Univ Med Sci 2010; 17(75): 33-50. [persion].]. This model was built based on the fundamental assumption that not only is the lack of awareness of patients with respect to the factors that lead to hospital readmission for a chronic problem (and one that also often leads to readmission), but also that a targeted strategy to address this could be an effective mechanism to control acute complications of chronic diseases (such as diabetes). So, this study aimed to determine the effectiveness of this concept through the implementation of the “Create Sensitivity” caring model in patients with type 2 Diabetes for the purpose of controlling blood glucose / glycosylated hemoglobin and improving quality of life.

2. METHODS

This is a quazi-experimental study. Using the “Create Sensitivity” caring model was an independent variable and blood glucose, glycosylated hemoglobin, and quality of life were three dependent variables of this study. This interventional study included all patients with type 2 diabetes who were referred to the diabetes clinic and/or the emergency unit of educational hospital in Kurdistan, Iran.

The sample size was determined via use of sample size equation and factors (d=1.1, S1= 1.74, S2= 1.35, β= 0.2, and α= 0.05) [13Khani Jeihooni A, Hazavehei MM, Kashefi M. Effects of the BASNEF model-based educational programs on blood Sugar control, (type 2 diabetes). J Diabetes Lipid Disord 2013; 1(1): 33-49. [persion].]. The sample size was determined to be 64 patients in both groups. Based on the nature of interventional studies, it is considered that 5% to 10% of the study population would be lost to attrition [13Khani Jeihooni A, Hazavehei MM, Kashefi M. Effects of the BASNEF model-based educational programs on blood Sugar control, (type 2 diabetes). J Diabetes Lipid Disord 2013; 1(1): 33-49. [persion].]. So, 70 patients with type 2 diabetes were initially selected to take part in the study. After obtaining informed consent, the patients were randomly assigned into 2 groups of equal size (intervention, n=35; control, n= 35). Inclusion criteria were: confirmed type 2 diabetes, the ages between 30 and 60 years, at least 4 months after the original diagnosis of diabetes and taking medications, and blood glucose above 200 mg/dl at baseline, and absence of either mental health problems or other incurable diseases (according to each patient’s statements). Exclusion criteria included migration, lack of cooperation/being lost to follow-up, and the patient’s death.

Patients were studied in 2 groups of 35 subjects. The test group comprised of 17 men (48.6%) and 18 women (51.4%), and the control group 18 men (51.4%) and 17 women (48.6%). In the test group, the mean age was 50.6 ± 7.8 years and the mean BMI was 26.7 ± 3.6 years. In the control group, the mean age was 50.4 ± 7.3 years and the mean BMI was 26.8 ± 2.8 years. About 29% of participants were under 40 and 71% over 40 years.

2.1. Intervention

The “Create Sensitivity” caring model Fig. (1) consists of four administrative stages that include cognitive reconstruction (during which patients and their families take part with the doctors and nurses comprising the patient’s healthcare team), a comprehensive and systematic patient discharge program, scientific self-treatment, and the development and maintenance of hope among patients. Two of these 4 stages were implemented in health centers, while the other 2 were followed at each patient’s home for 3 months after the intervention. The model was based on a general policy or strategy of building sensitivity (or creating sensitivity) among the medical team, the patients, and their families. The stages of the model were implemented as an overall strategy of care in the intervention group. Further details on this strategy appear in the next sections.

2.1.1. Pre Intervention

At first, after coordination with officials of the city health network, all necessary measures, such as assigning of the seminar hall, the patient’s education classes, and an office for follow-up, were provided to implement the model. Then, during a meeting with officials of the various health departments, it was announced to all related units to record the reasons with the relevant authorities for the readmission of patients due to lack of glycemic control. This coordinated effort was a factor that built awareness among the treatment team with respect to the reasons for repeated visits/readmissions due to lack of glycemic control.

Fig. (1)
"Create Sensitivity” caring model. (C: Community, H: Hospital, En: Entrance to hospital, Ex: Exit to community).


2.2.2. Intervention

2.2.2.1. Cognitive Reconstruction

A) Cognitive reconstruction of the treatment team: A two-hour conference (including host speakers and discussion) about the causes and risk factors of type 2 diabetes readmission was conducted with the purpose of creating and reinforcing awareness of these factors among the medical team. The participants were asked to record the reasons for their repeated readmissions in their nursing reports, and inform their physicians so that they also become sensitive to the issue.

  1. Cognitive reconstruction in patients and their family members: Face-to-face educational classes were held in a small group of patients it covered the factors of readmission and repeated visits, lack of control of blood sugar, complications and consequences of the disease, and self-care for patients and their families, as well as how to control the disease through a comprehensive regimen including diet, medication, and proper life style choices. Some of these education classes were held outside the main site (the hall) due to elderly patients being enrolled. Therefore, education booklets were used along with an educational CD for the implementation of the “Create Sensitivity” program in patients. They received individual instruction and more multimedia cases for private use at home and prevention of forgetfulness. Also, regular visits were announced by physicians of the research team to patients and their families. The patients were to return for follow-up and examination on a specific date.
2.2.2.2. A Comprehensive Program of Systematic Patient’s Discharge

Two nurses with clinical experience relevant to the treatment of diabetes were selected as assistants of the research team. They were responsible for implementing programs in health centers and follow-up of patients at home under the supervision of a primary researcher. During these programs, they trained patients with respect to self-care skills and provided supplementary educational materials. Then, comprehensive patient-discharge program was designed. Before discharge, a one-hour recall session was held to help patients remember the following self-care and collaborative (with the healthcare team) treatment techniques (in addition to the training given):

- How to prepare and follow a diabetic diet, adhere to the medication regimen, and implement lifestyle changes (including increases in physical activity).

- How to report progress and collaborate with two nurses after discharge. In this regard, CDs, pamphlets, videos, and photos were provided. Two patients with diabetes who had successfully controlled their blood sugar were also invited to take part in the class in order to relay their experiences to the other study enrollees.

2.2.2.3. Scientific Self-Treatment

To achieve “scientific self-treatment”, which for the purposes of this paper is defined as the building of knowledge and techniques that allow the translation of knowledge related to diabetes into independent action to control the disease, the following interventions were performed.

A) Continuous follow-up: Patients were asked to communicate with the research team in person and by telephone to obtain solutions if they encountered any problems or had questions.

B) Creating incentives: To motivate and sustain adherence to a medical regimen, the research team sent a short message each week (via SMS) or contacted them via telephone. The team reminded each patients of the training checklist, which contained many of the tips that had previously been discussed.

C) Identifying high-risk situations and aiding with compliance: Patients were given self-control strategies to balance their lifestyles.

D) Increasing self-efficacy: This intervention aimed to eliminate the top-down nurse – patient relationship in favor of the patient playing the role of “associate” in their healthcare and thereby monitoring his or her own behavior. Self-efficacy in this context referred to patients accepting responsibility and increasing their activity of daily living.

E) Removal of misconceptions: This intervention aimed to modify wrong beliefs about some behaviors. For example some patients have expected that taking opioids can decrease their blood glucose.

F) The management of relapse: One week after discharge, the patients were invited (either by phone or in person) to return as a group to discuss misperceptions and recall their training. The correct solutions to these types of challenges were also re-taught during this session, with the aim of strengthening patients’ sense of responsibility, potential benefits, and sense of being a part of the care system.

2.2.2.4. Development of Hope
  1. Giving hope: Through frequent calls with patients using phone, or mobile and SMS, particularly through the use of short messages.
  2. Advice and encouragement to continue treatment and participation in social occasions and activities that makes them happy.
  3. Introducing specific patients for psychiatric consultation.
  4. Positive role models: Introducing and connecting patients with people who have successfully controlled diabetes in their own lives.
  5. Self-management of diabetes: Training was provided to address the following important items:
    1. Patients’ self-management with respect to adjusting their wishes and objectives.
    2. Encouragement was provided with respect to helping patients control their motivations and abandon poor habits.
    3. Tendency management (for example, noting that a given habit, such as self-control, is off track).
    4. Understanding the mental path that leads to recurrence and relapse.

2.2. Data Gathering Tests

All fasting blood samples of both groups were tested using the PARS AZMOON Kit (Pars Azmoon, Tehran, Iran) (normal range, 70-110 mg/dl). HbA1C testing was performed using a NycoCard kit (Alere; Waltham, Massachusetts, USA) (normal range, 4.5% -6.3%).

The Diabetes Quality-of-Life Measure (DQOL) was used for quality of life measurement; it was used for the first time in Iran by Nasyhatkon et al. (r=0.72, α=0.77). The DQOL is a Likert-type questionnaire in which 15 questions about 6 quality of life dimensions are posed, with “scores ranging from at least 15 to 75” [14Nasyhatkon AA, Pishua A, Hbybzadh F, Tabatabai M, Qshqayyzadh T, Hafizi F. Determine the reliability and validity of clinical summary quality of life of diabetic patients (DQOL) to Persian. J Diabetes Lipid Disord 2012; 11(5): 483-7. [persion].].

All data were analyzed using SPSS 21 (X2, paired t-test and t-test) (IBM; Armonk, New York, USA); no patients were lost to follow-up.

2.3. Ethical Considerations

This study was approved by the Medical Ethics Committee of Arak University of Medical Sciences with the code: “MUK.REC.1394 (2015).49”. Each participant was recruited/ enrolled in the study after filling out the consent form.

3. RESULTS

The results of this study were measured after 3 months against the baseline measurements with respect to fasting blood sugar, glycosylated hemoglobin, and BMI. Importantly, the test and control groups were homogenous and without statistically significant differences based on chi-square test, Fisher's exact test and independent t test by demographic characteristics (sex, level of education, occupation, and age). Analysis of variance showed no significant difference in the three measurements that were compared at 3 months versus baseline based on any of these demographic characteristics. After 3 months of training according to the tenets of the “Create Sensitivity” model, mean of fasting blood glucose and glycosylated hemoglobin (laboratory parameters) in both groups had improved. The results of independent t-tests showed that the differences in the means for both fasting blood glucose and glycosylated hemoglobin were statistically significant between the two groups, and the paired t-test results suggest that, in the test and control groups, the difference in means for fasting blood glucose and glycosylated hemoglobin were significant before and after training Tables 1 and 2.

Table 1
Demographic data of two test and control groups in the study of implementation of “Create Sensitivity” caring model


Table 2
Comparing of the means of Fasting Blood Sugar between two test and control groups in the study of implementation of “Create Sensitivity” caring model.


The mean quality of life (as measured by the DQOL) in this study was at an intermediate level prior to the intervention (47.31 ± 5.30). The mean quality of life in patients in the test group increased post-intervention. A significant difference existed between the total mean of quality of life of the patients in the test group (58.25 ± 5.3) with the total mean of quality of life of the patients in control group (47.02 ± 4.5) (P=0.0001) Table 3.

Table 3
Comparing of the means of HBA1C between two test and control groups in the study of implementation of “Create Sensitivity” caring model.


The post-intervention results show that quality of life measures had improved significantly in the test group for dimensions such as treatment satisfaction, emotions, and satisfaction with socio-personal relationships (P ≤ 0.0001). Furthermore, after the intervention, the dimensions of diabetes-related anxiety and personal limitations were decreased; this was also statistically significant (P≤ 0.0001). The dimension of social concerns (job) was about the same as before and after the intervention. Overall, these results showed that the implementation of this model was effective in improving the quality of life among the recruited patient population Tables 4, 5.

Table 4
Comparing of the total means of Quality of life of the patients between two test and control groups in the study of implementation of “Create Sensitivity” caring model.


Table 5
Comparing of the means of dimensions of Quality of life of the patients between two test and control groups in the study of implementation of “Create Sensitivity” caring model.


4. DISCUSSION

The main goal of diabetes treatment is to achieve an appropriate and acceptable level of blood glucose, which is associated with the reduction of morbidity and mortality. The findings of this study showed that fasting blood glucose and glycosylated hemoglobin levels significantly decreased in both groups due to medication usage, but the reduction of fasting blood glucose in the test group was 32.7% versus 15% in the control group. Similarly, levels of glycosylated hemoglobin were reduced by 18% in the test group versus 6.5% in the control group. These differences may be related to the implementation of the “Create Sensitivity” caring model for the medical team, patients with diabetes, and their families.

The results of this study are similar to results reported in other studies on the implementation of caring models. Mohammad-Zadeh et al. studied 32 patients with type 2 diabetes that were enrolled in an intervention program devised by a diabetes association in Iran. Before exercise training, the importance and impact of exercise on the control of type 2 diabetes were described in a speaking session with patients who were also given an educational illustrated book that included information on how to exercise (with diagrams/examples), different types of movement to perform and the recommended exercise sequence. Based on the model, 3 months after training, a significant decrease was observed in the frequency of abnormal fasting blood sugar (15.6%) and glycosylated hemoglobin (28.1%) compared with before the intervention [14Nasyhatkon AA, Pishua A, Hbybzadh F, Tabatabai M, Qshqayyzadh T, Hafizi F. Determine the reliability and validity of clinical summary quality of life of diabetic patients (DQOL) to Persian. J Diabetes Lipid Disord 2012; 11(5): 483-7. [persion].].

In a study entitled “Making Sensitivity” caring model in patients suffering from congestive heart failure” by Hekmatpou et al., (2009), it was concluded that this model had a positive effect on most of the parameters related to control of congestive heart failure, including mean re-admission, BMI, blood indices, and the activities of daily living. A significant difference was also seen between the two groups (the intervention and control) in these variables [15Mohammadzadeh SH, Rajab A, Mahmoodi M, Adili F. Assessment of effect of applying the transtheoretical model to physical activity on health indices of diabetic type 2 patients. Med Sci J Islamic Azad Univ Tehran Med 2008; 18(1): 21-7. [persion].].

Although the effects of the “Create Sensitivity” caring model have not been studied in patients with diabetes, the impact of different models has been evaluated on glycemic control in diabetic patients [13Khani Jeihooni A, Hazavehei MM, Kashefi M. Effects of the BASNEF model-based educational programs on blood Sugar control, (type 2 diabetes). J Diabetes Lipid Disord 2013; 1(1): 33-49. [persion]., 16Hekmatpou D, Mohammadi E, Ahmadi F, Arefi SH. Lack of sensitivity to readmission: A grounded theory study for explaining the process of readmitting patients suffering from congestive heart failure. Eur J Cardiovasc Nurs 2009; 8(5): 355-63.[http://dx.doi.org/10.1016/j.ejcnurse.2009.08.003] [PMID: 19748830] ].

In a study on the effect of the training program based on the health belief model on reducing the level of glycosylated hemoglobin in patients with type 2 diabetes, 138 patients in the diabetes center at Zahedan (a city in South East of Iran) demonstrated a significant decrease in the level of glycosylated hemoglobin in the intervention group (from 9.63 mg/dl before the intervention to 8.30 mg/dl 3 months after the intervention) [16Hekmatpou D, Mohammadi E, Ahmadi F, Arefi SH. Lack of sensitivity to readmission: A grounded theory study for explaining the process of readmitting patients suffering from congestive heart failure. Eur J Cardiovasc Nurs 2009; 8(5): 355-63.[http://dx.doi.org/10.1016/j.ejcnurse.2009.08.003] [PMID: 19748830] ].

With respect to investigating the effect of patient education on blood glucose control in patients with type 2 diabetes based on Basnef’s model, a study was conducted in 100 patients with type 2 diabetes in a clinic in Shiraz (a city in the south of Iran). The level of glycosylated hemoglobin after 3 months of educational intervention in the test group declined from 8.65 mg/dl before intervention to 7.47 mg/dl after intervention, and in the control group from 8.57 mg/dl to 8.51 mg/dl. Fasting blood glucose in the intervention group was from 207.1 mg/dl to 124.2 mg/dl and in the control group from 181 mg/dl to 186.3 mg/dl [13Khani Jeihooni A, Hazavehei MM, Kashefi M. Effects of the BASNEF model-based educational programs on blood Sugar control, (type 2 diabetes). J Diabetes Lipid Disord 2013; 1(1): 33-49. [persion].].

Another study was carried out in 60 patients with type 2 diabetes in Mashhad, Iran to examine the effect of a care program based on Roy’s model of psychological adjustment. In this study, an educational intervention was performed for 4 months. The level of glycosylated hemoglobin in the test group declined from 9.14 mg/dl to 7 mg/dl before and after intervention, respectively; in the control group, this decline was from 9 mg/dl to 8.6 mg/dl [17Zareban I, Niknami SH, Hidarnia A, Rakhshani F, Shahrakipour M, Moshki M. The effect of education based on health belief model on reduction of HbA1c level in diabetes type 2. JHR 2013; 3(2): 370-8. [persion].].

In the present study, the increased scores for all dimensions of quality of life after intervention in the test group showed that the “Making Sensitivity” model could lead to changes in attitudes, knowledge, and practice levels among patients with type 2 Diabetes and promote improved quality of life. These results are similar to other related studies performed in Iran. In their study on quality of life in patients with type 2 diabetes, Taghdisi et al. have stated that the mean scores of psychological and physiological health in patients before and after interventions statistically significantly increased in the test group [18Sadeghnejad Forotaghe M, Vanaki Z, Memarian R. The effect of nursing care plan based on “Roy’s adaptation model” on physiological adaptation in patients with type II diabetes. Daneshvar Med 2011; 92: 25-34. [persion].]. Ghotbi et al. showed that using a model could increase self-care behaviors in a test group after intervention and that this could improve quality of life [19Taghdisi MH, Borhani M, Solhi M, Afkari ME, Hosseini ME. Effect of educational program based on PRECED model on quality of life in patients with type II diabetes. Majallah-i Danishgah-i Ulum-i Pizishki-i Gurgan 2011; 13(1): 29-36. [persion].]. Zare Bahramabadi et al. [20Ghotbi T, Maddah SB, Dalvandi A, Arsalani N, Farzi M. The effect of education of self- care behaviors based on family-centered empowerment model in type II diabetes. J Nurs Midwifery Shahid Beheshti Univ Med Sci 2014; 23(83): 43-50.] reported that mean scores for general health, role-playing deficit limitation due to emotional issues, social functioning, vitality, psychological health, body functions/role-playing deficit limitation due to body functions, and somatic pain all improved significantly with the use of cognitive behavioral therapy [20Ghotbi T, Maddah SB, Dalvandi A, Arsalani N, Farzi M. The effect of education of self- care behaviors based on family-centered empowerment model in type II diabetes. J Nurs Midwifery Shahid Beheshti Univ Med Sci 2014; 23(83): 43-50.]. Comparison of the results of this cross-section of studies with this study showed that the “Create Sensitivity” model can be a practical caring model for providing care to all patients with type 2 Diabetes due to its simplicity, applicability, and efficiency.

CONCLUSION

Our findings showed that the use of “Create Sensitivity” caring model was associated with reducing fasting blood glucose and glycosylated hemoglobin in patients with type 2 diabetes down below the upper border that constitutes control levels. Additionally, the quality of life scores were increased so that the test group demonstrated what could be considered a good quality of life. Given the increase in the number of individual with diabetes, finding ways to change the habits and improve the quality of life in these patients is important. Therefore, educational programs, which are clinically beneficial to patients, should be used to help control type 2 diabetes [21Zare Bahramabadi M, Qadri I, Taghvaei D, Vafa’i Bane F. The effectiveness of cognitive behavioral therapy on quality of life in patients with type 2 diabetes. J Endocrinol Metab 2013; 12(3): 225-53.]. These programs should be practicable according to the culture and traditions of the community. It is suggested that the “Create Sensitivity” caring model could be applied to those with diabetes due to the chronic nature of the disease, the treatment costs, the irreparable effects of diabetes, and the efficiency of the “Create Sensitivity” caring model to control blood glucose and the complications of the disease.

One of the limitations of this study was the short time period of the intervention. It is likely that an intervention lasting at least 6 months would lead to better control of blood glucose and glycosylated hemoglobin in patients with type 2 Diabetes.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

This study was approved by the Medical Ethics Committee of Arak with the code: “MUK.REC.1394 (2015).49”. Each participant was recruited/ enrolled in consent form.

HUMAN AND ANIMAL RIGHTS

Not applicable.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare that they had no conflict of interest.

ACKNOWLEDGEMENTS

This work was supported by Deputy of Research of Arak University of Medical Sciences as a grant for an academic dissertation. Special thanks to all colleagues and diabetics who took part in this study.

REFERENCES

[1] American Diabetes Association. Diagnosis and classification of diabetes mellitus 2015; 33(1): 567-74. Diabetes Car Available at http://care .diabetesjournals.org/content/33/Supplement_1/S62.full.pdf+html
[2] Jiao FF, Lam CL, Fung C, McGhee SM. Comparison of four cardiovascular risk prediction functions among Chinese patients with diabetes mellitus in the primary care setting. J Diabetes Investig 2014; 5(5): 606-14.[http://dx.doi.org/10.1111/jdi.12188] [PMID: 25411630]
[3] Khuwaja AK, Lalani S, Dhanani R, Azam IS, Rafique G, White F. Anxiety and depression among outpatients with type 2 diabetes: A multi-center study of prevalence and associated factors. Diabetol Metab Syndr 2010; 20: 2-72.[http://dx.doi.org/10.1186/1758-5996-2-72]
[4] Izadi A, Sepahvand F, Naderifar M, Mohammadipour F. The effect of an educational intervention on quality of life in patients with type 2 diabetes referring to Tamin Ejtemaei Hospital in 2013. J Diabetes Nurs 2014; 2(2): 18-28. [Persian].
[5] Alhyas L, McKay A, Balasanthiran A, Majeed A. Prevalences of overweight, obesity, hyperglycaemia, hypertension and dyslipidaemia in the Gulf: Systematic review. JRSM Short Rep 2011; 2(7): 55.[http://dx.doi.org/10.1258/shorts.2011.011019] [PMID: 21847437]
[6] Smeltzer S, Brenda GB, Janice LH, Kerry HC. Brunner and suddarths textbook of medical-surgical nursing 12th ed. 12th ed.2014.
[7] Abazari P, Vanaki Z, Mohammadi E, Amini M. Challenges of physicians’ training program on diabetes prevention and control. Iran J Med Educ 2012; 12(1): 32-7. [persion].
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Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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