ORIGINAL RESEARCH

Evaluation of group educational intervention for diabetics receiving care at Teaching Clinic

Lannye Barbosa^I; Priscila Costa Pontes Borges^II; Suyane de Souza Lemos^III; Claudia Bernardi Cesarino^IV

^I Graduated in Nursing by the Medicine College ofSão José do Rio Preto. São Paulo. Brazil. E-mail: lanny_barbosa@yahoo.com.br
^II Graduated in Nursing by the Medicine College ofSão José do Rio Preto. São Paulo. Brazil. E-mail: pri_pborges@yahoo.com.br
^III Post Graduated in Public Health by the Medicine College ofSão José do Rio Preto. São Paulo. Brazil. E-mail: suyane_lemos@yahoo.com.br
^IV Ph.D. of the General Nursing Department of the Medicine College ofSão José do Rio Preto. São Paulo. Brazil. E-mail: claudiacesarino@famerp.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.4968

ABSTRACT

Introduction: educational groups foster exchange of experience among their members and develop skills necessary for proper control of the problem. Objective: to report on evaluation of an educational intervention, using a questionnaire on knowledge of diabetes mellitus, at the São José do Rio Preto Centro de Saúde Escola. Method: this case report describes an educational intervention, in 2007-2008, in a sample of 64 patients diagnosed with diabetes mellitus receiving care at an academic health center in the municipality of São José do Rio Preto, SP, Brazil. Data was analyzed by was descriptive statistics. Results: the group receiving the guidelines returned better outcomes than the control group. Conclusion: group guidance was found to be an effective means of increasing knowledge, and improving control, of the disease. We suggest future studies of interventions in this area of knowledge.

Keywords: Education; diabetes mellitus; nursing; guidance.

INTRODUCTION

Diabetes mellitus (DM) is currently one of the main chronic diseases that affects man in the world, due to high rates of prevalence and mortality, representing a public health problem for its social and economic repercussions turned into premature deaths, absenteeism and disability at work, as well as high costs associated with the control and treatment of complications. There is a crisis of contemporary health systems, explained by the inconsistency between health situations with a predominance of chronic conditions¹.

The term diabetes mellitus describes a metabolic disorder of multiple etiologies characterized by chronic hyperglycemia with disturbances in the metabolism of carbohydrates, fats, and proteins that result from insufficient secretion and/or insulin action². Diabetes mellitus type 1 is characterized by complete lack of insulin production by the pancreas, usually diagnosed before age 20 years old³. Diabetes type 2 has an insulin resistance associated with a deficient secretion of the same by the pancreas and an increased glucose production. It corresponds to the most common type, generally reaching the individuals before 30 years old and most obese^4-5.

Considering that the educational practices in health, in current's society, recognize the importance of new teaching strategies that enhance the autonomy of the person with diabetes and promote the conscious decision-making to improve the quality of life, this study aimed to report the evaluation of the educational intervention with the use of diabetes mellitus knowledge questionnaire in Health School Center of São José do Rio Preto.

LITERATURE REVIEW

The DM prevalence in Central and South America was estimated at 26.4 million people and projected to 40 million in 2030. In European countries and the United States (US) this increase will take place, especially in more advanced age groups due to the increase in life expectancy while in developing countries this increase will occur in all age groups, and in the group 45-64 years old, the prevalence will be tripled, and doubled in the age groups 20-44 years old, and over 65 years old⁶. In Brazil, data from the Risk and Protective Factors Surveillance for Chronic Diseases by Survey Telephone (Vigitel), 2011, show that the prevalence of self-reported diabetes in the population above 18 years old increased from 5.3% to 5.6% between 2006 and 2011⁷.

It is of paramount importance to develop intervention strategies to improve treatment adherence since through this way it is possible to reduce the expenses arising from the complications resulting from poor control of the disease and to improve the health status of affected people. In this sense, the educational intervention and/or early guidance may favor in the prevention of complications of this patients².

The integral treatment should allow an educational process, directed to the assimilation of the fundamental aspects of diabetes, to completely transform the kind of normal life of the patient, as perhaps no other disease requires both the involvement, as such, which makes education one of the cornerstones of treatment². In the recent years, it was found that more than half of diabetics do not follow treatment. The Ministry of Health (MH) recommended that the DM care line is to strengthen and qualify the care for people with this disease through the comprehensiveness and longitudinally care, at all care points⁸.

The educational intervention is shown increasingly important and necessary since it significantly reduces mortality, complications, and expenses arising from diabetes, and improves the quality of life of patients ⁹.

There are some educational interventions already tested in patients with DM, and there isn't, until now, a defined model that can be standardized and recognized as effective for all individuals with the disease ¹⁰.

To assess the impact of health education, the use of instruments or evaluation questionnaires is an important resource for educational programs in health, as they allow measurement of the effects of the teaching and learning process and possible changes in attitudes about DM. It is also a way to meet the individual needs and implementation conditions of the educational process¹¹.

METHODOLOGY

This is a case report study that described and evaluated the educational intervention about DM. The Diabetes Mellitus Knowledge questionnaire was used as data collection instrument, Development of Diabetes Knowledge Assessment (DKN-A), which is a scale that evaluates aspects related to general knowledge of Diabetes Mellitus. It consists of 15 items divided into five categories: basic physiology, hypoglycemia, food group and their replacements, Diabetes Mellitus management in the complication of some other disease and general principles of disease care¹¹.

This study was conducted at Estoril Health School Center (Estoril-CSE) in the city of São José do Rio Preto, São Paulo, Brazil, from 2007 to 2008. The sample consisted of 64 patients enrolled in the Sweet is life Diabetes Program, which works in the Estoril Health School Center. This sample met the following inclusion criteria: patients registered in CSE-Estoril, with a diagnosis of DM type 2, insulin-dependent, of both sexes, aged over 18 years old, oriented in time and space, which has consented to participate in the research and with verbal communication skills.

The sample of 64 patients was randomly divided by lot into two groups: Experimental Group (EG), composed of 32 participants, that in addition to the conventional approach of CSE-Estoril of the Sweet is life Diabetes Program, participated in the educational intervention and were guided by the group regarding the knowledge of general aspects of DM. The Control Group (CG), composed of 32 participants who participated in the conventional care of CSE-Estoril of the Sweet is life Diabetes Program and did not receive educational interventions planned by the researchers.

Patients underwent the test of blood glucose, and blood pressure measurement and in this examination room were invited to participate in the study with explanations of the research objectives, the lot of EG and CG groups. The CG remained in the examination room, where received the routine care from the multidisciplinary team, and the EG was referred to group care room, where educational interventions about DM were performed.

Educational interventions in the EG were developed by the researchers, using as strategy, the expository dialogue-based class about diabetes and two teaching techniques for the evaluation of classes: colorful dice, where a dice was constructed, on each side of the dice one color, and each face corresponding to three questions covering issues of the class. A number was distributed to each participant, and that one called must play the dice and read the question. If they did not know the answer, the group should discuss and explain the correct answer. The other technique was the Right, Wrong and Why Panel, with a green panel for correct statements and a red panel to the incorrect statements. The sentences were placed in a bag, where each participant took a phrase and said whether it was correct or incorrect, why and glued on the panels. These panels were available in the Unit.

After all educational interventions performed in 12 meetings during the second half of 2008, in December 2008, the Diabetes Mellitus Knowledge questionnaire (DKN-A) was applied for the two groups (EG and CG).

As it is research involving human beings, the project was submitted to the Research Ethics Committee approval, by the resolution of the National Health Council (NHC), No. 196/96, in force at the time of the study. Each respondent signed a consent form with the necessary clarification about objectives and method of the study. The Research Ethics Committee of the institution under the opinion No. 130/2007 approved the study design. Descriptive statistics were used for data analysis.

RESULTS AND DISCUSSION

Study Subjects characteristics according to DKN-A Questionnaire

Regarding the Experimental Group (EG), composed by 32 people, it was found that 13 (40%) were male and 20 (60%) female. The Control Group (CG) showed equality with the distribution between men and women, 16 (50%) persons were male and 16 (50%) female.

The average age verified in EG was 50.81 years old (± 12.19), with a minimum age of 24 years old and maximum 75 years old, and the average age of the CG was 54.12 years old (± 12.68) with a minimum age of 26 years old and maximum age of 76 years old.

Regarding the variable of diagnosis time of the disease, cited by the EG participants, the average was 14.5 years old. This average was 15.4 years old for the CG.

Knowledge about Diabetes- Scores of DKN-A Questionnaire

Concerning the knowledge about the disease, according to the scores of the Questionnaire, for the group that did not receive the educational intervention (CG), twenty-one obtained Bad classification, i.e., score between 01-06 points. Nine patients had Regular classification, score 7 to 9 points, and two had a Good classification, a score between 10 to 12 points. Any participant was classified as Great, score between 13 to 15 points.

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For EG, which receives then proposed educational intervention, two had Regular classification; seventeen got a Good classification, and thirteen got a Great classification.

The average scores of CG were 6.22 with a standard deviation of 2.08, and the average of the EG was higher, i.e., 11.78, with a standard deviation of 1,23. When asked about the normal value of blood glucose, fifteen people of the CG hit the value, and 25 participants of the EG answered this question correctly.

In this study, we observed an adult population, relatively young, most often women, 50% in the CG and 60% in EG. The mean disease duration was 14.5 years in the first group and 15.4 years in the second group, i.e., the length of diabetes, in both cases, greater than ten years confirming other studies^12-13.

In a recent study conducted among patients with diabetes type 2 of long duration, to describe the clinical, psychological and social factors that affect the knowledge, it identified poor knowledge about the disease, which was highly influenced by age, education years, treatment time, cognitive function, gender and level of depression¹².

Regarding the knowledge about diabetes, we found that the Control Group obtained a lower score when compared to the Experimental Group, with a mean of CG of 6.22 and EG of 11.78. It is possible that people with diabetes, during the long period of illness, have received some information related to diabetes pathogenesis, however, factors involved in the acquisition process of this information may have limited/prevented its incorporation ¹³.

The educational intervention is very important in raising awareness of diabetes mellitus, as the acquisition of knowledge allows the displacement of the being reasons of the given situation, to be a transforming action of this reality. In the educational intervention of the present study, we used an interactive education model, according to which patients were encouraged to ration and rationalized about the matter and then discuss it, reflecting on everyday situations. The experiences exchange and experiences among members of the group were stimulated to adapt to this particular population, the necessary knowledge of the disease, its determinants, and its controls^14-15.

When there is an effective educational intervention, where the participants could assimilate the covered content, the level of knowledge becomes greater, as seen in this study, allowing subsequently, a better control of the disease by patients. Several publications have reported in different countries, the importance of educational programs to promote greater adherence to treatment, resulting in better control of diabetes ¹⁶.

The knowledge of the desirable parameters of normal blood glucose is very important for a better control of the disease. In this study, the group that had not received the educational intervention, 15 (35.71%) answered incorrectly about the normal value of blood glucose, the Experimental Group, 25 (78.12%) correctly answered that question. It is believed that the knowledge of these values ​​may encourage the involvement of the self-care of the person, knowing that their glycemic rate can fluctuate within a certain range and thus assist the blood glucose monitoring in the daily routine. In this sense, the education of people with diabetes is highlighted as a fundamental aspect of care in getting control of the disease¹⁴, and education of diabetic patients has become one of the key issues of treatment¹⁵. Therefore, the person with diabetes mellitus must actively participate in the monitoring of their disease: choice of food, number of meals, quality and quantity of food intake, regular physical activity, self-monitoring of blood glucose, foot examination, use of medications in the correct schedules and doses, periodic medical return consultation, knowledge of signs and symptoms of hyperglycemia, and other cares¹⁷.

Health education is essential for people suffering from chronic diseases to self-care, habits changing and improving the quality of life. The main focus would be a user-centered approach in promoting their autonomy and providing opportunities to the reflection of those involved about their experiences, living conditions, health, and disease, as well as experiences exchanges, seeking active methods with dynamics. The involved in the educational action planning should pursue a contextualized, participative and dialogical learning process. It highlights the role of nurses as an articulator of the process of knowledge production and educational practice focused on people with DM. In fact, nursing has been valuing the educational activity in health, but it is necessary to foster teamwork, according to several studies in this area^18-19-20.

CONCLUSION

The educational intervention proposed in this study was effective. The results of the groups that received the guidelines regarding the general aspects of DM were better when compared to the Control Group. This experience report showed the importance of group's guidance as an effective means to increase knowledge about the disease and may provide later, a better control of the disease and increased patient adherence to treatment. The implementation of Guidance Programs in groups for diabetic patients is one of the most important long-term investments in public health since the higher the acquired knowledge, better self-care regarding the disease, in addition to providing greater safety for the patient who is in treatment. This study provided a closer approach of the diabetic patient and the context where is inserted, being crucial future interventions in this area of ​​knowledge. This type of intervention can be maintained and expanded in the service of public health services. Therefore, further research is necessary to assess the diabetes mellitus knowledge associated with changing attitudes in the disease control.

REFERENCES

1.Mendes EV. The health care networks. Public Health Sciences, 2010; 15(5): 2297-305.

2.Grillo MFFE, Gorini MIPC. Characterization of people with diabetes mellitus type 2. Brazilian Nursing Magazine, 2007; 60(1): 49-54.

3.Edelman ST, Henry, RR. Diagnosis and management of diabetes type 2, Scientific Publications Ltda; 2003.

4.Norris SL, Engelgau MM, Narayan KMV. The effectiveness of self-management in type 2 diabetes. Diabetes Care. 25: 561-87.

5.Straub RO. Cardiovascular disease and diabetes. Health Psychology, 313-45.

6. International diabetes federation. Diabetes atlas update 2012: Regional & Country Facctsheets. Accessed in: 07^th November 2013. Available at: http://www.idf.org/diabetes-atlas-update-2012-regional-countryfactsheets

7.Ministry of Health (Br). Health Surveillance Department. Strategic and Participative Department. Vigitel-Brazil 2011: surveillance of risk and protective factors for chronic diseases through a telephone survey. Brasília, 2012.

8.Ministry of Health (Br). Health Care Department. Basic Health Care. Care strategies for the person with chronic illness: diabetes mellitus. Brasília: 2013 (Basic Care Notebooks, n. 36).

9.Quintares AH, Lopez LG, Curbelo VS. Municipal pilot program to improve the quality of life of diabetics: Results about mortality, complications, and costs of diabetes mellitus. Cuban Medical Magazine. Gen. Integr. 2000; 16(3): 227-32.

10. Ferreira GMF, Rolin NC, Fiore SS, Farias RR, Luiz GJ, Bauermann LC. Effects of different educational modalities for self-care of diabetes patients. Braz. Med. Ass. Magazine. 2013; 59(4): 400-5.

11.Validation of knowledge questionnaires (DKN-A) and attitude (ATT-19) of Diabetes Mellitus. Public Health Magazine. 2005; 39.

12. Brazilian Society of Diabetes. Update about diabetes. Brazilian Consensus about Diabetes, 2012.

13.Torres HC, Hortale, VA Schall, V. Validation of knowledge questionnaires (DKN-A) and attitude (ATT-19) of Diabetes Mellitus, Public Health Magazine. 2005; 30(6).

14.Emilia AP, Ochoa K, Caliri MHLC, Fernandes ANM. The knowledge about diabetes mellitus self-care process. Latin-Am. Nursing Magazine, 2006; 14 (5).

15. Torres HC, Roque C, Nunes C. Home visits: an educational strategy for self-care of diabetes clients in basic care. Nursing Magazine. UERJ, Rio de Janeiro, 2011; 19(1):89-93.

16.Coelho MS, Silva DMGV. Education Support Group: Visualizing self-care with the feet of people with diabetes mellitus. Science, Care and Health. 2007; 5(1): 11-5.

17.Baquedano IR, Santos MA, Teixeira CRS, Martins TA, Zanetti ML. Factors related to self-care of people with diabetes mellitus attended in ER in México. Nursing Esc Magazine USP. 2010; 44(4):1017-23.

18.Manoel MF, Marcon SS, Baldissera VDA. Educational strategies in SAH/DM. Nursing Magazine. UERJ, Rio de Janeiro, 2013; 21(3):403-8.

19. Acioli S, David HMSL, Faria MGA. Health education and nursing. Nursing Magazine. UERJ, Rio de Janeiro, 2012; 20(4):533-6.

20. Alves PD, Campos CNMS, Lima SAL, Veiga JPCB, Oliveira ZCR. The effect of educational intervention on the disease knowledge of diabetes mellitus patients. Latin-Am. Nursing Magazine. 2012; 20(3): 478-85.