Untitled Document



Educational intervention: implementation of self-care agency and adherence treatment from the perspective of diabetic patients


Nohemi Selene AlarcónLunaI; Mercedes Rizo BaezaII; Ernesto Cortés CastellIII; Francisco CadenaSantosIV; Helena Maria Scherlowski Leal DavidV; María Magdalena Alonso CastilloVI
IAcademic Secretariat and Full Time Lecturer, Faculty of Nursing at UAT, Nuevo Laredo, Tamaulipas, Mexico, Email: salarcon@uat.edu.mx
IIThesis Director, Professor, Department of Health Sciences, University of Alicante, Spain, Email: rizo.mercedes@gmail.com
IIIThesis Director, Secretary, Department of Pharmacology, Pediatrics and Organic Chemistry, University of Alicante, Spain, Email: ernesto.cortes@umh.es
IVDirector and Full-Time Professor, Faculty of Nursing, UAT, Nuevo Laredo, Tamaulipas, Mexico, Email: fcadena@uat.edu.mx
VAssociate Professor.School of Nursing State University of Rio de Janeiro. Brazil. Email: helena.david@uol.com.br
VIAssistant Director of Graduate Studies and Full Time Professor, School of Nursing at UANL
Monterrey, Nuevo Leon, México, Email: maalonso@fe.uanl.mx

ABSTRACT: Orem defines self-care as a regulatory function of man that people deliberately made for them to maintain life, health, development and wellbeing. Objective: to identify whether the perspective of the patient has about diabetes after participating in an educational intervention influences the implementation of recommendations and adherence to self-care. A descriptive, quasi-experimental methodological triangulation.Sample of 200 patients, divided into intervention and control group. Educational intervention of 12 sessions and focus groups to interviews, was happened in 2012. Results: demographic homogeneous,self-care index and adherence to treatment no significant differences initially, averages and medians higher in the intervention group self-care agency and post-treatment adherence intervention. In conclusion, there were changing attitudes to preserve the welfare of the participants, increased health responsibility, generation of new knowledge in nutrition and attitude change in the intake of medicines.

Keywords: Self-care; therapeutic adherence; diabetes; educational intervention.


Type 2 Diabetes Mellitus has become one of the most serious health problems in our country1. In Mexico, since 1940, diabetes was already within the first 20 causes of mortality, with a rate of 4.2 per 100,000 inhabitants. Ten years after occupying ninth place and for 1990 ranked fourth as a general cause of mortality. Since 2003 is the third leading cause of death and the first in the group of 45 to 65 years of age. In accordance with what is reported by the Secretary of Health in 2010, 10.75% of people from 20 to 69 years of age, has some type of DM, which is equivalent to a population of more than 5 and a half million people with the disease, of which 65% are women and 35% men. Every hour, diabetes mellitus causes the death of five people in Mexico2.3. It is noteworthy that on the border with the United States the prevalence of this disorder is 15%. An interesting fact is that in people 40 to 59 years of age, one out of every four deaths is due to diabetes mellitus in Mexico4. The aforementioned contextualizes the social relevance of this problem that affects the quality of life of a sizeable segment of the Mexican population.

People with type 2 diabetes mellitus have to perform a laborious self-care, ranging from self-analysis, the adjustment of the dietary and pharmacological treatment, and the modification of hygienic habits and physical exercise. It has been identified that with a good management of the disease, many of the complications of diabetes can be prevented or delayed5.

Adherence is a complex phenomenon, which can be explained based on their multiple determinants and constraints, among which the following are identified.Those related to the interaction of the patient and the health professional, the therapeutic regimen in itself, the characteristics of the disease and the psychosocial conditions of the patient, as well as some demographics(age, sex, ethnic group, socioeconomic position and level of studies) among others.

The World Health Organization defines the compliance or therapeutic adherence as the extent to which the patient follows the instructions, in counterpart Haynes and Sackett defined as the extent to which the patient's behavior in relation to taking medication, follow-up to a diet or a change in their lifestyle coincide with the indications given by health professionals and is therefore non-adherence the degree to which there are non of these indications6.

There are studies that suggest that one must implement strategies to improve the patient's adhesion in the control of type 2 Diabetes Mellitus through educational interventions. Thus, in Cuba, there have been educational interventions carried out in diabetic patients, finding that after the intervention, 100% of the patients increased their level of knowledge in regard to disease control. University students, young patients and those who are treated with insulin were the greatest number of correct answers after the educational intervention7.

In Canada it was found that the social and environmental factors were important for adherence to treatment, but the comorbidity such as depression and the macro and micro vascular problems have a greater impact on this phenomenon8.9. Additionally in Chile the effectiveness of an intervention has been investigated, which includes patient education and self-monitoring of blood glucose in patients with type 1 and 2 diabetes.It found that in the intervention group compliance with dietary recommendations increased by 57.5 percent was the principle that the study baseline(pretest) to 82.5 % as a final result (posttest); in the control group experienced, a change was not significant, concluding that the metabolic control was due mainly to the effect of the educational intervention in the diet10.

Other authors have assessed the relationship between adherence and compliance to treatment and mortality, finding that good adherence to treatment is associated with positive health development and a decrease in mortality, even in patients taking placebo11.

It has been found that with a good management of the disease, many of the complications of diabetes can be prevented or delayed.It is clear that the DM treatment is in the patient's ownhands12.

The World Health Organization recommends education for self care with the aim of preventing and treating people who suffer from chronic diseases. Education for the self-care of individuals with chronic health problems should provide support for the development of the self-care abilities, with the goal of empowering them to assume the responsibility for their health and helping them improve their quality of life, modify or maintain the healthy habits, stimulate self-confidence that allows them to develop feelings of wellbeing and comfort regardless of the severity of the disease13.

The assumption underlying this intervention is that if the person knows what is essential about his disease and how to take care of, you will be able to follow the clinical indications for their care and diabetes control.

The objective was to identify if the perspective that the patient has diabetes after participating in an educational intervention influences the implementation of the recommendations of the self-care agency and treatment adherence.


The conceptual framework from which this study was derived consists of the Self-Care Deficit Model of Orem, which took some of the concepts, such as self-care and self-care deficit. It also dealt with the concept of Diabetes Mellitus and adherence to treatment. It defines self-care as a regulatory function of man that people should deliberately conduct themselves or should be carried out to maintain life, health, development and wellbeing14.

The healthy person or with an appropriate self-care, in a delicate balance, is capable of meeting the requirements of universal self-care with self-care skills acquired throughout life, and carrying on maintaining an effective self-care resulting in an optimal level of wellbeing. When these skills cannot maintain the balance the nursing action becomes necessary to restore the balance, so being in a situation of self ineffective action requires health workers to help restore the well-being of patients with Diabetes Mellitus. Self-care skills are directly influenced by adherence, knowledge of self-management skills and the ability to cope with the difficulties found throughout their lives15.

The study was structured in two phases: first used a quasi-experimental design, qualitative exploration by what was considered to be one of the postulates of the methodological triangulation. In the qualitative exploration, trying to capture the phenomenon in a holistic manner, and to understand within its context emphasizing immersion and understanding of the human meaning attached to a group of circumstances or events shared by people who are experiencing a health problem, for this reason the methodological focus groups were used. It relies on the ethnography that describes and explains the regularities and variations of the social behavior,according to Lipson16.

For the quantitative component used a stratified random sampling with a significance level of 0.05 and the quality was theoretical sampling until saturation. The quantitative sample consisted of 200 patients diagnosed withtype 2 Diabetes Mellitus from the Center for Integral Formation of Nursing(CEFIEN) belonging to the Faculty of Nursing at the Autonomous University of Tamaulipas in the city of Nuevo Laredo, Tamaulipas, border city situated to the Northwest of Mexico. Distributed in an experimental group of 100 members who received the educational intervention and a control group of 100 people, both groups drawn from the patients of the same community center. In the qualitative sample,32 participants were considered who received the intervention and were grouped into four focus groups.

For the data collection, one Personal Data Form (PDF), the Appraisal of Self-care Agency Scale, ASA, developed by Evers17, which was validated by Gallegos in the Mexican population. It consists of 24 items with a Likert-type format response with five multiple choices, the score ranges from 24 to 120 points, the instrument has been reported to have proper reliability by the author. Lastly, theMorisky-Green questionnaire18 was used on the adherence to diabetestreatment (ADT), which evaluates if the patient adopts right attitudes regarding the treatment. Qualifies the patients as adherent, who correctly answer the four questions that they ask. An inadequate response by the patient qualifies as non compliant.

To be considered as a good adherence, the answer to all the questions must be adequate (no, yes, no, no), the questionnaire shows a high reliability (61 %) and is validated in the Spanish population. For thequalitative exploration, a focal interview was developed from theobjective of this study. The study, conducted in 2012, adhered to the provisions of the Regulations of the General Health Law in the Field of Health Research19. On the basis of article 14 section VII, VIII and Article 22, Section II; in addition to the favorable opinion of the Commission on Ethics and Research of the UAT Faculty of Nursing. The education program for the intervention or experimental group is structured in twelve sessions on a weekly basis, each of 50 to 60 minutes with a duration over a period of approximately three months, establishing a schedule, it was measured at the beginning and the end of the intervention. The control group only gave written information, with the objective to develop the educational intervention at the conclusion of the study. The qualitative exploration was done only with the patients participating in the study who received the educational intervention, four focus groups were formed with 8 members each, until reaching information saturation.

The quantitative data were processed in the Statistical Package for the Social Sciences (SPSS), 2000, version 18.0. The qualitative analysis was of content, this was carried out on a small scale through reading of the transcripts(line by line) by identifying codes that emerged to conclude with the categorization, in this analysis the researcher needs exercise their creativity and sensitivity, to penetrate and give them a meaning to the events that show the data20. To facilitate reference for the analyzed texts, following symbols were used to refer to the data examined, G: Group I: Interviewed, and each of these codes was supplemented with a number, which refers to the respondents or to the group number.


In the study sample it was noted that in both groups, 50% were women and men, in addition the 57% in the experimental and the control group were married and 45% of both groups had a middle socioeconomic level, in addition to the 37% of both groups had only grade school and in 54% of the experimental group and 55% of the control group did not have a fixed income the distributions of the sociodemographic data show similar proportions and without significant differences in both study groups.

The average age in the intervention and the control group was 47.1standard deviation(SD) =17.3) and 46.5 years in the control group(SD=16.1) with a minimum age of 16 years and a maximum of 89 years.The average weight was 67.7 kg(SD=15.6) and 66.7 kg (SD=15.5), a minimum weight of 39 kg and a maximum of 119kg.With regard to the average height of the patients in the intervention and the control group was 1.62 m(=.089) and 1.61 m(SD=.082), and body mass index (BMI) calculated based on these variables in both groups was 25.6 kg/2(SD=6.10), with a minimum BMI of 13.2kg/ 2 and maximum of 50.9 kg/ 2.The index scale self-care assessment agency reports an average of 69.3(SD=10.8) and 68.3(SD=10.1) respectively. The index of adherence to the diabetes treatment obtained an average of 55.0(SD=33.2) and 49.2(SD=30.5), respectively. In any of the continuous variables and numeric significant differences existed between the intervention group and control, as shown in Table 1.


Among the members of the intervention group and control group, 82% and 83% had no treatment adherence versus 18% and 17% respectively had if compliance with treatment, such distributionnot being significantly different, as can be seen in Table 2.
The test Mann-Whitney U for the assessment of self-care agency by intervention group and control group in the sensitivity the post test showed significant differences in self-care agency(p =.001) between the intervention and control groups, showing that the average and median was highest in the intervention group.


Likewise, for the adherence to the treatment of diabetes in the sensitivity and for both groups, the test Mann-Whitney U test showed that there were significant differences between the intervention group and the control group in regarding the adherence to diabetes treatment (p =.001), showing the average and median rather high in the intervention group.

Qualitative Analysis of the focus groups

Below is a description of the categories identified in the focus groups. See Figure 1.


This study made it possible to check the impact of an educational intervention in nursing care with the variables and adherence to treatment, studied in patients with type 2 diabetes mellitus who are cared for by a community center in a border town situated to the north of Mexico.The baseline measurement of the study variables showed similar averages, so that both groups are very homogeneous.

The nursing educational intervention model as a whole presents significant results in the self-care agency, which means that it had a impact on improving the care of diabetic patients, the patients likewise expressed this in the focus groups:

Now we know how to check the feet and take better care with diets. (G1, E1)
At the night I ate quite a bit and I was having a hard time to sleep, I sometimes felt ill and now I know that one should not do that because that is what hurts someone (G1, E3)

This coincides with what is reported by researchers21-23, those referred to as diabetic groups received an educational intervention increased their level of self care, showing significant difference in the ability of self-care on the results of pretest and posttest without any intervention after the nursing intervention.Thus, that nursing intervention brings significant changes in strengthening the self-care concept in patients with chronic diseasesthis type of educational strategy applied in patients with chronic degenerative diseases increases adherence, promotes wellness and improves the quality of life, in addition to reducing complications and costs that result from this disease24-26.

Based on the significant effect identified in the educational nursing intervention in the adherence variable for the treatment of diabetes, shows that the intervention had an effect on the patients by increasing treatment adherence; in the same sense the patients expressed:

II do not want to take it but I think now I justhave to do it because this is hurting me a lot (G2, E4)

I now more frequently check my sugar and prick my fingers. (G2, E2)

Coinciding with one study, comprehensive care of patients with diabetes and hypertension, where they mention that the patients who went to the intervention increased their adherence to treatment by which the information was a useful strategy in this improvement of adherence control, noting a decrease in the percentage of patients that forgot about taking their medication, which would help them to feel good and post-intervention there was an increase in the number of patients taking their medicine as instructed27. The nursing role in the care of a patient with diabetes mellitus has been identified in this study, the deficit theory of self care was shown to be a theoretical approach feasible to operate in the educational intervention with outcomes in the adherence to the treatment and self-care21-23.

Some authors recognize that diabetes education is an essential aspect of the treatment to achieve changes in the quality of life through therapeutic adherence to pharmacological treatment, by motivating and increasing the self-care agency and the promotion of healthy lifestyles28.29.


The 200 diabetic patients who took part in this study were divided into two groups: one is the control and the other intervention.The two groups of patients showed homogeneous behavior in relation to gender, socio-economic status, marital status, income and schooling weekly, in addition to the continuous variables such as age, weight, height and body mass index.

Subsequent to the development of the nursing educational intervention, the intervention group showed a higher average adherence to treatment with significant difference in the control group, as well as in the evolution in the intervened group (pre-intervention vs. post-intervention).

After the nursing educational intervention in self care index and knowledge of the disease, the intervention group showed a significant increase relative to the control group and their own values before the intervention.

In relation to diabetes self-care during the group interviews with the patients after receiving the educational intervention changed their actions to preserve their wellbeing.
The patients focus group participants expressed an increased responsibility in healthcare and generated new knowledge in nutrition, as reflected in the change of attitude towards medication intake.

One can improve all clinical parameters, both quantitatively and qualitatively, regarding the status of health with a nursing educational intervention in chronic patients, such as those affected by type 2 Diabetes Mellitus.


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