Effect of electronic education based on health promotion model on physical activity in diabetic patients

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Original article

Effect of electronic education based on health promotion model on physical activity in diabetic patients

Hamideh Lari

^a

, Rahim Tahmasebi

^b,c

, Azita Noroozi

^a,c,

*

aDepartmentofHealth,BushehrUniversityofMedicalSciences,Bushehr,Iran

bDepartmentofBiostatistics,BushehrUniversityofMedicalSciences,Bushehr,Iran

cThePersianGulfMarineBiotechnologyResearchCenter,BushehrUniversityofMedicalSciences,Bushehr,Iran

ARTICLE INFO

Articlehistory:

Availableonlinexxx

Keywords:

Healthpromotionmodel Physicalactivity TypeIIdiabetes Multimediatraining

ABSTRACT

Background:Byhighprevalenceofinactivity,particularlyindiabeticpatients,theneed toeffective interventionstopromotephysicalactivityisessential.Theaimofthisstudywastodeterminetheeffects ofeducationbasedonhealthpromotionmodel(HPM)throughmultimediaonthephysicalactivityin diabeticpatients.

Method:Inthisquasi-experimentalstudy,76patientswithtypeIIdiabeteswereevaluated(40patentsin interventiongroupand36patientsincontrolgroup).Theinterventiongroupmembersandafriendora familymember,thatcouldbesupportiveinphysicalactivity,receivedteachingCDbasedonhealth promotionmodel.Bothgroupmembersatthebeginningofthestudy,twoweeksandthreemonthsafter thetraining,completedquestionnaires.Afterdatacollection,statisticalanalysiswasconductedusing independentT-test,chi-squaretest,andrepeatedmeasurementofANOVA.

Results:Findingshowedthatself-efficacy(P<0.001),healthstatus(p=0.032),benefits(P<0.001)and friendssupportinphysicalactivity(P<0.001)wereperceivedtobehigher,andbarrierofphysicalactivity (P<0.001)wasperceivedtobelowerinmultimediagroupcomparedtocontrolgroup3monthsafter training.Therewasasignificantdifferenceinaverageofmetabolicequivalentoftask(MET)betweentwo groupsaftertheintervention(P<0.001).

Conclusion: PlanningofeducationbasedontheHPM andimplementationthrough multimediacan changebeliefaboutphysicalactivityandincreaseparticipationinphysicalactivity.

1.Introduction

Today,therateofdiabetesissigniﬁcantlyrising[1]asbasedon theWorldHealthOrganizationreport,theprevalenceofdiabetes in2004wasaround194millionandthisamountbytheyear2025 willbe333millionsofpeoplearoundtheworldandabouthalfof thepopulationwillbeinAsiaandOceania.Accordingtothereport ofinternationaldiabetesfederation,itisestimatedthatin2014,the prevalenceofdiabetesinIranwas8.43%[2].

Type 2 diabetes has high direct and indirect costs so has allocated15%ofthecostsofhealthcaresintheUnitedStatesof America[3],andinmanycountriesaroundtheworld,atleast10%

ofthetotalcostofhealthcareisspendingfordiabetics[4].

Environmental factors such as poor nutritional habits and especiallylackofphysicalactivityareeffectiveinthedevelopment

andprogressionofdiabetes[5].Physicalactivitythroughincreas- ing the number of insulin receptors,increasing tissue level of glucose transporters and improving insulin sensitivity, causes long-term effects in increasing sensitivity to insulin [6,7].

Therefore, theWorld HealthOrganization hasreportedat least 30minofdailyaveragephysicalactivityforatleast5daysaweek or25minofvigorousphysicalactivityforatleast3timesaweekas aminimumphysicalactivitytomaintaingoodhealthandprevent diabetes [8]. In high-incomecountries, 26% ofmenand 35% of women and in low-income countries 12% of men and 24% of women are physically active,and studieshave shown that the physicalactivityindiabeticpatientsisevenlessthanthegeneral populationsoinGreatBritain68%ofthetypeIIdiabetespatients and61%ofpatientswithtypeIIdiabeteswereclassiﬁedasinactive [9].InternationalDiabetesAssociationbelievesthatforpreventing complicationsofdiabetes,educationinself-managementbehav- iors, including physical activity can be successful up to 80%, however,theimpactofeducationdependsontheappropriateuse of behavioral change theories and appropriate educational techniques[10].

* Correspondingauthorat:ThePersianGulf MarineBiotechnology Research Center,BushehrUniversityofMedicalSciences,Bushehr,Iran.

E-mailaddress:[email protected](A.Noroozi).

http://dx.doi.org/10.1016/j.dsx.2017.08.013

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ContentslistsavailableatScienceDirect

Diabetes & Metabolic Syndrome: Clinical Research &

Reviews

j o u r n a lh o m e p ag e : w w w . e l s e vi e r . c o m / l o c a t e / d s x

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Sincethebaseofdiabetescontrolisonself-careandthemain emphasisofhealthpromotionmodelisalsoonself-regulation,so healthpromotionmodelforbehaviorchangeseemstobeeffective in this group of patients. This model includes three concepts includingindividual characteristics and experiences, behavioral specific cognition and affects and behavioral outcomes. The conceptofindividualcharacteristicsandexperiencesincludeprior relatedbehaviorandpersonalfactorsandtheconceptofbehavioral specificcognition and affects includingconstructs of perceived benefitandbarrier,perceivedself-efficacy,activityrelatedaffect, interpersonalinfluences(socialsupportandnorms)andsituation influences. Professor Pender identified constructs of the model thatwereeffectiveinmorethan50%ofstudiesincludingtheprior related behavior, personal factors (perceived health status), perceivedbenefit and barrier, perceivedself-efficacy and social support[11].

Nowadaysresearchershaveusedfromtechnologicaldevelop- mentforprovideinterventionsofhealthpromotion.Multimedia easilycommunicateswithusers,duetoitsdynamicandattractive graphicaleffectsanduseofvariousvisualandaudiomedia.Inthis method,thelearnerwillﬁndtheopportunitytopracticemoreto reach the proﬁciency level. So, given the increasing use of computer as a communication tool, we can teach educational conceptsin a charmingand diverseatmosphere bythehelp of multimedia [12,13]. So considering the importance of physical activityin diabetespatients, thisstudyaimedtodeterminethe

effectofeducationbasedonHPMusingmultimediaonphysical activityintypeIIdiabeticpatients(Fig.1).

2.Materialsandmethods 2.1.Studydesign

This quasi-experimental study has been carried out since October2016toFebruary2017toassesstheeffectofelectronic education onphysical activityof diabetic patientswith type II diabetesreferringtotwodiabetesclinicsinthecityofBushehr,a southwesternprovinceinIran.

Inclusioncriteriaforthisstudyincludedbeingabletoreadand write,havingnodiabeticfootulcers,willingnesstoparticipatein the study, having diabetes for 1 or more years; and exclusion criteria included functional inability to walk without a cane, inability to walk 1 mile with no rest, inability to continue participation in study for at least 3 months, and having cardiovasculardisease.

Thesamplesizewasestimatedbasedonsimilarstudy[14],36 subjectsforeachgroupandwithconsideringattritionrates(10%) inthree monthsfallowup,about40subjectswererequiredfor each groups. Two diabetes clinics were selected for sampling;

reviewing1775recordsofpatientsinHaftom-e-Tirdiabetesclinic, and514recordsindiabetesclinicoftheSocialSecurityHospital takingintoaccounttheinclusioncriteria,145patientsinHaftom-

Fig.1.Consortﬂowchartofparticipants.

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e-Tir clinic and 89 patients in Social Security Hospital were determinedeligible,and80 (outof234)patientswereselected usingsimple randomsampling. Aftera phone call,peoplewho would like to participate in the study were identiﬁed, and randomly divided in two groups of multimedia training and controlgroup.From40participantsineach group,4patientsin controlgroupwerenot willingtocontinue participationin the studyand wereexcluded.Ultimately,40patientsinmultimedia groupand36patientsinthecontrolgroupcompletedthestudy.

2.2.Methodanddatacollection

At the beginning of the study, the patients in both groups attendedattheclinicinaparticulardaydeterminedbythemselves, andcompletedthewrittenconsentformandthenquestionnaires includingdemographicquestionnaire,HPMconstructs,and7-day physicalactivity recallquestionnaire.Appointment intervalwas onehour per daysothatthe researchershaveenough time to completethephysicalactivityquestionnairethroughinterviews andtomonitorthequestionnairescompletion.

MultimediagroupmembersreceivededucationalCDbasedon HPM aftercompleting the questionnaires. The following topics wereinthiseducationalCD:

Tipsabout thebeneﬁts of physicalactivity tocontrol blood sugar and mental and physical effects of physical activity (perceivedbeneﬁts);

Tipsabouttheproblemsofdoing physicalactivity,including problemsrelatedtophysicalactivityintimesofhyperglycemiaand copingstrategiesandtrainingstoreducemusclecrampsrisingof physicalactivity(perceivedbarriers);

Trainingsbasedonstepbystepchangeofphysicalactivityand increaseitgraduallyoveraperiodof3monthsandmodifybelief basedontheusefulnessofheartrateincreaserisingfromphysical activity(perceivedself-efﬁcacy).

Thesetipshavebeenofferedtopatientsaseducationalslides withaudiorecordingandmobilityofplates.Also,educationalCD showed 8 strength move and 10 ﬂexibility move suitable for diabeticpatients.

A week after the package delivery, they dialed the person numberandensuredthattheeducationalCDhasbeenopenedby askingquestionsaboutitscontent.

In order to social support of friends, family members or significantpeople,thepatientswereaskedtointroducetheactive familymemberorfriendswhocanaccompanytheminperforming physicalactivity.The specialeducationalCDfor thesemembers havebeenalsodesigned andprovidedwhich inadditiontothe benefits, barriersand self-efficacy had alsosomeadvices about care,acceptance,trustandaccompanywiththepatient(perceived support).

TheeducationalCDwasautorunandwasdisplayedbyclickon anyﬁeld.InadditiontotheCD,multimediagroupmembers,since receivingthetrainingpackageto3monthslater,receivedweekly2 messagesviaSMStorecallthetips.

Participantsinbothgroups,4weeksafterthecompletionofthe ﬁrstphasequestionnaires,completedthequestionnairesrelatedto constructsofHPM,and3monthsafterthesecondstageofdata collectioncompletedquestionnairesrelatedtoconstructsofHPM andquestionnaireof7-dayrecallofphysicalactivity.

The participants of control group also after giving written consent, completed the questionnaires related to demographic factors,constructsofHPMand7dayrecallofphysicalactivityat baselineofthestudyand4weekslatercompletedquestionnaire relatedtoconstructs ofHPMand threemonthslatercompleted questionnairesrelated toconstructs ofHPM and7dayrecall of physicalactivity.Theparticipantsofcontrolgroupreceivedroutine

educationofclinicanddidn'treceivetrainingmaterialsuntilthe endofstudy.

2.3.Instrumentsandmeasures

Datacollectiontoolinthisstudywasaquestionnaireconsisted of three parts. The ﬁrst part of the questionnaire contained informationabouttheindividualcharacteristicsandexperiences demographic factors)suchasage,gender,education,household income,BodyMassIndex(BMI),typeofmedication,priorrelated behaviors,andperceivedhealthstatus.

Perceivedhealthstatuswasdeterminedby12-itemshortform health survey examining the physical and mental health.

Cronbach’s alpha for this instrument in physical health aspect was0.73andmentalhealthaspectwas0.72[15],andinthisstudy, Cronbach'salphacoefﬁcientwasobtained0.79fortheentiretools.

The second part of the questionnaire contained questions relatedtoconstructsofHPM.

Perceived beneﬁts: Sechrist and colleagues designed this instrumentfordeterminationofagreementordisagreementwith physicalactivitybeneﬁtsby28questionswith4-pointLikertscale.

Cronbach'salphacoefﬁcientofthisinstrumentwasreported0.89 [16];inthisstudy,Cronbach'salphacoefﬁcientwasobtained0.93.

Perceived barriers: individuals' perceptions of barriers to physical activity were examined by 14 questions with 4-point Likertscale.Cronbach'salphacoefﬁcientofthisscalewasreported 0.77[16];inthisstudy,itwasobtained0.74.

Perceived social support: People's perception of family and friendssupportinphysicalactivitywasmeasuredwith15and5 questionsrespectively,with5-pointLikertscale.Cronbach'salpha coefﬁcients were reported 0.9 and 0.86 for family and friends support,respectively[17];inthisstudy,itwasobtained0.92for familysupportand0.83forthefriendsupport.

Self-efficacy: confidence of people to do regular physical activity in differentconditions was evaluated byQuestionnaire of Norouzi et al. This questionnaire has18 questions and it is answered by a percentage scale (0–100%). Cronbach's alpha coefficientof thescale was reported0.92 [18]; in this study, it wasobtained0.92.

Thethirdpartofquestionnairemeasuredthephysicalactivity witha7-dayphysicalactivityrecallquestionnaire.Thequestion- naire was completed by a semi-structured interview. In the interview,subjectswereaskedtoremembertheactivitiesdonein thelastsevendays,todeterminetheduration(inmin),intensity (basedonthechangesoccurredinheartratecomparedtowalking andrunning),andtypeofeachactivity(dailyactivitiesorleisure activities).Then, usingtheinstructionsgivenin thesetools,the amountofMETwascalculatedinthelastweek.Thereliabilityof thesetoolswasstudiedinseveralinvestigationsbyanintra-class coefficient;ithadarangebetween0.34and0.99.Thisquestion- nairehasbeenidentifiedasausefultooltoassesstheamountof physical activity [19]. In this study, intra-class coefficient was obtained0.78.

Heightandweightofindividualsweremeasuredtodetermine MET and Body Mass Index. The data were analyzed by the statisticalpackageforsocialsciencessoftware(SPSS)version22.0.

Descriptive statistics, Chi-square test, independent t-test, and repeatedmeasurementANOVAwereusedfordataanalysis.

2.4.Ethicalconsideration

Thestudyprotocolfollowedtheprincipalsofthe“Declaration ofHelsinki”.Theparticipantsweretoldthattheycouldwithdraw fromthestudyatanytimeandthatallinformationwouldbekept secretandanonymous.Therequiredpermissionsforresearchwere obtainedfromthevicechancellorofBushehrUniversityofMedical

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ScienceswithethicsnumberIR.BPUMS.REC.1395.56.Writtenand informedconsentswereobtainedfromalltheparticipatinginthe study.

3.Results

Atotalof76diabeticpatients(N=40inmultimediagroupand N=36incontrolgroup)completedstudy.Therewerenosigniﬁcant differences between multimedia and control groups about individualcharacteristicsand experience(demographicfactors).

Forinstance,theaverageageofparticipantsinmultimediagroup was 47.358.47, and the average age in control group was 49.139.07(p=0.497).ThemeanSDofBMIinmultimediaand control group were 28.055.76 and 26.923.93 respectively (p=0.115),anddurationofdiabetesintwogroupswere7.555.78 inmultimediagroupand8.775.73incontrolgroup(p=0.999).

OtherdemographiccharacteristicswereshowninTable1.

Also, the participants in the SMS and control groups were similarintheirhealthbeliefs relatedtophysicalactivity before education,butthedifferencebetweentwogroupswasstatistically signiﬁcantaftertraininginseveralconstructs(Table2).

Comparison of pre and post-test results (immediate and 3 months later) in multimedia group by repeated measurement ANOVAfoundthatchangesoccurredintheperceivedhealthstatus, perceivedself-efficacy,perceivedbarrier,perceivedbenefit,friend and family support. The results demonstrated an increase in perceivedhealthstatus,self-efficacy,perceivedbenefit,friendand familysupportaswellasdecreaseinperceivedbarrier(p<0.001).

However,inthecontrolgroup,theresultsshowedthatthere werenosigniﬁcantchangesbetweenthepre-andpost-testscores fortheallofconstructs.

Comparison of two groups during thetime showed that no differencenoted in the scores of family support between two groups (p=0.052), but health status, self-efﬁcacy, beneﬁt, and friend support were perceived to be higher and barrier was perceivedtobeloweratthemultimediagroupcomparedtocontrol group(Table2).

Preandpost-testmeandifferenceofMETbetweentwogroups wasstatisticallysigniﬁcant(p<0.001).ThemeanSDofMETin multimediaandcontrolgroupsduringtimewereshowninTable3.

4.Discuss

In thisstudy,multimediatrainingimprovedperceivedhealth status, self-efficacy for physical activity, perceived benefits of physical activity, friends support for physical activity and also reducingperceptionof barriersof physicalactivity.In addition, there were statistically significant difference between the two groups during times in terms of perceived health status, self-

efficacy,benefits,perceivedbarriersandthesupportoffriendsin doingphysicalactivitysothatpatientsinmultimediagrouphad more understandingof theefficacy,benefits,health statue and friends support and less perceived barriers to doing physical activity.

Self-efficacy in multiple studies has been expressed as determinantsofphysicalactivitybehavior[20–22],thereforeits promotion will be an important factor in promoting physical activitybehavior.In thisstudy,learning throughmultimediaby providing positive feedback and encouraging people to daily recordofphysicalactivitypromotionhadenhancedtheperceived self-efficacyinphysicalactivity.Consistenttothefindingsofrecent studyresultsinastudybasedonsocial-cognitivetheoryfoundthat self-efficacyindiabeticwomen hasbeeneffectivein increasing physicalactivity[23].

In thisstudy, multimediacouldsigniﬁcantlyreducepeople's perceptionof barriersto physicalactivitythat this ﬁndingwas approvedbyseveralstudiesthatprovidedindividual[24]orgroup training[25].Inaddition,trainingthroughmultimediabasedon social-cognitive theory also had been able to change diabetic women's perception of the barriers to physical activity [23], thereforedynamismandattractivenesseducationbyaudio-visual media(multimedia)canreducepeople'sperceptionofbarriersto physicalactivityandthis trainingmethodseemsa goodwayto reduceperceivedbarriers.

Inmanystudieshaveidentifiedthatsocialsupportincluding familyorfriends,bothdirectlyandindirectlythroughpromoting knowledge,self-efficacy andillness perceptionwill impactself- managementbehaviorsandphysicalactivity[26–28].Inthisstudy, multimedia training improved the support of friends and so improved patients' perception of social support of friends in physicalactivity that subsequentlyresulted toself-efficacyand physicalactivitypromotion.In studieswheretraining hasbeen conductedinthepresenceoffriendsofpatients,similarfindings wereobtained[20,23,29]whichconfirmfindingsofthisstudy.

In this study, multimedia education could change people's perceptionof thebenefits ofphysicalactivitythatis consistent withmultiple studies'findings withdifferenttraining methods [23,24,29]whichrepresentsthevariabilityofthis constructand easiness of itschange, therefore,withlow-cost and convenient trainingmethodscanalsoincreasepeopleunderstandingofthe benefits of physical activity and there is no need for time- consumingandcostlyimmediateintervention.

People'sperceptionofhealthanddiseaseaffectsself-management behaviors [26]. Based on self-regulation model, disease symptoms create cognitive and emotional responsesabout the disease.Theresponsespassthreestages.Atﬁrstpeoplerespondto threaten or disease symptoms, then change their behavior to overcome these symptoms and ﬁnally verify their treatment

Table1

Demographiccharacteristicsintwogroupspriortotraining.

Demographicvariables Multimediagroup Controlgroup Chiesquarestatistics P-value

N % N %

Gender Female 15 37.5 17 47.2 0.735 0.266

Male 25 62.5 19 52.8

Educationlevel Diploma 22 55 20 55.6 0.368 0.832

Academiceducation 18 45 16 44.4

Marriedstatus Married 38 95 33 91.7 0.343 0.449

single 2 5 3 8.3

Job housekeeper 8 20 9 25 7.759 0.256

Employee 17 42.5 9 25

pensionary 15 37.5 18 50

Drugtype Metformin 9 22.5 9 25 4.389 0.356

Insulin 3 7.5 5 13.9

Combine 28 70 22 61.6

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effectiveness.Theperceivedself-efﬁcacyeffectcontrolbeliefsand canleadtoabetterunderstandingoftheirhealthstatue[30,31].

Therefore,inthisstudysincetraininghadbeenabletoimprove self-efﬁcacysohadchangedpeople'sperceptionofhealthstatusas well.

Thisstudyshowedthatchangeofperceivedhealthstatus,self- efficacy,benefitsandbarrierofphysicalactivity,andfriendsupport couldsignificantlyincreasetheaverageMETinmultimediagroup.

Resultsofseveralstudiesthathaveusedhealthpromotionmodel indesigningeducationalprogram,showedimpactoftheprogram on physical activity promotion [23,24,29] in addition, it was effectiveinanumberofmultimediatrainingstudies,regardlessof thetheoreticalframeworktoincreasephysicalactivity[12,13,21].

Allofthesestudiesverifiedthefindingsofrecentstudy,however, sinceinthisstudy,usingthetheoreticalframeworkhaschanged people'sbeliefssoweshouldexpectthatthisbehaviorchangehas moredurabilityandlastingthatitsconfirmationrequiresfurther studies.Therefore,multimediaeducationbasedonhealthpromo- tionmodelcanbeaproperapproachtoimprovepatientsbelieves aboutphysicalactivityandpromotingdiabetesphysicalactivity.

5.Conclusion

Accordingtotheresultsseemthatplanningofeducationbased ontheHPManditsimplementationbyusingmultimediahasa positiveimpactonchanginghealthbeliefsandthereforecreation andpromotionofphysicalactivitysoitisrecommendedtouse multimedia as an affordable tool to change health beliefs and behaviorsofdiabetics'healthpromotioninwiderange.

Authors’contribution

Azita Noroozi contributed to the critical revision of the manuscript, as well as the ﬁnal approval of the study. Rahim Tahmasebi contributed to the study design, data analysis, and auditinganddraftingofthearticle.Also,HamidehLaricontributed totheprovisionandcollectionofthedata.

Conﬂictofinterest

There is no conﬂict of interesttobe declaredregarding the manuscript.

Implicationforhealthpolicymakers/practice/research/medical education

Determine the effect of education based on HPM using multimediaonphysicalactivityintypeIIdiabeticpatientsasan affordable tooltochangehealth beliefs and physicalactivityof diabeticpatientsinwiderange.

Acknowledgments

We gratefully acknowledge all persons who helped in this research. This study was supported by the researchdeputy of BushehrUniversityofMedicalSciences.

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Table2

Constructs’scoresofhealthpromotionmodelduringintervention.

Constructs Time Multimediagroup Controlgroup P-value(betweengroup)

MSD MSD

Perceivedhealthstatus Beforeeducation 36.056.21 35.555.95 0.032

Aftereducation 39.525.71 36.385.87

3monthslater 40.274.62 37.006.20

P-value(withingroup) p<0.001 0.299

PerceivedSelf-efﬁcacy Beforeeducation 48.1722.54 58.8022.54 0.001

Aftereducation 56.5616.97 53.6520.10

3monthslater 64.8616.88 56.6521.33

P-value(withingroup) 0.046 0.114

Perceivedbarrier Beforeeducation 2.160.43 1.960.49 p<0.001

3monthslater 1.630.32 1.850.36

Perceivedbeneﬁt Beforeeducation 3.450.37 3.570.35 p<0.001

3monthslater 3.700.20 3.540.31

Friendsupport Beforeeducation 2.431.05 2.781.05 p<0.001

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Familysupport Beforeeducation 2.860.85 3.300.82 0.052

3monthslater 3.120.74 3.280.76

Table3

Meanmetabolicequivalentoftask(MET)intwogroupsDuringIntervention.

Group Beforeeducation 3monthslater P-value

Controlgroup 2546.98479.48 2500.55423.08 0.051 Multimediagroup 2539.81532.31 2614.03592.45 0.001

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