Diabetes: Analysis Of Scientific Articles And Researches
Diabetes affects nearly 30 million Americans each year across the nation, and unfortunately, West Virginia is at the top of the list (American Diabetes Association, 2016). According to Data Access and Dissemination Systems (DADS) (2010), the percentage of adults with diabetes is 11.4% in the United States while West Virginia is significantly higher at 16.2%. Furthermore, this statistic does not include people who are pre-diabetic which would further increase these percentages. Diabetes is a major concern because it can cause complications such as kidney failure, heart disease, stroke, lower-limb amputations, oral complications, and diabetic retinopathy. Type 2 diabetes mellitus can be prevented through education and lifestyle changes. With the increasing numbers, numerous hours of research are being conducted to improve interventional techniques to promote lifestyle changes and minimize complications in this population. Nurses, especially in the community setting, can help play an important role in decreasing the number of newly diagnosed diabetic patients and to minimize the complications in current diabetic patients. Nurses can do this through support and education of these patients based on evidence-based interventional literature.
Several of the articles reviewed for the synthesis had similarities that can be used to identify useful type 2 diabetes mellitus interventions and measurement tools. One similarity was several research studies measured HbA1c levels to determine the effectiveness of the intervention. Moghadam, Najafi, & Yektatalab (2018) drew blood samples to determine baseline HbA1c and at the 2 month follow up. Whitehead, Crowe, Carter, Maskill, Carlyle, Bugge, & Frampton (2017) also used HbA1c to measure the effectiveness of the intervention implemented. Participants with suboptimal glycemic control (>7%) were chosen to participate. Blood samples were drawn 6 months after the intervention to determine the effectiveness. Similarly, Saengtipbovorn & Taneepanichskul (2015) used HbA1c as a component to determine the effect of the study. Blood samples were obtained before the intervention for a baseline then for the 3 and 6 month follow up. Likewise, Arda, Sevgi, & Gul (2017) also monitored HbA1c. In the study, a baseline was obtained along with a follow-up sample at 6 months. HbA1c was used as a long-term measurement tool to determine the effectiveness of the interventions implemented among all of these studies.
The second similarity found was the educational content covered during the sessions. Moghadam et al. (2018) focused education on the disease process, normal glucose, diet, exercise benefits and the relationship between other diseases such as hypertension. Whitehead et al., (2017) also included similar educational components. The information included was the pathophysiology of diabetes, glucose control, complications, portion sizes, and self- management. Additionally, Hosein, Akbar, Leyla, & Mark (2017) included educational components similar to the other studies. Education was based on healthy lifestyle, self-adjustment, blood sugar control, nutrition, changing behaviors and prevention of acute complication. These studies all solely focused education on how to control diabetes.
A third similarity found was the length of time a participant had been diagnosed with type 2 diabetes mellitus in order to be included in the study. Inclusion criteria for Whitehead et al., (2017), participants were required to have had diabetes for at least 12 months to be eligible for the study. Comparably, inclusion criteria for the study conducted by Hosein et al., (2017), participants must have had the disease for over 1 year or 12 months.
The last similarity found among the articles was the inclusion and focus on oral hygiene, and the importance of proper oral health practices in a patient with diabetes. Malekmahmoodi, Shamsi, Roozbahani, & Moradzadeh, (2020) performed education on oral hygiene-related behaviors in patients with diabetes. Education included brushing teeth, the use of dental floss, how to wash the tongue, performing preventative behaviors and being aware of the possible oral complications of diabetes. Likewise, Saengtipbovorn & Taneepanichskul, (2015) performed a similar interventional component. The study provided participants with a lifestyle and oral health education program. In this program, diabetes and oral complications were discussed individually, then the relationship between these two components was discussed in further detail to help form the connection.
Although many of the articles shared common themes, they shared a number of differences as well. One difference was the collection and evaluation method used among the different research studies. For instance, Malekmahmo (2020) focused their efforts on the Health Belief Model which examined perceived susceptibility, severity, benefits, barriers, trigger or cue to action and self-efficacy. The focus was to examine how the participant perceived their health and risk factors, and if the participant’s actions after the education was affected by their belief of severity. Others, such as Saengtipbovorn & Taneepanichskul, (2015) included the Health Belief Model as a component in the program in addition to other components. The study used the LCDC program which included the Health Belief Model in addition to social cognitive theory and cognitive-behavioral theory. Moghadam et al., (2018) took a different approach and used a 90-question standardized Bar-On Questionnaire with a 5-point Likert scale to classify and evaluate data. In contrast, Arda et al., (2017) used DSME. DSME is a problem-solving process which includes assessment, goal setting planning, implementation, and evaluation.
The second difference was the session time frames and frequency. All of the studies were focused on education for diabetes, but the approach to the number of sessions and time per session differ between them. Malekmahmo et al., (2020) had 4 sessions lasting 120 minutes over the period of 1 month. Each of the 4 sessions pertained to a different topic. Moghadam et al., (2018) and Hosein et al., (2017) took a different approach with the educational sessions lasting 1-1.5 hours, once a week for 8 consecutive weeks. While some studies chose shorter and more frequent educational sessions, other studies chose longer and fewer sessions. The educational program session style used by Arda et al., (2017) lasted 3 hours each week for 3 consecutive weeks. Studies such as Whitehead et al., (2017) took yet another approach requiring participants to attend a 1-day workshop from 10 am to 5:10 pm. Saengtipbovorn & Taneepanichskul, (2015) took a completely different approach which included a 20-minute educational program with a discussion at the end to discuss what goals each participant set for themselves. Booster videos were given at month 1, 2, 4, and 5. At the 3-month mark, counseling was given along with a 15-minute educational video.
The third difference is how each study presented their educational material. Malekmahmo et al., (2020) approach included lectures, PowerPoint and booklets. Moghadam et al., (2018) presented education in group settings primarily through video. Hosein et al., (2017) used the approach of group discussion-based education. Participants in this setting were set up in a circular setting to facilitate conversation and discussion. In Arda et al., (2017), participants were split into groups of 5-10 and received supportive-educative nursing interventions based on diabetes self-education. Whitehead et al., (2017) conducted an educational program based on nurse-led education and acceptance and commitment therapy. Saengtipbovorn & Taneepanichskul, (2015) also focused on nurse and dental assistant led education, followed by educational videos in preceding months.
The last difference that is worth noting is only one study had a therapy component in the design. Whitehead et al., (2017) examined the effectiveness of education alone versus education plus acceptance and commitment therapy. The acceptance and commitment therapy approach helps one to be open to the unpleasant feelings that may arise with a type 2 diabetes mellitus diagnosis and helps patients better understand feelings and how to deal with them constructively. All other studies examined focused solely on educational components, disregarding how emotions may play into the participant’s success.
One common limitation found among the studies was longer program lengths are needed to increase educational benefits. Malekmahmo et al., (2020) concluded a longer program would be more beneficial for the participants. Additionally, Whitehead et al., (2017) stated a 1-day workshop is beneficial, however, to maximize the effects, maintenance sessions would be needed to sustain effects shown in preceding months.
Another common limitation found among the articles was concerning follow-up time and long-term effects. Both Malekmahmo et al., (2020) and Saengtipbovorn & Taneepanichskul (2015) stated a limitation to be that the study’s followed up at 3 months and to be more accurate, follow-ups should be done at 6 or 9 months, for example. Moghadam et al., (2018) also stated that a limitation was due to a short follow up of 2 months. Whitehead et al., (2017) and Hosein et al., (2017) also determined that results of the effectiveness of the studies are unknown at 12 months or longer making the long-term effectiveness of the study unclear.
The third common limitation among these studies was the small sample sizes. Malekmahmo et al., (2020) and Saengtipbovorn & Taneepanichskul (2015) stated a small sample size contributed to their limitations. Both stated a larger sample size would be warranted to help validate the effectiveness of the studies conducted.
The final notable limitation among the reviewed studies was the issue of generalization. Moghadam et al., (2018) discussed in the limitation section, the study was limited to one diabetic center which restricts generalization of the study. Additionally, Arda et al., (2017) also discussed the sample pool was recruited from only one diabetic education center. Recruiting from one diabetic center means results cannot be generalized to other diabetic centers or other countries.
With diabetes rates escalating in the United States, especially in West Virginia, nurses are in the position to help decrease these rates within the community and the state as a whole. The research examined within this synthesis provides information that can assist nurses and healthcare professionals to develop an interventional based project to help combat the increasing cases and minimize complications of type 2 diabetes mellitus. For instance, Moghadam et al. (2018), and Whitehead et al., (2017) focused on multi-faceted educational content presented in the intervention for a patient with diabetes specifically diet, exercise and lifestyle changes. These studies included informational packets such as booklets, handouts, video, and PowerPoint on the related material. Saengtipbovorn & Taneepanichskul, (2015) and Malekmahmo et al., (2020) also focused on this multi-faceted content with the addition of oral health hygiene into their educational material. These studies show the importance of teaching all aspects that affect diabetic control and information needed to help begin making lifestyle changes. A community health nurse could use all aspects of this important data content to help develop packets that provide education and visuals for a person that has diabetes. The nurse could present this package to a diabetic patient, highlighting important aspects, and allowing them to take the packet home with them to reference when needed. Presenting information about the disease, diet, and lifestyle modifications was shown to facilitate good patient outcomes.
Another way this synthesis can prove useful is through the incorporation of the Health Belief Model. For example, Malekmahmo et al., (2020) focused solely on the Health Belief Model which examined perceived susceptibility, severity, benefits, barriers, trigger or cue to action and self-efficacy and the behavioral changes in the patient after education. The Health Beliefs Model can be especially useful for community health nurses and healthcare professionals to gauge whether a diabetic patient has a perceived need for change. If the person perceives themselves to be susceptible or perceives the benefits to be high, they are more likely to accept and seek change. If the person perceives their susceptibility as low, or the barrier to change to be too significant then they will be less likely to adopt a healthier lifestyle. Additionally, Whitehead et al., (2017) added another component, acceptance and commitment therapy. This therapy shares some similarities to the Health Belief Model as they both focus on the participant’s specific feelings and viewpoints on the disease itself, and how this viewpoint can influence change. A nurse can use the information collected from the Health Belief Model to tailor the approach when providing educational information to different participants. The acceptance and commitment therapy component can be used to help the participant understand and express feelings and emotions related to the disease that may interfere or hinder their success.
Lastly, the interventional component used in Hosein et al., (2017) can prove especially helpful. In the study, participants partook in group discussion-based education. Participants in this setting were set up in a circular setting to facilitate conversation and discussion. Group discussion in this format was found to be especially useful in getting participants to partake and contribute to the conversation. Moghadam et al., (2018) also found success with the group setting approach. Additionally, Arda et al., (2017) found success in interventional groups split up into groups of 5-10. The small group setup allowed for more interaction between group members and the group leader. A community health nurse could use these approaches when educating participants on diabetes to help facilitate participation and increase the likelihood of better outcomes to help enable change in these individuals.