|Year : 2018 | Volume
| Issue : 1 | Page : 1-5
The effects of home-based nursing care on metabolic control among patients with type ii diabetes mellitus: A randomized clinical trial
Masoud Khodaveisi1, Farzaneh Miri2, Afsar Omidi1, Manouchehr Karami3, Ali Esmaili Vardanjani1, Nahid Mohammadi1
1 Chronic Diseases (Home Care) Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
2 Department of Community Health Nursing, Hamadan University of Medical Sciences, Hamadan, Iran
3 Social Determinants of Health Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
|Date of Web Publication||1-Feb-2018|
Department of Community Health Nursing, Chronic Diseases (Home Care) Research Center, Hamadan University of Medical Sciences, Hamadan
Source of Support: None, Conflict of Interest: None
Background: Diabetes mellitus (DM) management is challenging, particularly for people in developing countries. Objective: This study aimed to examine the effects of a home-based nursing care (HBNC) program on metabolic control among patients with type II DM. Methods: This single-blind randomized controlled trial was conducted in Hamadan, Iran, in 2014. Sixty patients with type II DM were consecutively recruited from a public diabetes care clinic in Hamadan, Iran, and randomly allocated to an experimental and a control group. Patients in the control group received usual discharge services, while their counterparts in the experimental group received HBNC services in addition to usual discharge services. The levels of fasting blood glucose, hemoglobin A1C, total cholesterol, triglycerides, high- and low-density lipoprotein cholesterols, and systolic and diastolic blood pressures were measured before and 3 months after the intervention. Data analysis was performed through the Chi-square, the paired-sample and the independent-sample t-tests. Results: HBNC program significantly decreased the levels of fasting blood glucose (from 206.60 ± 84.93 to 141.40 ± 48.75; P < 0.001), hemoglobin A1C(from 9.25 ± 2.19 to 7.55 ± 1.54; P < 0.001), and triglycerides (from 165.80 ± 78.96 to 126.63 ± 45.21; P < 0.01). However, it had no significant effects on total cholesterol, high- and low-density lipoproteins, and systolic and diastolic blood pressures (P > 0.05). Conclusion: HBNC is an effective strategy for managing type II DM and decreasing the risk of its complications.
Keywords: Home care services, Metabolic syndrome, Type II diabetes mellitus
|How to cite this article:|
Khodaveisi M, Miri F, Omidi A, Karami M, Vardanjani AE, Mohammadi N. The effects of home-based nursing care on metabolic control among patients with type ii diabetes mellitus: A randomized clinical trial. Nurs Midwifery Stud 2018;7:1-5
|How to cite this URL:|
Khodaveisi M, Miri F, Omidi A, Karami M, Vardanjani AE, Mohammadi N. The effects of home-based nursing care on metabolic control among patients with type ii diabetes mellitus: A randomized clinical trial. Nurs Midwifery Stud [serial online] 2018 [cited 2018 May 26];7:1-5. Available from: http://www.nmsjournal.com/text.asp?2018/7/1/1/224556
| Introduction|| |
With an increasing prevalence, diabetes mellitus (DM) is a major health problem throughout the world., According to the American Diabetes Association, DM was the seventh leading cause of death in the United States in 2010. It is also a major health problem in the Middle East countries such as Iran., Estimates show that from 78 million Iranians in 2015, 4.6 millions suffered from DM.
DM causes frequent hospitalizations. A study showed that adult people with DM are hospitalized 2.4 times more than the general population. Besides, DM is associated with heavy personal, social, and national burdens.
Several models have been developed and tested for DM management, including the chronic care model, the health belief model, the explanatory model of diabetes management, and the stages of change model. Pinto et al. used the health belief model to study factors behind patient retention in diabetes-related pharmaceutical care services and reported that the perceived susceptibility and the perceived threat constructs of the model significantly affected the use of the services. Sunaert et al. also found the effectiveness of the chronic care model in moderately improving the quality of diabetes care in Belgium. They finally concluded that two components of the chronic care model, i.e., delivery system design and clinical information systems need further improvement.
Patients with chronic diseases need detailed information and adequate support for the management of their diseases after hospital discharge. Such information and support should be provided not only at hospital discharge but also during the postdischarge period and even at patient home. One potential strategy for effective postdischarge DM management is home-based nursing care (HBNC). A recent study reported that patient education provided by nurses during home visits significantly improved quality of life among patients with congestive heart failure. Other studies also showed the effectiveness of different care delivery models in improving patient outcomes among patients with DM ,,, as well as patients who had undergone coronary artery bypass graft surgery. However, it is yet unclear whether HBNC can affect metabolic control. Therefore, this study sought to narrow this gap.
This study aimed to examine the effects of an HBNC program on metabolic control among patients with type II DM.
| Methods|| |
A single-blind randomized controlled trial was conducted from January to November 2014.
The sample size was calculated using the formula depicted in [Figure 1] and the results of a study which reported that the means of blood glucose levels in an experimental and a control group were 167.0 ± 31.9 and 198.7 ± 43.1, respectively. Considering an α of 0.05 and β of 0.20, the largest sample size was estimated to be 44 for each group, i.e., 88 for two groups. Yet, after applying the finite population correction, a sample of sixty patients was determined to be adequate. Thus, sixty patients with type II DM were consecutively recruited to the study from a public diabetes care clinic in Hamadan, Iran. Inclusion criteria were a diagnosis of type II DM for more than 1 year (according to the American Diabetes Association criteria), an age of eighteen or more, basic literacy skills, and no history of serious illnesses such as renal failure, hepatic failure, or mental illnesses (according to patients' medical records). Exclusion criteria were voluntary withdrawal from the study, move to another place for residence, and affliction by serious illnesses during the study.
Recruited patients were randomly assigned to an experimental and a control group using the balanced block randomization method. Primarily, two blank cards were labeled with the 'C' letter for the control group and two other cards with the 'E' letter for the experimental group. All cards were placed in a container. For each patient, one card was drawn from the container without replacement. After drawing all four cards for four patients, the cards were put back in the container, and the same process was gone through for every four patients until thirty patients were recruited to each group [Figure 2].
Patients in the control group received usual discharge services from registered nurses who were experienced in diabetes care. One day before discharge, nurses visited patients at the bedside and provided them with educations about DM causes, symptoms, symptom recognition, symptom management, treatments, medications, and complications as well as lifestyle modifications. Moreover, they answered patients' questions, if any. Patients in the experimental group were offered an HBNC program in addition to the usual discharge services. Accordingly, registered nurses who were experienced in diabetes care performed three home visits during a month for each patient in this group. The components of the HBNC program were as follows: physical, functional, psychological, financial, and social assessments; medication preparation and administration; medication management; measurement and documentation of blood glucose level; foot care; wound dressing; personal hygiene; consumption of a balanced diet; engagement in balanced physical activities; and patient and family education. Patients in this group also received an educational package which included a diabetes care booklet and an educational video.
At the beginning of the study, we assessed and documented patients' demographic characteristics including age, gender, body mass index, marital, educational, and employment status, income level, illness duration, and smoking history. Moreover, after an overnight fasting, blood samples were obtained from each patient before discharge and 3 months afterward for the measurement of blood glucose level (with the glucose oxidase method and the Pars Azmoon kit), hemoglobin A1C(with the NYCOCARD Hemoglobin A1C kit), and total cholesterol, triglycerides, and high- and low-density lipoprotein cholesterols (HDL-C and LDL-C) (with an automatic blood analyzer). All blood tests were performed in the same laboratory. In addition, blood pressure was measured twice before and twice after the intervention. All blood pressure measurements were made after a 15-min calm sit on a seat in a quiet room and using a portable sphygmomanometer (Microlife AG1-20).
The study was approved by the Research Ethics Committee of Hamadan University of Medical Sciences, Hamadan, Iran (approval code: P. 22.214.171.1249). Moreover, it was registered in the Iranian Registry of Clinical Trials (registration code: IRCT2013070113834N1). Each participant signed a written informed consent at the time of recruitment to the study. They were assured of the confidentiality of their data as well as their ability to voluntarily withdraw from the study.
The data were analyzed using the SPSS software version 13.0 (SPSS Inc., Chicago, IL, USA). The Kolmogorov–Smirnov test was applied for normality testing and the descriptive statistics measures for data description. Between-group and within-group comparisons respecting numerical and categorical variables were made through the Chi-square and the paired- and the independent-sample t-tests. The results of statistical analyses were considered statistically significant at the level of <0.05.
| Results|| |
Among sixty patients, 73.3% were women. Their age was 53.7 ± 17.1, on an average. No significant difference was found between the groups regarding patients' demographic characteristics (P < 0.05), [Table 1].
The results of the independent-sample t-test illustrated no significant between-group differences regarding the pretest mean values of total cholesterol, triglycerides, HDL-C, LDL-C, fasting blood glucose, hemoglobin A1C, and systolic and diastolic blood pressures (P > 0.05). However, after the intervention, the mean values of total cholesterol, triglycerides, HDL-C, LDL-C, fasting blood glucose, and hemoglobin A1C in the experimental group were significantly lower than the control group (P < 0.05), [Table 2].
|Table 2: Pre-test and post-test mean values of the assessed parameters in both groupsa|
Click here to view
The paired-sample t-test showed that in the control group, except for the mean value of diastolic blood pressure, the mean values of other parameters did not significantly change during the study. The mean value of diastolic blood pressure in this group decreased significantly from 83.50 ± 12.67 to 78.33 ± 9.58 (P = 0.011). In the experimental group, the mean values of total cholesterol, HDL-C, LDL-C, and systolic and diastolic blood pressures did not change significantly (P > 0.05), while the mean values of triglycerides, fasting blood glucose, and hemoglobin A1C decreased significantly (P < 0.05).
| Discussion|| |
The aim of this study was to examine the effects of an HBNC program on metabolic control among patients with type II DM. Findings revealed that the HBNC program improved metabolic control in patients with type II DM.
DM is a serious health-care challenge worldwide, particularly in Asia; hence, different interventions (such as electronic education, telephone consultation and follow-up, and phone text messaging) have been developed and used to improve DM-related outcomes.,,,,, A meta-analysis concluded that text messaging is an effective method for patient education about glycemic control. Another study showed that patient and family education based on empowerment models had positive effects on metabolic control among diabetic patients. Three other studies also reported that HBNC programs were effective in improving glycemic and metabolic control among these patients.,,
The study findings showed a significant decrease in fasting blood glucose after the HBNC program, denoting the effectiveness of the program in decreasing blood glucose level among patients with type II DM. Similarly, Ko et al. and Oduwole et al. in their study reported that individually tailored education provided by visiting nurses  and home visits  significantly decreased blood glucose.
The study findings also indicated a significant decrease in the level of hemoglobin A1C3 months after the intervention. In line with this finding, Lashkari et al. reported the effectiveness of telenursing in decreasing hemoglobin A1C. A study by Sadeghi et al. and Keogh et al. also found that family-centered care programs can significantly decrease hemoglobin A1C.
The other finding of the study was a significant decrease in the blood level of triglyceride following the HBNC program. This is consistent with the findings of a study made by Partapsingh et al. which showed that the stages of change model was effective in significantly decreasing the level of total triglyceride.
The positive effects of HBNC on metabolic control among diabetic patients can be attributed to the supportive roles of families in Iranian society. When family members are engaged in patient care, they can directly supervise patients' health-related activities, encourage them for regular physical activity and healthy eating, warn them against unhealthy lifestyle behaviors, promote their adherence to dietary and treatment regimens, and thereby improving metabolic control among them. On the other hand, the insignificant effects of HBNC on blood pressure may be because at baseline, systolic, and diastolic blood pressures in both groups were within normal ranges. Moreover, we monitored patients only for 3 months. Follow-up assessments in longer periods of time may produce different findings.
This study had three limitations. First, only those patients who referred to a public diabetes care clinic were included. Second, this was a single-blind study, in which complete blindness was not possible. Third, the follow-up period was as short as 3 months. Therefore, triple-blind trials with larger samples and longer follow-up periods are needed to produce conclusive evidence respecting the effects of HBNC on DM-related outcomes such as hospitalization rate and medical costs.
| Conclusion|| |
The findings of this study revealed that HBNC is an effective strategy for improving DM management and decreasing the risk of DM complications. However, despite the effectiveness of HBNC in maintaining care continuity after hospital discharge and improving patient outcomes, HBNC programs are not widely used for diabetic patients in Iran. Community health nurses can use HBNC to actively involve patients and their family members in the process of care and thereby, improve metabolic control and prevent DM complications.
The present study was granted by Hamadan University of Medical Sciences, Hamadan, Iran. We would like to thank patients and their family members who accepted to participate in the study.
Financial support and sponsorship
This article is part of the MSc thesis in Nursing Education, approved by the Vice-chancellor of research and Technology, Hamadan University of Medical Sciences, Hamadan, Iran.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dunning T. Care of People with Diabetes: A Manual of Nursing Practice. New Jersey: John Wiley & Sons; 2013.
Esteghamati A, Gouya MM, Abbasi M, Delavari A, Alikhani S, Alaedini F, et al.
Prevalence of diabetes and impaired fasting glucose in the adult population of Iran: National Survey of Risk Factors for Non-Communicable Diseases of Iran. Diabetes Care 2008;31:96-8.
Haghdoost AA, Rezazadeh-Kermani M, Sadghirad B, Baradaran HR. Prevalence of type 2 diabetes in the Islamic Republic of Iran: Systematic review and meta-analysis. East Mediterr Health J 2009;15:591-9.
Ramachandran A, Snehalatha C, Ma RC. Diabetes in South-East Asia: An update. Diabetes Res Clin Pract 2014;103:231-7.
Brunner LS, Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott Williams & Wilkins; 2014.
Omidi A, Miri F, Khodaveisi M, Karami M, Mohammadi N. The effect of training home care to type-2 diabetic patients on controlling blood glucose levels in patients admitted to the diabetes research center of Hamadan. Sci J Hamadan Nurs Midwifery Fac 2014;22:24-32.
Sunaert P, Bastiaens H, Nobels F, Feyen L, Verbeke G, Vermeire E, et al.
Effectiveness of the introduction of a Chronic Care Model-based program for type 2 diabetes in Belgium. BMC Health Serv Res 2010;10:207.
Pinto SL, Lively BT, Siganga W, Holiday-Goodman M, Kamm G. Using the Health Belief Model to test factors affecting patient retention in diabetes-related pharmaceutical care services. Res Social Adm Pharm 2006;2:38-58.
Alavi NM, Ghofranipour F, Ahmadi F, Babaee G, Rajab A, Emami A. Explanatory model of diabetes management; An experience from Iran. Nur Midwifery Stud 2012;1:100-6.
Partapsingh VA, Maharaj RG, Rawlins JM. Applying the stages of change model to type 2 diabetes care in Trinidad: A randomised trial. J Negat Results Biomed 2011;10:13.
Khodaveisi M, Ashtarani F, Beikmoradi A, Mohammadi N, Mahjub H, Mazdeh M, et al.
The effect of continuous care on the lifestyle of patients with multiple sclerosis: A randomized clinical trial. Iran J Nurs Midwifery Res 2017;22:225-31.
Mehralian H, Salehi S, Moghaddasi J, Amiri M, Rafiei H. The comparison of the effects of education provided by nurses on the quality of life in patients with congestive heart failure (CHF) in usual and home-visit cares in Iran. Glob J Health Sci 2014;6:256-60.
Salavati M, Fallahinia G, Vardanjani AE, Rafiei H, Mousavi S, Torkamani M, et al.
Comparison between effects of home based cardiac rehabilitation programs versus usual care on the patients' health related quality of life after coronary artery bypass graft. Glob J Health Sci 2015;8:196-202.
Mollaoǧlu M, Beyazit E. Influence of diabetic education on patient metabolic control. Appl Nurs Res 2009;22:183-90.
Lashkari T, Borhani F, Sabzevari S, Abbaszadeh A. Effect of telenursing (telephone follow-up) on glycemic control and body mass index (BMI) of type 2 diabetes patients. Iran J Nurs Midwifery Res 2013;18:451-6.
Saffari M, Ghanizadeh G, Koenig HG. Health education via mobile text messaging for glycemic control in adults with type 2 diabetes: A systematic review and meta-analysis. Prim Care Diabetes 2014;8:275-85.
Sadeghi M, Pedram Razi S, Nikbakht Nasrabadi A, Ebrahimi H, Kazemnejad A. Comparison of the impact of education based on the empowerrment model and family-center empowerrment model on knowledge and metabolic control of patients with type 2 diabetes mellitus. J Nurs Educ 2013;2:18-27.
Ko IS, Lee TH, Kim GS, Kang SW, Kim MJ. Effects of visiting nurses' individually tailored education for low-income adult diabetic patients in Korea. Public Health Nurs 2011;28:429-37.
Oduwole AO, Uko RI, Tade T, Doherty OK, Nwodo R, Imafidon EO, et al.
The effect of home visits on the quality of life of children and adolescents with type 1 diabetes mellitus. Pediatr Diabetes 2011;12:335-40.
Olry de Labry Lima A, Bermúdez Tamayo C, Pastor Moreno G, Bolívar Muñoz J, Ruiz Pérez I, Johri M, et al.
Effectiveness of an intervention to improve diabetes self-management on clinical outcomes in patients with low educational level. Gac Sanit 2017;31:40-7.
Keogh KM, Smith SM, White P, Mcgilloway S, Kelly A, Gibney J, et al.
Psychological family intervention for poorly controlled type 2 diabetes. Am J Manag Care 2011;17:105-13.
[Figure 1], [Figure 2]
[Table 1], [Table 2]