Effectiveness of health education program enhance ability of patients with type 2 diabetes 2

Compare the median point of knowledge, self efficacy and self-management behavior of patients with type 2 diabetes before and after DSME .... Therefore, we conducted this study to initia

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH

UNIVERSITY OF MEDICINE AND PHARMACY, HO CHI MINH CITY

NGUYEN THI GAI

EFFECTIVENESS OF HEALTH EDUCATION PROGRAM ENHANCE ABILITY OF PATIENTS WITH TYPE 2 DIABETES 2

MASTER'S THESIS OF NURSING

HO CHI MINH CITY - 2017

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH

UNIVERSITY OF MEDICINE AND PHARMACY, HO CHI MINH CITY

NGUYEN THI GAI

EFFECTIVENESS OF HEALTH EDUCATION PROGRAM ENHANCE SELF – MANAGEMENT ABILITY OF PATIENTS WITH

TYPE 2 DIABETES 2

MASTER'S THESIS OF NURSING

Major: Nursing Code: 60.72.05.01

Supervisor : Associate Prof Nguyen Thi Bich Dao, MD, PhD

Associate supervisor: Kathy A Fitzsimmons, RN, PhD

HO CHI MINH CITY - 2017

REASSURANCES ……… i

CATEGORY ii

LIST OF TABLES iii

LIST OF CHART vi

LIST OF ACRONYMS .vii

BACKGROUND 1

OBJECTIVES OF THE STUDY 4

Chapter 1: LITERATURE 5

1.1 General about diabetes type 2 5

1.2 Epidemiology of diabetes 11

1.3 Self-management education for type 2 diabetes 13

1.4 Apply nursing theories 16

Chapter 2: SUBJECTS AND METHODS 20

2.1 Study design 20

2.2 Research area 20

2.3 Research duration 20

2.4 Study subjects 20

2.5 Sample size 20

2.6 Sampling Technique 22

2.7 Control deviation 22

2.8 Data collection 23

2.9 Definition and classification variables 27

2.10Diabetes self-managent education program 30

2:10 Ethics in research 31

Chart Research 33

Chapter 3: RESULTS 34

3.1 Characteristics of patients with type 2 diabetes 35

3.2 Describe research results before and after DSME 41

3.4 Blood sugar of patients with type 2 diabetes before and after DSME 63

Chapter 4: DISCUSSION 65

4.1 The characteristics of the study sample 65

4.2 Description of knowledge and effective DSME programs to enhance self-management of type 2 diabetes 68

4.3 Description of self – efficacy and effectiveness of DSM programs to enhance self-management of patients type 2 diabetes 69

4.4 Describe the behavior and level ofeffectiveness of DSME programs to enhance self-management of patients type 2 diabetes 70

4.5 Effectiveness of intervention programs with glycemic of patients with type 2 diabetes 72

4.6 Strengths and weaknesses 73

4.7 Prospects of the thesis 75

CONCLUSION 76

1 Compare the median point of knowledge, self efficacy and self-management behavior of patients with type 2 diabetes before and after DSME 76

2 Compare the median of the glycemi of patients with type 2 diabetes before and after DSME 76

REQUEST 78 APPENDIX 1

APPENDIX 2

APPENDIX 3

APPENDIX 4

APPENDIX 5

LIST OF TABLES Table 1.1 Diagnosis guidelines of diabetes of the American Diabetes Association 5 Table 3.1.Demographic characteristics of patients with type 2 diabetes before the

intervention 35

Table 3.2 Demographic characteristics of patients with type 2 diabetes under treatment hospital 37

Table 3.3 Clinical characteristics of patients with type 2 diabetes 39

Table 3.4.Clinical characteristics of study subjects under treatment hospital 40

Table 3.5 Knowledge about the causes and symptoms of diabetes 41

Table 3.6 Knowledge of how to monitor and treat diabetes 42

Table 3.7 Knowledge about diabetes complications of diabetes 43

Table 3.8 Knowledge about diabetes self-care of patients with type 2 diabetes 44

Table 3.9 General knowledge of type 2 diabetes 45

Table 3.10 Self – efficacy to perform diet 46

Table 3:11 Self – efficacy to do exercise and maintain a healthy weigt 48

Table 3:12 Self – efficacy to self check glycemic and pedicure self - care 49

Table 3.13 Self – efficacy to use medication prescription 50

Table 3.14 Self – efficacy to self manage type 2 diabetes 50

Table 3.15 Dietary level of patients with type 2 diabetes 51

Table 3.16 Level of physical activity of patients with type 2 diabetes 52

Table 3.17 Level of glycemic self-monitoring of patients with type 2 diabetic patients 53

Table 3.18 Level of using of prescription medication of patients with type 2 diabetes 54

Table 3.19 Self - care level of patients with type 2 diabetes 55

Table 3.20 Behaviors of self-management of type 2 diabetes patients' 56

Table 3.21 Compare knowledge between the intervention group and the control group 57

Table 3.22 Compare knowledge between Bac lieu hospital group and Thanh Vu

hospital group 58

Table 3.23.Compare self - efficacy between the intervention group and control

groups 59

Table 3.24 Comparison self - efficacy between the group and the Bac lieu

hospital group and Thanh Vu hospital group 60

Table 3.25 Compare self-management behaviors between the intervention and

control groups 61

Table 3.26 Compare self-management behavior between Bac lieu hospital group

and Thanh Vu hospital group 62

Table 3.27 Compare glycemic between the control group and the intervention

group 63

Table 3.28 Compare glycemic between Bac lieu hospital group and Thanh Vu

hospital group 64

LIST OF CHART

Diagram 1: Apply the nursing theories in study 20Diagram 2: Diagram research… .33

LIST OF ACRONYMS

2 ĐTĐ Diabetes Đái Tháo Đường

3 KTPV Quartile range Khoảng tứ phân vị

4 SD Standard deviation Độ lệch chuẩn

8 BMI Body Mass Index Chỉ số khối cơ thể

9 DSMQ Diabetes self -management

12 FPG Fasting Plasma Glucose Đường huyết lúc đói

13 IDF The International Diabetes

16 OR odds Ration Tỷ số chênh

17 PG Plasma Glucose Đường huyết

18 SDSCA Summury of Diabetes self

-care activities from

Tóm tắt hoạt động đái tháođường tự chăm sóc

19 WDF Word Diabetes Foundation Quỹ đái tháo đường thế

giới

20 WHO Word Health Organization Tổ chức Y tế thế giới

Diabetes (diabetes mellitus) is a chronic disease, not contagious In 2011, theWorld Health Organization (WHO) estimates that more than 346 million people arediagnosed with diabetes By 2030 this figure will double if no intervention takesplace [35] In Vietnam, the incidence of diabetes is increasing at an alarming rateand has nearly doubled in 10 years According to WHO (2016), estimated at present

in our country will have a 1 in 20 people who have diabetes In addition, the number

of people in the prediabetes stage 3 times more than those who are diagnosed withdiabetes [99] Proportion of diabetes type 2 diabetes in particular are increasinglycomplex and tends [1], [3], [4], [80] Special rate diabetes patients in the communityundetected still is very high (> 60%)[4] Also due to late detection, complications

of diabetes has a significant proportion of type 2 diabetes in patients immediately atthe time of diagnosis of diabetes

This disease becomes a burden, both in terms of health and economy formany countries, especially the type 2 diabetes The cost of care for diabetes is highand increasing worldwide [21], [34], [44], [46] Cost of treatment, travel andprolonged hospital stays may affect the economics of the family of patients.According to the International Diabetes Federation (IDF), the average 2015 costsrelated to diabetes in Vietnam is over 162.7 USD per patient/year Too muchcompared to the average monthly income of the people of Vietnam is 150 USD[99]

Self-management refers to the ability of an individual to manage thesymptoms, treatment, physical, psychosocial and lifestyle changes inherent to adapt

to a chronic condition [96] Self-management concept was understood as bothprocess and self-management education It equips patients with the conditions andskills needed to reduce the negative impact of the disease, with or without thecollaboration with the medical team [44], [88] Self-management behavior of anindividual can affect diabetes care everyday and clinical results and metabolism

The foundation of a successful outcome in diabetes is self-management andeffective care [40], [42] Indeed, there has been a lot of research shows thateducational self-management of diabetes help to improve the knowledge, behaviorand outcomes of treatment of patients with diabetes, both type 1 and 2, especiallycontrol glucose, stable HbA1c, blood pressure, BMI, cholesterol [21], [34], [53],[54], [81], [82] According to the author Dao Tran Tiet Hanh et al (2012), self-management practice in adults with type 2 diabetes in Vietnam is suboptimal Theyadhere to treatment regimens good but self-management behaviors at low levels,blood glucose self-monitoring at a low level and the average level for actscontacting health care professionals [61] When diabetes is not controlled, it mayleave the tremendous consequences for the health of patients Therefore,counseling, health education for patients with diabetes is very important in thetreatment process, so that they know how to manage their disease, control ofclinical indications, prevent complications occur Which will significantly reducethe burden, complications for the patients themselves and their families.

Diabetes self-management educational (DSME) is the process of creatingconditions to provides for patient the knowledge, skills and ability necessary for selfcare This process combines the needs, goals and experience the lives of people withdiabetes or prediabetes and are driven by research, evidence-based research Theoverall objectives of DSME is supporting information for decision making,behavior, self-care, problem solving, collaborative activities with groups of healthcare and improve clinical outcomes, health status health and quality of life [93].Diabetes self-management education improves diabetes clinical and quality of life

of diabetes at least in the short term In addition, it also results in economicefficiency, help people save money by preventing hospitalizations to restrict theadmission and in emergency [66], [84], [94]

In Vietnam in general and in Bac Lieu province in particular, have a lot ofresearch on the treatment and care of diabetes especially type 2 diabetes as: quality

of life, treatment compliance, survey the risk of complications diabetes diabetes,

nutritional status of patients ; but, there is little research on the status, behavioralself-management patients diabetes Bac Lieu General Hospital and Thanh VuGeneral Hospital, are medical units of the province's largest performingexaminations treatment and care for patients with diabetes, especially type 2diabetes No studies evaluated in Bac Lieu counseling intervention results of healtheducation for diabetes tip 2 Therefore, we conducted this study to initially evaluatethe effectiveness of counseling programs and self-management education programfor patients with type 2 diabetes treated at Bac Lieu General Hospital with

research questions:

Diabetes self-management education:

- Have change the average score of knowledge, behavior of self-management,self – efficacy of type 2 diabetes ?

- Have change average the glycemic ?

OBJECTIVES OF THE STUDY

* General objective:

Evaluate the effectiveness of health education program on self-management fortype 2 diabetes are being treated as outpatients at Bac Lieu and Thanh Vu hospital

* Specific objectives:

1 Determination of the change in knowledge, behavior of self-management, sefl

- efficacy of patients with type 2 diabetes before and after health education

2 Determination of the change glycemic index of type 2 diabetes before andafter health education

Chapter 1: LITERATURE 1.1 General about diabetes type 2:

1.1.1 Define:

Diabetes mellitus is a chronic disease that occurs either when the pancreasdoes not produce enough insulin or when the body can not use the insulineffectively Hyperglycemia, or high blood sugar, is a common after-effect ofdiabetes is not controlled, and over time leads to serious damage to many systems

of the body, especially the nerves and blood vessels [43] Diabetes can causeserious health complications including heart disease, blindness, kidney failure, andlower limb amputation-

1.1.2 Criteria for diagnosis of diabetes: follow the guidelines of the

American Diabetes Association (ADA), 2015 [26]

Table 1.1 Diagnosis guidelines of diabetes of the American Diabetes

Association

HbA1c ≥6.5%

Done in laboratories using methods certified by a standardized program

glycehemoglobin countries

Fasting plasma glucose ≥126 mg / dL (7.0 mmol / L) *

Fasting glucose was defined as fasting totally ≥8 hours minimum

2-hour postprandial plasma glucose ≥200 mg / dL (11.1 mmol / L)

* When performing glucose.Nghiem tolerance test methods described by theWHO, patients who consume water-soluble sugar equivalent 75g of glucose

Random blood glucose test ≥200 mg / dL(11.1 mmol / L) * In people with symptoms

of hyperglycemia classic or hyperglycemic episodes

* In the absence of clear blood glucose results should be confirmed by repeattesting.

1.1.3 Classification of diabetes

a Type 1 diabetes

Type 1 diabetes, often called juvenile diabetes, the most common in youngpeople; However, type 1 diabetes can also evolve in adults In type 1 diabetes, thebody no longer able to produce insulin or does not produce enough, so the betacells of the pancreas are destroyed Langherhans Island [41] Clinical symptomsoccur suddenly, headlining: drink much, urination, weight loss more Type 1diabetes may account for 5-10% of all cases are diagnosed with diabetes [33]

b Type 2 diabetes

Type 2 diabetes usually begins with insulin resistance occurs when fat,muscle and liver cells do not use insulin to carry the glucose into the body's cells touse energy As a result, the body needs more insulin to help glucose enter the cells

At first, the pancreas keeps demand balance by adding insulin Over time, thepancreas does not produce enough insulin when blood sugar levels rise, as after ameal If the pancreas is no longer able to make enough insulin, need treatment oftype 2 diabetes disease [41] Type 2 diabetes may account for around 90% - 95% ofall diagnosed cases of diabetes Risk factors of type 2 diabetes include older age,obesity, family history of diabetes, history of gestational diabetes, glucosetolerance, physical inactivity, and race/ethnicity [33]

The symptoms of diabetes can vary from mild to severe, or the symptoms maynot be comprehensive The most common symptoms include:

- Thirst

- Hunger

- Tired

- Urination, especially at night

- Weight loss

- Amblyopia

- Sores that do not healFor people with type 2 diabetes, the symptoms are often develop gradually.Many people do not know they have diabetes type 2 until they discovered acomplication from the disease, such as a problem with vision or heart disease Insome cases, a person can have the disease for years before being diagnosed

c Gestational diabetes

Gestational diabetes can develop when a woman is pregnant Pregnancymakes hormones that can lead to insulin resistance All women with insulinresistance at the end of their pregnancy If the pancreas does not produce enoughinsulin during pregnancy, women will have high risk for gestational diabetes

Women are overweight or obese have a higher chance of gestational diabetes

In addition, excessive weight gain during pregnancy may increase the likelihood ofdeveloping the disease DTDthai period Gestational diabetes usually disappearsafter the baby is born However, a woman who has had gestational diabetes aremore likely to develop type 2 diabetes later in life Babies was borned frommothers with gestational diabetes are also more likely to develop diabetes obesityand type 2 [41]

d Other forms of diabetes due to various reasons such as the syndrome

of diabetes due to genetic defects in the function of beta cells (diabetes in infantsand onset at a young age), genetic defects in the operation of insulin In addition,due to the pathology of pancreatic exocrine, chemical or drug-induced (as in thetreatment of HIV / AIDS or after organ transplants) [53]

1.1.4 Complications of diabetes:

a Acute complications

Complications occur suddenly in a short time and very fatal if not treatedpromptly position or emergency These complications can be triggered fromuncontrolled blood sugar, high blood sugar (hyperglycemia) or too low(hypoglycemia), due to the lack or cause inactivation of insulin [89] Acutecomplications common:

- Coma ketones acidosis: is a complication in immediate danger to the life ofpatients, the cause is a lacking of insulin caused severe disturbances in proteinmetabolism; lipids and carbohydrates This is a medical emergency should bemonitored at the faculty of aggressive treatment The common symptoms are:nausea and vomiting, thirst for more, drink more and more diabetes, fatigue and/orloss of appetite, abdominal pain, blurred vision, drowsiness, dreaming Signs toidentify patients with coma due to infection ketones: tachycardia, hypotension,dehydration, hot dry skin, breathing type Kusmaul, impaired consciousness and/orcoma, bad breath ketones, slump shallow[6], [14]

- Hypoglycemia: causes increased secretion of insulin (substances inhibitingeffect glucose production in the liver, stimulate consumption of glucose in skeletalmuscle and adipose tissue), reduce the feed (due to diet demanding or have aproblem with malabsorption), increased levels of exercise (increases skeletal muscleglucose utilization) Clinical classification of hypoglycemia into 3 levels[6]:

+ The level of light: Usually symptoms of sweating, shaky and hungry.These are symptoms of the autonomic nervous system These symptoms will goaway after taking 10-15 grams of carbohydrates, 10 - 15 minutes This level ofpatient self treatment

+ Medium level: At this level of response clinical manifestations include 2levels of the nervous system automatically and neurological signs of reducing the

amount of glucose in tissues such as: headache, behavioral changes, easy irritation,decreased ability to pay attention, somnolence Without timely intervention, thepatient is quickly transferred to severe levels.

+ The severity: lowering blood glucose levels now very low Clinicalmanifestations of coma, paralysis or seizures Now you need to transmit emergencyintravenous glucose and/or glucagon

+ Hypoglycemia complications can be substantially reduced by preventivemeasures such as using drugs stabilize blood sugar (insulin or oral drug) right dose,duration of use medicines suitable for meals, mode proper nutrition (not abstinenceexcessive), physical exercise regime suitable, limited or no alcohol

- Coma hyperglycaemia not acidosis ketones [6] : Common in people withtype 2 diabetes over age 60, women are more common than male

+ Patients with poor prognosis, high mortality rate ratio even whenemergency centers with adequate facilities and there are experts, if any surviveoften leave sequelae

+ Increased blood glucose ketones acidosis can occur in people who havenever been diagnosed with type 2 diabetes

+ There are many similarities with ketones acidosis coma The maindifference is hyperglycaemia, dehydration and electrolyte disorders

+ Features important to distinguish acidosis coma ketones is not possible orvery mild ketones in the urine

- Diabetes type 2 diabetic especially also cause acute complications such ascoma, lactic acidosis, and acute infections

atherosclerosis causing embolism According to the program of prevention ofdiabetes National, over 65% of deaths in people with diabetes is heart disease andstroke The occurrence and progression of cardiovascular disease is unavoidableimplications for diabetics They are prone to high blood pressure, arteriosclerosis,myocardial infarction, stroke sequelae cause paralysis or death[11].

- Small vessel disease:

+ Complications in the eyes :

 Diabetic retinopathy: background retinopathy or retinopathy of "simple"include micro-aneurysms, hemorrhages, exudates, and macular edema proliferationwith anemia as arterioles points stringbed deflects image wool (the small infarct inthe retina) and proliferative retinopathy or "malignant", created by the creation ofnew blood vessels [19]

Glaucoma: Glaucoma occurs when pressure builds up in the eye In mostcases, the pressure causes the drainage system of the vitreous humor may slowdown so that it accumulates in the anterior chamber Pressure pinches the bloodvessels that carry blood to the retina and optic nerve are losing sight giac Sight isdying because the retina and nerves are damaged [52]

 Cataract: Cataract soon occur in patients with diabetes seem to becorrelated with diabetes duration and severity of prolonged hyperglycemia Theinfection can not sugar glass protein by enzymes in patients with diabetes is twicethat in normal people and can lead to cataract early[19]

+ Diabetic kidney disease: including glomerular complications, pathologicalrenal atherosclerosis, kidney infections and urinary tract The disease usuallyoccurs in 20-40% of patients with diabetes and is the leading cause of end-stagerenal disease [53], [58]

+ Neuropathy diabetes (neuropathy feeling - motor, autonomic): reducedability to feel pain, heat or cold, meaning that the patient can not feel the legs werehurt

- Coordinate neuropathy and vascular: diabetic foot ulcer Due to neurologicalcomplications should foot lost sensation, so every time the stand, the patient willnot be able to adjust the posture feet, the position under pressure will be thetransformation of the body and skin entail changes of the joints Consequently,deformed feet, typically called Charcot foot (but fortunately very rare), and veryprone to ulcers in the high pressure place Or occur in the instep and thumb, and isusually caused by tight shoes go to make up the pressure on the foot.

1.2 Epidemiology of diabetes 1.2.1 World

Worldwide, WHO (2104) estimated 422 million adults living with diabetes.Worldwide, the number of diabetes increased almost doubled from the year 108million people (4.7%) in 1980 to 422 million people (8.5%) in 2014 [103] WHOestimates that globally, high blood sugar is a risk factor for mortality ranks thirdafter high blood pressure and tobacco use [74], [91]

According to the International Diabetes Federation (IDF) 2015 [74] Every 11adults will have a 1 in diabetes, and more than half are not diagnosed in time 12%

of global health expenditure is paid to diabetes In countries with high incomes, incommunity diabetes An estimated 87% to 91% of people with diabetes type 2, 7%

to 12% have diabetes type 1 and a 1% to 3% is types of diabetes [57], [63], [71],[72]

An estimated 14.2 million people aged 20-79 with diabetes in the AfricanRegion Rate of diabetes is not diagnosed in the African region is very high, morethan two thirds (66.7%) of people with diabetes do not know they are infected Themajority (58.8%) of people with diabetes live in the city, although the population inthe region is mainly (61.3%) rural [64]

In Europe, more than 31.7 million people, 4.8% of adults aged 20-79,estimated to be living with impairment of glucose tolerance and high riskdevelopment of diabetes Indeed, in 2040, IDF predicts that there will be 71.1million adults living with diabetes in the European region About 627,000 people

aged 20-79 died of diabetes in 2015 in the European region About a quarter(26.3%) of the deaths are in people under 60 years of age[65].

In the Middle East and North Africa in 2015, about 35.4 million people or9.1% of the population relatively adults aged 20-79 years of age are living withdiabetes and 40.6% more of these cases are not diagnosed [49]This rate withinsteps Ty in North America and the Caribbean, respectively 44.3 million adults(12.9%), diabetes and 13.3 million people (29.9%) patients with diabetes areundiagnosed[49].year 2015, the Asian region has to 78.3 million people (8.5% ofthe population) living with diabetes Among them, more than half (52.1%) were notdiagnosed[49]

1.2.2 Vietnam:

Society is growing along with the process of urbanization and acculturationEast - West, diabetes type 2 has become a pandemic in Asian countries, adverselyaffect public health and socioeconomic, including Vietnam

In Vietnam, the incidence of diabetes is increasing and complex Theincidence of diabetes in Vietnam tends to increase in most regions of the country,especially in big cities and industrial zones In 2000, a survey in the urban area of 4big cities of Hanoi, Hai Phong, Da Nang and Ho Chi Minh city showed that therate of diabetes at age 30-64 is 4.0% 2002, Endocrinology Hospital conductedresearch in some ecoregions showed the rate of diabetes in this age group was 4.4%

in the city, 2.7% in the delta, 2.2 % in the midlands and coastal-zone and 2.1% inthe mountains [3], [4] According to a survey mapping diabetes epidemiologynationwide in 2012 by the Hospital of Endocrinology made, the rate of diabetesages 30-69 was 5.4%, the lowest rate of diabetes is Highland (3.8%), the highestrate of diabetes is the South West (7.2%) The survey also indicates an interestingsituation in our country, the percentage of patients with diabetes is not detected ondesktops copper remains very high (63.6%) compared with 2002 (64%) [4] Alsodue to late detection, complications of diabetes has a significant percentage of

patients with type 2 diabetes even at the time of diagnosis diabetes In Ho ChiMinh City, a screening for diabetes research across city in 2001 showed that therate of diabetes was 3.8% and this rate has increased 7% at 2014 [1], [80] By thenumbers say on raises a complex picture and unsolvable in the process ofdiagnosis, treatment and preventive care of type 2 diabetes.

1.3 Health education for type 2 diabetes self-management:

1.3.1 Self-management concept:

So far there is no "gold standard" will be accepted totally to definegeneralized self-management concept Instead, some of the terminology used,sometimes interchangeably, depending on the context and focus of the discussions.These include: preparation of self-management/training; empower patients; andself-care Although they generally meant to describe a similar phenomenon, withimplications for various attributes, roles and responsibilities of both aspects: peoplewith chronic diseases and the provider health care [45] This concept is described

as a complex structure, supports the ability of individuals to perform a variety ofactivities planned self-management [24], [32] Lorig and Holman (2003) uses theframework of Corbin and Strauss to work with patients who have chronic diseaseself-management concept into three tasks include; medical management orbehavior, role management, manage emotions and perceptions [32], [37], [45].These tasks to promote patient maintain positive behavior or change harmful habits

to avoid the effects of the disease on their health Also, Lorig and Holman (2003)also suggested five key skills needed by self-management These skills includeproblem solving, decision making, discovered resources support and use them,forming partnerships with health care professionals and act [32], [36]

Lorig (1993) defines self-management is "learning and skills needed toimplement a proactive life and emotional response when faced with a chronicmedical condition" [36] Lorig continue to emphasize that self-management is not a

substitute for medical care Instead, self-management "to help participants becomeproactive, not adversaries but partners with providers of health care services"[45].

In general, self-management can be defined as the active participation of thepatient in managing the problems of physical and their psychological and makesmaintaining adaptations and lifestyles based cornerstone of chronic disease withthe support and guidance of health care professionals Moreover, the support that isbased on the patient's concerns and considering the individual context Self-management should be considered in the context of the conditions of eachindividual community, socio-economic level, culture and the environment cancause differences in thinking and behavior [22], [32], [35] If the patient to activelyparticipate in managing their condition in collaboration with experts in health careand self-management can reasonably be assumed to be effective in reducing theburden of long-term venture served with a chronic illness

Another view, self-management refers to the ability of individuals to managethe symptoms, treatment, consequences of physical and psychosocial and lifestylechanges inherent in life with a condition chronic Effective self-management,including the ability to track the status of a person and to perform the reactioncognitive, behavioral and emotional necessary to maintain satisfactory quality oflife [28], [45] According to the American Association of Endocrinology, self-management behavior of type 2 diabetic patients includes dietary modifications,foot care, medication adherence, blood glucose monitoring, physical activity, andcoping with Side effects of drug development and disease [35], [50]

More importantly, the collaboration with the medical staff can help peoplemake their action plans with the strength to cope with difficult conditionsanticipated So three years tasks and skills stimulate the active participation ofpatients in self-management of their disease is very useful

Generally, "self-management" is characterized by a number of dimensional behavior Basically, self-management behaviors of diabetic patients

multi-include the use of medication, diet, exercise, monitoring blood sugar and foot care.Diabetes self-management behaviors is one of the most important measures toachieve optimal glycemic control, which is associated with a reduction in thedevelopment of diabetic complications Self-management behaviors are developedthrough the process of selecting targets, selection of information, informationprocessing and assessment, decisions, actions, and reactions themselves Somepredict the behavior of diabetes self-management have been identified, includingthe personal factors, knowledge of diabetes, age, gender, level of education, diseaseduration , attitudes, self-efficacy, social support, and problem-solving skills [27].

1.3.2 Effectiveness of diabetes self-management education:

Author Rosal MC (2005), in a study to try to intervene in knowledge diabetes,attitudes and skills in self-management through specific strategies in objectSpaniards with low incomes Results showed that blood glucose and HbA1creduction after 3 months and estimates for the intervention group was 0.8%compared with the control group change (p = 0.02) and at 6 months time, reduction

in the intervention group still significant, decrease of 0.85%, and the reduction isstill significantly different than the control group (p = 0.005) [39]

In 2010, author Lorig K et al have shown that self-management programsonline diabetes have HbA1c improved significantly compared with the usual careother [23] In another intervention study author Tricia S.Tang et al (2012) intervene

to support self-management of type 2 diabetes in African-American subjects,followed for 2 years Results showed an improvement in glycemic control andserum cholesterol and lipoprotein cholesterol concentrations decreased [48]

In Western countries, the self-management program diabetes has beenmodified successfully with social assistance, including spouses, family andcaregivers unofficial It is important to integrate social assistance in controllingdiabetes in Asia, consistent with the characteristics of the people's culture [38].Two systematic reviews related to self-management intervention for patients with

chronic musculoskeletal disease and type 2 diabetes have been conducted for thesynthesis of self-management effects Reduce pain and change the diet has beenreported as the benefits of self-management intervention in the treatment ofpatients with arthritis and type 2 diabetes, respectively Naik et al (2008) added thatdiabetic patients have good blood pressure control when they have engaged in self-management of disease [30], [31], [32] Author Fu Dongbo and colleagues, in aqualitative study of the effects of programs to manage chronic diseases isconducted in Shanghai in 2006 showed that programs to manage chronic conditions

to improve their knowledge, self-management skills, behavioral health, increaseself-confidence, health status and quality of life [29]

1.4 Apply nursing theories:

There are several theories to support the process of nursing research on healthproblems, taking soc.Whit problem in this study, self-care theory of Orem isappropriate to the application, orientation research Self - care is theimplementation or practical activities initiated by individuals and make their ownbehalf to maintain life, health and happiness When self - care is done effectively, ithelps to maintain the integrity of the structure and function of human activity, and

it contributes to human development [59], [62], [100]

Self-care theory of Orem have four main concepts: self-care, self care agency,therapeutic self care demand, self care requisites [100] Besides there is the linkwith the concept known as the factors underlying conditions include: age, gender,education level, health status, social factors, system care health, marital status andenvironmental factors

Self-care, self-management is an extremely difficult process in itself hascertain barriers to perform self-care behaviors In this study in order to realize thebenefits of self-management behaviors, they must have a certain platform affect it.First to mention the skills and experience Skills in self-care is essential, andpatients should have the ability to plan, set goals and make decisions Experience

also contributed to the development of skills, although some patients may havemany years of experience with a particular disease and never develop self-careskills The challenge for health care professionals is to determine which patientshave learned from experience, to distinguish what is called correctly,and facilitatethe development of the skills needed to perform self-care.

There are many assumptions in self-care theory of Orem Assuming the firsttheory of self-care theory of Orem that people should be independent andresponsible for their own care and other family who need their care squirrel Thisspeaks to the care of the most direct, most often is itself of type 2 diabetes patients

to monitor, manage, care for yourself

The second theory is the people (patients) are separate individuals, notconfused This shows the need to exploit the patient's background information.This information will help medical professionals assess objectively, in particularthe situation of diabetes subtype 2 From there will be plans and guidance they plan

to manage the disease, self care yourself better

The third hypothesis care is a form of action, interaction between two or morepersons Therefore, acts of self-management in patients with diabetes mellitus type

2 is a form of interaction between individual patients with the disease, theindividual with the confidence in the abilities themselves, between patients andcare professionals their health These interactions constitute a system of mutualsupport to each other in the process of treatment and care for patients with diabetestype 2

A fourth hypothesis is the knowledge of a person about potential healthproblems is necessary to promote self-care behaviors So in this study, theassessment of knowledge, faith in the ability of the patient himself This will be thefoundation for developing self-management behavior of patients

Thursday hypothesis that behavioral care of yourself and take care ofdependent socio-cultural context Seeing this, many studies have demonstrated

religious beliefs, culture and society also have a significant impact on the behavior

of human self-management of type 2 diabetes[25], [27]

After studying and analyzing the concept of self-care theory of Orem.Combined with the reference to some scientific studies other, the specific situation

of the people involved in research, the expected location of the study, theresearchers applied the theory of Orem on this study modeled as six:

Figure 2: Application of Theory in Nursing Research

Self-management requisites

Behavior of management:

self-Control dietManage GlucosePhysical ActivityUsing medication, contactmedical staff

Foot care

Health care system

Doctors, nurses, dietitians, healthservices

Chapter 2: SUBJECTS AND METHODS 2.1 Study design:

Randomized clinical trials

2.4.1 The target population:

Patients with type 2 diabetes in Vietnam

2.4.2 Population sampling

Outpatients with type 2 diabetes went to treated at Bac Lieu and Thanh Vugeneral hospital

2.4.3 The study population

Outpatients with type 2 diabetes went to treated at Bac Lieu and Thanh Vuhospital from 2/2017 to 7/2017

2.5 Sample size:

: standard deviation 1 : standard deviations 2 : mean 1

: mean 2

With = 0.05,  = 1.96

= 0.2,  = 0.845

In the study of Nazli (2008) [83]:

= 3,2 is the standard deviation of the self-care behaviors score of patients

after DSME

= 4 is the standard deviation of the self-care behaviors score of patients

before DSME

= 21,9 mean of self-care behaviors of patients after DSME

= 20 mean of self-care behaviors of patients before DSME

Instead formula is n = 57.1 people do So , minimum sample n = 58/group.Expected attrition of 10%: 12 people The total sample of the study is:

58 x 2 + 12 = 128 people

* Standard sampling:

Inclusion criteria:

- The patient was diagnosed with diabetes type 2 (according to the

diagnostic criteria of the American Diabetes Association 2015) [26], are treated inBac Lieu and Thanh Vu general hospitals from 02/2017 to 6/2017

- Over 18 years

- Agreed to participate in research

Exclusion criteria:

- Patients with mental illness, are pregnant

- Patient have severe acute diseases (stroke, acute myocardial infarction,acute hepatitis, acute renal failure, severe pneumonia )

- Patients dumb, deaf, incapable of communicating

- Patients do not have sufficient clinical tests necessary

- Patients do not agree to participate in research

- The patient's medical staff

- Patients with chronic renal failure accompanied

2.6 Sampling Technique:

Random sampling method application.

160 patients with type 2 diabetes were selected randomly by computer (usingRandom function in Excel) from the list of diabetic patients examined at theOutpatients department in Bac Lieu hospital and Thanh Vu hospital There were

140 patients who had enough inclusion criteria and argeed to participated in ourstudy

Randomization by: 140 pieces of paper numbered 1 to 140 and folded intoenvelopes (who numbered did not participate in any stage of the study as well) Theinvestigator gave them 1 envelope any If the number in envelope was odd, patientsassigned to the intervention group, the number was even, the patients wereassigned to the control group

We performed single-blind method: the patient did not know this studydivided into 2 groups: intervention and control groups They also did not know thatthey were in which group

2.7 Control deviation:

- Sampling method is simple randomized and single-blind, increase the value

of the survey results before and after health education

- To limit deviation reminiscent between the two times of surveys before andafter the intervention, the time between the two surveys is 2 months

- Designing the appropriate questionnaire, clear, easy to understand, avoid thewords/sentences uncertain

- Control errors by enumerators, select enumerators have the samequalifications and training for those involved

- Explain direct, obvious meaning of the question (if the patient does notunderstand), does not suggest the patient replied

-It train investigators how to instruct the patient answered each part of thesurvey clearly before conducting interviews

- Control the information on the questionnaire immediately after a day ofinvestigation, suspect data to verify immediately.

- Survey trial (30 subjects) to check the fit and adjustment to thequestionnaire

2.8 Data collection:

2.8.1 Tool data collection:

Data collected from the survey questions were prepared.

The questionnaire was translated from the original English version intoVietnamese with permission of the author to use Foreign language specialists andendocrinologists translate forward and back translation between Englishquestionnaires and Vietnamese under the WHO process to ensure semantic andprofessionalism of the questions in the process of translation

Structured questionnaire consisting of 4 parts:

- Part 1: Includes questions to assess the characteristics of the demographics

of the study subjects such as information on age, gender, place of residence,education level, occupation, length of illness, co-morbidities, the marital status,living situation

- Part 2:16-question general knowledge about diabetes [68], [72] The

content of questions about the causes and symptoms of diabetes Forms answer is

"Yes", "No" and "Do not know" Cronbach's alpha coefficient of this question inthe research trial is 0.81 The questionnaire was translated from the originalquestions of authors DKQ Garcia and colleagues [72] DKQ of 24 sentences, butthrough the process of evaluating the intrinsic reliability of the questionnaire and tofit the study should questionnaire has been shortened to 16 sentences 8 sentencewas omitted in turn ordered in the original question is: 3,4,5,6,10,12,13,24

- Part 3: 12 questions to assess the activities of self-care in patients with type

2 diabetes for 7 days (1 week) past (C - SDSCA) The areas of self-care includesperforming good diet for diabetes, physical exercise, blood glucose testing,

medication adherence and pedicure This questionnaire has been developed Chiou

in 2002 to suit the Asian culture from the original question of Toobert (US) 2000[47] This questionnaire is based on the theory of Orem Self Care Cronbach alpha

of the coefficient C-SDSCA questions in the study by Chiou 0.7[59] In our pilotstudy, Cronbach's Alpha index of this section is 0.65, lower than the study byChiou can be due to translations However, Cronbach's alpha index is higher in thestudy by Nguyen Thi Quynh Chi 2014 (0.61) [14]

- Part 4: 16 questions to assess self - eficacy in the type 2 diabetes disease

management (C-DMSES) [106] This questionnaire was Wu et al 2008 adjusted tosuit Asian culture from the original version of Bijl - Netherlands (DMESE)1999[55]20 sentence 2014, author Nguyen Thi Quynh Chi[14]transliteration andapply the questions to study in Khanh Hoa Province, Vietnam with Cronbac'sAlpha coefficient of 0.91 In this study based on the analysis of Cronbach's Alphaand characteristics of the study population, we have kind of four sentencesrespectively have the following order: 14, 16, 19, 20 of the original question,should the current question used a 16-question Although it has undergonetranslation and filtering to suit the characteristics of the study populationCronbach's alpha coefficient but the questionnaires C-DMSES in our pilot studywas 0.77 Although lower than in the study of the author Quynh Chi, but this figurealso proved reliable questionnaire for use in the study because of higher than 0.6.The questionnaire C-DMSES builds on Doctrine Confidence in the ability ofBandura in predicting behavior to take care of patients with diabetes type 2 on 3aspects: 1) Make or self care ( medication adherence, diet and physical activity); 2)Self-observation (check blood glucose, weight, foot); 3) Self-adjusting (adjustmentincreases and hypoglycaemia)[55]

2.8.2 Methods of data collection:

- Direct interview: investigators to directly interview patients to gatherinformation through questionnaires available, time of 20-25 minutes

- Investigators will rely on a list of patients receiving outpatient treatment atthe Outpatient Department - Bac Lieu General Hospital sand Thanh Vu generalhospital selected the patients with type 2 diabetes the criteria included in the study.All 140 patients will be interviewed on knowledge, behavior, belief in ability toself manage their diabetes.

- After the interview, the patient will receive one envelope with randomnumbers from 1 to 140, if an odd number of patients will receive 1 education,health advice on self management of diabetes type 2 ( the intervention group), if aneven number of patients will not get this program from the researcher (the controlgroup) The patients in the control group were still routine health education inhospitals from treating doctor or nurse at the clinic

-After being monitored for 8 weeks, patients will be interviewed with aquestionnaire similar to the original Simultaneously investigators also recordedfasting glycemic index

- Researcher handling and analyzing data to compare knowledge, behavior,self – eficacy of patients, as well as compare fasting blood glucose of patientsbefore and after intervention Since then evaluate the effectiveness of education,health counseling

- The interviews were conducted while patients wait for physician visits, orwaiting for test results (FPG), waiting to receive medication

- Educational programs, health counseling is conducted at the Faculty briefingroom doctor Time from 30-45 minutes

2.8.3 Processing and analysis of data:

Enter and analyze data using SPSS 20.0 software

 Descriptive statistics:

- Describe the frequency and percentage of research sample characteristics byethnicity, education level, occupation, marital status, cohabitation status, comorbidconditions

- Describe points mean ± standard deviation and 95% by age, diseaseduration, knowledge belief in personal abilities and behavioral self-management ofdiabetes before and after intervention (if data had normal distribution)

- In case of non-normal distribution of data: the number described by themedian and quartile range (25% - 75%)

 Statistical analysis:

-Inspection of gender differences, education, morbidities, prehistoric family

between the control group and intervention before and after health education byChi-squared-test

- Inspection of ethnic differences, career, marriage between the control groupand the intervention group before and after the health education by Fisher exact-test

- Inspection of the age difference between the control group and interventionbefore and after health education by the Student-test - impaired

- Inspection of the difference in duration between control group andintervention group before and after the health education by Mann-Whitney-test

- Compare the median score of knowledge, behavior, self - efficacy of thepatients between the control group and intervention group by Mann-Whitney-test

- Compare the median score of knowledge, practice, self - efficacy of patients

in the intervention group before and after intervention health education byWilcoxon non-parametric test

- Compare the average score of knowledge, behavior, belief in management of patients in the control group before and after intervention withhealth education Wilcoxon non-parametric test

self All differences were considered statistically significant at p <0.05; with95% confidence intervals

2.9 Definition and classification variables:

2.9.1 Variable background

- Age: is the time that patients live, measured in units of years This is the

quantitative variables, calculated using the formula: 2017 - day / month / year ofbirth Day / month / year of birth is collected from the identity card of the patient

- Gender: is the difference in the biology between men and women This is

the dichotomous variable, with two values: 0 female, 1 male

- Nation: the nominal variables, including 4 value and recorded on their

- Academic level: is the highest educational level that the patient has

learned through interviews to date, including cultural education and vocationaltraining, the nominal variables, with values:

1.≤ Primary school

2 Secondary school

3 High school 3

4 ≥ Intermediate level

- Occupation: work brings the highest income for workers, accounting for

most of the time This is the nominal variables, including values:

- Marital status: is the current marital status of the patient, the nominal

variables include the values:

1 Single

2 Marriage

- Living situation: the general condition of the objects present life, variable

nominal value including 2:

1 Live with family

2 Do not live with family

- Duration of illness: is the period from the time the disease is diagnosed

type 2 diabetes for the time of interview and was calculated using the formula:

2017 - year of disease

-The morbidities: Chronic diseases are enclosed apart from type 2 diabetes

(eg, hypertension, heart failure, ), is a dichotomous variable with 2 values:

- Self - efficacy of patients with type 2 diabetes: the patient's

self-assessment of the ability to manage type 2 diabetes, including 4 areas:

+ Make diet for diabetic patients

+ Exercise and weight maintenance+ Track blood sugar and pedicure+ Drug use prescription stabilize blood sugar

Measurement tools are C-DMSES questionnaire consisting of 16 questionsabout 4 areas on a scale from 0 to 10 for each question With 0 being "totallyimpossible" and 10 is "certainly do" Total points that patients achieved rangedfrom 0-160 points (corresponding to 16 questions) The higher the score the betterthey show confidence in yourself and have the ability to self-manage diabetes well.The lower point indicates the opposite

- Behaviors of self-management: is the action to take care of yourself everyday of diabetes, which include compliance with diet, exercise, exercise, bloodglucose testing, foot care, medication follow prescription stabilize blood sugar.This variable was assessed through questionnaires C-SDSCA (12 questions) with ascale of 0 to 7 corresponding to the week While 1 question for the opposite view(C3: 0 = 7, 1 = 6, 2 = 5, 3 = 4, 4 = 3, 5 = 2, 6 = 1, 7 = 0) Total points that patientsachieved ranged from 0-84 points (corresponding to 12 questions) The higher thescore the more the patient demonstrated regularly perform self-care activities Thelower point indicates the opposite

- FPG: the blood sugar levels tested at patients hunger (fasting for at least 8

hours before the blood test) [26] This is continuous variable, unit is mmol / l

2.9.3 Dependent variable:

- Knowledge of patients with type 2 diabetes after health education

- Self - efficacy of patients with type 2 diabetes after health education

- Self-management behavior of patients with type 2 diabetes after health

- Glucose of patients with type 2 diabetes after health educationTools that measure variables is the same before and after intervention.

2.10 Diabetes self-managent education program: (Attached appendix 4) 2.10.1 Content consulting, health education:including content on the

domains diet for patients with diabetes, diabetes and physical exercise, medication,self-blood glucose monitoring, foot care, The content is translated from themanual diabetes and the allows the organization that owns the sitelearningaboutdiabetes.org [69] Author Bradshaw (2015) also used this tool in hisstudy That showed good effectiveness for patients with type 2 diabetes [56]

 Signs of hyperglycemia, hypoglycemia and management

 Medicine for diabetes

 Blood sugar goals: how to set up, monitor blood sugar goals

 Diabetes – know the sign+ ―Exercise and diabetes‖

 The benefits of exercise, physical fitness

 Getting start

 Safe to exercise

 Time for proper exercise

 Blood sugar and Exercise+ ―Diabetes and Healthy eating‖

 Plan your meal

 Purpose of healthy eating

 Choosing Healthy Foods

 Foods low in fat and salt

 How much should you eat

 Dinning Out

 About Alcohol+ ―Diabetes and your feet‖

 The impact of diabetes on the feet

 Signs of diabetic foot complications

 Tips for good foot care+ ―My diabetes care – Daily reminder‖:

+ ―Diabetes care schedule- Take good care of yourself‖

- Facilities for the DSME program:

+ Location: Office of medical examination of Bac Lieu General Hospitaland Thanh Vu General Hospital

+ Documentation: Self-managed education content was printed in smallhand-written with formats A5

The patients may refuse to participate in research Ensure fair, there is nodiscrimination in the treatment, care, providing health care services among patientsagree and do not agree to participate in research

In the process of research participants, if any questions patients can askquestions of the investigators, research staff and are allowed to withdraw from the