INTRODUCTION:

The number of persons with diabetes (PWD) is increasing in South Asia. In India, 7.8% have diabetes with 21.4% being overweight, 4.7% obese, and 12.1% physically inactive, all risk factors for diabetes development.¹

Contributing factors to the increase in type 2 diabetes include a genetic predisposition, India’s continued economic development and urbanization, more people in the workforce contributing to less and poorer sleep quality, less intentional physical activity, and unpredictable mealtimes.^2,3 These factors are amenable to change. Formal diabetes education has been shown to decrease the incidence and minimize the development of complications from diabetes, thereby reducing morbidity and mortality in PWD.^4-6 However, barriers to formal diabetes education include a lack of time, the distance to an education center, and not having someone to accompany them.³

While nurses and nursing students (n=162, 70%) believe nurses have an important role in reinforcing patient nutritional education, attitudes about diabetes may limit education’s efficacy.⁷ Further, knowledge gaps exist in the nutritional management of diabetes among nurses.⁸ Interventions to enhance nursing students’ attitudes and knowledge have included mastery modeling (scripted classroom video/vignettes, simulation-based learning, and diabetes worksheets for use in the clinical setting),⁹ multiscale, computer-based models with a complexity perspective based on a small set of entities and simple rules,¹⁰ and a simulation-gaming instructional strategy.¹¹Additionally, low technology exposure to diabetes-related education enhanced attitudes that underlie the nursing care of PWD.¹² A service learning course for nursing students¹³ and integration of an evidence-based self-care interventions into a nursing curriculum¹⁴ demonstrated growth in confidence and understanding of community-based diabetes management; however, mixed results were demonstrated with diabetes knowledge. Diabetes pharmacology knowledge was significantly improved for the multiscale, computer-based model group¹⁰ but was unchanged for the simulation-gaming group;¹¹however, diabetes care attitudes improved over the course of the curriculum, and a service-learning diabetes camp improved confidence levels in nursing students.¹³

A complete, diabetes self-care behavioral-change education program, the American Association of Diabetes Educators (AADE) 7 Self-Care Behaviors^®(AADE7),¹⁵ is available from the AADE and provides curriculum for seven self-care behaviors: healthy eating, being active, monitoring and controlling, taking medications, problem-solving, risk reduction, and healthy coping. The AADE7 program has never been used with nursing students as part of a service learning, community health course in preparation to provide community-based diabetes education programs. Therefore, the purpose was to determine the effect of a community-based AADE7 diabetes behavior-change educational program on diabetes risk [body mass index (BMI), waist circumference, blood pressure (BP), serum glucose)], knowledge, and self-efficacy in nursing students in India. The study also sought to prepare nursing students for delivery of community-based diabetes prevention and treatment programs.

MATERIALS AND METHODS:

A quasi-experimental (pre-/post-test) design with purposive sampling was used to recruit/enroll 48 (three groups of 16) nursing students from the General Nurse Midwifery (GNM) at the Mission of Mercy School of Nursing General Midwifery Program in Kolkata, India was used.

Sample characteristics were determined using an 11-item investigator-developed demographic questionnaire (age, gender, marital status, ethnicity, religion, year in school, diabetes family history, health insurance). Diabetes risk was assessed using BMI calculated using the National Heart, Lung and Blood Institute’s online calculator.¹⁶ Height was assessed with a SECA 213 portable stadiometer (Chino, CA) measuring height in centimeters and weight with a Weight Watchers 24 TR Clear Glass Scale-Conair (New York, NY) measuring weight in kilograms. South Asians with a BMI greater than or equal to 23 are considered overweight whereas a BMI greater than or equal to 25 are obese.¹⁷ Waist circumference was assessed using a flexible tape at the umbilicus where a waist circumference greater than or equal to 80 cm was considered unhealthy.¹⁸ Blood pressure was measured manually using an adult-sized cuff with sphygmomanometer (American Diagnostic, Hauppauge, NY). Serum glucose was measured two-hours postprandial using the Accu-Chek Aviva serum glucose meter (Indianapolis, IN). Following instructions and with observation, each assessment was conducted by the nursing students on each other, working in pairs. Physical activity was assessed using a pedometer with a seven-day memory (Omron, Schaumburg, IL).

Diabetes self-efficacy was assessed using the Self-Efficacy for Diabetes scale (SED),¹⁹and diabetes knowledge using the Diabetes Knowledge Test 2 (DKT2).²⁰The SED is an eight-item, self-report survey¹⁹ that assesses perceived self-efficacy for diabetes self-care. The questions ask subjects how confident they are engaging in activities, such as eating meals every four to five hours, exercising 15 to 30 minutes four to five times a week, and knowing what to do when hyper- or hypoglycemia is experienced. Responses are provided on a Likert scale from one, not at all confident, to 10, totally confident. The scores are summed and divided by eight. Thus, total scores range from one to 10 with higher scores indicating greater self-perceived self-efficacy. The instrument has been used with PWD aged 10-16 years,²¹ parents of children with type 1 diabetes,²² and African American women aged 25-65 years with type 2 diabetes,²³ but not nursing students. Previously, the scale demonstrated strong reliability (α = 0.85) with a test-retest validity of 0.80.²⁴

Diabetes knowledge was assessed using the Diabetes Knowledge Test 2 (DKT2).²⁰ The instrument is comprised of two subscales: the 14-item general diabetes knowledge subscale and the nine-item insulin-use subscale. The items are multiple choice questions with a correct response provided. The total percent of correct responses is calculated for each subscale with total scores ranging from zero to 100 percent with higher scores indicating greater knowledge. The authors report the average percent correct reported for the general subscale is 77 with a standard deviation (SD) of 20 and for the insulin use subscale is 73 with a SD of 28. The DKT2 demonstrated reasonable reliability for the general (α=.77) and insulin use (α =.84) subscales.²⁵ The DKT2’s predecessor, the Michigan Diabetes Knowledge Test, has been used to determine the degree of diabetes knowledge among staff nurses in the Midwest,²⁶ among nursing students in north Jordan,²⁷ Japan, and Australia.²⁸ While the DKT2 has been used with Saudi Arabian adults with type 1 and type 2 diabetes mellitus,²⁹ no studies were found using the instrument with nursing students. The modifications to the Michigan Diabetes Knowledge Test were minor: seven were changed to clarify the question or response, four to match updated national standards, and two to improve grammar. Therefore, the DKT2 is acceptable for use in nursing students.

Following ethical approval from both the authors’ university and Mercy Hospital, consent, and enrollment, subjects completed the instruments and an initial 24-hour dietary recall. The ethical standards of responsible conduct for research involving human subjects and fidelity to the approved protocol were maintained throughout. Each subject was fitted with and instructed about a pedometer to track physical activity. The experiential, behavior-change educational program based on the AADE7 curriculum adjusted to reflect South Asian customs and foods.^15,30,31intervention was delivered over three to five-weeks from January through May 2018 (Table 1).Differences in program length between the groups were the result of having to adjust for the students’ varying, required clinical schedules. Those receiving training for three-weeks had condensed versions of the curriculum, more interactive activities to enhance learning, and a classroom seating arrangement that brought both students and the PI in closer proximity to one another.

Height and 24-hour food recall were assessed at enrollment only. Waist circumference and two-hour postprandial glucose were assessed at enrollment and at the final session. Weight, BP, specific, measurable, achievable, relevant and time-based (SMART) goals, and pedometer steps were assessed weekly. Subjects maintained their own data collection files, which included anthropometric measures, blood glucose, blood pressure, 3-day food journals, and pedometer steps. The PI reviewed the files and provided regular feedback about SMART goals and progress. In addition, subjects were rewarded for their efforts through prizes for the subject with the most physical activity and active participation/session attendance and best type and amount of carbohydrate choice adjustments. Bingo games, applause, and celebratory events were used as teaching/learning techniques to motivate and communicate an openness to receive information from a preceptor who values the information imparted to students.³²

A program completion celebration with invited hospital and nursing school administrators, leaders, and program supporters with a professional photographer was held on a single day for the three groups combined. The celebration included awarding completion certificates, recognizing, praising, and distributing small gift bags to each subject. Such public displays of congratulation to nursing students in front of high-level administrators were unique to the setting.

RESULTS:

Four subjects (8%) were excluded because they either missed half the class sessions (n=2) or did not complete the post-tests (n=2). Independent t-test analysis was conducted to determine if the four excluded subjects were different from the included subjects. The excluded and included subjects were different at enrollment with excluded subjects having higher general diabetes (mean = 8.5 + SD =2.0 versus mean = 6 + SD = 2.9) and insulin-use (mean = 4.5 + SD = 1.3 versus mean = 3 + SD = 1.4) knowledge, only. Thus, affecting diabetes knowledge improvement was more difficult than if the four excluded subjects had been included. The remaining 44 (91%) constituted the sample and a post hoc analysis determined that the observed power for a two-tailed hypothesis to detect a large effect with a .05 probability level was 0.73.³³

Subjects were female, single, about 20 years old, of the Hindu faith (n=31, 64.6%) of south Asia ethnicity (n=45, 93.76%), without health insurance (n=40, 83.3%) and no diabetes family history (n=29, 60.4%) (Table 2).

Due to shifting enrollments between the groups, group sizes changed from three equal groups of 16 nursing students each to three groups of unequal numbers (group 1, n =16, group 2, n = 13, group 3, n = 19). The same 48 nursing students were involved in the three groups as originally discussed. The shift was allowed to facilitate nursing school requirements. Although, the post-intervention serum glucose assessment was planned to be fasting, the assessment was non fasting secondary to school scheduling conflicts requiring later in the day, post meal measurements. Also, results differed across the groups (serum glucose, 1^st group M = 98.43, SD = 11.77, 2^nd group M = 86.62^,SD = 6.53, 3^rd group M = 91.00, SD = 6.42. F = 5.515, p = .004).

Pre-intervention, subjects had a BMI, waist circumference, BP systolic and diastolic, and serum glucose of in the healthy range (Table 3). Diabetes self-efficacy (M = 50.3, SD = 10.8) and general diabetes knowledge (mean = 8.5, SD = 2.0) and insulin-use knowledge (M = 4.45, SD = 1.3) were low.

Table 2: Sample demographic characteristics

Demographic characteristic	Group			Total
	1^st	2^nd	3^rd	Total
	n=16	n=13	n=19	n=48
	n	n	n	n	%
Racial or ethnic category
South Asia/South Asian	13	13	19	45	93.75
Southeast Asia/Southeast Asian	1	0	0	1	2.1
Blank	2	0	0	2	4.2
Faith tradition
Hindu	7	9	15	31	64.6
Muslim	1	0	0	1	2.1
Christian	1	4	4	9	18.7
Blank	7	0	0	7	14.6
Health insurance - No	12	13	15	40	83.3
If yes to health insurance, type (n = 7)
Universal	1	NA	2	3	42.85
Private	2	NA	1	3	42.85
Blank			1	1	14.3
Family history of diabetes - No	11	9	9	29	60.4
If yes to if family history, type of diabetes (n = 19)
Type 1	1	1	2	4	21.1
Type 2	4	3	3	10	52.6
Unknown	0	0	5	5	2.3

Table 3: Descriptives and pre-/post-intervention comparisons (n=44)

	Pre-intervention			Post-intervention			t^*	p
	Mean	SD	Range	Mean	SD	Range	t^*	p
BMI	21.9	4.1	16.3-31.9	22.0	3.9	16.3-32.0	-.9	.35
Waist circumference	76.6	12.9	60.0-126.0	75.62	9.98	59.5-101.0	1.06	.30
Systolic BP	102.7	11.8	90-130	103.5	11.1	80-120	-.64	.52
Diastolic BP	65.8	9.3	50-80	66.0	8.1	50-90	-.05	.96
Blood glucose	93.1	10.6	73-132	103.4	16.6	85-174	-3.79	<.001
Self-efficacy	50.3	10.8	22-66	62.2	9.9	39-77	-7.92	<.001
Diabetes knowledge
General	8.5	2.0	4-12	8.3	2.5	3-13	.4	.71
Insulin use	4.45	1.3	2-7	5.3	1.8	0-9	-2.45	.018

*2-tailed t test

Table 4: Knowledge questions answered incorrectly most frequently in rank order

	Pre-intervention		Post-intervention
	n	%	n	%
Diabetes knowledge - General subscale
4. Which of the following is a “free food”? a. Any unsweetened food b. Any food that has “fat free” on the label c. Any food that has “sugar free” on the label d. *Any food that has less than 20 calories per serving	28	63.6	21	47.7
5. A1C is a measure of your average serum glucose level for the past: a. Day b. Week c. *6-12 weeks d. 6 months	39	88.6	31	70.5
7. What effect does unsweetened fruit juice have on serum glucose? a. Lowers it b. *Raises it c. Has no effect	38	86.4	25	56.8
8. Which should not be used to treat a low serum glucose? a. 3 hard candies b. 1/2 cup orange juice c. *1 cup diet soft drink d. 1 cup skim milk	21	47.7	29	65.9
DKT2 Insulin use subscale
15. Signs of ketoacidosis (DKA) include: a. Shakiness b. Sweating c. *Vomiting d. Low serum glucose	43	97.7	32	72.7
16. If you are sick with the flu, you should: a. Take less insulin b. Drink less liquids c. Eat more proteins d. *Test serum glucose more often	27	61.4	22	50.0
21. If you take your morning insulin but skip your breakfast, your blood glucose level will usually: a. Increase b. *Decrease c. Remain the same	26	59.1	18	40.9
22. High blood glucose may be caused by: a. *Not enough insulin b. Skipping meals c. Delaying your snack d. Skipping your exercise	30	68.2	18	40.9
23. A low blood glucose reaction may be caused by: a. *Heavy exercise b. Infection c. Overeating d. Not taking your insulin	26	59.1	23	52.3

* Correct response

One question, which should not be used to treat a low serum glucose, was worse post-intervention.

DISCUSSION:

Subjects were in the second year of a three-year general nurse midwifery (GNM) program, similar to subjects in previous studies with respect to gender and age; however, a GNM program is more similar to an associate degree in nursing program (ADN) than the bachelor’s degree programs from which subjects were studied, previously. Moreover, the GNM curriculum focuses mainly on obstetrics and community health nursing where pathophysiology may receive limited emphasis. The lack of pathophysiology knowledge is consistent with the diabetes knowledge questions most frequently missed (Table 4). The foundation for understanding diabetes, the influence of different foods on glucose control, and management strategies may be limited the lack of pathophysiology knowledge, also.

In a study of Australian and Japanese nursing students in their final year of a three-year program with differing curricula (clinically-based versus rote/didactic-based learning), no difference was found in diabetes knowledge;²⁸ however, both groups fared better than our subjects. Other findings suggested that in North Dakota, medical-surgical nurses had the least nutrition knowledge and community public health nurses had the most.³⁵Nurse practitioners in New England had limited nutrition education and spent little time in nutrition counseling with patients.³⁶ Thus, additional knowledge of diabetes, nutrition, and nutritional interventions is needed for students, nurses, and nurse practitioners.

Australian nursing students had significantly greater perceived competence and confidence in caring for PWD than Japanese nursing students²⁸with the potential reasons being related to pedagogy where teaching methods are tailored to traditional, didactic applications of lecture-centered learning. Our students had high diabetes self-efficacy, perhaps as a result of the multiple methods of instruction (interactive, competitive, case-study, role-/game-playing, and food models-based) supporting Bandura’s contention that “a strong sense of efficacy enhances human accomplishment” (p. 2).³⁷ Through paired assessments, learning, and classmates’ successes, subjects influenced each other to make behavior changes. Additionally, because of the PI modeling healthy behaviors, subjects may have gained confidence that practicing healthy behaviors is manageable. Moreover, through the PI’s persuasion/praise, subjects may have been able to develop new skills and self-perceived self-efficacy.

When implementing strategies to achieve their self-determined behavioral goals, subjects needed assistance and support similar to previous findings.¹⁴ Cultural norms and the rote/lecture-centered teaching methods employed at both the Japanese school and our school require that students ask few questions.²⁸ The need for goal reinforcement may have been due to the differing pedagogy employed by the PI, unanticipated linguistic challenges, and/or subject discomfort in responding to questions when directly posed to subjects.

Potential reasons for no significant improvements in BMI, waist circumference, BP, or general diabetes knowledge may include the short time available for behavior change implementation. Further, because groups had eleven to twenty sessions with the PI, the variability may have affected both the teaching quality and general diabetes knowledge.

The increase in serum glucose may have resulted from variability in dietary intake by one group on the day of assessment. The third group was assessed following an event where more carbohydrates and concentrated sweets were provided potentially elevating subjects’ serum glucose.

The PI wore a visible pedometer to track her own steps and promote the 10,000 steps/day goal to reflect current practice.³⁸ While all subjects were encouraged to enhance their physical activity, the encouragement and pedometer may have been insufficient incentive. Moreover, as subjects were dispersed across three groups and multiple locations, the PI was unable to provide consistent and regular encouragement for continued behavior change.

Several studies of female, undergraduate nursing students of similar ages who participated in diabetes knowledge and behavior-change education to prepare them for practice in the community setting.^{8, 14, 28} The nursing students reported improved diabetes knowledge^13,14 and self-efficacy^8,13 and were able to implement diabetes behavior-change programs in their communities.¹³ These findings support the possibility of our culturally-modified AADE7 curriculum preparing subjects to offer diabetes behavior-change programs in their communities.

The study had several limitations including the use of purposive sampling from a single GNM program, thereby, potentially introducing selection bias and limiting generalizability. Utilization of nursing students versus actual PWD limits generalizability to only second-year nursing students between the ages of 19 and 26. However, all potential subjects were included, initially, and differences between those included and excluded in the analyses were minimal and only served to decrease the potential change that could be detected.

Data was self-reported, and the sample size was small as 52 subjects were needed to determine a large effect with a .05 probability level.³⁹Since subjects were aware of their study inclusion, the self-reported perceptions may have been biased. A larger sample and or the use of a control group would serve to mitigate these threats.

The planned intervention implementation was different for each of the three groups due to schedule constraints; however, the entire intervention was delivered to each of the three groups by the same PI. The content was condensed, as necessary, to accommodate those subjects’ whose schedules dictated content modification.

Several subjects skipped questions throughout their pre-and post-intervention surveys. Those questions were scored as incorrect for analyses as subjects may skip questions if they have less knowledge.⁸ Potentially, the results may have been affected; however, the differences across the intervention would have been more, not less, difficult to achieve. Thus, the results may have improved if the skipped questions were excluded or sample means imputed.

The PI was informed that students spoke English, a criterion for entry into the nursing program; however, many subjects came from Indian states where the official language is Hindi with up to 22 different dialects.³⁴ Thus, how well information was received and interpreted is unknown. Moreover, if English was the subjects’ second language, their understanding of survey items may have been limited. All subjects were deemed English literate; however, results may have been different if the surveys were administered in each subject’s preferred dialect.

Because patient safety was of utmost concern and these subjects had concurrent, inpatient clinical hours, educational emphasis was placed on diabetes medications, glucose control, and signs and symptoms of hypo- and hyperglycemia recognition and management. As subjects had their clinical hours in the acute care setting only, integration of the content may have been facilitated by their inpatient clinical hours.

While subjects were living in a hostel away from home with no discernable income of their own, income data might augment and inform the findings. Other factors/events may have affected the pre-and post-intervention assessments about which there was no knowledge or control. Further, the variability in the time frame between the pre- and post-intervention assessments across the groups may threaten validity. While the intent was to deliver the intervention equitably across the groups, such was not possible due to GNM program limitations. Validity may have been threatened by repeated subject testing with the same surveys, also,^40,41 Finally, the effect of subjects’ previous diabetes education is unknown and was not controlled.

CONCLUSION:

This study evaluated diabetes risk, knowledge, and self-efficacy. Subjects demonstrated enhanced diabetes insulin-use knowledge and self-efficacy and practiced the necessary diabetes management behavior-changes. Anthropometric parameters that place individuals at greater diabetes risk, proper serum glucose testing techniques and target range knowledge for pre- and post-meal, hypo- and hyperglycemia treatment, and goal-setting skills were learned and applied. Setting weekly nutrition and/or physical activity SMART goals while receiving timely feedback may have enhanced their appreciation of the challenges their future patients will experience with diabetes self-care. Future studies of the AADE7intervention with PWD and of Indian nursing students providing the community-based program are warranted.

ACKNOWLEDGEMENTS:

We would like to acknowledge the faculty, nurses, and nursing students from the General Nurse Midwifery program at the Mission of Mercy School of Nursing General and Calcutta Mercy Hospital and Research Centre in Kolkata, India. In addition, we would like to thank the Fulbright Scholar Program, Institute of International Education, United States Department of State for their financial support of the work.

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

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Received on 17.08.2020 Modified on 06.10.2020

Int. J. Nur. Edu. and Research. 2021; 9(2):167-174.

DOI: 10.5958/2454-2660.2021.00041.7