A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED HEALTH EDUCATION MODULE ON HOME CARE MANAGEMENT FOR DIABETICS AMONG THE DIABETIC PATIENTS AT HORAMAVU VILLAGE IN BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
Ms. J. Jinila Jasphine.
NAVANEETHAM COLLEGE OF NURSING
BANGALORE
SEPTEMBER 2009
RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
- Name of the CandidateMs. J. Jinila Jasphine.
M.Sc (N) I Year
Navaneetham College of Nursing
Banaswadi
Bangalore
- Name of the InstitutionNavaneetham College of Nursing
Bangalore
- Course of Study& SubjectMaster of Science in Nursing in
Community Health Nursing
- Date of Admission 10-12-2008
- Title of the TopicA study to evaluate the effectiveness
Of structured health education module on home care management for diabetics among the diabetic patients at Horamavu village in Bangalore
6. BRIEF RESUME OF THE INTENDED WORK
6.1 INTRODUCTION
Diabetes represents a spectrum of metabolic disorders,which has become a major health challenge world wide. The unprecedented economic development and rapid urbanization in Asian countries, particularly has led to a shift in health problems from communicable to non communicable diseases.
Diabetes is pandemic in both developed and developing countries.In India 2000,there were an estimated 175 million people with Diabetes worldwide and by 2030, the projected estimate of Diabetes is 354 million .By the year 2030 over 85% of the world’s Diabetic patients will be in developing countries. In Indiaalone, the prevalence of Diabetes is expected to increase from 31.7 million in 2000 to 79.4 million in 2030.
The national survey of Diabetes conducted in six major cities in India in the year 2000 has shown that the prevalence of Diabetes in Urban Indian adults was 12.1%.
Diabetes mellitus is a common disease which is estimated that over 31.7 million Indians are already caught with diabetes, and 5.4 million diabetics are not aware of the existing disease. Diabetes prevalence has increased steadily in the last half of this century and will continue rising among Indian population. It is believed to be one of the main criterions for deaths in India, every year. This Diabetes information hub projects on the necessary steps and precautions to control and eradicate diabetes, completely.
Diabetes is a metabolic disorder where in human body does not produce or properly uses insulin, a hormone that is required to convert sugar, starches, and other food into energy. Diabetes mellitus is characterized by constant high levels of blood glucose (sugar). Human body has to maintain the blood glucose level at a very narrow range, which is done with insulin and glucagon. The function of glucagon is causing the liver to release glucose from its cells into the blood, for the production of energy
The percentage of diabetic patients all over the world is increasing day by day.
Diabetes is the third widespread and serious disease after heart disease and cancer.
We need energy to carry out any activity by the body. Our body converts glucose into working power and remains active. Digestive process converts carbohydrates from our food into glucose. As the proportion of glucose in the blood increases, immediately pancreas gland situated behind the stomach releases hormones known as insulin. It converts glucose in the form of power and stores the extra glucose in the cells of liver and muscles. Thus the quantum of glucose in the blood remains balanced.Diabetes mellitus is a disease state in which pancreas not functions normally, no sufficient insulin is produced and so, the body is not capable to manage its food intake properly, body’s metabolism gets disturbed.
The sugar, starch and other carbohydrates are not burnt properly because of missing insulin, it leads high blood sugar. The kidneys cannot bear too much sugar (glucose) in the blood and as a result it is filtered out with the urine. Body therefore, utilizes fat instead of glucose. When glucose is converted to strength, the fuel is fully utilized but when fat is utilized as a fuel, poisonous gases like acetone are produced. A diabetic patient becomes comatose called as diabetic coma.
Diabetes-Related Problems for Home Care
In the current health care environment, there will be no administrative movement toward improving quality of diabetes care unless there is a related profit incentive or a care deficit-related penalty. Evidence-based improved methods and tools for achieving optimal glycemic control are now available. It is ironic that barriers exist simultaneously to prevent the delivery of state-of-the-art diabetes assessment, care, and self-management education to this population of patients in the most cost-effective care-delivery setting: the home. An analysis of the current dilemma follows:
There is, at present, no regulatory or accreditation mandate, and thus no incentive, to provide state-of-the-art diabetes care and education. Although the diagnosis of diabetes results in a higher reimbursement for home health care, there is no regulatory agency that evaluates the quality of home health interventions for patients with diabetes. If diabetes is not the primary diagnosis, documentation of patients’ blood glucose level is not required by CMS or any other agency that reviews home care standards.
Many home care agencies do not permit nurses to carry blood glucose meters. If patients do not have a blood glucose meter and test strips that are quality controlled with glucose control solution, there is no valid way to assess their glycemic control. Blood glucose testing for patients with diabetes is as important a component of home health care nursing visits as assessment of blood pressure, temperature, weight, heart sounds, and lung sounds.
Many physicians of home health care patients are not concerned about hyperglycemia. In fact, many prefer to have patients’ blood glucose levels high rather than risk them running serious low blood glucose, because hypoglycemia is regarded as a significant change in condition (SCIC) and is implicated in mental status changes. A SCIC must be reported to CMS.
Physicians may not routinely order hemoglobin A1c or fructosamine tests or follow any ADA standards of care with their home care patients with diabetes. Home health care nurses have the potential to assist physicians to comply with such standards if their agencies consider such goals a priority. It is clear, however, that elderly patients (the largest percentage of home health care clients) with diabetes do not appear to be receiving optimal diabetes care
6.2 Need for study
Research in Action, Issue 2, Nov 2007, on “Improving Care for Diabetes Patients through Intensive Therapy and a Team Approach” says that
“Diabetes is the sixth leading cause of death in the United States and proper treatment can be complex. This synthesis provides good evidence to show that intensive therapy using a team approach is an effective way to reach the major goals of diabetes therapy: lowering glucose (blood sugar) to appropriate levels”
International studies [2001] say that Diabetes mellitus is a global health problem, affecting all age groups. Currently, around 177 million people have diabetes worldwide; however, it has been projected that this number will increase to at least 300 million by 2025. If diabetes is undetected or not treated, or if its complications are poorly managed, it can have a devastating impact on quality of life. Diabetes also places a significant burden on health care costs, with the major single item of expenditure being hospital admissions for the treatment of complications.
Landmark studies, including the Diabetes Control and Complications Trial (DCCT)in 1998 explains that early identification of risk factors can help reduce the development and progression of diabetic complications, and improve patients' quality of life.
Rodney Dangerfield an author in article (March 1995) remarks that “Diabetes is an chronic disease because it gets no respect”
Joanne Dalton, s Evaluation of a Diabetes Disease Management Home Care Program tells that “ Diabetes disease management home care programs is to provide education, promote self-care, and empower patients. Guided by Orem’s self-care deficit nursing theory, this program evaluation project examined outcomes of home care patients”.
An article from AAACN (Sep 2004) gives this S M Pragramn which include:
Education on how daily activities affect blood glucose levels
Blood glucose monitoring instructions
Appropriate food and meal planning
Instruction and education on diabetic medication
Exercise and activity suggestions
Education on potential diabetes problems and complications
According to the American Diabetes Association (ADA).its a difficult disease to treat because:
It is closely related to patient behaviors that require complex interventions.
Patients may have the disease for years without knowing it, and even after diagnosis may remain asymptomatic
Patients need to actively manage the disease through diet, exercise, self-monitoring, and medicating, even in the absence of symptoms.
Providers may need to coordinate interventions with different specialists.
A recent epidemiological study[1999] reported that two or more complications are apparent in almost one-fifth of people with diabetes.Prevention of complications through home care management specific to diabetes is a key issue because of the morbidity and mortality associated with the disease.
At newyork R. Keith Campbell (2002), a professor of pharmacy at Washington State University believe that Pharmacists can serve both themselves and their customers well by learning more about diabetes care and passing that information on to patients. The prevalence of that attitude was confirmed, he maintains, in a recent federal study that indicates a wide variation in the quality of diabetes care in most states, an inconsistency that the report called "an overall national disgrace.
Cavanagh, Peter R ,September 22, 2004 in the Article“The Diabetic Foot Article” he identified a number of areas in the screening and prevention of foot complications of diabetes where an evidence base seemed to be lacking. Annually more than 125,000 people in the U.S. undergo lower extremity amputations (Armstrong et al., 1998)
The Investigator has a strong family history of Diabetes mellitus. She in her own personal experience, comes across this condition in her family and during her visit to various health centre in her area . This has enabled her to go deeper into this field of research and also to know the effectiveness of an health education module (Home care management) for these Diabetic patients.
6.3 STATEMENT OF THE PROBLEM:
“A study to evaluate the effectiveness of structured health education module on home care management for diabetics among the diabetic patients at Horamavu village in Bangalore”
6.4 OBJECTIVES OF THE STUDY:
To asses the existing knowledge (pretest) on home care management for diabetics
To develop an structured health education module on hone care management for diabetics
To implement structured health education module among the diabetic patients
To evaluate the (post test) effectiveness of structured health education module
To associate knowledge between the pretest and post test with demographic variables
6.5OPERATIONAL DEFINITIONS:
1.EVALUATE:
Measure the level of knowledge regarding home care management for Diabetes, pre and post test interventions.
2.EFFECTIVENESS:
Outcome of the interventions measured in the terms of numerical scores.
3.STRUCTURAL HEALTH EDUCATION:
It is a set of information consists of the different aspects of Home Care of Diabetic patients and its effectiveness
4. DIABETES:
Diabetes is the disorder of carbohydrate metabolism characterized by impaired ability of the body to produce or respond to insulin and thereby maintain proper levels of sugar in the blood.
6.6 Assumptions:
The investigator assumes that the structured teaching modules will improve the knowledge on home care management of Diabetes among diabetic patients
6.7 Delimitations:
The study is delimited to 60 samples
The duration of study is delimited to 4 weeks
The study is delimited to only villages
7. REVIEW OF LITERATURE
Caliskan D, et.al (July 2005) conducted a survey in which he found that As in all chronic diseases, providing patients with necessary information about Diabetes Mellitus (DM) and educating them are the best method of control of DM and preventing further complication. The aim of this study was to investigate the awareness of DM and related factors in diabetics. Results from this study have implications for patient education efforts. Accurately, clinicians need to strive to improve overall levels of patients' awareness and knowledge of their specific conditions, regardless of their literacy. Many opportunities exist for raising diabetic's awareness of their disease and linking diabetic's growing health awareness with those health promoting behaviors known to reduce morbidity and mortality.
Baker, Neilet.al (Jun 22, 2005) in peripheral arterial disease he aims to provide a clear, simple and practical approach to diabetic foot assessment. Each of the three articles will focus upon a particular aspect of foot examination and, although they will appear individually, they should be combined to give an overall approach to foot examinations. This article focuses upon identifying the at-risk foot due to peripheral arterial disease. The intention is to provide a simple guide to foot examination for everyday use by clinicians that is derived from evidence-based literature.
Swanson. (2004 Jul-Sep;13) says that Despite treatment regimens, which can reduce blindness, diabetic retinopathy remains the leading cause of irreversible blindness for persons less than 75 years. The epidemiology findings suggest that certain persons with well-controlled type 2 diabetes may not warrant yearly examination for diabetic retinopathy; however, given the low percentage of diabetics who are currently screened for retinopathy, it would seem unwise to recommend changes in the timing of examination. Evidence appears to suggest that photoscreening is a viable alternative to a screening examination.
ThamKY,et.al (2004 Jul)
A Singapore study reported that 99% of diabetics had received some diabetes mellitus (DM) education. Another study reported that the Singapore public is generally well-informed about DM but whether diabetics are well-informed is not known. The objectives of this study were to determine DM knowledge of diabetics visiting the Emergency Department (ED) and to determine the diabetics' knowledge versus practice gap. "
Detaille SI,et.al (Dec 2006)
To identify and compare patient and professional perspectives on what enables employees with diabetes mellitus (DM) to maintain their position in the workplace. To provide information on how professionals can help DM patients cope at work. METHODS: Qualitative study used to concept-mapping sessions involving 23 employees with DM and 22 health professionals (GP's, occupational physicians and specialists).help the cope at work: the ability to accept and cope with DM, supportive health professionals, a supportive work environment, work adaptations and good information. Patients emphasized the importance of emotional acceptance of DM and communication with colleagues, while the professionals emphasized the patient's capacity for self-care.
An increasing number of Americans have diabetes—approximately 16 million as of 1999—and diabetes costs society close to $100 billion per year in medical and nonmedical costs. In 2001, almost 800,000 people will be diagnosed with the disease, and close to 200,000 will die from its complications. Furthermore, the burden of diabetes is considerably higher for the elderly and minorities than the general population.
In Home Health Care Management & Practice says that the patient's physician is notified of our assessment findings after the initial visit. Based upon the physician's orders, a plan of care and diabetic self-management plan is discussed with the patient and implemented.
AAACN Viewpoint (September 1, 2004) says that Clinical Practice Guidelines for Care of the Adult Diabetic in Ambulatory Care: Creation and Implementation. It is necessary to ensure that the clinical, financial, and human resources involved in the implementation process are managed effectively. The aim of this article is to demonstrate that outcome measurement is a key factor required to ensure the sustainability of a wound care program.
AHRQ (1990-97). New EnglandMedicalCenter. Measured the effectiveness of existing clinical care in controlling blood sugar and avoiding or postponing complications. Showed that help from family members increases elderly diabetics' adherence to treatment and dietary regimens.
Underscoring provider perceptions of patient barriers to care, an AHRQ-funded study (1999-2003) looking at how diabetic patients respond to physician recommendations found that patients were much less likely to follow recommendations about diet (69 percent) and exercise (19 percent) than they were to follow medication regimens (91 percent). The researchers suggested that the reasons for poor adherence to lifestyle recommendations could include public awareness of controversy over the validity of recommendations, belief that physicians can sometimes be wrong, belief that physician instructions can be ignored, and the difficulty of incorporating new behavior into their daily lives
7.1 Conceptual Theoretical Framework
8. Methodology:
8.1 Source of Data:
The diabetic patients those who are living in HoramavuVillage, Bangalore
8.2 Methods of Data Collection:
Using close ended questioners
8.3 Research Approach :
Quasi Experimental approach
8.4 Research Design:
The research design adopted for this study is Quasi Experimental design
8.5 Setting of the Study:
The target population of the study includes Diabetic patients in Horamavu village.
8.6 Population:
It comprises of all diabetic patients belonging to selected village in Bangalore
8.7Sample:
Sample is taken from population of diabetic patients belonging to the selected villages
8.8 Sample size:
It comprises of 60 diabetic patients, 30 for the study group and 30 for the control group