Padjadjaran Nursing Journal (Jurnal Keperawatan Padjadjaran)

ISSN 2338-5324 (print)

ISSN 2442-7276 (online)
Online di http://jkp.fkep.unpad.ac.id
DOI : 10.24198/jkp

The Effect of InGDEP on Type 2 Diabetes Patients’ Knowledge

and Self-Care

Hema Malini, Fitra Yeni, Dilya Eka Saputri

Faculty of Nursing, Universitas Andalas
Email: hema.maliniyusuf@gmail.com

Submitted: 20-2-2018 Accepted: 25-12-2018 Published: 25-12-2018

Abstract

In the recent years, there is an increasing number of the diabetes incidence worldwide. Self-care is believed as one
of key in chronic disease management. In order to increase the capability to self-care, diabetics patients need to
be empowered with the knowledge and skills through an educational program. There were some existed diabetes
educational programs, however for developing country such as Indonesia, there was a need to develop a culturally
relevant diabetes education program. This study was aimed to identify feasibility and the effect of the Indonesian
Group-based Diabetes Education Program (InGDEP) on knowledge and self-care behaviors among type 2 diabetic
patients. This quasi experimental with one group pre-and post-test only design involved 62 diabetic patients and 16
health professionals who actively delivered the program in four community health centers (Puskesmas). Data were
collected using Diabetes Knowledge Questionnaire (DKQ) and Summary of Self Care Activities (SDSCA). Paired
t-test used to analyze the effect of the InGDEP on the knowledge, self-care, and biometric measurement (HbA1c).
The knowledge score for pre-test was 13.2+3.9 and post-test was 16.1±3.5, self-care activities score for pre-test
was 3.31±1.10 and post-test was 3.99±1.27 and the HbA1C level was 10.56±2.32 The results showed there was the
significant effect of InGDEP on diabetes patients’ knowledge, some changes in self-care and biometric measurements
even though it was not significant. The program also can be accepted by the health professionals where there was a good
team work in delivering the educational program. It can be recommended that the InGDEP has an effect in improving
knowledge and self-care among diabetics’ patients, however since the effect on self-care and biometric changes was
not significant, further research related to the factors that influence the self-care and biometric changes is needed.

Keywords: Active involvement, behavior, self-management.

Volume 6 Issue 3 Dec 2018 235

Hema Malini : The Effect of InGDEP on Type 2 Diabetes Patients’ Knowledge and Self-Care

Introduction diabetes known as diabetes self- management

education (DSME). This program has goals
Worldwide, there is a significant increase in on empowering patients with knowledge
the number of people with diabetes, where and skills in order the diabetic patients
one of the 11 adults suffers from diabetes able to perform proper self-management
(WHO, 2014). Data from International independently. There are several educational
Diabetes Federation (IDF) (2015) showed programs for diabetics’ patients that has been
that the incidence of diabetes in 2015 was 415 developed and proven as an effective program
million people were suffering from diabetes, in increasing knowledge and skills. Dose
and it is estimated that in 2040 the number Adjustment for Normal Eating (DAFNE),
will grow to 642 million people. Moreover, Diabetes Education and Self-Management for
the data also indicated that there are 193 Ongoing and Newly Diagnosed (DESMOND)
million cases of diabetes, where around 5 are some of the diabetes education program
million was undiagnosed (IDF, 2015). that have been implemented in several
Diabetes Mellitus is also known as “lifelong countries especially in developed countries
disease”, cannot be cured, and people need to (DAFNE study group, 2003; Davies et al.,
live with the condition after being diagnosed. 2008; Deakin & Whitham, 2009). These
Although diabetes cannot be cured, it can programs in general have the same impact
be controlled, and diabetic patients could in lowering the glucose level of diabetics’
life normally with their condition. Diabetes patients, improve patients’ understanding
self-management (DSME) is the key aspect of diabetes and its management, and also
for managing chronic diseases and should improve the lifestyle of diabetics patients
be delivered in newly diagnosed people (Malini, Copnell, & Moss, 2017). However,
with DM (Funnell & Piatt, 2017). Diabetes those programs were effective where all the
self-management has been known as the systems have been established. For country
effective program that can help people with like Indonesia, where most of the health
DM manage their condition well. Diabetes professionals were overload with their jobs,
self-management program focused on the where the ratio between nurse and patient is
changing behavior in maintaining the life still 87 per 100,000 people, there is a need
style, diet management, activity and exercise. for an alternative and effective approach in
The diabetics patients need to perform a conducting a structured health education
favorable behavior that known as self- program. Thus, in order to support their
management. The self-care behavior is job, a suitable program with their situation.
an action in maintaining and managing Moreover, the materials especially regarding
the environment in order to regulate the the diet and activity alternatives information,
function of a person and integrates the not all the information from the established
condition to maintain the quality of life program suit to Indonesian situation. Some of
(D’Souza et al., 2017). According to information such as food choices and activity
Indonesian Endocrinologist Association alternatives need to slightly changes to match
[PERKENI] (2015) one of the cornerstones with Indonesian setting.
in the managing DM is by providing the In choosing a health education program
educational program. Health professionals that would suit for Indonesian society requires
need to actively provide some information some consideration including cultural,
regarding diabetes management, thus ethnic, accessibility and geographical issues.
diabetics patients could have significant Thus, the Indonesian Group-based Diabetes
knowledge and skills in managing diabetes. Program (InGDEP) was developed as a
All the health professionals especially who culturally relevant education program with
involved in providing health care directly Indonesia situation (Malini, Copnell, &
to patients have some obligation which is Moss, 2017). However, the implementation
become a support system for patients through of the program in the previous research is
their role as educators. limited to only small number of patients.
Providing health information through Further investigation is needed to prove
health education program for people with that the program has similar impact to

236 Volume 6 Issue 3 Dec 2018

Hema Malini : The Effect of InGDEP on Type 2 Diabetes Patients’ Knowledge and Self-Care

other respondents with different cultural Both questionnaires have been translated
background such as in West Sumatera. The into Indonesian and have been applied
aim of this study was to investigate the in some research (Malini, 2015). For the
feasibility and the effect of InGDEP to the glycemic control, within cooperation with
glycemic control, self-care knowledge and local government health laboratory which
behaviors among people with T2DM. have obtained ISO, this study conducted a
measurement of the HbA1c. The HbA1c
were measured before the program started
Method (baseline result) and were measured again
three months after the respondents finish
This study used quasi experiment with one the program. Between at the end of program
group pre-and post-test only. There were 62 until the second measurement of HbA1c, the
people with type 2 DM that live in working respondents were visited by the researcher
area of community health center (Puskesmas) once a week to examine their self-care
in Solok city, West Sumatera that recruited behavior recorded in the diary including
based on some criteria namely willing to diet intake, activities and foot care. The data
participate during four sessions of educational analysis was measured using the paired t-test
program in a month; able to read; able to do to identify the changes of knowledge and
activities independently; no complication self-care behavior, and also the glycemic
because of diabetes yet; age between 35– control before and after attending the
65 years old. This study also involved four program. The program consisted of two days
health professionals from each Puskesmas, educational training for health professionals
consist of nurse, doctor, nutritionist, and as the educator team, four education sessions
public health who act as the team member provided by the educator team to the group
of educational program and attended two- of patients once a week for a month. Each
days training provided with local diabetes session last for 45–60 minutes. After the
educators prior program implementation. whole session finished, regular home visit
Training materials cover diabetes and its was conducted once a week for one month.
management and conveyed in the active The total length of the educational sessions
learning style. and home visits were two months.
Diabetes Knowledge Questionnaire This study was conducted in accordance
with 24 questions (DKQ-24) developed by with good clinical practices as defined
Garcia, Villagomez, Brown, Kouzekanani, by Helsinksi Declaration for research
and Hanis (2001) was used to measure T2DM using human as subjects (World Medical
patients’ knowledge. The questionnaire Association, 2001). The study was approved
consisted of six domains including the by the ethical committee of Faculty
definition of diabetes; recognize the diabetes Medicine, Universitas Andalas, and also
symptoms; perception towards the diabetes granted permission from The Health Office
management (diet, activities, lifestyle, and of Padang, West Sumatera.
complication). The high scores indicate a
better understanding on diabetes. Summary
of Diabetes Self Care Activities (SDSCA) by Result
Toobert, Hampson, and Glasgow (2000) was
used for measuring T2DM patients’ self-care There were 62 respondents completed
behaviors. It consisted of diet, exercise and the four sessions of educational program,
activities, foot care, medication and smoking with around 16 health professionals in four
behavior. For all the four components were Puskesmas actively delivering the program.
measured using the average days of people The mean age of participants was 49.7 years
with diabetes performed it. For the smoking old, and the mean of patients were diagnosed
components, it was measured by asking with diabetes was 4.2 years. Post test score
whether the respondents smoking or not, if of patients’ knowledge (16.1+3.5) was
the answer was yes, the respondents need to significantly higher (p = 0.021) than the pre-
provide the number of cigarettes in a day. test score (13.2+3.9). Meanwhile, there is

Volume 6 Issue 3 Dec 2018 237

Hema Malini : The Effect of InGDEP on Type 2 Diabetes Patients’ Knowledge and Self-Care

Table 1 DKQ 24 Score Before and After Attending the Educational Program InGDEP for People
with Type 2 Diabetes in 2017 (N=62)
Variable and domains Pre Test Post Test p Value
Diabetes Knowledge 13.2±3.9 16.1±3.5 0.021
Definition of Diabetes 2.3±1.2 3.1±1.1
Recognize the Symptoms 3±1.5 2.5±0.8
Perception of Diabetes 0.2±0.4 0.9±0.8
Diet 1.8±0.7 2±0.7
Life Style 2.7±1.1 3.9±1.1
Diabetes Complication 3.2±1.0 3.6±0.6

Table 2 SDSCA Score Before and After Attending the InGDEP for People with Type 2 Diabetes
in 2017 (N=62)
Variable and Domains Pre Test Post Test p Value
Self-Care Behaviors 3.31±1.10 3.99±1.27 0.043
Diet 3.16±1.59 4.32±1.62
Exercise 1.23±1.48 2.83±2.02
Foot Care 4.05±1.56 4.69±1.52
Medication 4.52±3.21 4.57±3.10
Blood Check 1.00±1.14 3.14±3.27
Number of Smokers
(n (%))

No 62 (100) 62( 100)

Yes 0 (0) 0 (0)

significant changes for self-care behaviour. the changes in self-care behavior. Before the
There were some changes, the post test of program, most of the respondents performed
HbA1c scores, the three months measurement the self-care behavior was 2 days in average,
after the program, (10.56±2.32) significantly after attending the program, it increases to
lower (p=0.001) than the pre-test score 3 days in average (see Table 2 for SDSCA
(12.48±2.61). from 2.31 to 3.99). Even the number of
days of performing self-care behavior only
increase by one day, it still shows significant
Discussion changes. Meanwhile, patients’ glycemic
control improved indicated by lower HbA1c
This study measured the effect of InGDEP level after three months, however generally
in improving knowledge, behaviours and the the level of HBA1c is still above normal for
glycaemic control (HbA1c) by comparing people with diabetes (value of 8.5–9.0).
between pre and post test. Based on the The diabetes education program is
analysis, this study found that InGDEP has performed in order to improve knowledge and
some influence on changing the knowledge skill of people with diabetes in performing
related to diabetes (pre 13.2 ± 3.9; post 16.1 ± self-management toward their illness. Based
3.5; p value = 0.021). This result indicates there on the results of the study, the average age
is increasing of knowledge of respondents of respondents is 49 years old, this shows
towards diabetes and its management. The that diabetes is experienced by people in the
improvement of knowledge was followed by productive age. It is expected that at this age,

238 Volume 6 Issue 3 Dec 2018

Hema Malini : The Effect of InGDEP on Type 2 Diabetes Patients’ Knowledge and Self-Care

some person would be on the best performance of the respondents still do not perform the
of their careers and life. Within the diagnosis expected behavior every day. However, in
of diabetes, it meant that this person should terms of category, there is a difference in the
consider their productivity should be suit to frequency of changes in diet, exercise and
their health status. On the other hand, people foot care category before and after attending
at their productive age, tend to have sedentary the program. This change indicates that
lifestyle that can lead to diabetes or make the most of the respondents aware that diet and
condition with diabetes worse if they cannot exercise are important for their condition.
perform diabetes self-management well. In For the foot care, most of respondents are
terms of, length of diabetes experience, the Moslem, so it should become their habits
average time would be 4.2 years, shows that for the respondents to check their foot every
most of the respondents in this study have day. However, in this study, the foot care
experience chronic condition. The chronic was not performed everyday due to there
condition meant that people who experience is still limited information on patients how
it, need to have significant knowledge and they should perform foot care. However, for
skill on managing their disease in order to the blood glucose level checking, most of
prevent further complication. the respondents did not have the Glucotest,
The result of this study shows some thus they only perform it when they attend
changes on knowledge, self-care and followed to the Puskesmas once a week. Some of the
by the glycemic control. The implementation respondents only check their blood glucose
of group-based diabetes education program once a month or if it is necessary. All of the
has some expected impact. The awareness respondents in the study taking the drug orally
of respondents towards the definition of to control blood sugar levels, the majority of
diabetes, the symptoms and its complication respondents do some exercise and activities,
have some impact on how they willing but not much in accordance with the rules of
to perform the self-care behavior in daily activity, exercise in diabetes patients which
routine. Ideally, people with diabetes need consider the intensity, the durations, and
to manage their intake nutrition, exercise, endurance that is appropriate.
lifestyle, foot care and medication every day. The increase in the value of knowledge
The involvement of health professionals in is significant because health education
the program provide social support which was designed to improve knowledge and
is needed by people with chronic disease. ability through a learning process and active
It is believed that the involvement of health involvement from the health providers. This
professionals could increase the awareness study has proven that a diabetes education
of diabetes patients with their self-care program that conducted by multi health
management includes diet, foot and eye professional could increase the knowledge
care (Ruggeri et al., 2018). The role of and self-care of people with diabetes. Health
health professionals in diabetes management education program consider as the best way
considered as significant role in improving in providing support for people with chronic
knowledge and skill through a diabetes disease. It is expected that the program
education program. would beneficial not only for the person who
Diabetes education program has been suffer the disease but also for the family in
proven could enhance the knowledge and preventing and improving potential health
change behavior when there is some support problems in future. A study conducted by
to the patients. Study of Sari, Haroen, and Siwi, Putri, Yudianto, and Kurniawan (2013)
Nursiswati (2016) shows that educational found that there is significant relationship
program has an impact in increasing the foot between knowledge and self-care of diabetes
care among people with diabetes when the management. The study found that through
family involvement was existing. providing information to patients and family,
The measurement of self-care using the the health behavior is improved.
SDSCA shows that in general that most There is some limitation to this study

Volume 6 Issue 3 Dec 2018 239

Hema Malini : The Effect of InGDEP on Type 2 Diabetes Patients’ Knowledge and Self-Care

which the involvement of family member many health professionals concerned with
has not explored further yet. A study by Sari their health condition. Thus, the program
et al. (2016), the family involvement has provided supports not only for the patients
significant impact on the ability of diabetics’ but also for the health professionals since they
patients in conducting foot care. Family worked together as a team which enhance
involvement is a very necessary supports for interprofessional collaboration.
diabetics’ patients in the treatment against the This study has some limitation. First, the
disease. Theory and research aforementioned education program was implemented for
explain that health education can enhance research goals only, thus, the sustainability of
the ability of patients to perform self- the program need to be further investigated.
care activities. The group-based education Second, this study need to explore more on
program has several advantages compare how the experience and perspective of all
to individual approaches, the excess of the participants involved in this program,
which education is more attractive, dynamic so, qualitative research method need to be
intervention, and has social aspect of support implemented in future research. This present
to each member (Mensing & Norris, 2003). study has provided a new insight of diabetes
Thus, it is recommended that for the further education program should conducted even
development of the proposed educational further research need to conduct to measure
program in this study need to include and the effectiveness of the education program.
emphasize more on the family involvement.
The InGDEP as a group-based model in
health education program provides not only Conclusion
health information materials, but also there
was a sharing of experiences among patients The implementation of InGDEP as a diabetes
with patients and between patients with health educational program has been successfully
care professionals in Puskesmas (Malini et enhanced knowledge and self-care of people
al., 2017). During the implementation of the with diabetes in three Puskesmas. The
program, based on the observation conducted program has increased the knowledge and
by the researcher, most of the session would self-care activities especially in diet, exercise,
contain some process of sharing information and lifestyle. The group-based approach that
among the attendee both health professionals used in this proposed education program
and patients, health professionals are the provide a supporting environment for the
expert in the health related information, patients since in the group approach, patients
meanwhile the patients are the expert of could learn from each other’s.
their health condition. The presence of being For the measurement of HbA1c level,
valued as a person who knew better of the there is some decrease from the basis line
health condition make the patients seem more level steadily to the three months level after
open to health professionals. patients completed the educational session.
Research conducted by Shrader, Martin, InGDEP has shown significant changes in
and Cogdill (2013) found that the education knowledge, even though the self-care did
program on diabetics patients who exercise not change significantly. However, in term
in groups is effective in controlling blood of the active involvement, all respondents
sugar, HbA1c levels, systolic blood pressure, and health professionals felt some benefits
resulted in weight loss, and increase the of the program. It is expected that in future
knowledge of the patients. It can be concluded the program will be developed more, and the
that providing health education effect on self- further research is still needed to search the
care behavior, but the influence is greater effectiveness of the program.
when health education conducted in groups,
structured and involved a multidiscipline
of health professionals. Educational group References
session which involved multidiscipline
health professionals provide reinforcement to D’Souza, M.S., Karkada, S.N., Parahoo,
the patient, where the patients would feel that K., Venkatesaperumal, R., Achora, S., &

240 Volume 6 Issue 3 Dec 2018

Hema Malini : The Effect of InGDEP on Type 2 Diabetes Patients’ Knowledge and Self-Care

Cayaban, A.R.R. (2017). Self-efficacy and Malini, H. (2015). Development of Indonesian

self-care behaviours among adults with Group-Based Diabetes Education Program (
type 2 diabetes. Applied Nursing Research, InGDEP ): A Mixed Method Study.
36, 25–32. https://doi.org/10.1016/j.
apnr.2017.05.004. Malini, H., Copnell, B., & Moss, C.
(2017). Considerations in adopting a
DAFNE study group. (2003). Training in culturally relevant diabetes health education
flexible, intensive insulin management to programme: An Indonesian example.
enable dietary freedom in people with type Collegian, 24(2), 183–190. https://doi.
1 diabetes: Dose adjustment for normal org/10.1016/j.colegn.2015.11.002.
eating (DAFNE) randomized controlled
trial. Diabetic Medicine: A Journal of the Mensing, C.R., & Norris, S.L. (2003).
British Diabetic Association. https://doi. Group education in diabetes: Effectiveness
org/10.1034/j.1600-6143.2003.000987_3.x. and implementation. Diabetes Spectrum,
16(2), 96–103. https://doi.org/10.2337/
Davies, M.J., Heller, S., Skinner, T.C., diaspect.16.2.96.
Campbell, M.J., Carey, M.E., Cradock, S.,
… Khunti, K. (2008). Effectiveness of the PERKENI. (2015). Konsensus pengelolaan
diabetes education and self management for dan pencegahan diabetes melitus tipe 2 di
ongoing and newly diagnosed (DESMOND) Indonesia 2015. Jakarta: PERKENI.
programme for people with newly diagnosed
type 2 diabetes: Cluster randomised controlled Ruggeri, M., Drago, C., Moramarco, V.,
trial. BMJ (Clinical Research Ed.). https:// Coretti, S., Köppen, J., Islam, M.K., … Elliott,
doi.org/10.1136/bmj.39474.922025.BE. R.F. (2018). New professional roles and
patient satisfaction: Evidence from a European
Deakin, T., & Whitham, C. (2009). Structured survey along three clinical pathways. Health
patient education: The X-PERT Programme. Policy, 122(10), 1078–1084. https://doi.
British Journal of Community Nursing, org/10.1016/j.healthpol.2018.07.020.
14(9), 398–404. https://doi.org/10.12968/
bjcn.2009.14.9.43916. Sari, C.W.M., Haroen, H., & Nursiswati.
(2016). Pengaruh program edukasi perawatan
Funnell, M.M., & Piatt, G.A. (2017). kaki berbasis keluarga terhadap perilaku
Incorporating diabetes self-management perawatan kaki pada pasien diabetes melitus
education into your practice: When, what, tipe 2. Padjadjaran Nursing Journal, 4(3),
and how. Journal for Nurse Practitioners, 305–314. https://doi.org/10.1007/s11119-
13(7), 468–474. https://doi.org/10.1016/j. 010-9200-7.
nurpra.2017.05.019.
Shrader, S.P., Martin, A., & Cogdill, B.
Garcia, A.A., Villagomez, E.T., Brown, S.A., (2013). Effect of group diabetes self-
Kouzekanani, K., & Hanis, C. L. (2001). management education classes on clinical
The starr county diabetes education study. outcomes and patient satisfaction in a family
Journal Diabetes Care, 24(1), 16–21. https:// medicine clinic. Journal of Pharmacy
doi.org/10.2337/diacare.24.1.16. Technology, 29(1), 35–39. https://doi.
org/10.1177/875512251302900106.
Group, D.P.P.R. (2002). The diabetes
prevention program: Description of Siwi, D., Putri, R., Yudianto, K., & Kurniawan,
lifestyle intervention. Diabetes Care, T. (2013). Perilaku self-management pasien
25(12), 2165–2171. https://doi.org/10.2337/ diabetes melitus (DM) self-management
diacare.25.12.2165. behaviour of patient with diabetes mellitus
(DM), 1(April 2013), 30–38.
International Diabetes Federation (IDF).
(2015). Diabetes Atlas. International Toobert, D.J., Hampson, S.E., & Glasgow,
Diabetes Federation.Brussels, Belgium. R.E. (2000). The summary of diabetes self-

Volume 6 Issue 3 Dec 2018 241

Hema Malini : The Effect of InGDEP on Type 2 Diabetes Patients’ Knowledge and Self-Care

care. Diabetes Care, 23(7), 943–950. https:// World Health Organ, 79(4), 373–374. https://
doi.org/10.2337/diacare.23.7.943. doi.org/S0042-96862001000400016 [pii].

World Medical Association. (2001). WHO. (2014). Health Systems. World Health
Declaration of Helsinki World Medical Organization. Geneva
Association Declaration of Helsinki. Bull

242 Volume 6 Issue 3 Dec 2018