FACTORS INFLUENCING EATING BEHAVIORS AMONG TYPE 2...
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FACTORS INFLUENCING EATING BEHAVIORS AMONG TYPE 2 DIABETES
MELLITUS PATIENTS IN SIDOARJO SUB-DISTRICT,
EAST JAVA, INDONESIA
KUSUMA WIJAYA RIDI PUTRA
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE MASTER DEGREE OF NURSING SCIENCE
(INTERNATIONAL PROGRAM)
FACULTY OF NURSING
BURAPHA UNIVERSITY
MAY 2015
COPYRIGHT OF BURAPHA UNIVERSITY
This master thesis has been supported by
the master and doctoral thesis support grant
from Burapha University,
fiscal year 2015
ACKNOWLEDGEMENT
There are many people who have made this journey possible through their
generous support. I would like to express my deep appreciation to my advisor,
Assistant Professor Dr. Chanandchidadussadee Toonsiri for her patience, unending
guidance, support, encouragements and believing in me. I am indebted to my
co-advisor, Associate Professor Dr. Suwanna Junprasert for her countless influential
supports. Their tireless efforts and inspiring discussions are instrumental for my
achievement. I would like to offer my special gratitude to thesis examination
committee members for providing their suggestions and enriching my thesis.
I also wish to extend my heartfelt thanks to the Institutional Review Board at
the Faculty of Nursing for providing invaluable comments and suggestion to improve
my thesis writing. My great appreciation is given to the Dean at the Faculty of
Nursing, Burapha University, Associate Professor Dr. Nujjaree Chaimongkol and all
lecturers and staff of the Faculty of Nursing, Burapha University for providing
excellent teaching and learning environment to complete my Master of Nursing
Science degree in Thailand.
I extend my deeply felt gratitude to the Indonesian planning and cooperation
of foreign affairs for granting me the scholarship for a full time study in Thailand. I
also extend my deeply felt gratitude to Graduate Studies of Faculty of Nursing for
supporting me the research fund. I would like to offer my sincere appreciation to the
Health Resources of Sidoarjo Health Department for expediting the ethical approval.
Special thanks to the staff working at Sidoarjo Community Health Center for their
kind assistance. I am also very grateful to those people who participated in this study,
for taking their time to complete the questionnaires. And also I would like to say a big
thanks to someone who has been editing my thesis so it becomes better.
Lastly, I am totally indebted to my mother and my grandmother for their
strong prayers and blessings during my two years away from home. I also would like
to deeply thank my brother and my wife for their immense support and
encouragement. I will always remember the sacrifices they made for me.
Kusuma Wijaya Ridi Putra
v
56910104: MAJOR: NURSING SCIENCE; M.N.S.
KEYWORDS: EATING BEHAVIORS/ SELF-EFFICACY/ FAMILY SUPPORT/
PSYCHOLOGICAL STRESS/ TYPE 2 DIABETES MELLITUS
PATIENTS
KUSUMA WIJAYA RIDI PUTRA: FACTORS INFLUENCING EATING
BEHAVIORS AMONG TYPE 2 DIABETES MELLITUS PATIENTS IN
SIDOARJO SUB-DISTRICT, EAST JAVA, INDONESIA. ADVISORY
COMMITTEE: CHANANDCHIDADUSADEE TOONSIRI, Ph.D., SUWANNA
JUNPRASERT, Dr.P.H. 127 P. 2015.
This correlational predictive study aimed to describe and examine predictive
factors toward eating behaviors among type 2 diabetes mellitus (T2DM) patients in
Sidoarjo Sub-district, East Java, Indonesia. A simple random sampling was conducted to
recruit 117 people with T2DM from Sidoarjo Community Health Center, Sidoarjo Sub-
district, East Java, Indonesia. Research instruments consisted of the demographic data
questionnaire, the eating behaviors questionnaire, the knowledge of DM eating behaviors
questionnaire, the self-efficacy on eating behaviors questionnaire, the psychological stress
questionnaire, the family support questionnaire, and the health worker communication
questionnaire. Data were collected from January to February, 2015. Descriptive statistics
and Stepwise multiple regression analysis were used to analyze data.
The results revealed that T2DM patients reported having eating behaviors,
monthly income of family, self-efficacy on eating behaviors, psychological stress, and
family support at moderate level. Educational level and knowledge of DM eating
behaviors were considered as high level and health worker communication was at
a sufficient level. The influences of self-efficacy on eating behaviors (β = 0.36, p < .001)
together with family support (β = 0.31, p < .001), monthly income of family (β = 0.24,
p < .001), and psychological stress (β = -0.18, p < .01) were significantly predicted
66.5 % of the variance of eating behaviors.
The results provide important information for nurses and other health
professionals. Development a nursing intervention to promote eating behaviors in order to
control blood sugar among T2DM should focus on increasing their self-efficacy, motivate
family support, and decrease psychological stress. In addition, the intervention should be
integrated in their everyday life and suit with the income of the family.
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CONTENTS
Page
ABSTRACT .............................................................................................................. v
CONTENTS ............................................................................................................... vi
LIST OF TABLES .................................................................................................... viii
LIST OF FIGURES ................................................................................................... ix
CHAPTER
1 INTRODUCTION ......................................................................................... 1
Background and significance ................................................................... 1
Research objectives .................................................................................. 5
Research hypotheses ................................................................................ 6
Scope of the study .................................................................................... 6
Operational definitions............................................................................. 7
Conceptual framework ............................................................................. 9
2 LITERATURE REVIEWS ............................................................................ 11
Overview of type 2 diabetes mellitus ....................................................... 11
Eating behavior of type 2 diabetes mellitus ............................................. 21
Factors influencing eating behavior of type 2 diabetes mellitus patients 24
3 RESEARCH METHODOLOGY................................................................... 30
Population and sample ............................................................................. 30
Research instruments ............................................................................... 32
Quality of instruments.............................................................................. 35
Protection of human subjects ................................................................... 36
Data collection procedure ........................................................................ 36
Data analysis ............................................................................................ 37
4 RESULTS ..................................................................................................... 38
Part 1 Description of T2DM patients’ characteristics .............................. 38
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CONTENTS (CONTINUED)
CHAPTER Page
Part 2 Description of eating behaviors, monthly income of family,
educational level, knowledge of DM eating behaviors, self-efficacy on
eating behaviors, psychological stress, family support, and health worker
communication of T2DM patients .......................................................... 40
Part 3 Examination of the influences of predisposing factors, reinforcing
factor, and enabling factor toward eating behaviors among T2DM
patients ..................................................................................................... 42
5 CONCLUSION AND DISCUSSION ........................................................... 45
Conclusion .............................................................................................. 45
Discussion ............................................................................................... 46
Implication of the findings ....................................................................... 53
Recommendation for future research ...................................................... 54
REFERENCES .......................................................................................................... 55
APPENDICES ........................................................................................................... 66
Appendix A ......................................................................................................................... 67
Appendix B ......................................................................................................................... 74
Appendix C ........................................................................................................................ 90
Appendix D ........................................................................................................................ 108
Appendix E ........................................................................................................................ 116
Appendix F ........................................................................................................................ 118
Appendix G ........................................................................................................................ 120
Appendix H ........................................................................................................................ 122
Appendix I ......................................................................................................................... 125
BIOGRAPHY .......................................................................................................................... 127
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LIST OF TABLES
Tables Page
1 Description of T2DM patients’ characteristics ............................................... 38
2 Mean, standard deviation, and level of eating behaviors ............................... 40
3 Mean, standard deviation, and level of monthly income of family, educational
level, knowledge of DM eating behaviors, self-efficacy on eating behaviors,
psychological stress, family support, and health worker communication ....... 41
4 Correlation between predictors and eating behaviors ..................................... 43
5 Results of final model of stepwise multiple regression analysis examining
factors influencing eating behaviors among T2DM patients .......................... 44
6 Description of items of eating behaviors ........................................................ 109
7 Description of items of self-efficacy on eating behaviors ............................... 111
8 Description of items of psychological stress .................................................. 112
9 Description of items of family support ........................................................... 113
10 Description of items of health worker communication .................................. 115
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LIST OF FIGURES
Figures Page
1 Conceptual framework .................................................................................... 10
2 Precede-proceed model ................................................................................... 25
3 Sampling diagram ............................................................................................ 32
CHAPTER 1
INTRODUCTION
Background and significance
Diabetes Mellitus (DM) is one of the leading causes of death due to serious
complications (National Conference of State Legislature [NCSL], 2014). According
to the World Health Organization [WHO] (2013), 347 million people worldwide have
diabetes. Based on data from the Indonesian Ministry of Health in 2012, the number
of diabetic patients has reached 5.7 % of Indonesian population or about 12 million
people (Indonesian Ministry of Health, 2013). The number of diabetes mellitus cases
in Sidoarjo obtained from Sidoarjo’s Health Department as of 2013 reached 55,107
cases. This is the second highest incidence for the province of East Java after
Surabaya. The cases were diagnosed and recorded by the Health Department, but
there are still many cases of undiagnosed diabetes incidence in the community (East
Java Health Department, 2011).
Diabetes mellitus in Indonesia accounted for 4.2 % of deaths in the age
group 15-44 years in urban areas and this is the sixth leading cause of death
(Indonesian Ministry of Health, 2013). In the developing countries such as Indonesia,
increasing incidence of diabetes will have an impact on economic growth because
most people with diabetes are at a productive age (Indonesian Ministry of Health,
2013). Diabetes Mellitus, if not handled properly will result in the onset of
complications in various organs such as the eyes, heart, kidneys, leg veins, nerves and
others. Diabetes is difficult to be controlled in good condition, but it will be more
difficult if the state of type 2 diabetes mellitus (T2DM) exacerbated by emotional
disturbances, instability home, or lack of desire to try because of the lack of
motivation due to insufficient knowledge (Guthrie & Guthrie, 2002). Many people
with diabetes are admitted to hospital because they have an active diabetes
complication (Dunning, 2009). This situation occurs in Sidoarjo sub-district, there are
still many cases of undiagnosed diabetes incidence in the community and T2DM
patients only learned about their condition when they had to be hospitalized because
of their active complications from diabetes, among the most frequently recorded
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coronary heart disease, kidney disease and diabetic foot (Sidoarjo Community Health
Center, 2014).
Nutrition intervention in type 2 diabetes mellitus is one of the parts that are
integral with the other treatments (Yannakoulia, 2006). Therefore, changes in lifestyle
associated with eating behaviors in T2DM patients greatly impact on their quality of
life. By having healthy eating behaviors, they can keep their blood sugar levels in
a stable state, and they are also able to control the progression of the disease so that
they can avoid the complications that can aggravate their condition and reduce insulin
resistance (Albarran, Ballesteros, Morales, & Ortega, 2006; Whittemore, Melkus, &
Grey, 2005).
According to some previous research, there are many factors that can affect
food selection and eating patterns of T2DM patients. According to Savoca and Miller
(2001), factors that affect selecting foods and eating patterns are divided into 3
domains, including personal dimension, behavioral patterns and environmental
characteristic. Personal dimension is the desire of individuals to consume favorite
foods when suffering emotional stress, along with nutrition-related knowledge, and
lifelong history of eating beyond the point of self-satisfaction. All of that affects the
type and quantity of food consumed by T2DM patients.
Planning arrangements for a diabetic diet would be more effective if it
involves a certain pattern of behavior, such as organizing meals in advance,
alternative identification favorite foods, and learning to prepare unfamiliar foods
(ex. vegetables). The environment can also affect the behavior of T2DM patients in
selecting foods and their eating habits. For example, when T2DM patients go out to
eat outside, the tendency of a T2DM patient will be to have difficulty in selecting
healthy foods because of the limitation alternative menus, such as vegetables and
low-fat foods. As an example, in the home, family support is key characteristic that
makes it easy or difficult to maintain a healthy diet plan. It is caused by the presence
of family support which will further facilitate in decision making for planning healthy
meals and the family will have a tendency to motivate T2DM patients undergoing
healthy eating behaviors. In addition, there are also researchers who recognize that
income, health care services, environmental insecurity and misleading "popular"
knowledge become key barrier to behavior change (Albarran et al., 2006).
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For example, income and misleading "popular" knowledge, T2DM patients who have
low incomes are likely to have difficulty in making decisions of food consumed and
do not have the chance to separate the foods that should be consumed by T2DM
patients with the food consumed by the entire family. Misleading "popular"
knowledge, often due to lack of information obtained and already trusted by the
community around T2DM patients. In addition, the usual supported by the low level
of education thus making T2DM patients easily to believe that information.
In precede-proceed model developed by Green and Kreuter (2005) to assess
the factors can influence behavior, especially on fourth phase (educational and
organizational diagnosis). There are three factors on educational and organizational
diagnosis phase: Predisposing factors (monthly income of family, educational level,
knowledge, self-efficacy, psychological stress, belief, attitude, etc.), reinforcing
factors (family support, peer support, social support, etc.) and enabling factors (health
worker communication, program services, and resources or development of new
skills). These factors have become references for the researcher in conducting the
preliminary study in March to April 2013 by interviewing six people with diabetes
mellitus in Pamotan village. For preliminary study, the researcher used an open-ended
questionnaire. It was found that the participants had budget limitation for daily living,
the lack of information obtained by the family (only getting information from
neighbors), and ineffective communication between patients from health workers so
often misunderstanding of the information submitted from the health workers, most of
them also have a belief that they do not feel any effects of the disease so they tend to
neglect their health. Some of the interviewed patients experience stress which affects
the decision to consume foods that cause them not to control their blood sugar levels.
Based on previous research, there are multiple factors that can affect self-
management in patients with diabetes mellitus, as well as eating behaviors. The
factors include monthly income of family, level of educational, knowledge, co-morbid
illnesses of hypertension, hyperlipidemia and cardiac diseases, the level of family
functioning, family support, social support, health care service especially provider-
patient communication on self-management, misleading "popular" knowledge and
advice, belief, and self-efficacy (Alavi, Alami, Taefi, & Gharabagh, 2011; Albarran
et al., 2006; Marcy, Britton, & Harrison, 2011; Savoca & Miller, 2001; Wen,
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Parchman, & Shepherd, 2004; William et al., 2010; Xu, Toobert, Savage, Pan, &
Whitmer, 2008).
Based on the results of research conducted by Marcy et al. (2011), they
found several barriers associated with low income and eating behaviors among T2DM
patients. When asked about the considerations in selecting foods, the highest response
obtained were about taste and price. This is resulting in the emergence of a barrier.
A major obstacle that arises is that they want food to taste good at a price that is
affordable to them and which is also healthy. Finally it was the result of them
experiencing stress which cause over-eating or unhealthy food choices as well as
difficulty in resisting the temptation to eat unhealthy food. Income is also often
associated with education level. In the group with low income will have a lower level
of education that will influence the decision making for the selection of foods and
understanding the information related to the importance of eating behaviors for
T2DM patients (Mocan & Altindag, 2014; William et al., 2010). Mocan and Altindag
(2014) also mentioned that the level of education had limitations which impact on
health behaviors, but these can be over if health workers can provide information
related to the management of the disease (especially changing behaviors) which must
be adhered to and should be clearly and easily understood by T2DM patients.
Other factors such as family support and health worker communication can
impact directly or indirectly on self-management, especially dietary behaviors. These
factors can exert their influence indirectly when they affect the confidence of people
with diabetes that will motivate them to follow good dietary behavior (Xu et al.,
2008). Communication and support of families will create a social environment that is
feasible for a patient with diabetes mellitus for treatment by medical professionals
(Hara et al., 2013). Just medical and drug treatment for chronic diseases such as
diabetes mellitus are not enough, but they also to be aware of self-management,
especially eating behaviors. Provision of information about disease suffered by the
patient is the duty of a health workers. The process of providing information or
communication by medical practitioners greatly affect the understanding of the patient
so that they can carry out self-management independently. Effective communication
of health workers is more important to decision-making styles in predicting diabetes
self-management (Heisler, Bouknight, Hayward, Smith, & Kerr, 2002).
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Dietary self-efficacy is a variable that may affect eating behaviors, such as
foods selection and eating patterns. Increased self-efficacy will impact decision
making stage and adherence to the treatments. In addition to self-efficacy,
psychological stress can also influence a person in making decisions regarding
diabetes dietary needs. According Polonsky (2002), emotional stress can affect
the mindset of patients in decision-making related to diabetes health behaviors that
can affect their quality of life. Patients with diabetes often have to know about their
illness, but they often fail to perform good health behaviors because of psychological
stress and cope less well so that they have difficulty in establishing patterns of
behaviors to solve the problem of diet (Nomura et al., 2000).
In conclusion, the process to determine the factors that can affect eating
behaviors of a given population is very important to follow because it enables health
care providers to see which factors can influence the eating behaviors of T2DM
patients so that they can use these factors in the preparation of program planning for
eating behaviors within the population. Research in Indonesia is often performed on
T2DM patients who are undergoing treatment in hospital and is still rarely carried out
on patients living in community.
This research studied factors influencing eating behaviors among type 2
diabetes mellitus patients, which consist of predisposing factors (monthly income of
family, educational level, knowledge of DM eating behaviors, self-efficacy on eating
behaviors, and psychological stress), reinforcing factor (family support), and enabling
factor (health worker communication). The results of this study can be used as a
reference to assist anyone to will learn about the factors that influence the
management of type 2 diabetes mellitus, especially eating behaviors, and used as
input for health professionals to prepare effectively and efficient nursing plan or
program for T2DM patients.
Research objectives
The objectives of the study were to:
1. Describe eating behaviors, predisposing factors (monthly income of
family, educational level, knowledge of DM eating behaviors, self-efficacy on eating
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behaviors, and psychological stress), reinforcing factor (family support) and enabling
factor (health worker communication) of Indonesian people with T2DM.
2. Examine the influences of predisposing factors (monthly income of
family, educational level, knowledge of DM eating behaviors, self-efficacy on eating
behaviors, and psychological stress), reinforcing factor (family support) and enabling
factor (health worker communication) toward eating behaviors among T2DM patients
in Sidoarjo sub-district, East Java, Indonesia.
Research hypotheses
Predisposing factors (monthly income of family, educational level,
knowledge of DM eating behaviors, self-efficacy on eating behaviors, and
psychological stress), reinforcing factor (family support) and enabling factor (health
worker communication) predict eating behaviors among T2DM patients in Sidoarjo
sub-district, East Java, Indonesia.
Scope of the study
This study has been conducted to examine the influences of predisposing
factors (monthly income of family, educational level, knowledge of DM eating
behaviors, self-efficacy on eating behaviors, and psychological stress), reinforcing
factor (family support) and enabling factor (health worker communication) toward
eating behaviors among T2DM patients diagnosed with diabetes mellitus in the
Community Health Center Sidoarjo, Sidoarjo district, East Java, Indonesia. Data
collection was conducted from January to February 2015 with the total of participants
are 117 people.
Variables of this study included the following:
1. Independent variables: Monthly income of family, educational level,
knowledge of DM eating behaviors, self-efficacy on eating behaviors, psychological
stress, family support, and health worker communication.
2. Dependent variable: Eating behaviors
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Operational definitions
T2DM patients referred to as adult residents in Sidoarjo sub-district who
have been diagnosed with diabetes mellitus by doctors.
Monthly income of family referred to the total of family income of T2DM
patients in each month. According Central Bureau of Statistics (2008), monthly
income of family classified into 3 levels, including low income (< 1,500,000 IDR),
moderate income (1,500,000-2,500,000 IDR), and high income (≥ 2,500,001 IDR).
Educational level referred to the total years of education of T2DM patients.
Law no. 2 of 1999 on the measurement of the level of formal education, educational
level classified into 3 levels, including low educational level (6 years), moderate
educational level (9 years), and high educational level (≥ 12 years).
Knowledge of DM eating behaviors referred to the T2DM patients’
cognitive about eating behaviors of diabetes mellitus, including healthy eating pattern,
inappropriate foods, the important of eating behaviors than other treatments, and
dietary self-management. Knowledge of DM eating behaviors was measured using
combination of the Diabetes Knowledge Questionnaire (DKQ) from two previous
study. In this study, DKQ measured using 18 items, which derived from 7 items of
Garcia, Villagomez, Brown, Kouzekanani, and Hanis (2001) and 11 items of Park
et al. (2010). The potential response choice were used, “yes”, “no”, and “don’t know”.
The higher scores indicated high levels of the T2DM patients’ knowledge.
Self-efficacy on eating behaviors referred to the T2DM patient’s
perception of their ability to maintain their eating behaviors, including the start of the
measurement of choosing appropriate foods, following eating plan in any conditions,
and controlling T2DM conditions. In this study, self-efficacy on eating behaviors was
measured using 10 items of modification self-efficacy of diet from 15 items of the
Diabetes Management Self-Efficacy Scale-UK (DMSES-UK) are considered to be
interpreted T2DM patient self-efficacy for diet. DMSES-UK developed by Sturt,
Hearnshaw, and Wakelin (2010). This used rating scale from 0-10. The higher
scores indicated high levels of the T2DM patients’ self-efficacy.
Psychological stress referred to the feelings of T2DM patients for potential
problems that may be faced by them, including emotional burden, physician-related
distress, regimen-related distress, and interpersonal distress. In this study,
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psychological stress was measured using 16 items from Diabetes Distress Scale (DSS)
developed by Polonsky et al. (2005). This used rating scale, which included “not a
problem”, “a slight problem”, “a moderate problem”, “somewhat serious problem”,
“a serious problem”, and “a very serious problem”. The higher scores indicated high
levels of the T2DM patients’ distress.
Family support referred to the perception of supporting system and motivation
given by the family to help engage in healthy eating behaviors of T2DM patients
which aims to improve the quality of life of these patients, including give motivation
to keep compliance with the healthy eating behaviors, meet the food needs in
accordance with the T2DM patients conditions, and choose place that serve
appropriate foods for T2DM.Family support was measured using 20 items of Diabetic
Social Support Questionnaire-Family (DSSQ-family) in Om (2013). This used rating
scale, “never”, “less than 2 times a month”, “twice a month”, “once a week”, “several
times a week”, and “at least once a day”. The higher scores indicated high support
from family.
Health worker communication referred to the T2DM patient’s perception
about communications made by health workers in providing information associated
with diabetes mellitus, including attitude of health workers while communicating with
T2DM patients, readiness of health workers in conveying information, and readiness
of health workers while consulting related to healthy eating behaviors. Health worker
communication was measured using Health Care Communication Questionnaire
(HCCQ) developed by Gremigmi, Sommarugo, and Peltenburg (2007). This used
rating scale, “not at all”, “a little, somewhat”, “very much”, and “completely”.
The higher scores indicated good communication between health worker and T2DM
patients.
Eating behaviors referred to the response of T2DM patients associated with
the consumption of foods that are recommended for diabetic patients, including the
start of the measurement of food intake, the selection of a healthy diet, the
consumption of meal planning that appropriate, and challenges dietary settings
(selecting a place to eat for good health when eating out and portion control). Eating
behaviors were measured using the Self-Management Dietary Behaviors
Questionnaire (SMDBQ) which has been developed by Primanda, Kritpracha, and
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Thaniwattananon (2011). This used rating scale, “never”, “sometimes”, “often”, and
“routinely”. The higher scores indicated good dietary behaviors.
Conceptual framework
Precede-proceed model address by Green and Kreuter (2005) has nine
phases. Precede section, there are five phases. They consists of social diagnosis
(phase 1), the epidemiological diagnosis (phase 2), behavioral and environment
diagnosis (phase 3), educational and organizational diagnosis (phase 4), and
administrative and policy diagnosis (phase 5). To perform the evaluation associated
with behaviors that will be aimed at the end of the evaluation of the level of health
and quality of life, it can be done through an evaluation of the factors contained in the
educational and organizational diagnosis. It should be noted that the administrative
and policy diagnosis phase can affect the educational and organizational diagnosis
phase.
The conceptual framework of this study was educational and organizational
diagnosis phase of precede-proceed model that consists of three factors: predisposing
factors, reinforcing factors and enabling factors. While the impact evaluation phase is
the phase in which to evaluate the implementation of which is based on the
assessment of three factors on educational and organizational diagnosis phase.
According to Green and Kreuter (2005), predisposing factors are any characteristics
of a person or population that motivates behavior prior to or during the occurrence of
that behavior. The predisposing factors in this study were monthly income of family,
educational level, knowledge of DM eating behaviors, self-efficacy on eating
behaviors, and psychological stress. Reinforcing factors are rewards or punishments
following or anticipated as a consequence of a behavior. They serve to strengthen the
motivation for behavior. The reinforcing factor in this study was family support.
Enabling factors are those characteristics of the environment that facilitate action and
any skill or resource required to attain specific behavior. The enabling factor in this
study was health worker communication.
In present study, eating behaviors of diabetes mellitus patient can be
influenced by multiple factors as figure 1. Based on precede-proceed model
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developed by Green and Kreuter (2005), changes in lifestyle or behavior, especially
eating behaviors in T2DM patients greatly impact on their quality of life.
Figure 1 Conceptual framework
CHAPTER 2
LITERATURE REVIEWS
This chapter contains the information and study findings relevant to this
research. This section is divided into 3 main parts as follows:
1. Overview of type 2 diabetes mellitus
2. Eating behaviors of type 2 diabetes mellitus
3. Factors influencing eating behaviors of type 2 diabetes mellitus patients
Overview of type 2 diabetes mellitus
The overview of type 2 diabetes mellitus described the definition,
pathophysiology, complications, and management of type 2 diabetes mellitus
(T2DM).
1. Definition of type 2 diabetes mellitus
According to American Diabetes Association [ADA] (2004), type 2 diabetes
mellitus is a group of metabolic diseases characterized by hyperglycemia resulting
from defects in insulin secretion, insulin action, or both.
A person is said to suffer from type 2 diabetes when their body does not
produce enough insulin to function properly, or the body's cells do not respond to
insulin, which is commonly known as insulin resistance. That situation can be caused
by age, obesity, lack of exercise, and increase in unhealthy diets (National Health
Service [NHS], 2014).
According to the Indonesian Society of Endocrinology [Perkeni] (2006),
a person is suffering from diabetes who has a fasting plasma glucose (FPG) level
> 126 mg/ dl and the oral glucose tolerance test (OGTT) > 200 mg/ dl. Blood sugar
levels vary throughout the day which will increase after a meal and returning to
normal within 2 hours. As for T2DM itself is a medical condition that is often
characterized by elevated blood glucose levels that are usually caused by metabolic
disorders such as insulin resistance and/ or insulin deficiency.
T2DM is a condition that is most dominant in the world because it
represents 90 % of cases of diabetes (Hassan, 2013).
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Based on the above understanding, it can be concluded that T2DM is
a condition of endocrine disorders caused by several factors, such as insulin resistance
and or insulin deficiency and characterized by elevated levels of blood sugar, fasting
plasma glucose (FPG) levels ≥ 126 mg/ dl and the oral glucose tolerance test (OGTT)
> 200 mg/ dl.
2. Etiology or risk factors of type 2 diabetes mellitus
The factors that may influence the occurrence of T2DM, among others
genetic factors leading to susceptibility, age, obesity and physical inactivity, and
ethnic and environmental factors (Alexander, Fawcett, & Runciman, 2006).
` 2.1 Genetic factors leading to susceptibility.
The role of genes is very strong in T2DM. Having a certain combination
of genes will increase or decrease the risk factors for developing this disease. This is
evident from the high rate of diabetes mellitus in the family and identic twins and
a wide variation in the prevalence of diabetes by ethnicity (National Institute of
Health, 2011; Watkins, 2003). Type 2 diabetes occurs more frequently in African
Americans, Alaska Natives, American Indians, Hispanics/ Latinos, and some Asian
Americans, Native Hawaiians, and Pacific Islander Americans than it does in
non-Hispanic whites (National Institute of Health, 2011).
Recent studies have combined genetic data from many people and accelerate
the pace of gene discovery. These studies have identified many gene variants that
increase susceptibility to T2DM. Also gene variants that affect the production of
insulin rather than insulin resistance. The researchers are also trying to identify
additional gene variants and learn how they interact with each other and with
environmental factors that cause diabetes. Much research on T2DM-gene and
genomics related to the increase in the incidence of T2DM. People with T2DM who
have the unique phenotype may show an increase in the incidence of T2DM (Grant,
Moore, & Florez, 2009). The diabetes prevention program clinical trial involving
people at high risk found that if the group with this variant, if used the appropriate
diet and physical activity for weight loss, it would have helped them to delay
the occurrence of T2DM (National Institute of Health, 2011).
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2.2 Age
The incidence of T2DM will increase significantly with age. One in ten
people at the age of 70 years have a tendency to suffer from T2DM (British Diabetic
Association, 1996). Metabolism of glucose in the blood will begin to decline in the
third or fourth decade of life, especially at the age above 60 years, and will be
exacerbated and accelerated by other factors that also contribute to the onset of
diabetes (Alexander et al., 2006; Valliyot, Sreedharan, & Muttappallymyalil, 2013).
2.3 Obesity and physical inactivity
Obesity and physical activity have a very strong relationship to
the incidence of T2DM, especially in those who are genetically susceptible to diabetes
mellitus will further increase the risk. The imbalance between caloric intake and
physical activity can lead to obesity, which causes insulin resistance and is common
in people with T2DM. This condition decreased glucose tolerance caused by
increased body weight and tolerance it will return to normal with a decrease in body
weight. Excess abdominal fat is a major risk factor not only as a cause of insulin
resistance and type 2 diabetes but also can be a cause of heart and blood vessel
disease, also called cardiovascular disease (CVD). That is because excess "belly fat"
will produce hormones and other harmful substances that may cause chronic effects in
the body such as blood vessel damage (Alexander et al., 2006; National Institute of
Health, 2011; Wei, Gaskill, Haffner, & Stern, 1997).
2.4 Ethnic and environmental factors.
There is a wide geographical variation in the incidence of T2DM with
"Western" diet style and lack of physical activity. In addition, the incidence will be
growing in the urban areas with hard working atmosphere and diet are more
dependent on high-fat diets and lack of time to exercise or physical activity can lead
to obesity. This is a health burden experienced by urban areas. In the UK,
the prevalence of T2DM is particularly high in Asian and Afro-Caribbean people,
with 20 % of Asians and 17 % of Afro-Caribbean over the age of 40 known to
have T2DM (Alexander et al., 2006; Griggs, 1998; National Institute of Health, 2011;
Watskins, 2003).
14
3. Pathophysiology of type 2 diabetes mellitus
T2DM is a common type of diabetes and is usually caused by a combination
of factors, including insulin resistance, where the body's muscle, fat and liver cells do
not use insulin effectively. T2DM can also be caused by the body can no longer
produce enough insulin to compensate for the impaired ability to use insulin (National
Institute of Health, 2011).
3.1 Impaired insulin secretion
Impaired insulin secretion is a condition in response to a decrease in
blood glucose was observed before the clinical onset. It is particularly in impaired
glucose tolerance (IGT) caused a decrease in insulin secretion in the early phase of
glucose-responsive, insulin secretion and a decrease in additional after eating that
causes postprandial hyperglycemia. An oral glucose tolerance test (OGTT) in the case
of IGT generally indicates an over-response in Caucasian people and Hispanics who
have a high incidence of resistance to insulin. On the other side, Japanese patients
often decrease insulin secretion. Even when over-response was seen in people with
obesity or other factors, they showed a decrease in the early phase of secretion
response. The decline in the early phase of secretion is an important part of this
disease, and is very important as a basic pathophysiological changes during the onset
of the disease in all ethnic groups (Abdul-Ghani, Matsuda, & Jani, 2008).
Impaired insulin secretion generally occurs progressively, and involves
the development of glucose toxicity and lipo-toxicity. If not treated, it is known to
cause a decrease in pancreatic β cell mass. Pancreatic β cell destruction affect
the long-term control of blood glucose. While patients in the early stages after
the onset of the disease mainly showed increased postprandial blood glucose as
a result of increased insulin resistance and decreased early-phase secretion,
development of impaired function of pancreatic β cells which then will lead to
a permanent elevation of blood glucose (Kaku, 2010).
3.2 Insulin resistance
Insulin resistance is a condition in which insulin in the body cannot act in
proportion to the concentration of the blood. Decreased insulin action in organs such
as liver and muscle are in general pathophysiological feature that occurs in T2DM.
In the experiment for the molecular mechanism of action of insulin showed that
15
insulin resistance associated with genetic factors and environmental factors
(hyperglycemia, free fatty acids, inflammatory mechanisms, etc.). On genetic factors
keep in mind that not only includes the insulin receptor and insulin receptor substrate
(IRS)-1 gene polymorphisms that directly affect insulin signaling, but also genetic
polymorphisms such as β3-adrenergic receptor genes and uncoupling protein (UCP)
gene, which is associated with obesity visceral and increased insulin resistance.
Glucolipotoxicity and inflammatory mediators have an important effect on
the mechanism of impaired insulin secretion and decreased insulin signaling.
Attention is focused on the involvement of adipocyte-derived bioactive substances
(adipokines) in insulin resistance. While TNF-α, leptin, resistin, and free fatty acids
act as an ingredient to improve insulin resistance whereas adiponectin will help
increase the insulin resistance. An easier way to estimate the increase in insulin
resistance is by examining the presence of high fasting blood insulin, visceral obesity,
hyper triglyceridemia, etc. (Kaku, 2010; Matsuda & DeFronzo, 1999).
4. Sign and symptoms of type 2 diabetes mellitus
Patients with T2DM will show different clinical symptoms from one person
to another. In fact, there are some patients who do not experience clinical symptoms
until at a certain moment that they knew that they was suffering from diabetes
mellitus type 2. In general, there are three symptoms that often occur in people with
T2DM that is polydipsia, polyuria, and polyphagia. Based on Alexander et al. (2006),
the effects due to the relative lack of insulin is divided into 4, including
hyperglycemia-related symptoms, genital or oral fungal infections, staphylococcal
skin infections and non-specific symptoms.
4.1 Hyperglycaemia-related symptoms
In the circumstances we find symptoms of hyperglycemia such as
nocturia, polyuria and possibility of thirst gradually and in patients with risk factors
such as obesity.
4.2 Genital or fungal infections
Candida infection is a common thing that happens in people with T2DM.
The candida infection can be pruritus vulvae in the female and balanitis in male.
The condition is caused by high levels of glucose from urine around the genitals and
16
the lack of hygiene in the area so that the area becomes a place that is favorable for
the proliferation of candida.
4.3 Staphylococcal skin infections
The incidence of infection is usually detected in patients with type 2
diabetes who had boils and abscesses and usually it is that drives them to see
the doctor for consultation.
4.4 Non-specific symptoms
This condition is usually in the form of tiredness and lethargy - often
reported as the symptoms experienced by patients with T2DM. It is not clearly
known, but the cause is suspected to be the result of fluid and electrolyte imbalance in
the body.
In addition to the four above symptoms, there are also symptoms associated
with the occurrence of complications. Incidence of vascular and neurological
complications, such as proteinuria, sexual dysfunction, and retinopathy, developed
when people with diabetes mellitus type 2 is coming to the medical personnel. This is
likely to occur when the patient is likely to have diabetes with hyperglycemia
persistent asymptomatic for several years before diagnosis (Alexander et al., 2006).
5. Complication of type 2 diabetes mellitus
For people with diabetes mellitus either type 1 diabetes mellitus or T2DM
should be able to maintain body condition of the occurrence of hyperglycemia
because these conditions will improve morbidity and mortality in patients with
diabetes mellitus. Complications that may occur as a result of prolonged
hyperglycemia and uncontrolled are divided into two, namely macrovascular
(coronary artery disease, peripheral arterial disease, and stroke) and microvascular
(diabetic nephropathy, neuropathy, and retinopathy) (Alexander et al., 2006; Fowler,
2008; Lemone & Burke, 1996).
5.1 Macrovascular complication
Macrovascular complication include cardiovascular disease (such as
coronary artery disease, myocardial infarction, etc.), peripheral arterial disease,
hypertension, stroke and paralysis (Alexander et al., 2006; Lemone & Burke, 1996;
Smelter, Brenda, Hinkle, & Cheever, 2010).
17
Based on the results of research conducted by the British Diabetic
Association in collaboration with the World Health Organization [WHO] on 497
people aged 35-54 years old with diabetes mellitus showed that the prevalence of
cardiovascular disease was 45 % and the prevalence of obtained 43 % had coronary
disease. It also obtained cerebrovascular disease and peripheral vascular disease
(4.5 % and 4.2 %, respectively) (British Diabetic Association, 1995). Based on
research by Stratton et al. (2000) found that in patients with T2DM have risks of
complications associated with previous hyperglycemia. This is evident from the
results of research that found 14 % of participants suffered myocardial infarction.
In addition, diabetes is also a strong independent predictor of the risk of stroke and
cerebrovascular diseases, such as in coronary artery disease. Patients with T2DM
have a 150 % - 400 % increase in the risk of stroke (Fowler, 2008).
5.2 Microvascular complication
Microvascular complications are caused by blockage of the small blood
vessels, especially capillaries. Microvascular complication diagnosis sometimes
originated from the reduction in visual acuity or other disorders of the eye that can
lead to blindness. Diabetic retinopathy is divided into 2 groups, namely
non-proliferative retinopathy and proliferative retinopathy. Non-proliferative
retinopathy is an early stage with a marked presence of micro-aneurysms.
Proliferative retinopathy is characterized by the growth of capillary blood vessels,
connective tissue and the presence of hypoxia in the retina (Alexander et al., 2006;
Permana, 2009).
In the early stages, retinopathy can be repaired with good blood sugar
control. But at an advance level, it can hardly be repaired only with blood sugar
control, even going to get worse if there is a decrease in blood sugar levels which are
too drastic and short. That situation would be exacerbated if patients with T2DMare
also suffering from hypertension (Alexander et al., 2006; American Diabetes
Association [ADA], 2007; Permana, 2009).
Aside from being the cause of retinopathy, T2DM is a cause of the most
widely nephropathy. And nephropathy is a major cause of terminal renal failure.
Specific renal damage in diabetes mellitus results in changes in the function of the
filters, so that large molecules such as proteins can escape into the urinary system
18
(eg. Albuminuria). Diabetic nephropathy can lead to the onset of progressive renal
failure (Permana, 2009).
Diabetic nephropathy is characterized by persistent proteinuria (> 0.5
gr/ 24 hours) and urinary albumin loss is between 30-300 mg/ day, and there is
retinopathy and hypertension. Thus preventive efforts on nephropathy are by
controlling metabolism and blood pressure control (ADA, 2007; Permana, 2009).
Diabetic neuropathy is a frequent complication in patients with diabetes,
50 % of patients suffering from diabetes mellitus. Clinical manifestations may include
sensory disturbances, motoric, and autonomic. The process of incident neuropathy
usually occurs where there is a progressive degeneration of nerve fibers with
symptoms of pain or numbness, which is usually affected limb nerve fibers. This is
due to the presence of damage and dysfunction in neural structures due to an increase
in polyol pathway, decreased the formation of myoinositol, decreased Na/ K ATPase,
causing structural damage to the nerves, demyelination segmental, or axonal atrophy
(Permana, 2009).
6. Management of type 2 diabetes mellitus
Management in patients with T2DM required multidisciplinary treatment.
Management of diabetes mellitus conducted by professionals in the diabetes care team
will be adapted to needs of each individual with diabetes mellitus. Management of
diabetes mellitus is aimed at the achievement and maintenance of normoglycemia,
monitor response to therapy, prevention and early detection of diabetic complications
that may appear, facilitating the self-care education, promotion of social and
psychological adjustment.
Based on Alexander et al. (2006), there are 4 main therapeutic approaches in
the management of diabetes; those are weight control, dietary therapy, oral
hypoglycemic therapy, and insulin therapy.
6.1 Weight control
Weight control is an important thing done by people with T2DM because
of obesity will lead to an increase in blood glucose levels. Aside from dietary
adjustments, advice for physical activity should also be performed (Alexander et al.,
2006; International Diabetes Federation, 2012).
19
6.2 Dietary therapy
Appropriate dietary advice in patients with diabetes mellitus is
an effective effort in the management of diabetes. Provision of information about diet
in diabetes management aims to train people with diabetes to be able to have their
own types and is able to determine the quantity of food they eat. Dietary therapy is
associated with consumption of carbohydrate restriction, restriction of fat intake,
consumption of fruit and alcohol consumption (Alexander et al., 2006).
6.2.1 Carbohydrate
All foods that contain carbohydrates can lead to the increasing of blood
glucose levels. Increased blood glucose levels are influenced by the amount of food
consumed, carbohydrate source such as glucose or starch, cooking method and other
components of food. Sucrose is no longer considered to be more harmful to the blood
glucose levels than other carbohydrates. However, sucrose is still a source of empty
calories and harmful to the teeth so that we can consume them sparingly. Fruit
containing fructose consumption should be encouraged because it has a low glycemic
effect. In addition, fruits consumption are also used to meet the needs of fibers so that
people with diabetes should be encouraged to eat five portions of fruit and vegetables
per day. However, excessive consumption of fruits can also lead to increased blood
glucose levels so that number should also be considered (Alexander et al., 2006;
International Diabetes Federation, 2012).
6.2.2 Fat
Fat should not be overlooked when giving dietary advice for people
with diabetes. This is one of the main sources of dietary energy. Decrease fat intake
generally required for weight control. Diabetes mellitus patients generally should be
encouraged to consume less fat and, if possible, within the selected fat consumption,
which comes from monounsaturated sources (Alexander et al., 2006; International
Diabetes Federation, 2012).
6.2.3 Alcohol
People with T2DM should avoid alcohol consumption because
it impacts to insulin sensitivity which is resulting to the decrease of blood glucose
levels drastically. In such conditions, it should be noted that adequate carbohydrate
intake to avoid diabetes is the condition of hypoglycemia (Alexander et al., 2006).
20
6.3 Oral hypoglycemic therapy
Oral hypoglycemic therapy will work effectively if β cells are still able to
secrete insulin. Oral hypoglycemic therapy used specifically in patients with T2DM.
Based on United Kingdom Prospective Diabetes Study Group [UKPDS] (1998), there
are five groups of oral agents play are available for use, such as sulphonylureas,
biguanides (metformin), prandial glucose regulators, thiazolidinediones, and alpha-
glucosidase inhibitors.
6.3.1 The sulphonylureas
These drugs stimulate the β cells of the pancreas to produce more
insulin in response to blood glucose levels, improve insulin sensitivity and decrease
hepatic metabolism for insulin productions. Side effects often occur from the use of
these drugs is hypoglycemia. Other side effects may include weight gain,
gastrointestinal disturbance and skin rash.
6.3.2 The biguanides (metformin)
The effects of metformin are reducing glucose absorption in the
intestine, reduce insulin resistance in peripheral tissues, and inhibit liver glucogenesis.
Common side effects are gastrointestinal upset occurs. The use of metformin may also
result in malabsorption of vitamin B12 and an increase in lactic acid. Metformin
should not be used in patients with diabetes mellitus with renal, liver and severe
cardiovascular disease or serious systemic illness.
6.3.3 Prandial glucose regulators
These drugs designed to stimulate additional insulin to coincide with
the digestive process. These drugs usually taken 15 minutes before meals; so
it contains can be absorbed quickly by the body. Side effects tend to be very rare, but
still it can lead to gastrointestinal upset, nausea, and skin rash.
6.3.4 Thiazolidinediones
These drugs handling in insulin resistance and improve insulin
sensitivity in peripheral tissues, increases glucose uptake in peripheral tissues, and
decrease hepatic glucose production. These drugs are usually used in conjunction with
other oral agents. Side effects that arise are weight gain, headaches, and fluid
retention. The use of this drug is not recommended in people with cardiac failure or
poor liver function.
21
6.3.5 Alpha-glucosidase inhibitor
Acarbose is the name of drugs classified on this type. Acarbose is now
very rarely used because of the side effects which is stand out. Mechanism of action
of this drug is delaying the formation of monosaccharides derived from sucrose and
starch. Side effects of these drugs are flatulent and diarrhea.
6.4 Insulin therapy
Insulin therapy is the treatment of which people with type 1 diabetes
mellitus should carry out throughout their life. But for T2DM patients, the most
important is the management of change in lifestyle. According UKPDS (1998), only
25 % of T2DM patients who use insulin therapy or intensive blood-glucose control
can decrease the risk of microvascular complication. Insulin is only given to T2DM
patients who have prolonged periods at elevated blood glucose control despite
lifestyle changes and taking hypoglycemic drugs (Casey, 2011). Insulin therapy has
several purposes, among others, to keep blood glucose levels under normal
circumstances, relieve symptoms of hyperglycemia, improve metabolic/ biochemical
disturbances, and prevent complications associated with hyperglycemia.
In conclusion, the main purpose of doing management in patients with
diabetes are keeping their blood glucose levels in normal and prevent complications.
Diabetes management can be done in 4 ways, including weight control, dietary
therapy, oral hypoglycemic therapy, and insulin therapy. One of the four most
important ways management for T2DM patients is dietary therapy. All the way
diabetes management cannot be separated with lifestyle changes and physical activity
done by T2DM patients.
Eating behaviors of type 2 diabetes mellitus
Eating behaviors are always associated with three factors, type, frequency
and amount of food consumed by a person. Eating behaviors are difficult condition to
conceptualize and complex behaviors of a person or group of people to meet the
demand for food which includes attitudes, beliefs, culture, lifestyle, and choice of
food (food groups, individual foods, components of foods, specific micronutrients or
phytochemicals) that describes the daily food consumption, including the type of
food, amount and frequency of eating (Handjani, 1996; Jacobs, Gross, & Tapsell,
22
2009; Jacobs & Tapsell, 2007; Jacobs & Steffen, 2003; McKeown & Jacobs, 2010).
They also define eating behaviors as a condition that is difficult to conceptualize
because it all depends on the diversity of belief, culture, and lifestyle patterns within
community. Individual conceptualization of eating behaviors come from faith and
lifestyle that they profess in their daily life, which have the possibility of not being in
accordance with scientific recommendations (Sangperm et al., 2008).
Based on the above understanding, it can be concluded that eating behaviors
are complex behaviors of a person or group associated with the fulfillment of the need
to eat who are often influenced by their beliefs, culture and daily lifestyle which will
result in the selection of the type, frequency and amount of food consumed.
After a person has been diagnosed with T2DM, the problems that often
appear are always associated with eating behaviors. The eating behaviors of T2DM
patients who are diagnosed early will remain the same as others who do not suffer
from T2DM, especially in women, they are often less able to make dietary changes
early after being diagnosed and having received dietary advice (Van De Laar et al.,
2006). There are several factors that can affect eating behaviors among T2DM, such
as gender, knowledge, income, education level, belief, family support, social support,
time management, health care services, and dietary self-efficacy (Alavi et al., 2011;
Albarran et al., 2006; Kaiser, Razurel, & Jeannot, 2013; Savoca & Miller, 2001).
Based on the research of Savoca & Miller (2001), which according to them with
increased knowledge of healthy diets diabetics with diabetes will affect one's
awareness of eating behaviors. The same thing is also expressed by Albarran et al.
(2006), they provide health education intervention that they think will improve the
knowledge of the respondents and care givers about how to benefit the families and
the people around T2DM patients so as to raise awareness about the treatments that
T2DM patients are undergoing and with emphasis on their eating behaviors.
In addition to the factors derived from individuals with T2DM patients and
the surrounding environments, the health care service also plays an important role in
improving the quality of life of T2DM patients such as health care service, which is a
support system that can affect the patient's self-efficacy and lifestyle behaviors (Lee et
al., 2011). According to Lee et al. (2011), there should be a partnership between the
23
general clinical and social work to conduct programs related to improve quality of life
of T2DM patients.
T2DM patients must have a strict adherence to the activities and actions
related to the condition, one of which is healthy eating behaviors to maintain and
sustain their health. By adhering to a diet that has been recommended so that they can
keep their blood sugar levels in a stable state and controlling progression of
the disease so that they can avoid complications (Whittemore et al., 2005).
The diabetic food pyramid recommended by the ADA is often used as a guide to
healthy eating for diabetics in which there is the calculation of the proportion of
consumption of carbohydrates, fats and proteins for diabetics. The proportion
recommended by the ADA, among others are 10 % to 20 % protein, 30 % fat, and
50 % to 60 % carbohydrate. But in addition to these three components, fiber contained
in each food consumed by T2DM patient is also very important because the fiber is
often associated with a significant reduction in fasting blood sugar levels, lipid levels,
and also reduction of body weight in diabetics (Ding & Malik, 2008).
T2DM is always related to lifestyle, especially eating behaviors. It is
expected that adherence to good eating behaviors would impact on blood glucose,
blood pressure, cholesterol levels and also help to control weight. Several studies have
explained that by changes in eating habits can help to overcome T2DM disease
progression and prevent the sufferer from the occurrence of complications and reduce
insulin resistance (Albarran et al., 2006; Kaiser et al., 2013; Mohan, Sandeep, Deepa,
Shah, & Varghese, 2007).
In Indonesia, the Indonesian people have a habit of eating rice. Indonesian
people did not feel able to eat until they have eaten rice or other food made from rice
(Primanda et al., 2011). Regarding traditional Indonesian culture and ceremonies,
many traditional events and ceremonies that combine food and invite relatives and/
or other guests to share a meal. They prepare food that is high in fat and too sweet.
Though both of these food types are not recommended for diabetics. In such
conditions, people with diabetes are expected to manage their own eating behaviors.
Often the management of eating behaviors of patients with diabetes is associated with
self-confidence in their health-illness and is always associated with the religious or
traditional beliefs that they profess.
24
The habit of consuming foods containing saturated fats, trans-fats,
cholesterol, high-salt, added sugar which are eaten in large portions are habits that can
be the cause of T2DM. These habits can cause a person to become overweight and
obese, which will result in a decline in organ function. Therefore, to understand the
importance of eating behaviors and make decisions to choose healthy eating behaviors
is most crucial to maintain the condition of T2DM patients.
Factors influencing eating behaviors of type 2 diabetes mellitus
patients
1. Precede-proceed model
Precede-proceed model address by Green and Kreuter (2005) is used for
delivering programs in practice settings and conducting behavior change
interventions. Precede-proceed model is community-oriented, participatory model for
creating successful community health promotion interventions. The model offers a
framework within which individual level theories, community level theories,
interpersonal communication, interactive technologies media campaigns, and grass
roots organizing can be utilized. Precede-proceed model has nine phases. Precede
section, there is five phases. It consists of social diagnosis (phase 1), epidemiological
diagnosis (phase 2), behavioral and environment diagnosis (phase 3), educational and
organizational diagnosis (phase 4), and administrative and policy diagnosis (phase 5).
Proceed section, there is four phases. It consists of implementation (phase 6), process
evaluation (phase 7), impact evaluation (phase 8), and outcome evaluation (phase 9).
To perform the evaluation associated with behaviors which aims to evaluate the health
and quality of life, it can be done through an evaluation of the factors contained in the
educational and organizational diagnosis. It should be noted that the administrative
and policy diagnosis phase can affect the educational and organizational diagnosis
phase.
Educational and organizational diagnosis phase of precede-proceed model is
used to determine the influencing factors of eating behaviors among T2DM patients.
It consists of three factors: Predisposing factors, reinforcing factors and enabling
factors. Once behavioral and environment factors have been selected for intervention
25
the next step is to identify antecedent and reinforcing factors that need to be in place
to initiate and sustain the change process. There are 3 specified:
Predisposing factors – antecedents to a behavior that provide rationale or
motivation for that personal behaviors, such as monthly income of family, educational
level, knowledge, self-efficacy, stress management, belief, attitude, etc.
Reinforcing factors – factors that following a behavior provide continued
reward or incentive for repetition of that behavior, such as family support, peer
support, social support, etc.
Enabling factors – antecedents to behavioral or environmental change that
allow a motivation or environmental policy to be realized, such as communication of
health care provider, programs services and resources or development of new skills.
Figure 2 Precede-proceed model (Green & Kreuter, 2005)
2. Predisposing factors
2.1 Monthly income of family
Family income had direct and indirect impact between eating behaviors
and health among T2DM patients (Vlismas, Stavrinos, & Panagiotakos, 2009).
26
According Marcy et al. (2011), in low-income communities often found the incidence
of diabetes is caused by factors related to the cost of healthy food, stress-related
eating inappropriate, and the temptation to eat unhealthy food. With low income
levels and supported by a low-SES environment would affect one's perception of
health and result in health disparities (Gallo, Smith, & Cox, 2006). Type of work and
the ability to pay for treatment are often the cause of disparities in health care so that
it will affect a person's perception of health behaviors (Shawahna et al., 2012). On the
other hand, income affects a person in making decision in determining the food they
consume. At higher income levels, some people have a tendency to choose unhealthy
foods more due to the custom of the environment around them then ability to buy it
(Muhammad, Karim, Othman, & Ghazali, 2013).
2.2 Educational level
Low educational level is often drive T2DM patient had difficulty in
understanding all the information related to self-management, especially the
importance of eating behaviors to maintain their condition. It also makes them will
have difficulty in making decisions related to eating behaviors, such as food selection
and eating patterns. However, these problems will be over if the health worker can
provide information related to the management of the disease (especially changing
the behaviors of everyday life, such as eating behaviors) that must be endured by
those with a clear and easily understood and in accordance with their conditions
(Mocan & Altindag, 2014). The same thing also expressed by Atak, Gurkan, and
Kose (2008), who state that the level of education has a limited impact on health
behaviors.
2.3 Knowledge of DM eating behaviors
According Serrano-Gil and Jacob (2010), T2DM patients will achieve
successful clinical outcomes and health if they have knowledge about their health so
that they are involved in controlling and managing their condition. More information
lead to a more selection methods too choose good diets based on the patient’s
experience, but still it must be balanced with the proper knowledge so that patients
know when they should still consult to doctor and when they can take action on their
own (Alavi et al., 2011). T2DM patients are expected to remain informed and more
critical in assessing the information about their treatment that lead to motivate them to
27
change behavior generated by the learning (Hartayu, Izham, & Suryawati, 2012).
Health education on nutrition knowledge is needed to improve the nutritional
knowledge, skills, and food intake behaviors (Fitzgerald, Damio, Pérez, & Escamilla,
2008).
2.4 Psychological stress
Emotional distress is common in diabetes. Emotional distress can affect
the mindset of patients with diabetes-related health behaviors that lead to health-
related quality of life (Polonsky, 2002). Statement of Polonsky is reinforced by the
statement of Lustman, Penckofer, and Clouse (2008) who state that the stress
condition of patients with diabetes will affect insulin sensitivity and resulted in a
sustained reduction in HbA1c. Psychological stress can affect eating behaviors, either
directly or indirectly. Stigma or psychosocial problems are obtained by T2DM
patients will deliver tremendous impact stress on the concept of health-illness in
people so that they will experience problems related decisions taken by health
behaviors, especially for diet (Guthrie, Bartsocas, Jarosz-Chabot, & Konstantinova,
2003). Patients with diabetes often have to know about their illness, but they often fail
to perform health behaviors because of stress management and coping less well so
that they have difficulty in establishing patterns of behaviors to solve the problem of
diet and exercise therapy (Nomura et al., 2000). The patients of chronic diseases such
as diabetes mellitus who are confident, motivated, able to regulate their emotions, and
are equipped to use a rational approach to solving the problem should be adjusted in
routine and stressful circumstances. However, it will be the opposite when they
experience a variety of challenges and cannot manage the stress (Elliott, Shewchuk,
Miller, & Richards, 2001).
2.5 Self-efficacy on eating behaviors
Dietary self-efficacy in T2DM patients identified as one of variables that
can affect eating/ dietary behaviors, such as food selection and eating patterns
(Savoca & Miller, 2001). Increased self-efficacy influence the development of
depression and will impact the decision-making process and adherence to
the treatments (Sacco & Bykowski, 2010). There is also research which states that
increasing self-efficacy in T2DM patients will lead to a good impact in the diabetic
self-management behaviors, such as dietary, exercise, blood sugar testing, and taking
28
medication, so it is predicted better glycemic control (Al-Khawaldeh, Al-Hasan,
&Froelicher, 2012; Atak et al., 2008).
3. Reinforcing factor
Family support
Communication and support of families create a social environment that is
feasible for a patient with diabetes mellitus treatment of medical professionals (Hara
et al., 2013). For example, in children who suffer from diabetes mellitus, parental
negative behavior will greatly affect the metabolic control and the level of adherence
to treatment regimens that are being undertaken (Lewin et al., 2005). It is proved that
family support is very closely related to medication adherence, metabolic control, and
quality of life. Higher family social support leads to the higher diabetes management
adherence to control glycemic status and higher quality of life. On the other hand,
higher family conflict predicts lower quality of life (Pereira, Berg-Cross, Almeida, &
Machado, 2008). According Wen et al. (2004), the increasing of family support leads
to decreasing of perceived-barriers toward dietary self-care. This idea comes from
their assumption that the function of the family to support the needs of patients with
diabetes obtained a good quality of life can be fulfilled. Therefore, the role of health
workers when T2DM patients come to check themselves for the first time is to
explore the role of family support and family function of the patients with T2DM.
4. Enabling factor
Health worker communication
The severity of illness and stress management problems in patients with
diabetes mellitus are often increase the number of visits to health care so that they
may influence the views of paramedics to services as well as the influence of
prescription issued (TzOu et al., 2012). In the treatment of chronic diseases such as
diabetes mellitus, it is not enough to run medical and drug treatment, but they should
also aware their self-management. Provision of information about the disease suffered
by the patient is the duty of a health worker. The process of providing information or
communication by medical practitioners greatly affect the understanding of the patient
so that they can carry out self-management independently. Ratings of provider
communication effectiveness are more important than a participatory decision-making
style in predicting diabetes self-management (Heisler et al., 2002). Giving the right
29
information will have a much better effectiveness in improving patient empowerment
in diabetes mellitus in terms of self-management and diabetes patients to modify
lifestyle rather than just involving those in decision making about their care will live
(Lee et al., 2011).
From the literature review, it can be concluded that T2DM is
a non-communicable chronic disease, which is caused by a deficiency of insulin and/
or insulin resistance. Controlling blood sugar levels is an important thing done by
T2DM patients. One way to control blood sugar levels is through eating behaviors as
a mean of therapy. Non-compliance in the management of eating behaviors in
accordance with the rules will result in poor glycemic control, increasing the value of
mortality and morbidity, and increase health care utilization and cost. Literature
review shows that many factors can affect eating behaviors among T2DM patients.
Among these factors are the monthly income of family, educational level, knowledge
of DM eating behaviors, psychological stress, self-efficacy on eating behaviors,
family support and health worker communication. Accordance to the conditions in
Indonesia which have a wide variety of cultures, find out the factors that influencing
eating behaviors among T2DM patients are very important. Since by finding out its
factors, professionals teams can make and prepare programs that more effective and
efficient in improving glycemic control of T2DM patients.
CHAPTER 3
RESEARCH METHODOLOGY
A predictive correlation research was selected to examine predictive factors
between predisposing factors (monthly income of family, educational level,
knowledge of DM eating behaviors, self-efficacy on eating behaviors, and
psychological stress), reinforcing factors (family support), and enabling factors
(health worker communication) to eating behaviors among T2DM patients in Sidoarjo
sub-district, East Java, Indonesia.
Population and sample
Population referred to adult people who were diagnosed with T2DM from
doctor, they live in Sidoarjo sub-district. Sidoarjo sub-district has three Community
Health Center with total of T2DM patients were 5,788 people (Sidoarjo Health
Department, 2013).
Sample referred to adult people who were diagnosed with T2DM from
doctor, they live in Sidoarjo sub-district, and visited the Sidoarjo Community Health
Center for follow up. The inclusion criteria were used to include T2DM patients
become participants, among others:
1. Age between 20-60 years old
2. Able to read, write, and comprehend Indonesia language
3. Willing to participate in the study
Sample size
In this study, researcher used Tabachnick and Fidell (2007) to calculate the
sample size, due to the calculation method of Tabachnick and Fidell had been
recommended to use multiple regression test with several independent variables.
Formulation of Tabachnick and Fidell:
n = 50 + 8m
Explanation:
n = the sample size
m = the number of independent variables
31
There are seven independent variables that will be used, so the sample size:
n = 50 + 8m
n = 50 + 8(7)
n = 106
In this study, the sample size was 106 participants. In social science research
does not rule out the presence of missing data. The determination of the number of
missing data is not consistent definition of a variety of literature, but the literature
suggests that 20 % or less of values (Little & Rubin, 2002 citied in Saunders et al.,
2006). Therefore, this study used 10 % to compensate for missing data, so the total
number of samples in this study was 117 participants.
Setting
Participants were gathered from the Sidoarjo Community Health Center.
Researcher conducted the research by home visits. T2DM patients who become
participants are people who live within the scope of Sidoarjo Community Health
Center only.
Sampling technique
The total of T2DM patients in Sidoarjo sub-district were 5,788 people.
Sidoarjo sub-district has three Community Health Center with the same characteristics
of participant. By using cluster random sampling, from three Community Health
Center, Sidoarjo Community Health Center was elected as the research location,
within nine villages for their scope with the total of T2DM patients were 3,356
people. Participant recruitment process performed by making person with diabetes
mellitus who visited the Sidoarjo Community Health Center for follow up as potential
participant. The researcher asked their willingness to participate, when T2DM patients
are willing to become a participant, then researcher continued for collecting the data.
With time limitation for collecting data in the Sidoarjo Community Health Center,
researcher obtained address of T2DM patients from Sidoarjo Community Health
Center and conducted research by home visit. The number of participants whom the
data obtained from is approximately 7 up to 8 participants per day. The researcher
continuously doing this until the number of participants reach 117.
32
Figure 3 Sampling diagram
Research instruments
The seven instruments used in this study were Indonesian version, including:
1. Demographic data questionnaire developed by the researcher. It
consists of questions for gender, age, marital status, educational levels, and monthly
income of family.
2. Eating behaviors questionnaire: Using self-management diabetes
dietary behaviors questionnaire (SMDBQ) developed by Primanda et al. (2011).
SMDBQ had commonly used for various researches in Indonesia since it is valid with
the situation in Indonesia. Researcher wants to measure the response of T2DM
patients toward the consumption of foods that are recommended for diabetic patients,
including food intake, the selection of a healthy diet, the consumption of meal
planning that appropriate, and challenges dietary settings (selecting a place to eat for
good health when eating out and portion control). SMDBQ consists of four
dimensions with the total of statement are 33 items: Recognizing the amount of
calorie needs (4 items), selecting a healthy diet and amount (16 items), arranging a
meal plan (6 items), and managing dietary challenges (7 items). In SMDBQ there are
28 items that are positive statements and 5 items that are negative statements.
SMBDQ using a 4-point rating scale from never to routinely with scoring for never =
33
"1", sometimes = "2", Often = "3", and routinely = "4" for positive statements.
In contrast to the negative statements to never = "4", sometimes = "3", Often = "2",
and routinely = "1". Which include positive statements are numbers 1-12, 14-18, 21,
22, 24-28, and 30-33. As for the negative statements are numbers 13, 19, 20, 23, and
29. The total score of SMDBQ ranges from 33 to 132, with the higher scores
indicated good eating behaviors. According Primanda et al. (2011), SMBDQ
classified by the number of scores into three levels, namely high (101-132), moderate
(67-100), and low (33-66). Based on the result from Primanda et al. (2011), SMDBQ
attained a reliability coefficient of Cronbach's alpha .73.
3. Knowledge of DM eating behaviors questionnaire: Using diabetes
knowledge questionnaire (DKQ) from combination of diabetes knowledge
questionnaire developed by Garcia, Villagomez, Brown, Kouzekanani, and Hanis,
(2001) and Park et al. (2010). This questionnaire consists of 18 items, which derived
from 7 items of Garcia, Villagomez, Brown, Kouzekanani, and Hanis, (2001) and 11
items of Park et al. (2010). The choice of the potential response are 1) Yes, 2) No, and
3) Don’t know. Items were scored as correct or incorrect, and the correct items were
summed to attain a total score. The total score ranges from 0 to 18, with the higher
scores indicated high level of the patient’s knowledge. Based on two previous study,
the scoring of the DKQ in this case is classified into 3 levels, including low
knowledge (0-5), moderate knowledge (6-11) and high knowledge (12-18).
4. Self-efficacy on eating behaviors questionnaire: Using modification of
diabetes management self-efficacy scale-United Kingdom (DMSES-UK) version
developed by Sturt et al. (2010). The researcher used10 items of modification self-
efficacy for diet from15 items of DMSES-UK statements with scale of 0-10. The total
score of DMSES ranges from 0 to 100, with the higher scores indicated high level of
the patient's self-efficacy. According Sturt et al. (2010), the scoring of the DMSES in
this case is classified into 3 levels, including high self-efficacy (68-100), moderate
self-efficacy (34-67), and low self-efficacy (0-33).
5. Psychological stress questionnaire: Using diabetes distress scale (DDS)
developed by Polonsky et al. (2005). The DDS were used to measure potential
problem areas that people with diabetes may experience. The DDS consists of 17
items that contain the distress that occurred in diabetics and it is divided into 4
34
subscales, including emotional burden (numbers 2, 4, 7, 10, and 13), physician
distress (numbers 1, 5, 11, and 14), regimen distress (numbers 3, 6, 8, 12, and 15), and
interpersonal distress (numbers 9 and 16). The DDS were rated on a rating scale that
lined the start of “not a problem” to “a very serious problem” with scoring for not a
problem = “1”, a slight problem = “2”, a moderate problem = “3”, somewhat serious
problem = “4”, a serious problem = “5”, and a very serious problem = “6”. The total
score of DDS ranges from 16 to 102, with the higher scores indicated high level of the
patient's distress. Based on Polonsky et al. (2005), the scoring of the DDS in this case
is classified into 3 levels, including low distress (16-31), moderate distress (32-47),
and high distress (≥ 48). The DDS had adequate reliability coefficient to Cronbach’s
alpha .87 and validity yielded significant linkages with the Center for Epidemiological
Studies Depression scale, meal planning, exercise, and total cholesterol (Polonsky et
al., 2005).
6. Family support questionnaire: Using diabetic social support
questionnaire-family (DSSQ-Family) from La Greca and Bearman citied in Om
(2013) was used to measure family support. The DSSQ-Family consists of 20 items
for meal plan. The DSSQ-Family were rated on a rating scale that lined the start of
“never” to “at least once a day” with scoring for never = "0", less than 2 times a
month = "1", twice a month = "2", Once a week = "3", several times a week = "4",
and at least once a day = “5”. The total score of DSSQ-Family ranges from 0 to 100.
According Om (2013), the DSSQ-Familyis divided into 3 levels, which are a low
family support (0-33), moderate family support (34-66), and high family support
(67-100). The higher score indicated high support from family. Based on the result of
Om (2013), DSSQ-Family had adequate internal consistency score to Cronbach’s
alpha .95.
7. Health worker communication questionnaire: Using health care
communication questionnaire (HCCQ) developed by Gremigmi et al. (2007).
The HCCQ used by researcher to determine the perception of T2DM patients about
communications made by health workers in providing information associated with
diabetes mellitus. HCCQ statements composed of 13 items using a 5-point rating
scale that lined the start of “not at all” to “completely” with scoring for not at all =
"1", a little = "2", somewhat = "3", very much = "4", and completely = "5". The total
35
score of HCCQ ranges from 13 to 65, with the higher scores indicated good
communication from health worker to T2DM patients. Under these conditions and
according Gremigmi et al. (2007), the communication of health worker is classified
into 3 T2DM patients levels, among others, good communication (48-65), sufficient
communication (30-47), and bad communication (13-29).Based on the result of
Gremigmi et al. (2007), Cronbach’s alpha values met the criterion of .70, ranging
from .72 to .86.
Instrument translation
In order to have the appropriate instrument of demographic data, eating
behaviors, knowledge of DM eating behaviors, self-efficacy on eating behaviors,
psychological stress, family support, and health worker communication and it can be
used in Indonesia, all questionnaires was translated from English to Indonesian
language by back-translation technique (Cha, Kim, & Erlen, 2007). The specific
translation procedures that were used in this study, are in follow: 1) the original
English versions translated into the Indonesian language by one person (the person
who is expertise both of languages, English and Indonesian), 2) Indonesian-native
bilingual who is expertise related to this study was a review and revise Indonesian
version, then 3) the revised Indonesian version was translated again into English by
an another bilingual, and 4) both of instrument in the form of English version
(the original and the back-translation) was reviewed again to see compatibility.
Quality of instruments
Content validity
The researcher used the instruments had been tested for validity, therefore
content validity in this study was skipped.
Reliability
The researcher gave the questionnaire to 30 people with T2DM who visited
the Buduran Community Health Center with the same characteristics as the sample in
this study. The Cronbach’s alpha coefficient was used to determine the reliability for
eating behavior, self-efficacy on eating behaviors, psychological stress, family
support, and health worker communication. The Kuder-Richardson formula 20
(KR-20) coefficient was used to identify the reliability of the knowledge of DM
36
eating behaviors questionnaire. The results of Cronbach’s alpha test for eating
behaviors (SMDBQ) was .83, self-efficacy on eating behaviors (DMSES) was .89,
psychological stress (DDS) was .85, family support (DSSQ-Family) was .97, and
health worker communication (HCCQ) was .90. The reliability of knowledge of DM
eating behaviors was KR-20 = .61.
Protection of human subjects
The research proposal prior to use in further research must obtain ethical
approval from the Institutional Review Committee of the Faculty of Nursing, Burapha
University and through permission from Sidoarjo Health Department. In conducting
the study, researcher informed consent prior to the approval for T2DM patient as the
respondents in this research. Researcher also explained participant have the right to
end their participation in this study at any time without any penalty and no identified
risks involved with participation in this study. In addition, confidentially and
anonymity will be maintained by the researcher. To that end, each form submitted to
each respondent is always a no-name and the identity of the patient remains awake.
Every form and the data will still be stored properly so that no one knows about the
form and the data of T2DM patients who were respondents in this research. The data
will be destroyed by the researcher after 1 year from the publication of this research.
Data collection procedure
Collecting data in this study conducted in the following manner:
1. Before conducting the study, researcher conducted a test of ethics by the
Institutional Review Committee of the Faculty of Nursing, Burapha University and
obtained a legal permit from the Sidoarjo Health Department.
2. Letter from Burapha University used as an attachment to get permission
from Sidoarjo Health Department in case of collecting data.
3. Participants were gathered from the Sidoarjo Community Health Center.
Participant recruitment process performed by making person with diabetes mellitus
who visited the Sidoarjo Community Health Center for follow up. With time
limitation for collecting data in the Sidoarjo Community Health Center, researcher
37
obtained address of T2DM patients from Sidoarjo Community Health Center and
conducted research by home visit.
4. Before starting data collection, the researcher explained about the human
protection, purpose and method used in this study, if a potential respondent is
accepting and willing to serve, then they sign an agreement proved they were agreed
to give contribution to this research.
5. After declaring consent as respondent, the researcher explained briefly
about the direction to fill the questionnaire and allowed respondents to fill it out
according to their own circumstances. Each respondent will be given 20-30 minutes to
answer each questionnaire package.
6. The researcher continued conducting the data collection until the number
of target samples is reached.
Data analysis
1. To describe eating behaviors, monthly income of family, educational
level, knowledge of DM eating behaviors, self-efficacy on eating behaviors,
psychological stress, family support, and health worker communication by Mean and
SD, researcher used descriptive statistic, especially central tendency and dispersion/
variation.
2. In the analysis of data, the researcher used stepwise multiple regression to
check the prediction factors of eating behaviors. Statistical significance level was
assumed when p < .05.
CHAPTER 4
RESULTS
This chapter presents the results of the study. The study aims to examine the
influences of monthly income of family, educational level, knowledge of DM eating
behaviors, self-efficacy on eating behaviors, psychological stress, family support, and
health worker communication toward eating behaviors among T2DM patients in
Sidoarjo sub-district, East Java, Indonesia. The results of this study are presented as
the followings:
Part 1 Description of T2DM patients’ characteristics.
Part 2 Description of eating behaviors, monthly income of family,
educational level, knowledge of DM eating behaviors, self-efficacy on eating
behaviors, psychological stress, family support, and health worker communication of
T2DM patients.
Part 3 Examination of the influences of predisposing factors, reinforcing
factor, and enabling factor toward eating behaviors among T2DM patients.
Part 1 Description of T2DM patients’ characteristics
Table 1 presents characteristics of the T2DM patients including gender, age,
marital status, educational level, and monthly income of family.
Table 1 Description of T2DM patients’ characteristics (n = 117)
Characteristics Number (n) Percentage (%)
Gender
Male 42 35.90
Female 75 64.10
Age (M = 47.07, SD = 7.83, Min = 27, Max = 60)
21-30 4 3.42
31-40 21 17.95
41-50 53 45.30
39
Table 1 (Continued)
Characteristics Number (n) Percentage (%)
51-60 39 33.33
Marital status
Single 2 1.71
Married 90 76.92
Divorced/Widow 25 21.37
Educational level (M = 12.43, SD = 2.45)
6 years (primary school) 1 0.90
9 years (junior high school) 21 17.90
12 years (high school) 65 55.60
15 years (diploma) 7 6.00
16 years (undergraduate) 20 17.10
18 years (graduate) 3 2.50
Monthly income of family (M = 1,746,846.15, SD = 521,828.66, Min = 750,000;
Max = 3,775,000) (1 USD = 12,000 IDR)
≤ 1,499,999 29 24.79
1,500,000-2,500,000 82 70.09
≥ 2,500,001 6 5.12
Table 1 shows that most of participants (64.10 %) were female. Age range
41-50 years (45.30 %) followed by age range 51-60 (33.33 %). For marital status,
majority of participants (76.92 %) were married. In educational level, more than half
of participants (55.60 %) completed 12 years (high school). The majority of
participants (70.09 %) earned monthly income of family per month between
1,500,000-2,500,000 IDR (125 USD-208.33 USD).
40
Part 2 Description of eating behaviors, monthly income of family,
educational level, knowledge of DM eating behaviors, self-efficacy on
eating behaviors, psychological stress, family support, and health
worker communication of T2DM patients
1. Description of eating behaviors of T2DM patients
Table 2 presents description of eating behaviors.
Table 2 Mean, standard deviation, and level of eating behaviors (n = 117)
Variables Total
score M SD Mean % Level
Overall eating behaviors 132 75.44 10.58 57.15 Moderate
Arranging a meal plan 24 16.51 1.92 68.79
Selecting a healthy diet and
amount
64 36.28 4.87 56.69
Recognizing the amount of
calorie needs
16 8.97 2.28 56.06
Managing dietary
challenges
28 13.68 2.82 48.86
The table 2 shows that eating behaviors were considered as moderate level
(M = 75.44, SD = 10.58). For dimensions of eating behaviors, the highest of Mean %
(68.79) was arranging a meal plan and followed by selecting a healthy diet and
amount (Mean % = 56.69). The lowest of Mean % (48.86) was managing dietary
challenges.
41
2. Description of monthly income of family, educational level,
knowledge of DM eating behaviors, self-efficacy on eating behaviors,
psychological stress, family support, and health worker communication of T2DM
patients
Table 3 presents description of monthly income of family, educational level,
knowledge of DM eating behaviors, self-efficacy on eating behaviors, psychological
stress, family support, and health worker communication.
Table 3 Mean, standard deviation, and level of monthly income of family,
educational, knowledge of DM eating behaviors, self-efficacy on eating
behaviors, psychological stress, family support and health worker
communication (n = 117)
Variables Total
score M SD Level
1. Monthly income of family - 1,746,846.15 521,828.66 Moderate
2. Educational level - 12.43 2.45 High
3. Knowledge of DM eating
behaviors 18 12.08 2.29 High
4. Self-efficacy on eating
behaviors 100 60.88 6.30 Moderate
5. Psychological stress 102 42.59 5.77 Moderate
6. Family support 100 55.38 13.83 Moderate
7. Health worker
communication 65 33.42 5.34 Sufficient
Table 3 shows that monthly income of family, self-efficacy on eating
behaviors, psychological stress, and family support were considered as moderate level
(M = 1,746,846.15, SD = 521,828.66; M = 60.88, SD = 6.30; M = 42.59, SD = 5.77;
M = 55.38, SD = 13.83, respectively). Educational level and knowledge of DM eating
behaviors were considered as high level (M = 12.43, SD = 2.45; M = 12.08,
42
SD = 2.29, respectively) and health worker communication was considered as
sufficient level (M = 33.42, SD = 5.34).
Part 3 Examination of the influences of predisposing factors,
reinforcing factor, and enabling factor toward eating behaviors
among T2DM patients
Stepwise multiple regression analysis was used to predict eating behaviors
among T2DM patients in Sidoarjo sub-district, East Java, Indonesia. Assumption of
regression analysis were tested including normality of dependent and independent
variables, autocorrelation, multi-collinearity, homoscedasticity, and linearity. For
normality, normal distribution was tested using both Kolmogorov-Smirnov with
significance value > .05 and Skewness-Kurtosis coefficient with significance value
between -1.96 to +1.96. The results found that normal distribution of eating
behaviors, educational level, monthly income of family, knowledge of DM eating
behaviors, self-efficacy on eating behaviors, psychological stress, family support, and
health worker communication. Autocorrelation means the scores of a sample are not
independent. Autocorrelation can be known through Durbin-Watson value.
In the model summary table, Durbin-Watson value in this study equals to 2.212
indicated no autocorrelation. In the colinearity statistics, the tolerance values were all
greater than .10 and Variance Inflation Factor (VIF) values were less than 10, it
means no multicollinearity among predictors. However, it was found that some
correlation coefficient had value greater than 0.5 which might affect the estimates of
the regression coefficients. According Tabachnick and Fidell (2007) stated that
the correlation coefficients if less than 0.85 is not indicative of multicollinearity
(Table 4). The value of standard residual was between +3.00 and -3.00, it means no
multivariate outlier. Linearity was tested using both statistic and scatterplot. There
were all significant for indicating linearity. Scatterplot of regression standardized
residual were on the same straight line, therefore linearity and homoscedasticity
assumption was met.
43
Table 4 Correlation between predictors and eating behaviors (n = 117)
1 2 3 4 5 6 7 8
1. Educational level 1.00
2. Monthly income of
family
.63*** 1.00
3. Knowledge of DM
eating behaviors
.21* .31*** 1.00
4. Self-efficacy on
eating behaviors
.57*** .54*** .31*** 1.00
5. Psychological
stress
-.15 -.14 -.21* -.09 1.00
6. Family support .49*** .46*** .28** .60*** -.27** 1.00
7. Health worker
communication
.09 .18* .34*** .33*** -.05 .33*** 1.00
8. Eating behaviors .60*** .61*** .33*** .69*** -.33*** .68*** .27** 1.00
According results of stepwise multiple regression analysis, table 5 showed
the factors influences eating behaviors among T2DM patients.
44
Table 5 Results of final model of stepwise multiple regression analysis examining
factors influencing eating behaviors among T2DM patients (n = 117)
Independent variables b SE(b) Beta t p-value
1. Self-efficacy on eating
behaviors
0.60 7.41 0.36 4.83 < .001
2. Family support 0.24 0.13 0.31 4.27 < .001
3. Monthly income of
family
4.95*10-6 0.056 0.24 3.67 < .001
4. Psychological stress -0.33 0.00 -0.18 -3.14 .002
Constant 31.07 0.11 4.19 < .001
R² = .665, F(4, 112)= 55.63, p < .001
From table 5, the results shows that self-efficacy on eating behaviors
(β = 0.36, p < .001), family support (β = 0.31, p < .001), monthly income of family
(β = 0.24, p < .001), and psychological stress (β = -0.18, p < .01) were significant
predictors of eating behaviors and accounted for 66.5 % in the variance of eating
behaviors (R² = .665, F(4, 112)= 55.63, p < .001). Educational level, knowledge of DM
eating behaviors, and health worker communication were not significant predictors of
eating behaviors. The prediction equations were showed as follows:
1. The typical multiple regression equation based on raw scores
Eating behaviors = 31.07 + 0.60 (self-efficacy on eating behaviors) + 0.24
(family support) + 4.95*10-6 (monthly income of family)
- 0.33 (psychological stress).
2. The typical multiple regression equation based on Z scores
Zeating behaviors = 0.36 (Zself-efficacy on eating behaviors) + 0.31 (Zfamily support) + 0.24
(Zmonthly income of family) - 0.18 (Zpsychological stress).
CHAPTER 5
CONCLUSION AND DISCUSSION
This study aims to describe and examine predictive factors toward eating
behaviors among T2DM patients in Sidoarjo sub-district, East Java, Indonesia. A
simple random sampling was conducted to recruit 117 people with T2DM from
Sidoarjo Sub-district. The research instruments consist of demographic data
questionnaire, eating behaviors questionnaire, knowledge of DM eating behaviors
questionnaire, self-efficacy on eating behaviors questionnaire, psychological stress
questionnaire, family support questionnaire, and health worker communication
questionnaire. The results of Cronbach’s alpha test for eating behaviors (SMDBQ)
was .83, self-efficacy on eating behaviors (DMSES) was .89, psychological stress
(DDS) was .85, family support (DSSQ-Family) was .97, and health worker
communication (HCCQ) was .90. The result of test reliability values of knowledge of
DM eating behaviors (DKQ) KR-20 was .61. Data were collected during January to
February, 2015. Descriptive statistics and stepwise multiple regression were used to
analyze data.
Conclusion
1. Most of participants (64.10 %) were female. Age range 41-50 years
(45.30 %) followed by age range 51-60 (33.33 %). For marital status, majority of
participants (76.92 %) were married. In educational level, more than half of
participants (55.60 %) completed 12 years (high school). The majority of participants
(70.09 %) earned monthly income of family per month between 1,500,000-2,500,000
IDR (125 USD-208.33 USD).
2. Eating behaviors, monthly income of family, self-efficacy on eating
behaviors, psychological stress, and family support were considered as moderate level
(M = 75.44, SD = 10.58; M = 1,746,846.15, SD = 521,828.66; M = 60.88, SD = 6.30;
M = 42.59, SD = 5.77; M = 55.38, SD = 13.83, respectively). Educational level and
knowledge of DM eating behaviors were considered as high level (M = 12.43,
46
SD = 2.45; M = 12.08, SD = 2.29, respectively) and health worker communication
was considered as sufficient level (M = 33.42, SD = 5.34).
3. The stepwise multiple regression analysis shows that self-efficacy on
eating behaviors (β = 0.36, p < .001), family support (β = 0.31, p < .001), monthly
income of family (β = 0.24, p < .001), and psychological stress (β = -0.18, p < .01)
were significant predictors of eating behaviors and accounted for 66.5 % in the
variance of eating behaviors (R² = .665, F(4, 112)= 55.63, p < .001). Educational level,
knowledge of DM eating behaviors, and health worker communication were not
significant predictors of eating behaviors. The prediction equations were showed as
follows:
3.1 The typical multiple regression equation based on raw scores
Eating behaviors = 31.07 + 0.60 (self-efficacy on eating behaviors) + 0.24
(family support) + 4.95*10-6 (monthly income of family)
- 0.33 (psychological stress).
3.2 The typical multiple regression equation based on Z scores
Zeating behaviors = 0.36 (Zself-efficacy on eating behaviors) + 0.31 (Zfamily support) + 0.24
(Zmonthly income of family) - 0.18 (Zpsychological stress).
Discussion
The findings of this study were discussed as follows:
1. Eating behaviors
In the current study, the most of participants have moderate level of eating
behaviors. The model showed that the highest of Mean % (68.79) was arranging a
meal plan and followed by selecting a healthy diet and amount (Mean % = 56.69).
The lower score of Mean % (48.86) was managing dietary challenges. That is one of
the causes in which T2DM patients have moderate level of eating behaviors, but there
are several other causes, such as the habit of Indonesian people for eating rice in huge
portions and also Indonesian culture for many events or ceremonies. The dietary
management was as recommended by ADA: proportion of 50 % to 60 %
carbohydrates, 30 % fats, and 10 % to 20 % protein for T2DM patients. Further, fiber
and complex carbohydrates become the most important consumption for T2DM
patients because it contains fructose which will lead to significant reduction in fasting
47
blood sugar level, lipid level, and also reduction of body weight in diabetics
(Alexander et al., 2006; Ding & Malik, 2008; International Diabetes Federation,
2012). But for the Indonesian people will find it difficult to replace their habits, where
the majority of Indonesian people did not feel able to eat until they have eaten rice or
some other foods made from rice (Primanda et al., 2011). In traditional Indonesia
culture, Indonesian people often serves foods contain high fat and very sweet for most
of the party, traditional events or ceremonies. This condition often makes the
Indonesian people who have difficulties to manage dietary challenges, especially
outside the home or attending a party. The results of this study showed that
participants in this study had difficulty in choosing a place that can provide a low-fat
dishes and low-cholesterol (M = 1.51, SD = 0.64), and they had a low propensity to
consume vegetables and fruit when outside the home (M = 1.57, SD = 0.62).The
results also found that Indonesian people have inappropriate habit as recommended
for food selection. Participants reported that they are more frequent using any oil for
cooking than vegetable oils, such as sunflower, soybean or saffola oil for cooking
their food (M = 1.66, SD= .44). In addition, many of Indonesian people still apply
bulk oil which actually should have been no longer allowed to be used because it
contains highly saturated fat. Those habits can cause someone get overweight, which
in turn will disrupt the work of organs’ function. The findings of this study is line
with the statement of Yannakoulia (2006), nutrition intervention in T2DM is one of
the parts that integrated with the other treatments and changes in lifestyle associated
with eating behaviors so T2DM patients should increase their awareness about
healthy dietary behaviors, both in understanding the importance of eating behaviors
regarding their condition, including to choose healthy eating behaviors. It is intended
to enable them to achieve a good quality of life.
2. Monthly income of family
In the current study, the majority of participants (70.09 %) have moderate
level of monthly income of family, they earned monthly income of family between
1,500,000-2,500,000 IDR (125 USD-208.33 USD). Total income per month was still
below the minimum district standard of Sidoarjo for years 2015 which is 2,705,000
IDR (225.42 USD) (East Java Provincial Government, 2014). The low income in this
study due to several factors, among others, most of participants were retirees who
48
earn a monthly salary of 1,500,000-2,500,000 IDR. In addition, some of them work as
a pedicab driver and vegetable vendors in the market who earn approximately
750,000-1,500,000 IDR per month. With monthly income of family between
1,500,000-2,500,000 IDR per month, people can meet the needs of the household for
3-4 people, but this number had limitation on the cost of children's education and
health care costs. This is somewhat becomes problem for T2DM patients to adhere
healthy eating behaviors (Central Bureau of Statistics, 2008). According Marcy et al.
(2011), in low-income communities often found the incidence of diabetes is caused by
factors related to the cost of healthy food, stress-related eating inappropriate, and the
temptation to eat unhealthy food.
3. Educational level
The present study shows that the most of participants have high level of
educational. More than a half of participants (55.60 %) completed 12 years for
educational level. Only a few of them completed 9 years (17.90 %) and 6 years
(0.90 %). This relatively high level of education can be achieved by them since it is
already become Indonesian government agenda to state 12 years as the minimum
compulsory education needs. This is evidenced by the budget allocation revenues and
expenditures of the central government which reach146.4 trillion Rupiahs (USD 12.2
billion), that 10.5 % of budget revenues and expenditures allocated for the education
sector (Finance Ministry, 2014). Low educational level is often drive T2DM patients
had difficulty in understanding all the information related to self-management and
making decisions related to eating behaviors, such as food selection and eating
patterns (Mocan & Altindag, 2014).
4. Knowledge of DM eating behaviors
The most of participants have high level of knowledge of DM eating
behaviors. It shows that participants have a good understanding and able to analyze
their needs to continue performing appropriate eating behaviors. High level of
knowledge in this study due to participants already well informed by health worker of
Sidoarjo Community Health Center. Health education on nutrition knowledge is
needed to improve the nutritional knowledge, skills, and food intake behaviors
(Fitzgerald et al., 2008).
49
5. Self-efficacy on eating behaviors
In this study, participants mostly have moderate level of self-efficacy on
eating behaviors. The model shows that participants had been able to choose
appropriate foods for their circumstances (M = 6.81, SD = 0.79), but they had
difficulty in scheduling meal time when in a condition of sick, away from home, and
feeling depressed or anxious (M = 5.64, SD = 1.16; M = 5.64, SD = 0.86; M = 5.61,
SD = 0.87, respectively). Dietary self-efficacy in T2DM patients identified as one of
variables that can affect eating/ dietary behaviors, such as food selection and eating
patterns (Savoca & Miller, 2001).
6. Psychological stress
In this study, the most of participants have moderate distress. There are
several reasons that might contribute to the level of psychological stress among
T2DM patients. The model shows that participants feel that their doctor is still pay
less attention to their problems associated with eating behaviors (M = 3.07, SD =
0.63). Further, this leads participants to give a little concern regarding their health
condition, particularly counseling related to healthy eating behaviors (M = 2.78, SD =
0.69). Additionally by their conditions, participants feel less appreciated by the family
or friends (M = 2.93, SD = 0.58) and also feel that their family or friends provide a
lacking emotional support to them (M = 2.96, SD = 0.76). Patients with diabetes often
have to know about their illness, but they often fail to perform health behaviors
because of stress management and coping less well so that they have difficulty in
establishing patterns of behaviors to solve the problem of diet and exercise therapy
(Nomura et al., 2000).
7. Family support
The most of participants in this study have moderate level of family support.
Family support in this study actually being nice. Other family members tend to
support by giving advice to avoid inappropriate foods for T2DM patients (M = 3.91,
SD = 0.77) and even continuously notice and warn them when they are trying to eat
unsuggested foods for T2DM (M = 3.92, SD = 0.96). In addition, other family
members also show that they understand how important to eat right for T2DM
patients (M = 3.81, SD = 0.91), and they show their pleased when participants eaten
right (M = 3.82, SD = 1.02). But the family members also faced difficulty in buying
50
special foods that can be eaten by T2DM patients (M = 2.80, SD = 1.16) and had
difficulty in choosing a place to eat which accordance with the needs of participants
when they go outside (M = 2.49, SD = 1.09). In addition, some of T2DM patients
living with children who worked from morning until evening, this condition then
leads the children gave them less attention, especially related to healthy eating
behaviors. According Wen et al. (2004), the increasing of family support leads to
decreasing of perceived-barriers toward dietary self-care.This idea comes from their
assumption that the function of the family to support the needs of patients with
diabetes obtained a good quality of life can be fulfilled.
8. Health worker communication
The most of participants in this study assume that health worker
communication in sufficient level. They assume that the way to communicate on the
health worker is good enough and able to provide the information required by T2DM
patients. The model shows that participants felt their need were being respected
(M = 2.82, SD = 0.82) and healthcare provider was able to manage to the consultation
(M = 2.80, SD = 0.63). But on the other hand, participants sometimes also feel that the
information given was not enough and delivered with inappropriate manner or rough
(M = 2.05, SD = 0.51). Sufficient level of health worker communication means that
health workers have good communication skills and able to convey enough
information needed by patients, so there was effective communication between health
workers and patients (Haq & Hafeez, 2009). Ratings of provider communication
effectiveness are more important than a participatory decision-making style in
predicting diabetes self-management (Heisler et al., 2002). Giving the right
information will have a much better effectiveness in improving patient empowerment
in diabetes mellitus in terms of self-management and diabetes patients to modify
lifestyle rather than just involving those in decision making about their care will live
(Lee et al., 2011).
9. Factors predicted eating behaviors
9.1 Self-efficacy on eating behaviors
Self-efficacy on eating behaviors was significant predictor of eating
behaviors. It was asserted that by increasing self-efficacy of T2DM patients then it
would be give a good effect on diabetic self-management, especially eating behaviors.
51
Increasing self-efficacy impacted decision-making process for food selection and
eating patterns and other treatments adherence (Rygg, Rise, Grønning, & Steinbekk,
2012). This finding was consistent with many previous studies. Dietary self-efficacy
in T2DM patients identified as one of variables that can affect eating behaviors, such
as food selection and eating patterns (Savoca & Miller, 2001). The statement was
reinforced by other statements, increasing self-efficacy in T2DM patients will lead to
a good impact in the diabetic self-management behaviors, such as dietary (odds ratio
(OR) = 0.13, 95 % confidence interval (CI): 0.07–0.23), exercise (OR = 0.07, 95 %
CI: 0.03-0.13), blood sugar testing (OR = 0.33, 95 % CI: 0.12-0.91), and taking
medication (OR = 0.09, 95 % CI: 0.03-0.31), so it predicted better glycemic control
(Al-Khawaldeh et al., 2012; Atak et al., 2008).
9.2 Family support
The present study showed that family support predicted eating behaviors.
There are several reason about it, the model showed that the presence of family
support to T2DM patients in the form of advice and criticism would make T2DM
patients more aware of the importance of glycemic control through healthy eating
behaviors. This finding was consistent with many previous studies. Pereira et al.
(2008) found higher family support leads to the higher adherence of treatments (β =
0.226, p < .01) and had good quality of life (β = -0.309, p < .001). On the other hand,
higher family conflict predicts lower quality of life (β = -0.188, p < .05) (Pereira et al.,
2008). According Wen et al. (2004), higher family support should be decreased the
perceived-barriers of T2DM patients to dietary self-care because they assume that the
function of the family to support the needs of T2DM patient obtained a good quality
of life can be fulfilled. Communication and support of families is creating a social
environment that is feasible T2DM patients’ treatments from medical professionals
(Hara et al., 2013).
9.3 Monthly income of family
The result of this study showed that monthly income of family predicted
eating behaviors. Monthly income of family in this study impacted on eating
behaviors among T2DM patients, the model showed that T2DM patients had
inappropriate food selection and their habit of using bulk oil. This finding was
consistent with many previous studies. Family income had direct and indirect impact
52
between eating behaviors and health among T2DM patients (Vlismas et al., 2009).
The statement is reinforced by the statement of Marcy et al. (2011), in low-income
communities often found the incidence of diabetes is caused by factors related to cost
of healthy food, stress-related eating inappropriate, and the temptation to eat
unhealthy food. With low income levels and supported by a low-SES environment
would affect one’s perception of health and it results on health disparities (∆R2 = .02,
F(2, 293) = 3.52, p < .01) (Gallo et al., 2006).
9.4 Psychological stress
In this study, psychological stress as one of factors that predicted eating
behaviors. Psychological stress in this study impacted on eating behaviors among
T2DM patients since it had a strong correlation with the decision-making process for
food selection and eating patterns (Guthrie et al., 2003). This finding was consistent
with previous studies. Symptoms of depression significantly affected eating behaviors
of T2DM patients in a different form based on age, sex, and education for people in
the highest quartile of depressive symptoms (relative hazard [RH], 1.63; 95 % CI,
1.31-2.02) (Golden et al., 2004). Polonsky (2002) found that emotional stress affects
the mindset of patients in decision-making related to health behaviors-diabetes that
further also impact to their quality of life. Patients with diabetes often had to know
about their illness but they often failed to perform health behaviors because of
psychological stress and coping less well so that they had difficulty in establishing
patterns of behaviors to solve the problem of diet (Nomura et al., 2000).
10. Factors unpredicted eating behaviors
10.1 Educational level
Educational level was not a predictor of eating behaviors. The results of
this study is in accordance with some previous researches, which mentioned that the
level of education had limitation impact on health behaviors (Atak et al., 2008; Mocan
& Altindag, 2014). In this study, the model showed that the number of T2DM patients
were more than half completed 12 years for their educational level and 25.60 % of
T2DM patients completed more than 12 years who must be able to manage
information toward eating behaviors so that increasing their awareness of the
importance of healthy eating behaviors, which in this study it is showed at moderate
levels.
53
10.2 Knowledge of DM eating behaviors
Knowledge of DM eating behaviors was not a predictor of eating
behaviors. Eventhough T2DM patients have found out information about healthy
eating behaviors, but they still have limitations to continue performing healthy eating
behaviors due to other factors. This finding was inconsistent with previous studies.
Some researchers even considered the knowledge about healthy eating behaviors is
very important for T2DM patients because they assume that T2DM patients are
expected to remain informed and more critical in assessing the information about their
condition and how to maintain, which in turn will lead to motivate them to change
their behaviors, especially eating behaviors (Hartayu et al., 2012). Health education is
needed to improve the nutritional knowledge, skills, and food intake behaviors due to
prevent increasing number of T2DM in the community (Fitzgerald et al., 2008).
10.3 Health worker communication
Health worker communication was not a predictor of eating behaviors.
Eventhough in general T2DM patients considered health worker communication was
good enough but still they got slightly less favorable treatment which sometimes little
rushed and they also did not get enough counseling related to healthy eating
behaviors. This finding was inconsistent with previous study. Some researchers
considered that the process of providing information by health worker greatly affect
the understanding of the patient in improving their healthy behaviors and also modify
their lifestyle (Heisler et al., 2002; Lee et al., 2011). In the treatment of chronic
diseases such as diabetes mellitus, it is not enough to run medical and drug treatment,
but they should also aware their self-management. Provision of information about the
disease suffered by the patient is the duty for health worker. Ratings of provider
communication effectiveness are more important than a participatory decision-making
style in predicting disease self-management (Heisler et al., 2002).
Implications of the findings
1. Nursing practice
The results of this study, community nurses are expected to make
interventions related how to improve T2DM patients’ self-efficacy, increase family
support for the creation of an atmosphere which aware of T2DM patients situation,
54
and decrease psychological stress that affects the decision-making for food selection.
For monthly income of family, community nurses cannot improve it, but from the
result of this study, community nurses can determine the low income population to be
the main target of nursing intervention.
2. Nursing education
Nurse educators should educate nurse student about the importance of some
factors related to the management of type 2 diabetes mellitus, especially which is
discussing eating behaviors.
Recommendation for future research
1. Sample in this study were limited only T2DM patients who visited the
Sidoarjo Community Health Center and living in Sidoarjo district, therefore future
research should replicate the study in the different setting and in the large areas.
2. This study were limited on seven factors of behaviors (monthly income
of family, educational level, knowledge of DM eating behaviors, self-efficacy on
eating behaviors, psychological stress, family support, and health worker
communication), therefore future research should be adding by other factors
associated with eating behaviors and making interventions.
3. The findings suggested that researchers or nurses can apply the advance
research related to effective interventions or programs associated with increasing
T2DM patients’ self-efficacy, family support, and also decreasing T2DM patients’
psychological stress and make a long term commitment toward healthy eating
behaviors.
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APPENDICES
67
APPENDIX A
Permission letter to use instruments
68
Permission letter to use “Self-Management Dietary Behaviors Questionnaire
(SMDBQ)”
Yanuar Primanda
To Me, [email protected]
4 Agt
Dear Kusuma Wijaya,
I'm so sorry for my late respond. Here I attached the Self-Management Dietary
Behaviors Questionnaire. You can adopt or modify it depend on your need and the
population in the area of your study. Hope that it will useful for your research. Good
luck for your thesis.
Yanuar Primanda, MNS
School of Nursing
Faculty of Medicine and Health Science
Muhammadiyah University Yogyakarta
Mobile:
+62 878 383 05050
+62 821 3553 1188
69
Permission letter to use “Diabetes Knowledge Questionnaire (DKQ)”
Garcia, Alexandra A ([email protected])
10/10/2014
To: kusuma putra
Dear Kusuma Wijaya Ridi Putra,
Thank you for your interest in the DKQ-24. You are welcome to use the questionnaire
in your research. I believe it has been translated to Indonesian, however, I do not have
a copy of the Indonesian version. Please let me know if you have questions about
scoring or other aspects of its use. Do you already have a copy of the questionnaire
from the Diabetes Care journal? If not, I will be happy to share it with you. You are
welcome to modify the questionnaire for your use. I would very much appreciate it if
you would send me a copy of the modifications and a brief summary of your findings.
Best regards,
Alexandra Garcia
Alexandra Garcia, PhD, RN, FAAN
Associate Professor
The University of Texas at Austin
School of Nursing
1700 Red River
Austin, TX 78701
Office: 5.156, 512/471-7973
Fax: 512/471-3688
70
Permission letter to use “Diabetes Management Self-Efficacy Scale (DMSES)”
Sturt, Jackie
To: kusuma putra
Thank you for your interest in using the DMSES UK. Yes you may use it. I have
attached the scale and the scoring instructions for your use. Good luck with your
project. Yes, you are welcome to do this although there is no supporting data for the
validity or reliability of a sub scale associated with eating behaviours so you might
want to do the psychometric analysis at the same time and establish whether this is
valid and reliable. That would make an additional paper for you if you have enough
participants (roughly 10 participants per item so, for example, if there are 6 dietary
items you would need 60 respondents/participants).
Best wishes
Jackie Sturt
Professor of Behavioural Medicine in Nursing
Florence Nightingale Faculty of Nursing and Midwifery
King's College London
Room 4.30
James Clerk Maxwell Building
57 Waterloo Road
LONDON
SE1 8WA
Tel: 020 7848 3108
Mob 07743190301
Email: [email protected]
www.kcl.ac.uk
71
Permission letter to use “Diabetes Distress Scale (DDS)”
William Polonsky
To Me
Okt 8 pada 11:24 PM
Dear Kusuma,
Yes, you are very welcome to use the DDS in your research. And I wish you very
good luck!
One request: If you are going to be creating a translated version of the DDS, I would
greatly appreciate if you could send me a copy when you are done.
Thanks,
Bill
William H. Polonsky, PhD, CDE | President | Behavioral Diabetes
Institute | Associate Clinical Professor | University of California, San Diego |
760.525.5256
72
Permission letter to use “Diabetes Social Support Questionnaire-Family (DSSQ-
Family)”
Phuntsho Om
To Me
29 Jul
Hello Kusuma,
Happy to know that you are interested to the same topic in your country. You can use
the questionnaire. Hope it brings beneficial changes among the Type 2 Diabetes in
your country.
Cheers.
Phuntsho Om
Associate Lecturer
Royal Institute of Health Sciences
University of Medical Sciences, Thimphu
Bhutan
"For every minute you are angry you lose sixty seconds of happiness.” - Ralph Waldo
Emerson
73
Permission letter to use “Health Care Communication Questionnaire (HCCQ)”
Sommaruga Marinella
10/10/2014
To: kusuma putra
We give you the permission, Prof. Gremigni will send you some suggestions.
I remain
Marinella Sommaruga
APPENDIX B
Questionnaires (English version)
75
No. of Responden : ……
The date of issue : ……
QUESTIONNAIRE
“FACTORS INFLUENCING EATING BEHAVIORS AMONG TYPE
2 DIABETES MELLITUS PATIENTS IN SIDOARJO
SUB-DISTRICT, EAST JAVA, INDONESIA”
There are several question formats. Please read each question carefully and give the
most honest response you can. No one else will read your answers. There is no time
limit for completing the questionnaire, but it is best to work as quickly as you are
comfortable with. There is no right or wrong answers. Please answer all questions.
Part I: DEMOGRAPHIC DATA
Direction: Please fill out your information in the space below.
1. Gender
Male Female
2. Age ___________ years old
3. Marital status
Single Married Divorced Widow
4. Education level __________ Years
5. Monthly income of the family __________________ Rupiahs
76
Part II: EATING BEHAVIORS QUESTIONNAIRE
Direction: Below are statements about your dietary behaviors to manage your diabetes
during the past month. Please fill the statements by circle in the column which indicates
your usual dietary behaviors. There is no right or wrong answer. If you have any
question, please feel free to ask the person giving you this questionnaire.
Scoring
Positive
Statement
Negative
Statement
Never: Never conduct it at least last whole month 1 4
Sometimes: Once at a time, not habitual 2 3
Often: Repeat the activity for several times, but not
as a habit 3 2
Routinely: Continuously, regularly, and always
conduct the activity 4 1
No Statements Never Some
Times Often Routinely
1
Recognizing the Amount of Calorie
Needs
I am concerned about the best amount of
calorie in foods to be consumed each day.
1 2 3 4
2 …………………………………………
………………………. 1 2 3 4
3 I estimate the amount of calorie in my
food at one meal by using at least one of
the following techniques:
a. Using simple measurements such as
palm or handful.
1 2 3 4
77
No Statements Never Some
Times Often Routinely
b. Measuring the meal using a cup/glass,
gram/ounce, tablespoon/teaspoon, or
serving size.
c. Using plate method (using a 9 inch
plate and divide it into 2 parts. Half part is
for vegetables and the other half is
divided into 2 parts; one for carbohydrate,
and one for food with protein).
4 …………………………………………
…………………… 1 2 3 4
5
Selecting a Healthy Diet+ Amount
When choosing the prepared foods, I
always read the nutrition facts
information on the food label.
1 2 3 4
6 I eat variety of fruits every day for 2-4
servings per day such as:
2 - 4 small to medium apple, guava,
peer, orange, etc
1 - 2 cup canned fruits
4 - 8 tablespoon dried fruits
1 2 3 4
7 …………………………………………
…………………………………………
………………..
1 2 3 4
8 I choose foods containing complex
carbohydrate such as brown rice, peas,
bran, beans, whole wheat/brown bread,
oats, and potatoes.
1 2 3 4
9 …………………………………………
……………………………………. 1 2 3 4
78
No Statements Never Some
Times Often Routinely
10 I avoid high calorie fruit such as jackfruit,
sweet mango, and grape. 1 2 3 4
11 …………………………………………
………………… 1 2 3 4
12 I more often consume baked, boiled, or
steamed foods than the fried ones. 1 2 3 4
13 …………………………………………
………………….. 4 3 2 1
14 I (or the person cooking for food) use
vegetable oil such as sunflower or
soybean or saffola oil to cook.
1 2 3 4
15 …………………………………………
………………. 1 2 3 4
16 I avoid salty food. 1 2 3 4
17 I avoid eating sweets or desert high in
sugar such as fruit cocktail with cream,
cake, pudding, and jam.
1 2 3 4
18 …………………………………….. 1 2 3 4
19 …………………………………………
………………. 4 3 2 1
20 ………………………………… 4 3 2 1
21
Arranging a Meal Plan
I eat 3 meals a day. 1 2 3 4
22 I eat meal in the same time within interval
at least 6 hours every day. 1 2 3 4
23 ……………………….. 4 3 2 1
24 …………………………………… 1 2 3 4
25 I eat various kind of food in every meal
daily including vegetables, whole grains/ 1 2 3 4
79
No Statements Never Some
Times Often Routinely
rice/ bread/ cassava (shingkewa/ potato),
fruits, non-fat dairy products, beans, lean
meats or lean poultry, and fish.
26 I take snack that contain low
carbohydrate and low sugar between meal
such as an apple (medium size), orange/
guava (medium size), tea without sugar,
green tea, orange juice without sugar,
fruits salad without mayonnaise, etc.
1 2 3 4
27
Managing Dietary Challenges
…………………………………………
…………………………………………
………………
1 2 3 4
28 …………………………………………
…………………………………. 1 2 3 4
29 I finish all foods served by the restaurant
although I have been full. 4 3 2 1
30 …………………………………………
……………………………………… 1 2 3 4
31 I eat the same portion of food as my daily
meal in family events or other
invitations/social gathering/parties.
1 2 3 4
32 …………………………………………
…………………………………………
…………………….
1 2 3 4
33 I have candy bar/ sweets with me always,
for hypoglycemia prevention when going
out.
1 2 3 4
80
Part III: KNOWLEDGE OF DM EATING BEHAVIORS
QUESTIONNAIRE
Direction: Please mark a check (√) in the column that best applies to your response.
There is no right or wrong answer. If you have any question, please feel free to ask
the person giving you this questionnaire.
Questions Yes No Don’t know
1. Eating too much sugar and other sweet foods is a
cause of diabetes.
2. ………………………………………………………
3. ……………………………………………………….
………………………………………
4. Only carbohydrates have to be restricted for diabetic
patients.
5. Instant foods or Junk foods have to be restricted for
diabetic patients.
6. ……………………………………………………….
………………………………………
7. Drink coffee or tea no sugar doesn’t have to be
restricted for diabetic patients.
8. ……………………………………….
9. …………………………………………………
10. Sodium doesn’t have to be restricted for diabetic
patients.
11. Fresh vegetables should be consumed by the diabetic
patients.
12. ………………………………………………………
13. Medication is more important than diet and exercise
to control my diabetes.
14. ……………………………………………………….
………………………………………
81
Questions Yes No Don’t know
15. A diabetic diet consists mostly of special foods.
16. ……………………………………………………….
………………………………………
17. ……………………………………………………….
………………………………………
18. The meal plans for diabetes is eat 3 meals a day in
time.
Part IV: SELF-EFFICACY ON EATING BEHAVIORS
QUESTIONNAIRE
Direction: Below is a list of activities you have to perform to manage your diabetes.
Please read each one and then put a line [/] through the number which best describes
how confident you usually are that you could carry out that activity.
For example, if you are completely confident that you are able to check your blood
sugar levels when nessessary, put a line through 10. If you feel that most of the time
you could not do it, put a line through 1 or 2.
I am confident that……..
Cannot do Maybe Yes Certain
At all Maybe no Can do
1. ……………………………………
1 2 3 4 5 6 7 8 9 10
2. I am able to keep my weight under control
1 2 3 4 5 6 7 8 9 10
3. ……………………………………………..
1 2 3 4 5 6 7 8 9 10
4. I am able to follow a healthy eating pattern most of the time
1 2 3 4 5 6 7 8 9 10
5. …………………………………………………………….
1 2 3 4 5 6 7 8 9 10
82
I am confident that……..
Cannot do Maybe Yes Certain
At all Maybe no Can do
6. ……………………………………………………..
1 2 3 4 5 6 7 8 9 10
7. ……………………………………………………………………
1 2 3 4 5 6 7 8 9 10
8. I am able to adjust my eating plan when I am feeling stressed or anxious
1 2 3 4 5 6 7 8 9 10
9. …………………………………………………………….
1 2 3 4 5 6 7 8 9 10
10. I am able to control diabetes complication with healthy eating pattern
1 2 3 4 5 6 7 8 9 10
83
Part V: PSYCHOLOGICAL STRESS QUESTIONNAIRE
Direction: This questionnaire is asking about potential problem areas that participant
may experience. There is no right or wrong answer. If you have any question, please
feel free to ask the person giving you this questionnaire. Give mark a circle on the
scale that you think is appropriate to your condition.
Please note that we are asking you to indicate the degree to which each item may be
bothering you in your life, NOT whether the item is merely true for you. If you feel
that a particular item is not a bother or a problem for you, you would circle "1". If it
is very bothersome to you, you might circle "6".
Not
a P
rob
lem
A S
ligh
t P
rob
lem
A M
od
erate
Pro
ble
m
Som
ewh
at
Ser
iou
s P
rob
lem
A S
erio
us
Pro
ble
m
A V
ery S
eri
ou
s
Pro
ble
m
1. Feeling that my doctor
doesn't know enough about
diabetes and diabetes care.
1 2 3 4 5 6
2. ………………………………
………………………………
………………………………
………………
1 2 3 4 5 6
3. Not feeling confident in my
day-to-day ability to manage
diabetes.
1 2 3 4 5 6
4. ………………………………
………………………………
……………………….
1 2 3 4 5 6
5. Feeling that my doctor
doesn't give me clear enough 1 2 3 4 5 6
84
Not
a P
rob
lem
A S
ligh
t P
rob
lem
A M
od
erate
Pro
ble
m
Som
ewh
at
Ser
iou
s P
rob
lem
A S
erio
us
Pro
ble
m
A V
ery S
eri
ou
s
Pro
ble
m
directions on how to manage
my diabetes.
6. Feeling that I am not testing
my blood sugars frequently
enough.
1 2 3 4 5 6
7. ………………………………
………………………………
………………………………
……………………
1 2 3 4 5 6
8. ………………………………
………………………… 1 2 3 4 5 6
9. Feeling that friends or family
are not supportive enough of
self-care efforts (e.g. planning
activities that conflict with
my schedule, encouraging me
to eat the "wrong" foods).
1 2 3 4 5 6
10. ………………………………
…………………. 1 2 3 4 5 6
11. Feeling that my doctor
doesn't take my concerns
seriously enough.
1 2 3 4 5 6
12. ………………………………
………………………………
……………….
1 2 3 4 5 6
85
Not
a P
rob
lem
A S
ligh
t P
rob
lem
A M
od
erate
Pro
ble
m
Som
ewh
at
Ser
iou
s P
rob
lem
A S
erio
us
Pro
ble
m
A V
ery S
eri
ou
s
Pro
ble
m
13. Feeling overwhelmed by the
demands of living with
diabetes.
1 2 3 4 5 6
14. Feeling that I don't have a
doctor who I can see
regularly enough about my
diabetes.
1 2 3 4 5 6
15. ………………………………
………………………………
……………………..
1 2 3 4 5 6
16. ………………………………
………………………………
…………………………….
1 2 3 4 5 6
Part VI: FAMILY SUPPORT QUESTIONNAIRE
Direction: We just want to know how often your family provide help and support
your diabetes. There is no right or wrong answer. Just mark a circle in the column that
best applies to your response.
How often
does this
happen?
0 1 2 3 4 5
Never
Less than
twice a
month
Twice a
Month
Once a
Week
Several
Times a
Week
At Least
Once a
Day
Note: If a behavior listed never happens, mark circle“0” for “never”.
86
No. Statements
Nev
er
Les
s th
an
2 t
imes
a
mon
th
Tw
ice
a m
on
th
On
ce a
wee
k
Sev
eral
tim
es a
wee
k
At
least
on
ce a
day
1. ………………………………
………………………… 0 1 2 3 4 5
2.
Let me know they understand
how important it is for me to eat
right.
0 1 2 3 4 5
3.
Ask if certain foods are okay
for me to eat, before serving
them.
0 1 2 3 4 5
4. ………………………………
………………………… 0 1 2 3 4 5
5. ………………………………
………………………… 0 1 2 3 4 5
6. ………………………………
………………………… 0 1 2 3 4 5
7. Suggest foods I can eat on my
meal plan. 0 1 2 3 4 5
8. ………………………………
………………………… 0 1 2 3 4 5
9. ………………………………
………………………… 0 1 2 3 4 5
10. ………………………………
………………………… 0 1 2 3 4 5
11. Watch what I eat to make sure
that I eat the right foods. 0 1 2 3 4 5
87
No. Statements
Nev
er
Les
s th
an
2 t
imes
a
mon
th
Tw
ice
a m
on
th
On
ce a
wee
k
Sev
eral
tim
es a
wee
k
At
least
on
ce a
day
12. Cook meals for me that fit my
meal plan. 0 1 2 3 4 5
13. ………………………………
………………………… 0 1 2 3 4 5
14. Eat at the same time I do 0 1 2 3 4 5
15. ………………………………
………………………… 0 1 2 3 4 5
16. ………………………………
………………………… 0 1 2 3 4 5
17. ………………………………
………………………… 0 1 2 3 4 5
18. Keep track of my meal plan for
me. 0 1 2 3 4 5
19. Buy special foods that I can eat. 0 1 2 3 4 5
20. Tell me not to eat something I
shouldn't. 0 1 2 3 4 5
88
Part VII: HEALTH WORKER COMMUNICATION
QUESTIONNAIRE
Direction: Please mark a circle in the column that best applies to your response.
There is no right or wrong answer. If you have any question, please feel free to ask
the person giving you this questionnaire. This questionnaire concerns your experience
with the healthcare provider you have just encountered. If you think healthcare
provider had good communication, mark circle completely (5).
No. Statement
Not
at
all
A l
ittl
e
Som
e w
hat
Ver
y m
uch
Com
ple
tely
1. …………………………………………………
……………………………………. 1 2 3 4 5
2. I felt my needs were being respected 1 2 3 4 5
3. ……………………………………………… 1 2 3 4 5
4. I was asked questions in an aggressive manner 1 2 3 4 5
5. I received clear and precise information 1 2 3 4 5
6. …………………………………………………
……………………………………. 1 2 3 4 5
7. I have been treated with kindness 1 2 3 4 5
8. I have been treated in a rude and hasty manner 1 2 3 4 5
9. …………………………………………………
……………………………………. 1 2 3 4 5
10. …………………………………………………
……………………………………. 1 2 3 4 5
11. The healthcare provider was able to manage
the consultation 1 2 3 4 5
12. …………………………………………………
……………………………………. 1 2 3 4 5
89
No. Statement
Not
at
all
A l
ittl
e
Som
e w
hat
Ver
y m
uch
Com
ple
tely
13. The healthcare provider showed respect for my
privacy 1 2 3 4 5
APPENDIX C
Questionnaires (Indonesian version)
91
No. Responden : ……
Tanggal pengisian : ……
KUESIONER
“FACTOR YANG MEMPENGARUHI PERILAKU MAKAN PADA
PASIEN DIABETES MELLITUS TIPE 2 di KECAMATAN
SIDOARJO, JAWA TIMUR, INDONESIA”
Ada beberapa format pertanyaan. Silakan baca setiap pertanyaan dengan hati-hati dan
berikan respon yang paling jujur yang Anda bisa. Tidak ada orang lain akan membaca
jawaban Anda. Tidak ada batas waktu untuk menyelesaikan kuesioner, tapi yang
terbaik adalah untuk bekerja secepat yang Anda bisa dan merasa nyaman dengan itu.
Tidak ada jawaban benar atau salah. Silahkan menjawab semua pertanyaan.
Bagian I: DATA DEMOGRAFI
Petunjuk: Silahkan mengisi informasi anda dibawah ini.
1. Jenis Kelamin
Laki-laki Perempuan
2. Usia _______ tahun
3. Status pernikahan
Belum menikah Menikah Bercerai Janda/Duda
4. Level pendidikan ______ tahun
5. Pendapatan keluarga tiap bulan __________________Rupiah
92
Bagian II: KUESIONER PERILAKU MAKAN
Petunjuk: Di bawah ini adalah pernyataan tentang perilaku makan anda untuk
mengelola diabetes anda selama sebulan terakhir. Silahkan mengisi pernyataan tanda
(√) pada kolom yang menunjukkan perilaku makan anda yang biasa. Tidak ada
jawaban yang benar atau salah. Jika anda memiliki pertanyaan, jangan ragu untuk
bertanya kepada orang memberikan kuesioner ini.
Tidak pernah: Tidak pernah melakukannya paling sedikit sebulan penuh
terakhir
Kadang-kadang: Sekali waktu, bukan kebiasaan
Seringkali: Mengulangi kegiatan selama beberapa waktu, tetapi bukan sebagai
suatu kebiasaan
Secara rutin: Terus menerus, secara berkala, dan selalu dilakukan
No Pernyataan-Pernyataan
Tid
ak
per
nah
Kad
an
g-k
ad
an
g
Ser
ingk
ali
Sec
ara
ru
tin
1
Mengenali jumlah kebutuhan kalori
Saya memperhatikan jumlah terbaik kalori
dalam makanan untuk dikonsumsi setiap hari.
2 …………………………………………………
…………………………………………
3 Saya memperkirakan jumlah kalori makanan
yang saya konsumsi dalam satu kali makan
dengan menggunakan teknik-teknik berikut :
a. Menggunakan takaran sederhana seperti
sekepal atau segenggam.
b. Menakar makanan dengan menggunakan
satu cangkir /gelas, gram/ons, sendok
makan/ sendok teh, atau seukuran saji.
93
No Pernyataan-Pernyataan
Tid
ak
per
nah
Kad
an
g-k
ad
an
g
Ser
ingk
ali
Sec
ara
ru
tin
c. Menggunakan metode piring (menggunakan
piring diameter 9 inci dan membaginya dalam
2 bagian. Separuh bagian untuk sayuran dan
separuh bagian lainnya dibagi dalam 2 bagian
lagi; satu bagian untuk makanan
berkarbohidrat, dan satu bagian lainnya untuk
makanan berprotein).
4 …………………………………………………
…………………………………
5
Pemilihan Diet Sehat + Jumlah
Saat memilih makanan yang disajikan, saya
selalu membaca informasi fakta kandungan
nutrisi pada label makanan.
6 Saya makan bermacam-macam buah setiap hari
sebanyak 2 - 4 penyajian seperti:
a. 2 - 4 apel, jambu merah, pir, jeruk, dll.
ukuran kecil hingga sedang
b. 1 - 2 cangkir buah-buahan kaleng
c. 4 - 8 sendok makan buah-buahan kering
7 …………………………………………………
…………………………………………………
……………….
8 Saya memilih makanan yang mengandung
karbohindrat kompleks seperti beras merah,
kacang polong, bekatul, buncis, gandum utuh
94
No Pernyataan-Pernyataan
Tid
ak
per
nah
Kad
an
g-k
ad
an
g
Ser
ingk
ali
Sec
ara
ru
tin
/brown bread (roti tawar dari biji gandum
utuh), gandum, dan kentang.
9 …………………………………………………
…………………………………………………
…………………….
10 Saya menghindari buah-buahan berkalori
tinggi seperti: nangka, mangga manis, dan
anggur.
11 …………………………………………………
……………………………………………
12 Saya lebih sering mengkonsumsi makanan
yang di-oven, direbus atau dikukus dibanding
makanan yang digoreng.
13 …………………………………………………
…………………………………..
14 Saya (atau tukang masak saya) menggunakan
minyak sayur seperti minyak bunga matahari
atau kacang kedelai atau saffola untuk
memasak
15 …………………………………………………
…………………………………………………
…………………………….
16 Saya menghindari makanan bergaram
17 Saya menghindari makanan manis-manis atau
makanan penutup yang sangat tinggi gula,
95
No Pernyataan-Pernyataan
Tid
ak
per
nah
Kad
an
g-k
ad
an
g
Ser
ingk
ali
Sec
ara
ru
tin
seperti koktail buah dengan krim, roti (cake),
puding dan selai.
18 ………………………………………..
19 …………………………………………………
…………………………………………………
…………………
20 ………………………….
21
Pengaturan Jadwal Makan
Saya makan 3 kali sehari.
22 Saya makan dalam waktu yang sama dalam
interval (jeda waktu) paling sedikit 6 jam setiap
hari.
23 …………………………………
24 …………………………………..
25 Saya makan berbagai jenis makanan dalam
satu kali makan, termasuk sayuran, gandum
utuh/ nasi/ roti tawar/ ketela (shing
kewa/kentang), buah-buahan, produk susu
tanpa lemak, buncis, daging tanpa lemak atau
daging unggas tanpa lemak, dan ikan.
26 Saya makan kudapan rendah karbohidrat dan
rendah gula diantara jam makan seperti apel
96
No Pernyataan-Pernyataan
Tid
ak
per
nah
Kad
an
g-k
ad
an
g
Ser
ingk
ali
Sec
ara
ru
tin
(ukuran sedang), jeruk/ jambu merah (ukuran
sedang), teh tanpa gula, teh hijau, jus jeruk
tanpa gula, salad buah-buahan tanpa
mayonnaise, dll.
27
Pengelolaan Tantangan Diet
…………………………………………………
…………………………………………………
…………………..
28 …………………………………………………
…………………………………………………
………………..
29 Saya menghabiskan semua makanan yang
disajikan oleh restoran meskipun sudah
kenyang.
30 …………………………………………………
…………………………………………………
…………………
31 Saya makan makanan dalam porsi yang sama
seperti porsi makan saya sehari-hari saat ada
acara keluarga atau undangan acara lain/
perkumpulan sosial/ pesta-pesta.
32 …………………………………………………
…………………………………………………
…………………
97
No Pernyataan-Pernyataan
Tid
ak
per
nah
Kad
an
g-k
ad
an
g
Ser
ingk
ali
Sec
ara
ru
tin
33 Saya selalu membawa batangan permen/gula-
gula untuk mencegah hypoglycemia
(rendahnya kadar gula darah) saat bepergian
Bagian III: KUESIONER PENGETAHUAN DARI PERILAKU
MAKAN DM
Petunjuk: Silahkan mengisi pernyataan tanda (√) pada kolom yang menunjukkan
perilaku makan anda yang biasa. Tidak ada jawaban yang benar atau salah. Jika anda
memiliki pertanyaan, jangan ragu untuk bertanya kepada orang memberikan
kuesioner ini.
Pertanyaan-Pertanyaan Ya Tidak Tidak
tahu
1. Makan terlalu banyak gula dan makanan-makanan
manis lain merupakan penyebab diabetes.
2. ……………………………………………………...
……………………………………………………...
3.
……………………………………………………...
……………………………………………………...
……………………………………………………...
4. Hanya karbohidrat yang harus dibatasi untuk para
penderita diabetes.
5. Makanan-makanan instan atau Junk foods (makanan
sampah) harus dibatasi untuk para penderita diabetes.
6. ……………………………………………………...
……………………………………………………...
98
Pertanyaan-Pertanyaan Ya Tidak Tidak
tahu
7. Minum kopi atau teh tanpa gula tidak harus dibatasi
untuk para penderita diabetes.
8. ……………………………………………………...
9. ……………………………………………………...
……………………………………………………...
10. Sodium tidak harus dibatasi untuk para penderita
diabetes.
11. Sayur-sayuran segar harus dikonsumsi oleh para
penderita diabetes.
12. ……………………………………………………...
……………………………………………………...
13. Pengobatan lebih penting daripada diet dan olah raga
untuk mengontrol diabetes saya.
14. ……………………………………………………...
……………………………………………………...
15. Diet diabetes banyak yang berupa makanan-makanan
khusus
16. ……………………………………………………...
……………………………………………………...
17.
……………………………………………………...
……………………………………………………...
……………………………………………………...
18. Jadwal makan untuk penderita diabetes adalah makan
tepat waktu 3 kali sehari.
99
Bagian VI: KUESIONER KEMAMPUAN MENGENDALIKAN
DIRI PADA PERILAKU MAKAN
Petunjuk: Di bawah ini adalah daftar kegiatan yang harus Anda lakukan untuk
mengelola diabetes Anda. Silakan baca masing-masing dan kemudian menempatkan
garis [/] melalui nomor yang paling menggambarkan seberapa yakin Anda biasanya
bahwa Anda bisa melakukan kegiatan itu.
Sebagai contoh, jika Anda benar-benar yakin bahwa Anda dapat memeriksa kadar
gula darah Anda saat nessessary, menempatkan garis melalui 10. Jika Anda merasa
bahwa sebagian besar waktu Anda tidak bisa melakukannya, membuat garis melalui 1
atau 2.
Saya percaya bahwa ……..
Tidak bisa Sama sekali Mungkin ya
Mungkin tidak Pasti Bisa
1. ………………………………..
1 2 3 4 5 6 7 8 9 10
2. Saya bisa menjaga berat badan
1 2 3 4 5 6 7 8 9 10
3. ……………………………………………….
1 2 3 4 5 6 7 8 9 10
4. Saya hampir selalu bisa mengikuti pola makan sehat
1 2 3 4 5 6 7 8 9 10
5.
………………………………………………………………………….
……………………………...
1 2 3 4 5 6 7 8 9 10
6. ……………………………………………………...
1 2 3 4 5 6 7 8 9 10
7.
………………………………………………………………………….
……………………………...
1 2 3 4 5 6 7 8 9 10
8. Saya bisa menyesuaikan jadwal makan saat merasa tertekan atau gelisah
1 2 3 4 5 6 7 8 9 10
100
Tidak bisa Sama sekali Mungkin ya
Mungkin tidak Pasti Bisa
9. ………………………………………………………………………
1 2 3 4 5 6 7 8 9 10
10. Saya bisa mengontrol komplikasi diabetes dengan pola makan sehat
1 2 3 4 5 6 7 8 9 10
Bagian V: KUESIONER TEKANAN PSIKOLOGIS
Petunjuk: Kuesioner ini menanyakan tentang perasaan, pikiran, dan cara-cara untuk
mengatasi masalah yang Anda hadapi selama sebulan terakhir. Tidak ada jawaban
benar atau salah. Jika Anda memiliki pertanyaan, jangan ragu untuk bertanya kepada
orang memberikan kuesioner ini. Beri tanda lingkaran pada skala yang anda anggap
sesuai dengan kondisi Anda.
Harap dicatat bahwa kami meminta Anda untuk menunjukkan sejauh mana setiap
item dapat mengganggu Anda dalam hidup Anda, tidak apakah item tersebut hanya
berlaku untuk Anda. Jika Anda merasa bahwa barang tertentu tidak mengganggu atau
masalah bagi Anda, saudara harus melingkari "1". Jika sangat mengganggu bagi
Anda, Anda mungkin lingkaran "6".
Bu
kan
masa
lah
Ag
ak
sed
ikit
masa
lah
Ber
masa
lah
tin
gk
at
sed
an
g
Ag
ak
sed
ikit
ber
masa
lah
ser
ius
Masa
lah
Ser
ius
Ma
sala
h y
an
g
san
gat
seri
us
1. Merasa dokter saya tidak
cukup mengetahui seluk
beluk dan perawatan diabetes.
1 2 3 4 5 6
2. ………………………………
………………………………
………………………………
……………………………
1 2 3 4 5 6
101
Bu
kan
masa
lah
Agak
sed
ikit
masa
lah
Ber
masa
lah
tin
gk
at
sed
an
g
Agak
sed
ikit
ber
masa
lah
ser
ius
Masa
lah
Ser
ius
Masa
lah
yan
g
san
gat
seri
us
3. Saya tidak merasa percaya
diri bisa mengatasi penyakit
diabetes ini dari hari ke hari.
1 2 3 4 5 6
4. ………………………………
………………………………
………………………………
…………………...
1 2 3 4 5 6
5. Saya merasa dokter tidak
cukup memberi pengarahan
yang jelas mengenai cara
menangani diabetes saya.
1 2 3 4 5 6
6. Saya merasa tidak cukup
sering mengetes gula darah
saya
1 2 3 4 5 6
7. ………………………………
………………………………
………………………………
………………………………
………………….
1 2 3 4 5 6
8. ………………………………
………………………………
……………………
1 2 3 4 5 6
9. Saya merasa teman-teman
atau keluarga tidak cukup
mendukung usaha perawatan
mandiri (misalnya
1 2 3 4 5 6
102
Bu
kan
masa
lah
Agak
sed
ikit
masa
lah
Ber
masa
lah
tin
gk
at
sed
an
g
Agak
sed
ikit
ber
masa
lah
ser
ius
Masa
lah
Ser
ius
Masa
lah
yan
g
san
ga
t se
riu
s
merencanakan kegiatan-
kegiatan yang bertentangan
dengan jadwal saya,
mendorong saya untuk makan
makanan-makanan yang
"salah").
10. ………………………………
………………………………
…………………..
1 2 3 4 5 6
11. Saya merasa dokter tidak
cukup serius memperhatikan
masalah saya.
1 2 3 4 5 6
12. ………………………............
................................................
..............................
1 2 3 4 5 6
13. Saya merasa kewalahan
dengan tuntutan-tuntutan
yang harus dipatuhi penderita
diabetes.
1 2 3 4 5 6
14. Saya merasa tidak memiliki
dokter yang bisa saya temui
secara teratur untuk
mengkonsultasikan diabetes
saya
1 2 3 4 5 6
103
Bu
kan
masa
lah
Agak
sed
ikit
masa
lah
Ber
masa
lah
tin
gk
at
sed
an
g
Agak
sed
ikit
ber
masa
lah
ser
ius
Masa
lah
Ser
ius
Masa
lah
yan
g
san
gat
seri
us
15. ………………………………
………………………………
………………………………
………………….
1 2 3 4 5 6
16. ………………………………
………………………………
………………………………
…………………
1 2 3 4 5 6
Bagian VI: KUESIONER DUKUNGAN KELUARGA
Petunjuk: Kami hanya ingin tahu seberapa sering keluarga Anda memberikan
bantuan dan dukungan diabetes Anda. Tidak ada jawaban benar atau salah. Hanya
menandai lingkaran pada kolom yang paling berlaku untuk respons Anda.
Seberapa
sering hal
ini
terjadi?
0 1 2 3 4 5
Tak
Pernah
Kurang
dari 2
kali
dalam
sebulan
Dua kali
dalam
sebulan
Sekali
dalam
seminggu
Beberapa
kali
dalam
seminggu
Palings
sedikit
sekali
sehari
Catatan: Jika perilaku terdaftar pernah terjadi, tanda lingkaran "0" untuk
"tidak pernah".
104
No. Pernyataan-Pernyataan
Tid
ak
per
nah
Ku
ran
g d
ari
2 k
ali
dala
m s
ebu
lan
Du
a k
ali
dala
m
seb
ula
n
Sek
ali
dala
m
sem
inggu
Beb
erap
a k
ali
dala
m s
emin
ggu
Pali
ngs
sed
ikit
sek
ali
seh
ari
1. …………………………………
………………………………… 0 1 2 3 4 5
2.
Memberitahu saya bahwa
mereka mengerti betapa
pentingnya saya untuk makan
dengan benar
0 1 2 3 4 5
3.
Bertanya apakah makanan-
makanan tertentu bisa saya
makan, sebelum menyajikan
makanan yang dimaksud.
0 1 2 3 4 5
4. …………………………………
………………………………… 0 1 2 3 4 5
5. …………………………………
………………………………… 0 1 2 3 4 5
6. …………………………………
………………………………… 0 1 2 3 4 5
7.
Menyarankan makanan-
makanan yang bisa saya makan
dalam jadwal makan saya.
0 1 2 3 4 5
8. …………………………………
………………………………… 0 1 2 3 4 5
9. …………………………………
………………………………… 0 1 2 3 4 5
10.
…………………………………
…………………………………
…………………………………
0 1 2 3 4 5
105
No. Pernyataan-Pernyataan
Tid
ak
per
nah
Ku
ran
g d
ari
2 k
ali
dala
m s
ebu
lan
Du
a k
ali
dala
m
seb
ula
n
Sek
ali
dala
m
sem
inggu
Beb
erap
a k
ali
dala
m s
emin
ggu
Pali
ngs
sed
ikit
sek
ali
seh
ari
11.
Mengawasi apa yang saya
makan untuk meyakinkan
bahwa saya makan makanan
sehat
0 1 2 3 4 5
12.
Memasak makanan untuk saya
yang sesuai dengan jadwal
makanan saya.
0 1 2 3 4 5
13.
…………………………………
…………………………………
…………………………………
0 1 2 3 4 5
14. Makan pada waktu yang sama
dengan saya. 0 1 2 3 4 5
15. …………………………………
………………………………… 0 1 2 3 4 5
16.
…………………………………
…………………………………
…………………………………
0 1 2 3 4 5
17.
…………………………………
…………………………………
…………………………………
0 1 2 3 4 5
18. Menjaga jadwal makan saya 0 1 2 3 4 5
19. Membeli makanan khusus yang
bisa saya makan. 0 1 2 3 4 5
20.
Menasihati saya untuk tidak
makan makanan pantangan
saya.
0 1 2 3 4 5
106
Bagian VII: KUISIONER KOMUNIKASI PEKERJA KESEHATAN
Petunjuk: Tandai lingkaran di kolom yang paling berlaku untuk respons Anda. Tidak
ada jawaban benar atau salah. Jika Anda memiliki pertanyaan, jangan ragu untuk
bertanya kepada orang memberikan kuesioner ini. Kuesioner ini menyangkut
pengalaman Anda dengan penyedia layanan kesehatan Anda baru saja mengalami.
Jika Anda berpikir penyedia layanan kesehatan memiliki komunikasi yang baik, tanda
lingkaran sepenuhnya (5).
No. Pernyataan
Tid
ak
sam
a
sek
ali
Sed
ikit
Agak
San
gat
Ben
ar-
ben
ar
1. ……………………………………………...
……………………………………………... 1 2 3 4 5
2. Saya merasa kebutuhan-kebutuhan saya
dihormati 1 2 3 4 5
3. ……………………………………………... 1 2 3 4 5
4. Saya diberi pertanyaan secara kasar 1 2 3 4 5
5. Saya menerima informasi dengan jelas dan
tepat 1 2 3 4 5
6. ……………………………………………... 1 2 3 4 5
7. Saya diperlakukan dengan baik 1 2 3 4 5
8. Saya diperlakukan kasar dan terburu-buru 1 2 3 4 5
9. ……………………………………………...
……………………………………………... 1 2 3 4 5
10. ……………………………………………...
……………………………………………... 1 2 3 4 5
11. Penyedia perawatan kesehatan menguasai
pembahasan konsultasi 1 2 3 4 5
12. ……………………………………………...
……………………………………………... 1 2 3 4 5
107
No. Pernyataan
Tid
ak
sam
a
sek
ali
Sed
ikit
Agak
San
gat
Ben
ar-
ben
ar
13.
Penyedia perawatan kesehatan
menunjukkan rasa hormat pada kehidupan
pribadi saya
1 2 3 4 5
APPENDIX D
Additional analysis
109
Table 6 Description of items of eating behaviors (n = 117).
Item M SD Range = 1 - 4
Recognizing the amount of calorie needs (Total score = 16, M = 8.97, SD = 2.28)
1. The best amount of calorie in foods
to consumed each day
2.32 0.59
2. The same portion size of food every
day
2.30 0.80
3. The amount of calorie in my food at
one meal by using at least one of the
techniques
2.18 0.64
4. The calories of food estimated every
day
2.16 0.67
Selecting a healthy diet and amount (Total score = 64, M = 36.28, SD = 4.87)
5. Reading the nutrition facts
information on the food label
1.90 0.64
6. Eat variety of fruits every day for 2-4
servings per day
2.21 0.45
7. Eat variety of vegetables every day
for 3-5 servings of cooked vegetables
per day
2.54 0.52
8. Choosing foods containing complex
carbohydrate
2.57 0.63
9. Avoid foods that contain high
cholesterol
2.16 0.44
10. Avoid high calorie fruit 2.13 0.41
11. Use artificial sweeteners 1.70 0.59
12. More often consume baked, boiled,
or steamed foods
2.03 0.51
13. Use any oil in cooking 1.89 0.54
110
Table 6 (Continued)
Item M SD Range = 1 - 4
14. Use vegetable oils 1.43 0.58
15. Take fish and soy protein more
often than poultry or red meat
2.62 0.59
16. Avoid salty food 2.32 0.61
17. Avoid eating sweets or desert in
high sugar
2.08 0.51
18. Choose non-fat or low-fat milk 2.27 0.89
19. Eat the meat with fat rather than
remove the fatty part
2.49 0.84
20. Drink alcohol 3.93 0.25
Arranging a meal plans (Total score = 24, M = 16.51, SD = 1.92)
21. Eat 3 meals a day 3.26 0.52
22. Eat meal in the same time within
interval 6 hours
2.11 0.43
26. Take snack that contain low
carbohydrate and low sugar between
meal
2.26 0.49
Managing dietary challenges (Total score = 28, M = 13.68, SD = 2.82)
27. Select a restaurant that serves
appropriate foods
1.51 0.64
28. Order food to include vegetables
and fruits during dining out
1.57 0.62
29. Finish all food served by the
restaurant although have been full
2.55 0.58
30. Order foods in the same portion as
daily meal when eat out in
restaurants
1.92 0.62
31. Eat the same portion of food as 1.93 0.75
111
Table 6 (Continued)
Item M SD Range = 1 - 4
daily meal in family events, other
invitations/social gathering/parties
1.93 0.75
32. Do exercise rather than taking
food when feel stress or depressed
2.50 0.69
33. Have candy bar/sweets for
hypoglycemia prevention when
going out
1.70 0.69
Table 7 Description of items of self-efficacy on eating behaviors (n = 117).
Item M SD Range = 1 - 10
1. Able to choose the correct foods 6.81 0.79
2. Able to keep weight under control 6.40 0.91
3. Able to adjust eating plan when ill 5.64 1.16
4. Able to follow a healthy eating pattern
most of time
6.38 0.79
5. Able to adjust eating plan when taking
more exercise
5.71 0.76
6. Able to follow a healthy pattern when
away from home
5.64 0.86
7. Able to follow a healthy eating pattern
when eating out or at party
5.71 0.95
8. Able to adjust eating plan when feeling
stressed or anxious
5.61 0.87
9. Able to control blood sugar with
healthy eating pattern
6.51 0.82
10. Able to control diabetes complication
with healthy eating pattern
6.47 0.75
112
Table 8 Description of items of psychological stress (n = 117)
Item M SD Range = 1 - 6
1. Feeling that doctor doesn't
know enough about diabetes
and diabetes care
2.79 0.76
2. Feeling that diabetes is taking
up too much of mental and
physical energy everyday
2.74 0.67
3. Not feeling confident in day to
day ability to manage diabetes
2.55 0.55
4. Feeling that doctor doesn't give
clear enough directions on how
to manage diabetes
2.81 0.75
5. Feeling that not testing blood
sugars frequently enough
2.66 0.73
6. Feeling that will end up with
serious long-term complication,
no matter what to do
2.39 0.57
7. Feeling that often failing with
diabetes routine
2.62 0.67
8. Feeling that friends or family
are not supportive enough of
self-care effort
2.34 0.58
9. Feeling that diabetes controls
life
2.59 0.65
10. Feeling that doctor doesn't take
concerns seriously enough
3.07 0.63
11. Feeling that not sticking closely
enough to a good meal plan
2.44 0.64
113
Table 8 (Continued)
Item M SD Range = 1 - 6
12. Feeling that friends or family
don’t appreciate how difficult
living with diabetes can be
2.93 0.58
13. Feeling overwhelmed by the
demands of living with diabetes
2.58 0.73
14. Feeling that don't have a doctor
who can see regularly enough
about diabetes
2.78 0.69
15. Not feeling motivated to keep
up diabetes self-management
2.78 0.68
16. Feeling that friends or family
don’t give emotional support
2.96 0.76
Table 9 Description of items of family support (n = 117)
Item M SD Range = 0 - 5
1. Encourage to eat the right foods 3.74 0.91
2. Let me know they understand
how important to eat right for
me
3.81 0.91
3. Ask if certain foods are okay to
eat, before serving
3.51 1.09
4. Do the grocery shopping for
meals
2.50 1.19
5. Schedule meals at the times
need to eat
3.37 1.14
114
Table 9 (Continued)
Item M SD Range = 0 - 5
6. Remind about sticking to meal
plan
3.68 0.89
7. Suggest foods can eat on meal
plan
3.57 1.06
8. Join eating the same foods 3.16 1.25
9. Get on my case after I ate
something I shouldn’t
3.92 0.96
10. Avoid tempting me with food or
drinks that I shouldn’t have
3.78 1.04
11. Watch what foods consumption
to make sure for the right foods
3.42 1.15
12. Cook meals that fit for meal
plan
3.68 1.17
13. Choose restaurants that serve
appropriate foods
2.49 1.09
14. Eat at the same time 2.87 0.82
15. Praise for following diet 3.52 1.03
16. Tell me when I've eaten too
much or too little
3.62 0.97
17. Show they're pleased when
eaten right
3.82 1.02
18. Keep track of meal plan 3.41 0.94
19. Buy appropriate foods 2.80 1.16
20. Tell me not to eat something I
shouldn’t
3.91 0.77
115
Table 10 Description of items of health worker communication (n = 117)
Item M SD Range = 1 - 5
1. The healthcare provider do eyes
contact when doing
communication
2.61 0.79
2. Felt the needs were being
respected
2.82 0.82
3. Asked questions in a clear
manner
2.73 0.75
4. Asked questions in an
aggressive manner
2.09 0.55
5. Received clear and precise
information
2.63 0.65
6. Have been given answers in an
aggressive manner
2.05 0.51
7. Have been treated with kindness 2.68 0.59
8. Have been treated in a rude and
hasty manner
2.09 0.57
9. The healthcare provider
addressed with a smile
2.77 0.77
10. The healthcare provider was
able to resolve the problem
2.72 0.63
11. The healthcare provider was
able to manage the consultation
2.80 0.63
12. The healthcare provider showed
to be able to stay calm
2.73 0.63
13. The healthcare provider showed
respect for privacy
2.71 0.67
APPENDIX E
Institutional review board approval
117
APPENDIX F
Recommendation letter for data collection
119
APPENDIX G
Certificate of completing the research
121
APPENDIX H
Participants’ information sheet and consent form
123
PARTICIPANT’S INFORMATION SHEET
Dear …………………………………..
I am Kusuma Wijaya Ridi Putra a graduate student at the Faculty of Nursing,
Burapha University Thailand. My study entitled, “Factors Influencing Eating
Behaviors among Type 2 Diabetes Mellitus in Sidoarjo Sub-district, East Java,
Indonesia”. The objective are to describe and examine the influences of eating
behaviors, income, education level, knowledge, self-efficacy, psychological stress,
family support and health worker communication of 117 adults with type 2 diabetes
mellitus who living in Sidoarjo Sub-district and visited the Sidoarjo Community
Health Center for follow up.
If you agree to participate in this study, you will be asked to complete the self-
report questionnaires. It will take you about 20-30 minutes to complete the
questionnaires. There are no identified risks involved with participation in this study.
Participation is voluntary. You have the right to end your participation in this study at
any time without any penalty. Any information received from this study, including
your identity, will be kept confidential. A coding number will be assigned to you and
your name will not used. Findings from the study will be presented as a group of
participants and no specific information from any individual participant will be
disclosed. All data will be destroyed completely within 1 year after publishing or
presenting the findings. You will receive a further and deeper explanation of the
nature of the study upon its completion, if you wish.
The research will be conducted by Kusuma Wijaya Ridi Putra under
supervision of my major-advisor, Assist. Prof. Dr. Chanandchidadussadee Toonsiri. If
you have any questions, please contact me at # telephone: 081331251929 or by email:
[email protected], and/or my advisor’s e-mail address:
[email protected]. Your cooperation is greatly appreciated. You will be given a
copy of this consent form to keep.
Kusuma Wijaya Ridi Putra
124
INFORMED CONSENT
Title: “Factors influencing eating behavior among type 2 diabetes mellitus
patients in Sidoarjo sub-district, East Java, Indonesia”.
Date of collection data ……………Month ………….Years………………
Before giving my signature below, I have been clearly explained by the
researcher, Mr. Kusuma Wijaya Ridi Putra, about purpose, method, procedures,
benefits and possible risk associated with participation in this study, and I understood
all of that explanation.
I agree to participate in this research project and I have received a copy of this
form.
I, Ms. / Mrs. / Mr. ……………………………..……., hereby give my consent
voluntarily after understanding everything the researcher has explained to me
regarding the nature and purpose, benefit and possible risk associated with
participation in this research with honesty. All data and information of the participant
will only be used for the purpose of this research study.
Signature……………………………………………… Participant
(………………………………………)
Signature……………………………………………… researcher
(Kusuma Wijaya Ridi Putra)
APPENDIX I
List of back-translation persons
126
List of back-translation persons
1. Ery Juliani SWORN Translator
Juliani Language
2. Dra. Nurdjannah Taufiq SWORN Translator
Lugas Language Center
3. Assoc. Prof. Dr. Chintana Wacharasin Chairperson of the IRB Board
Associate Dean for Research and
Academic Services
Faculty of Nursing, Burapha
University, Thailand
127
BIOGRAPHY
Name Kusuma Wijaya Ridi Putra
Date of Birth October 31, 1986
Place of Birth Sidoarjo, East Java, Indonesia
Present address Pagerwojo RT 02 RW 01 No. 31, Gelam
Village, Candi Sub-district, Sidoarjo District,
East Java, Indonesia
Mobile: +62 81331251929
Email: [email protected]
Position held
2011-current Lecturer
Kerta Cendekia Nursing Academy, Sidoarjo,
East Java, Indonesia.
Education
2005-2010 Bachelor of Nursing
Faculty of Nursing, Airlangga University,
Surabaya, East Java, Indonesia.
2010-2011 Professional Nursing Practice (Ners)
Faculty of Nursing, Airlangga University,
Surabaya, East Java, Indonesia.
2013-2015 Master of Nursing Science
(International Program)
Faculty of Nursing, Burapha University,
Chonburi, Thailand.
Awards or Grants
2015 The master and doctoral thesis support grant,
fiscal year 2015, Burapha University,
Chonburi, Thailand.