PREDICTORS OF HEALTH OUTCOMES AMONG PATIENTS WITH TYPE II DIABETES MELLITUS

A Thesis Presented tothe Faculty of the Graduate School

of the University of the VisayasCebu City, Philippines

In Partial Fulfillment of the Requirements for the Degree ofMASTER OF ARTS IN NURSINGMajor in Medical-Surgical Nursing

NORMAN B. JURUENA

August 2015

APPROVAL SHEET

This thesis titled “PREDICTORS OF HEALTH OUTCOMES AMONG PATIENTS WITH TYPE II DIABETES MELLITUS” submitted by NORMAN B. JURUENA in partial fulfillment of the requirements for the degree of MASTER OF ARTS IN NURSING MAJOR IN MEDICAL-SURGICAL NURSING has been examined and is recommended for acceptance and approval for ORAL EXAMINATION.

BRENDA P. MANGUILIMOTAN, Ph.D.Professor, Graduate SchoolUniversity of the Visayas

Adviser

THE THESIS COMMITTEE

EDSEL P. INOCIAN, Ph.D.Professor

Velez CollegeChairman

GERONIMA EMMA A. AMORES, D.M. ISABELITA T. ABELLANOSA, D.M.Program Coordinator, Graduate School Professor, Graduate School

University of the Visayas University of the VisayasMember Member

Accepted and approved for oral examination

ZOSIMA A. PANARES, Ph.D.Dean, Graduate School

PANEL OF ORAL EXAMINERS

Approved by the Committee on Oral Examination with a grade of PASSED.

EDSEL P. INOCIAN, Ph.D.Professor

Velez CollegeChairman

GERONIMA EMMA A. AMORES, D.M. ISABELITA T. ABELLANOSA, D.M.Program Coordinator, Graduate School Professor, Graduate School

University of the Visayas University of the VisayasMember Member

Accepted and approved in partial fulfilment of the requirements for the degree of MASTER OF ARTS IN NURSING Major in Medical-Surgical Nursing.

Comprehensive Examination: PASSEDOral Examination: August 08, 2015Book Submission:

ZOSIMA A. PANARES, Ph.D.Dean, Graduate School

ACKNOWLEDGEMENT

The researcher would like to express his deepest gratitude and indebtedness to the

several individuals who have contributed in making this study possible:

Dr. Brenda P. Manguilimotan, Adviser, for her patience, support, untiring

guidance, valuable advises and provisions that benefited the researcher for establishing

and completion of this study;

Dr. Zosima A. Panares, Dean of Graduate School, for allowing the researcher to

conduct this study;

The Committee, Chairman Dr. Edsel P. Inocian, Dr. Geronima Emma A.

Amores and Dr. Isabelita T. Abellanosa, for their assistance, valuable comments and

recommendations that benefited the researcher for the improvement of this study;

The family and friends, for their undying support, words of encouragement in

order to sustain the researcher in his field of endeavor and inspirations that helped the

researcher to achieve this study; and

Most of all, to Almighty God, who is the researcher’s ultimate source of strength,

knowledge, wisdom, inspiration, and guiding consciousness during the course of this

study and as well as the overall success of this study.

The Researcher

ABSTRACT

Diabetes Mellitus is a common chronic condition almost worldwide. The management of this disease is a lifelong care with complex course of therapy which requires thorough understanding of the disease and adherence to treatment regimen. However, Diabetes Mellitus remains to be a major public health challenge worldwide. The study examined the factors that predict the health outcomes among patients with Type II Diabetes Mellitus for the month of July 2015 utilizing a descriptive-analytical design. The study was composed of 128 patients who were 18 years old and above, diagnosed at least a year with Type II Diabetes Mellitus, no previous surgeries or hospitalization from May 2015 up to dated study conducted, independent and with little assistance in self-care activities, able to read, understand and sign informed consent, lives in a home setting, and currently on an outpatient status. An adapted-and-modified Health Interview Questionnaire from the National Health and Nutrition Examination Survey (NHANES) and Diabetes Attitudes, Wishes and Needs (DAWN™) Study were used to determine the factors that predict the health outcomes among patients with Type II Diabetes Mellitus.

Most of the respondents were 60 years and above and were females with vocational education, married, retired, with more than 16 years of diagnosis, with perceived good health status, mostly weighing below 50 kilograms, and were within the 1.54 to 1.69 meters (5’1 to 5’6 feet) height range. In terms of treatments as perceived barriers to action, 60 respondents agreed that there were too many treatments to manage. Most respondents considered situational influences a moderate problem. The adherence level to health-promoting behaviors of the respondents was rated good. The health outcomes of the respondents in terms of body mass index, lipid profile, fasting blood sugar, and glycosylated hemoglobin A1c had normal results. Sex and weight were predictors of health outcomes for body mass index. Weight was a predictor of health outcomes for lipid profile. Dietary behavior, civil status and weight predicted the health outcomes for glycosylated hemoglobin A1c. The researcher proposed to develop a health promotion program to improve and prolong the lives of the patients with Type II Diabetes Mellitus.

Keywords: Healthcare Management, Health-Promoting Behaviors, Predictors of Health Outcomes, Type II Diabetes Mellitus Patients, Asia, Philippines

TABLE OF CONTENTS

TITLE PAGE i

APPROVAL SHEET ii

ACKNOWLEDGMENT iv

ABSTRACT v

TABLE OF CONTENTS vi

LIST OF FIGURES ix

LIST OF TABLES x

Chapter Page

I THE PROBLEM

Introduction 1

Theoretical Framework 3

Statement of Purpose 12

Null Hypothesis 13

Significance of the Study 13

DEFINITON OF TERMS 15

II REVIEW OF RELATED LITERATURE AND STUDIES

Personal Factors 18

Perceived Barriers to Action 22

Situational Influences 24

Health-Promoting Behaviors 27

Health Outcomes 34

Overall Summary of the Review 37

III METHODOLOGY AND PROCEDURES

Design 38

Environment 38

Respondents 39

Instruments 39

Data Gathering Procedure 41

Data Analysis 42

Ethical Considerations 43

IV PRESENTATION, ANALYSIS AND INTERPRETATION OF DATA

Profiles of the patients with Type II Diabetes Mellitus 46

Adherence Level to Health-Promoting Behaviors 52

Health Outcomes of the patients with Type II Diabetes Mellitus60

Predictors of Health Outcomes for Body Mass Index 61

Predictors of Health Outcomes for Lipid Profile 63

Predictors of Health Outcomes for Fasting Blood Sugar 65

Predictors of Health Outcomes for Hemoglobin A1c 66

V SUMMARY OF FINDINGS, CONCLUSIONS AND RECOMMENDATIONS

Summary of Findings 69

Conclusions 71

Recommendations 71

REFERENCES 74

APPENDICES

Appendix A: Transmittal Letter to the Dean of Graduate School 82

Appendix B: Transmittal Letter to the Medical Center Chief 83

Appendix C: Informed Consent English Version 84

Appendix D: Informed Consent Cebuano Version 85

Appendix E: Instrument English Version 86

Appendix F: Instrument Cebuano Version 91

Appendix G: Proposed Health Promotion Program 96

Appendix H: Certificate of Integrated Research Board Approval 101

Appendix I: Certificate of Anti-plagiarism Check 104

Appendix J: Certificate of Critic Reader 109

CURRICULUM VITAE 110

LIST OF FIGURE

Figure Page

1 Schematic Diagram of Theoretical Framework of the Study 11

LIST OF TABLES

Table Page

1 Personal Factors of the patients with Type II Diabetes Mellitus 47

2 Treatments as Perceived Barriers to Action of the patients with

Type II Diabetes Mellitus 49

3 Situational Influences of the patients with Type II Diabetes Mellitus 50

4 Adherence Level to Health-Promoting Behaviors of the patients with

Type II Diabetes Mellitus 53

5 Summary of Adherence Level to Health-Promoting Behaviors of the

patients with Type II Diabetes Mellitus 58

6 Health Outcomes of the patients with Type II Diabetes Mellitus 60

7 Predictor of Health Outcomes for Body Mass Index 61

8 Predictor of Health Outcomes for Lipid Profile 64

9 Predictor of Health Outcomes for Fasting Blood Sugar 65

10 Predictor of Health Outcomes for Glycosylated Hemoglobin A1c 66

Chapter I

THE PROBLEM

Introduction

Diabetes Mellitus is a common chronic condition almost worldwide. The

management of this disease is a lifelong care with complex course of therapy which

requires thorough understanding of the disease and adherence to treatment regimen.

Every diabetic individual is expected to assume his duties to manage himself, requiring

involvement in the treatment regimen. Adherence to health-promoting behaviors may

improve the over-all diabetic individual’s health outcome.

However, Diabetes Mellitus remains to be a major public health challenge

worldwide. Apparently, the global prevalence of the Diabetes Mellitus is significantly

growing. This may due to lack of health education regarding on the disease and lack of

health promotions, thus, poor understanding of the disease and poor adherence to health-

promoting behaviors which may lead to poor health outcome among diabetic individuals.

According to the International Diabetes Federation (2011), approximately 366 million of

populace worldwide has a Diabetes Mellitus. In 2012, nearly 1.5 million deaths were

directly caused by the Diabetes Mellitus and over 80% of Diabetes Mellitus deaths were

come from in low- and middle-income countries (World Health Organization, 2012).

Moreover, this public health challenge has reached pandemic proportions and a

prevalence of 552 million people with Diabetes Mellitus in the year 2030 has been

predicted (International Diabetes Federation, 2011).

In the Philippines, there is a drastic increase in number of incidence of the

diabetes mellitus affecting the Filipinos. In fact, a survey conducted by the Philippine

Cardiovascular Outcome Study on Diabetes Mellitus last 2008 that one out of every five

Filipinos aged 30 years and above were found to have a Diabetes Mellitus which means

20.6% of the population have Diabetes Mellitus from only 3.9% in 1998 (Philippine

Diabetes Statistics, 2012). Furthermore, according to the International Diabetes

Federation (2010), Philippines ranks in the top 15 worldwide and now become one of the

world’s emerging Diabetes Mellitus hotspots.

According to the Department of Health (2010), in Davao Region, there are 1,122

reported cases of deaths in Diabetes Mellitus, a significant increase of mortality rate from

784 in 2001. In Davao City, there are 329 mortality rates of Diabetes Mellitus in 2011

from 227 reported cases of deaths in 2010 according to Davao City Health Office.

Provision to every Filipino of the highest possible quality of health care that is

accessible, efficient, equitably distributed, adequately funded, fairly financed, and

appropriately used by an informed and empowered public is the greatest aim of the

Universal Health Care of the Department of Health in order to address the equity of the

health care delivery system in the Philippines (Department of Health, 2010). Health and

Wellness advocacy towards health-promoting behaviors is strongly encouraged.

Therefore, health care providers need effective ways to develop, implement and support

health promotions among diabetic individuals. The purpose of this study is to examine

the factors that predict the health outcomes among patients with Type II Diabetes

Mellitus.

Theoretical Framework

This study anchored the Health Promotion Model (HPM) by Nola J. Pender

(1996). The theory discussed about the factors that predict the health promotion

behaviors which can influence the individual to engage on health-promoting behaviors

and these may affect the individual’s over-all health outcomes.

Nola J. Pender’s background in nursing, human development, experimental

psychology, and education led her to use a holistic nursing perspective, social

psychology, and learning theory as the foundations for the Health Promotion Model.

Health Promotion Modeld expands to encompass behaviors for enhancing health and

potentially applies across the lifespan (Tomey & Alligood, 2002).

Health Promotion Model is an attempt to describe the multifaceted nature of

persons interacting with the environment as they pursue health. It is driven by the desire

to increase well-being and actualize the human potential. Nola J. Pender asserts that there

are complex biophysical processes that motivate individuals to engage in behaviors

directed toward the enhancement of health (Tomey & Alligood, 2002).

The major concepts utilized in the Health Promotion Model are divided into three

following categories: (1) individual characteristics and experiences; (2) behavior-specific

cognitions and affect; and (3) behavioral outcome.

The major concepts in the Individual Characteristics and Experiences category are

as followed: (1) prior related behavior; and (2) personal factors such as biological,

psychological, and socio-cultural.

Prior related behaviors are defined as frequency of the same or similar behavior in

the past. Personal factors are defined as those distinguishing characteristics, which might

affect behaviors. It categorized into three factors as: (1) biological factors including age,

gender, body mass index, pubertal or menopausal status, aerobic capacity, strength,

agility, or balance; (2) psychological factors including self-esteem, self-motivation,

personal competence, perceived heath status, and definition of health; and (3) socio-

cultural factors including race, ethnicity, acculturation, education, and socio-economic

status (Tomey & Alligood, 2002).

The major concepts in the Behavior-specific Cognition and Affect category are as

followed: (1) perceived benefits of action; (2) perceived barriers to action; (3) perceived

self-efficacy; (4) activity-related affect; (5) interpersonal influences; and (6) situational

influences.

Perceived benefits of action are defined as anticipated positive outcomes that will

occur from health behavior. Perceived barriers to action are defined as anticipated,

imagined or real blocks and personal costs of undertaking a given health behavior.

Perceived self-efficacy is defined as the judgment of personal capacity to organize and

execute a health-promoting behavior. Perceived self-efficacy influences perceived

barriers to action so higher efficacy results in lowered perceptions of barriers to the

performance of the behavior. Activity-related affect is defined as the subjective positive

or negative feelings that occur prior to, during, and following behavior based on the

stimulus properties of the behavior itself. It also influences perceived self-efficacy, which

means the more positive the subjective feeling, the greater the feeling of efficacy. In turn,

increase feelings of efficacy can generate further positive affect. Interpersonal influences

are defined as the cognitions concerning the behaviors, beliefs, or attitudes of others. It

includes the norms (expectations of significant others), social support (instrumental and

emotional encouragement), and modeling (various learning through observing others

engaged in a specific behavior). Primary sources of interpersonal influences are families,

peers, and healthcare providers. Situational influences are defined as those personal

perceptions and cognitions of any given situation or context that can facilitate or impede

behavior. It includes perceptions of options available, demand characteristics, and

aesthetic features of the environment in which a given health-promoting behavior is

proposed to take place. It may have direct or indirect influences on health behavior

(Tomey & Alligood, 2002).

The major concepts in the Behavioral Outcome category are as followed: (1)

commitment to a plan of action; (2) immediate competing demands and preferences; and

(3) health-promoting behavior.

Commitment to a plan of action is defined as the concept of intention and

identification of a planned strategy leads to implementation of health behavior.

Immediate competing demand is defined as an alternative behavior over which

individuals have low control because there are environmental contingencies such as work

or family care responsibilities. Immediate competing preference is defined as an

alternative behavior over which individuals exert relatively high control, such as choice

of ice cream or an apple for a snack. Health-promoting behavior is defined as endpoint or

action outcome directed toward positive outcomes such as optimal well-being, personal

fulfillment, and productive living (Tomey & Alligood, 2002).

The independent and dependent variables used in this study had been categorized

according to the Health Promotion Model by Nola J. Pender (1996). The independent

variables were divided into two properties: (1) profile of the patients with Type II

Diabetes Mellitus in terms of personal factors, treatments as perceived barriers to action

and situational influences; and (2) adherence level to health-promoting behaviors in terms

of health-responsibility, medication adherence, dietary and exercise behaviors. On the

other hand, the dependent variable was the health outcomes of the patients with Type II

Diabetes Mellitus in terms of body mass index, lipid profile, fasting blood sugar and

glycosylated hemoglobin A1c.

The following independent variables were categorized under the construct of

personal factors including the demographic profiles such as age, sex, educational

attainment, civil status, occupation and financial status, the length of disease diagnosis,

perceived health status, and body measurements such as weight and height.

Demographic Profile. The respondents were asked to self-report their age in

years; sex whether male or female; elementary indicated as the lowest educational

attainment and post-graduate indicated as the highest educational attainment; civil status

whether single, married, widow/er or annulled/separated; occupation whether none, self-

employed, employed or retired; financial status whether below average, average or above

average income earner/pensioner.

Length of Disease Diagnosis. The respondents were asked to self-report the year

at the time when they were diagnosed with Type II Diabetes Mellitus by their physician.

The researcher calculated the length of disease diagnosis by subtracting the respondents’

reported year from the present year of this study conducted. The researcher categorized

the length of disease diagnosis using the 4-point likert scale indicating value 1 as 1 to 5

years, value 2 as 6 to 10 years, value 3 as 11 to 15 years and value 4 as more than 16

years.

Perceived Health Status. The respondents were asked to rate their general health

condition using the 4-point likert scale indicating “very good”, “good”, “fair”, and

“poor”. These values were reverse scored by the researcher and used to represent the

variable perceived heath status in the study where a value of 1 indicated poor and a value

of 5 indicated excellent. The researcher calculated the variable “perceived health status”

by taking the frequency and percentage of the respondents’ responses from this item.

Body Measurements. The body measurements including the weight and height

were obtained thru actual assessment at the time of scheduled interview using calibrated

equipment such as weighing scale and stadiometer respectively. The weight

measurements were reported in kilograms and the height measurements were reported in

meters. The researcher categorized the weight using the 6-point likert scale indicating

value 1 as less than 50 kg, value 2 as 51 to 55 kg, value 3 as 56 to 60 kg, value 4 as 61 to

65 kg, value 5 as 66 to 70 kg and value 6 as more than 71 kg. Also, the researcher

categorized the height using 4-point likert scale indicating value 1 as less than 1.53

meters, value 2 as 1.54 to 1.69 meters, value 3 as 1.70 to 1.84 meters and value 4 as more

than 1.85 meters. These body measurements were used for the calculations of the body

mass index. The researcher also obtained the baseline data of both weight and height thru

chart review within the period from January to April 2015.

The following independent variables were categorized under the construct of

Perceived Barriers to Action and Situational Influences.

Treatments as Perceived Barriers to Action. The respondents were asked to

rate the treatments as perceived barriers to action using the 4-point likert scale from 1 to 4

indicating “strongly disagree”, “disagree”, “agree” and “strongly agree” that addressed

the difficulties on treatment adherence where a value of 1 indicated strongly disagree and

a value of 4 indicated strongly agree. The researcher calculated the variable “treatments

as perceived barriers” by taking the frequency and percentage of the respondents’

responses from this item.

Situational Influences. The respondents were asked to answer 20 items in the

problem areas in diabetes survey that addressed the diabetes-related emotional distress

which also correlates with measures of related concepts such as depression, social

support, health beliefs, and coping style, as well as predicts future blood glucose control

of the patient. The respondents were asked to rate each item using the 5-point likert scale

from 0 to 4 indicating “not a problem”, “minor problem”, “moderate problem”,

“somewhat serious problem” and “serious problem” where a value of 0 indicated not a

problem and a value of 4 indicated serious problem. The researcher calculated the

variable “diabetes-related emotional distress” by taking the weighted mean of the

respondents’ responses from each item and grand weighted mean from these 20 items. A

serious problem is an indicative of emotional burnout and warrant special attention. The

result may drop up to moderate problem in response to educational and medical

interventions. An extremely low score combined with poor glycemic control may be

indicative for denial.

The following independent variables were categorized under the construct of

Health-Promoting Behaviors including health responsibility, medication adherence,

dietary and exercise behaviors.

Health-Promoting Behaviors. The respondents were asked to answer 14 items in

the health-promoting behavior survey that addressed the adherence level to the following

variables of health-promoting behaviors including three-item health responsibility

behaviors, four-item medication adherence behaviors, five-item dietary behaviors and

two-item exercise behaviors. The respondents were asked to rate each item using the 5-

point likert scale from 1 to 5 indicating “never/poor”, “rarely/fair”, “sometimes/good”,

“oftentimes/very good” and “always/excellent” where a value of 1 indicated never/poor

and a value of 5 indicated always/excellent. The researcher calculated each variable of

“health-promoting behaviors” by taking the weighted mean of the respondents’ responses

from each variable. The lower the result is an indicative of low adherence level and the

higher the result is an indicative of high adherence level.

The following dependent variables were categorized under the construct of Health

Outcomes including the body mass index and the diabetic control measures such as lipid

profile, fasting blood sugar and glycosylated hemoglobin A1c.

Body Mass Index. The respondents received body measurements including

weight and height were obtained thru actual assessment at the time of scheduled

interview. The weight and height measurements were reported in kilograms and meters

respectively and these values were used in the direct calculation of body mass index by

the researcher. Body Mass Index (BMI) values were calculated using the formula of

weight in kilograms divided by the squared value of the height in meters. The researcher

also obtained the baseline data of body mass index thru chart review within the period

from January to April 2015. The results were scored using the 3-point likert scale from 1

to 3 indicating “below normal”, “normal” and “above normal”. A value of 1 indicated

below normal and a value of 3 indicated above normal.

Diabetic Control Measures. The diabetic control measures including the lipid

profile, fasting blood sugar and glycosylated hemoglobin A1c were obtained thru actual

assessment of the latest results within the period from May to July 2015 and were

extracted from the respondents’ records from Mindanao Diabetes Center Clinic thru chart

review. The researcher also obtained the baseline data of these diabetic control measures

thru chart review within the period from January to April 2015. The results were scored

using the 3-point likert scale from 1 to 3 indicating “below normal”, “normal” and

“above normal”. A value of 1 indicated below normal and a value of 3 indicated above

normal.

Based on the findings of this study, the researcher developed a propose health

promotion program to the patients with Type II Diabetes Mellitus.

Health outcomes in terms of:Body Mass IndexLipid ProfileFasting Blood SugarGlycosylated Hemoglobin A1c

Profile in terms of:Personal FactorsTreatments as Perceived Barriers to ActionSituational Influences

Adherence level to health-promoting behaviors in terms of:Health-Responsibility BehaviorsMedication Adherence BehaviorsDietary BehaviorsExercise Behaviors

Health Promotion Model(Pender, 1996)

Type II Diabetes Mellitus PatientsSouthern Philippines Medical Center

J.P. Laurel Avenue, Bajada, Davao City

Proposed Health Promotion Program Figure 1. Schematic Diagram of the Theoretical Framework of the Study.

Statement of Purpose

The purpose of the study was to examine the factors that predict the health

outcomes among patients with Type II Diabetes Mellitus in a tertiary government

retained hospital in Davao City for the month of July 2015.

Specifically, the study attempted to answer the following questions:

1. What were the profiles of the patients with Type II Diabetes Mellitus in terms of:

1.1. personal factors;

1.2. perceived barriers to action; and

1.3. situational influences?

2. What was the adherence level of the patients with Type II Diabetes Mellitus to health-

promoting behaviors in terms of:

2.1. health responsibility behaviors;

2.2. medication adherence behaviors;

2.3. dietary behaviors; and

2.4. exercise behaviors?

3. What were the health outcomes of the patients with Type II Diabetes Mellitus in

terms of:

3.1. body mass index;

3.2. lipid profile;

3.3. fasting blood sugar; and

3.4. glycosylated hemoglobin A1c?

4. Which factor predicted the health outcomes of the patient with Type II Diabetes

Mellitus?

5. Based on the findings, what health promotion program can be developed?

Null Hypothesis

Ho: There is no factor that predicts the health outcomes of patients with Type II

Diabetes Mellitus.

Significance of the Study

The result of this study will benefit the following:

Patients with Type II Diabetes Mellitus. They may benefit from the result of

this study because the information will make them more cognizant about their illness and

will give them a better understanding on the importance of their treatment regimen.

Health Care Providers. This study may aid the health institutions, medical and

allied practitioners, and nurses to plan more attainable goals for the patients with

Diabetes Mellitus. Also, this can facilitate the improvement of the patient’s health

outcomes.

Health Policy Makers. This study may help them to further develop a standard of

care to support the needs of the diabetic patients.

Non-government Organizations. This study may aid the local and international

non-government organizations to establish a community support group of among the

diabetic patients and to help conduct concrete researches on adjuvant or alternative

treatments on diabetes mellitus.

Department of Health. This study may help the officials, the rank and files of the

Department of Health to further develop health promotion programs in order to

strengthen the preventive campaign against diabetes mellitus and may aid them to

educate the public who are already affected with diabetes mellitus on the other well-

studied treatment modalities on such disorder.

The Researcher. The researcher as being part of the health care providers, this

study may aid him to develop effective ways to promulgate health promotions.

Future Researchers. This study may enhance the knowledge and skills for future

purposes for the improvement of the nursing practice for the regimen of care of diabetes

mellitus in the hospital and even in the community.

DEFINITION OF TERMS

To have better understanding of this study, the following were operationally

defined by the researcher:

Adherence level to health-promoting behaviors refers to the degree of

collaborative involvement of the patient with the healthcare provider in the treatment of

care to produce therapeutic results.

Health-responsibility behaviors refer to the patient’s key role in self-care

management in adherence to treatment regimen.

Medication adherence behaviors refer to the medicines prescribed by the health

care provider which may help to control the patient’s blood glucose and lipid levels.

Dietary behaviors refer to the nutritional intake of the patients advised by the

health care provider which may help to improve or maintain the optimal health condition.

Exercise behaviors refer to the physical activity which may help to enhance or

maintain the physical fitness and overall health and wellness of the patients.

Health outcomes among patients with Type II Diabetes Mellitus refer to the

change of health status of the patients in adherence to health-promoting behaviors.

Body mass index refers to the body measurement to determine the patient’s

thickness or thinness using the weight and height.

Lipid profile refers to the diabetic control measure to identify the average amount

of blood lipids while the patients are refrained from eating, and drinking any liquids for

the minimum of eight hours.

Fasting blood sugar refers to the diabetic control measure to identify the average

amount of blood glucose while the patients are refrained from eating, and drinking any

liquids for the minimum of eight hours.

Glycosylated hemoglobin A1c refers to the diabetic control measure to identify

the average amount of blood glucose over prolonged periods of time.

Predictors of health outcomes refer to the determinant factors that can affect the

patient’s health outcomes.

Profiles of the patients with Type II Diabetes Mellitus refer to the brief

biography of the patient diagnosed with chronic metabolic disorder in terms of personal

factors, treatments as perceived barriers to action and situational influences.

Patient with Type II Diabetes Mellitus refers to the patient diagnosed with

chronic metabolic disorder characterized with high blood sugar due to relative lack of

insulin or insulin resistance and receives a medical care treatment of such disorder.

Personal factors refer to the patient’s characteristics such as age, sex and etc. that

define the nature of patient’s behaviors.

Treatments as perceived barriers to action refer to the patient’s treatment of

care as the anticipated possible impediments on the achievement of positive health

outcomes.

Situational influences refer to the internal or external stimuli which can directly

affect the patient’s cognition towards achieving positive health outcomes.

Chapter II

REVIEW OF RELATED LITERATURE AND STUDIES

This chapter presents related literature and studies relevant to the study on the

predictors of health outcomes among patients with Type II Diabetes Mellitus. Related

literatures are provided information taken from the reliable resources such as journals,

books, and government and non-government organizations website. Related studies are

the previous studies conducted by the several researchers to explore and examine the

variables being studied. Some of the variables used in the previous studies are the same

variables being used in this present study. However, this present study will further

examine the predictors of health outcomes among diabetic patients. Hence, this will help

the present study to determine of what is not yet known and unknown.

Though diabetes mellitus cannot be cured, this chronic disease usually requires a

combination of therapies including adherence to health-promoting behaviors such as

prescribed maintenance blood glucose-regulating drugs, prescribed diet, regular exercise

and regular blood glucose self-monitoring in order to prevent the progression of diabetes-

related complications. Therefore, health care providers need effective ways to develop,

implement and support health promotions among diabetic individuals.

However, the most important thing than the medical management prescribed by

the health care providers is the patients’ key role in the self-care management. On a daily

basis, patients have to take responsibility for a large number of behavioral choices and

activities to manage their condition, predominantly outside the healthcare setting (Jarvis

et al., 2009). The choices that patients make during daily life have a greater impact on

health outcomes than those made by the health care providers. Once patients are outside

the healthcare setting, they themselves are in control. They decide whether or not to

implement recommendations in their daily life (Funnell et al., 2004).

Personal Factors

According to Nola Pender’s Health Promotion Model, personal factors are

defined as those distinguishing characteristics, which might affect behavior. It

categorized as biological, psychological, or socio-cultural factors (Tomey & Alligood,

2002). The following personal factors used in this study were age, sex, education, civil

status, occupation, financial status, length of disease diagnosis, perceived health status

and body measurements.

Age. Age can affect the diabetes treatment care regimen, especially in older

individuals. Older diabetic individuals are often have poor financial status, experience

higher frequency of social isolation and depression, and are often more susceptible to

hypoglycemic episodes (Sinclair, 2006). Age is also associated with worsening of

diabetic-related complications such as diabetic retinopathy, nephropathy and neuropathy.

This can cause to be more challenging for the older diabetic individuals on their self-

management.

Recent epidemiological studies have shown a clear relationship between age and

prevalence of Type II Diabetes Mellitus in the United States. Approximately 11% of

individuals aged 65 years and older and 6% of those aged 45 to 64 years have Diabetes

Mellitus, while only 1.5% among those aged 18 to 44 years is affected by this chronic

disease. At the same time, younger age groups are being diagnosed with Type II Diabetes

Mellitus (Harris, 1998).

Sex. Health behaviors are dynamically different between men and women. While

most studies have found that men are more physically active than women. Women’

exercise patterns are more health-promoting and sustainable relative to those of men

(Dean, 1989). Women and men also differ in health care utilization, with men generally

utilizing fewer health services (Courtenay, 2000). Although women are more likely to

seek preventive care, extensive research has documented sex disparities in the care that

men and women receive (Bird et al., 2007).

Educational Attainment. The associations between educational attainment and

health behaviors are particularly important in Diabetes Mellitus, given the critical role of

health behaviors, including diabetes self-care management and health-related lifestyle

(Mirowsky, 1998).

According to American Medical Association (1999), functional health literacy is

the ability to read and understand the prescription bottles, appointment slips, and other

health-related materials of which will be required to successfully function as a person.

Functional health literacy may mediate the relationship between low financial and health

status (American Medical Association, 1999). Lower educational attainment is strongly

associated with worse health literacy (Baker et al., 1998) and inadequate health literacy

has been linked to poorer health status (Street et al., 1993). Diabetic individuals who have

inadequate or marginal literacy are less likely to know the hypoglycemic symptoms

(Williams, 1998) and they have higher results of glycosylated hemoglobin A1c

(Schillinger, 2002).

Financial Status. In 2012, nearly 1.5 million deaths were directly caused by

Diabetes Mellitus and over 80% of Diabetes Mellitus deaths were come from in low- and

middle-income countries (World Health Organization, 2012). The influence of wealth on

healthcare access and utilization of healthcare services affects the individual’s adherence

to health promoting behaviors. Even within publicly and universally accessible systems,

there is evidence that individuals from lower financial groups have impaired access to

care reflected in longer wait times and fewer referrals to specialist care (Dunlop et al.;

2002). This might contribute to the observation of worse health outcomes, such as the

increased rate of diabetic-related complications (Booth et al., 2003).

According to the study of Rabi and colleagues (2006), they explored the

association between financial status with prevalence and utilization of diabetes care

services. Their findings showed that low income earners have higher prevalence of

Diabetes Mellitus than those high income earners. In another study conducted, only 30%

were treatment regimens compliant and the non-compliant were greater among groups

belonging to the lower socio-economic status (Shrivastava et al., 2013).

Length of Disease Diagnosis. According to the study conducted by Rhee and

colleagues (2005) and Lee and colleagues (2009), they explored the relationship between

personal factors and glycemic control, which was defined as glycosylated hemoglobin

A1c levels.

Rhee and colleagues (2005) explored the relationship between age, length of

diabetes diagnosis, and glycosylated hemoglobin A1c levels and the study obtained

significant results. The length of diabetes diagnosis was found to be positively related to

glycosylated hemoglobin A1c level. The longer the diagnosis the higher the glycosylated

hemoglobin A1c level. Age was negatively related to glycosylated hemoglobin A1c level,

indicating that the older the individual the lower the glycosylated hemoglobin A1c level.

Conversely, Lee and colleagues (2009) explored the relationship between the

same variables (age, length of diabetes diagnosis, and glycosylated hemoglobin A1c

levels) but no significant relationship was found. The Rhee and colleagues study had a

sample size of 1,560 whereas the Lee and colleagues study only had a sample size of 55.

Perceived Health Status. Perceived health is a subjective assessment that people

make about their own health state and it is an indicator of over-all health status (European

Community Health Indicators and Monitoring, 2010). It is included as one of the World

Health Organization (WHO) health targets. Perceived health status is not a substitute for

more objective health outcomes but rather complements them (The European

Commission, 2011). Perceived health status accords well with objective health status

(Unden et al., 2001).

According to Mitchell and colleagues (2004) study, they explored the relationship

between perceived health status, blood glucose self-monitor, and glycosylated

hemoglobin A1c levels but no significant relationship was found between these variables.

Another study conducted by Vince and colleagues (2004), they explored the relationship

between personal factors and adherence to blood glucose self-monitor. The personal

factors of age, length of diabetes diagnosis, and perceived health status were included. No

significant relationship was found between these personal factors and adherence to blood

glucose self-monitor.

Perceived Barriers to Action

According to Nola Pender’s Health Promotion Model, perceived barriers to action

are defined as anticipated, imagined, or real blocks and personal costs of undertaking a

given behavior (Tomey & Alligood, 2002). The perceived barriers to action used in this

study were too many treatments to manage.

There are a number of potential barriers to self-management. People may not be

able to access the information, resources or services that will enable them to develop their

self-management skills, or the actual services and information may not be available.

Physical barriers include the nature of their condition or conditions where people have

different needs. Financial or logistical barriers include physical limitations of access to

services, time and locations, financial cost, local availability of services and ongoing

support once people have had self-management training or guidance. System barriers

include conflicting advice or a lack of collaborative working between healthcare social

care professionals in providing joined-up information, services and ongoing support for

self-management (Diabetes UK, 2009).

Perceived barriers to action have an important role in the self-care process among

diabetic individuals. Important barriers are non-awareness of health nutritional program,

lack of social support and self-care management perception (Nagelkerk et al., 2006).

According to Rothman and colleagues (2008) study, they showed inappropriate diet and

sport habit among diabetic patients were related with perceived barriers. In the study of

Glasgow and colleagues (2001), there is a significant but reverse relationship between

perceived barriers to action and self-care behaviors.

Perceived barriers to action have been associated with lower rates of adherence to

a variety of self-care regimens including diet, exercise, blood glucose self-monitor, and

medication adherence behaviors (Aljasem et al., 2001). The increased impact of these

barriers, in turn, may have longer reaching implications, including influencing metabolic

control and overall functioning. In one study, greater reported frequency of barriers to

general diabetes self-care among Type I and II diabetic patients was associated with

higher glycosylated hemoglobin A1c levels, demonstrating poorer metabolic control and

increased likelihood complications (Mollem et al., 1996).

According to Wen and colleagues (2004) study, they showed as perceived barriers

to action among their research groups increase, prescribed physical activity and following

nutritional diet increase. Koch (2002) study indicated a negative significant relationship

between perceived barriers to action and self-care behaviors. Corina (2004) study showed

as perceived barriers to action increase, a significant decrease happens in diabetic self-

acre action. These were the same results seen in both Karter and colleagues (2000) and

Adams and colleagues (2003) studies.

According to the study of Nagelkerk and colleagues (2006), they provided

examples of common barriers to diabetes self-care management. Frequently reported

barriers were time constraints, limited social support, limited coping skills, lack of

knowledge related to diet management, helplessness and frustration from lack of

glycemic control, and continued disease progression despite of treatment adherence.

Although some of these barriers may appear static and not likely to change and many of

these perceived barriers to action can vary in intensity from day to day.

In spite of different studies, which demonstrated reverse and significant

relationship between self-care behaviors and perceived barriers to action, one study did

not receive this negative correlation (Gillibrnad et al., 2006). In fact, according to Janz &

Becker (1984) study, in a review of the general medical literature, concluded that the

increased presence of perceived barriers to treatment was consistently reported as the

strongest predictor of health action.

Situational Influences

According to Nola Pender’s Health Promotion Model, situational influences are

defined as those personal perceptions and cognitions of any given or context that can

facilitate or impede behavior. It includes perceptions of options available, demand

characteristics, and aesthetics features of the environment in which a given health-

promoting behavior is proposed to take place. It may have direct or indirect inlfuences on

health behavior (Tomey & Alligood, 2002). Situational influences used in this study were

the diabetes-related emotional distress.

Diabetes-related emotional distress can be defined as a range of emotional

responses and reactions to life with diabetes, especially those related to the treatment

regimen and self-care demands. It is part of a person’s experience of managing diabetes

and its treatment in the social context of family and health-care personnel (Fisher et al.,

2012; and Polonsky et al., 2005). The under recognition of emotional problems, such as

depression, anxiety, and diabetes-specific emotional distress, has been reported (Pouwer

et al., 2006), and when such concerns are recognized, problems might be identified as

depression, even in patients whose problems are directly related to diabetes and its

treatment related to diabetes and its treatment (Gonzales et al., 2011).

The ability to self-manage also includes how people are supported by peers,

family and care givers. The provision of emotional and psychological support should be

an integral part of a diabetes service. Emotional and psychological needs of a person with

diabetes have to be properly assessed in partnership with the person as part of the care

planning process. It is important that people are made aware of the support available, so

that they are able to choose if and when they need to access it (Diabetes UK, 2009).

Family relationships play a significant role in diabetes care management. Studies

have demonstrated that low levels of conflict, high levels of cohesion and organization,

and good communication patterns are linked with better treatment adherence (Delameter

et al., 2001). Higher levels of social support, specifically the diabetes-related support

from partners and their significant others are linked with better treatment adherence

(Glasgow et al., 1998). Social support serves as to buffer the adverse reactions of stress

on diabetes care management (Griffith et al., 1990).

Poor stress management and coping mechanism have been linked with more

adherence problems (Peyrot et al., 1999). Diabetes-related emotional distress such as

anxiety, depression, and eating disorders has also been associated with worse diabetes

care management in both young and adult diabetic population groups (Delametrer et al.,

2001). According to the recent Diabetes Attitudes, Wishes and Needs Study (2001)

initiated by Novo Nordisk, the study showed that a significant number of diabetic patients

have poor psychological well-being and those health care providers handling them

reported that there psychological problems adversely affected the treatment adherence

(Peyrot et al., 2005).

Depression may exert its effect through poor self-care behaviors such as over-

eating, not exercising, or failing to keep medical appointments (Trief, 2007). The over-all

depression rate in people with chronic illnesses is 20% to 70% paralleled to the estimated

5% seen in the general population group. The incidence of depression in diabetic

individuals has been approximately estimated to 25% (Madden, 2010). Identifying and

treating depression in Diabetes Mellitus is strongly recommended (Trief, 2007). One of

the issues linked with Diabetes Mellitus is that many individuals are not clinically

depressed but still experience feelings that are associated to depression in the course of

living with their chronic disease. This state is sometimes referred to as diabetes-related

emotional distress, and is associated to depression but not suffice to qualify a diagnosis of

depression (Solowiejczyk, 2010).

Depression may affect the communication with healthcare providers, self-care

management behaviors, utilization of healthcare services, and metabolic control. In a

study conducted by Ciechanowski and colleagues (2000), among diabetic individuals

with more depressive symptoms were found to have higher rates of non-adherence to oral

anti-diabetes medications than those with fewest symptoms, with the results of 15% and

7% respectively. A meta-analysis study revealed a positive correlation between

depression and glycosylated hemoglobin A1c levels (Lustman et al., 2000). Though, it is

not known whether the treatment of depression is linked with better Diabetes Mellitus

management.

According to the study of Fisher and colleagues (2012), they found non-linear

relationships of diabetes-specific emotional distress with glycosylated hemoglobin A1c,

diet, self-efficacy, and physical activity in two samples of persons with Type II Diabetes

Mellitus, with stronger relationships for lower levels of diabetes-specific emotional

distress.

Health-Promoting Behaviors

According to Nola Pender’s Health Promotion Model, health-promoting behavior

is defined as endpoint or action outcome directed toward attaining positive health

outcomes such as optimal well-being, personal fulfillment, and productive living (Tomey

& Alligood, 2002). The following health-promoting behaviors used in this study were

health responsibility, medication adherence, dietary and exercise behaviors.

In spite of the remarkable success in improving the lives of those living with

diabetes mellitus with technological innovation in biomedical sciences, the management

of Type II Diabetes Mellitus lies largely with those with diabetic individuals. It includes

the practices that must be carried out by the patients themselves. Such practices include

eating a healthy diet, performing physical activity, taking prescribed medications, self-

monitoring of blood glucose level, regular clinic appointments, and stress management,

among other practices (American Diabetes Association, 2002).

There are seven essential self-care behaviors in diabetic individuals which predict

the good health outcomes. These are healthy eating, being physically active, self-

monitoring of blood glucose level, compliant with prescribed medications, good problem-

solving skills, healthy coping skills, and risk reduction behaviors. All these seven

behaviors have been demonstrated to be positively associated with good glycemic

control, reduction of diabetic-related complications, and quality of life improvement

(Shrivastava et al., 2013).

Adherence to the prescribed maintenance blood glucose-regulating drugs, blood

glucose self-monitoring, prescribed diet, and regular exercise are often identified as

health-promoting behaviors. Diabetic individuals are expected to follow a multifaceted

set of behaviors to manage their chronic disease on a daily basis. These actions include

positive lifestyle behaviors engagement such as following a meal plan, do an appropriate

physical activity, taking prescribed medications, self-monitoring blood glucose levels,

responding to and self-treating diabetes-related symptoms, following foot-care

guidelines, and seeking individually appropriate medical care for Diabetes Mellitus or

other health-related problems (Shrivastava et al., 2013).

Health-responsibility behaviors. Successful self-care management requires

knowledge about the condition, how it needs to be treated and what needs to be done. The

key of self-care management activities specific to diabetes care and living with Diabetes

Mellitus are: (1) managing the relationships between food, activity and medications; (2)

self-monitoring of blood glucose, blood pressure and having retinal screening carried out;

(3) targeting goals tailored to individual need, for example around foot care, weight loss,

injection technique and self-monitoring activities; (4) applying sick day rules when ill, or

what to do if going into hospital; (5) understanding diabetes, what care to expect and how

to access services; (6) managing acute complications such as hypoglycemia and

hyperglycemia; and (7) understanding legislative issues such as those related to

employment and driving (Diabetes UK, 2009).

Successful control of diabetes mellitus requires lifelong adherence to multiple

self-management activities in close collaboration with the health care professionals. Lack

of adherence to such activities has been revealed to be linked with negative health

outcomes. For instance, prescription refill adherence to Diabetes Mellitus medications

correlates with improved glycosylated hemoglobin A1c results (Schectman et al., 2002).

Blood glucose self-monitoring is a cornerstone of Diabetes Mellitus management that can

warrant patient participation in specific glycemic controls achievement and maintenance.

It has been utilized for over 25 years with current technological innovations making the

procedure very easy to practice. Research has exhibited that higher blood glucose self-

monitoring practice is linked with glycemic control improvement. In spite of the

technology advancement, however, patients often do not adhere well to this diabetes care

regimen (Delamater, 2008).

Daily blood glucose self-monitoring is believed to be essential for the diabetic

patients under treatment to detect asymptomatic hypoglycemia and to guide the patients

and healthcare providers’ behaviors toward reaching the adequate blood glucose control

(Harris, 2001). Blood glucose self-monitoring provides detail about current glycemic

status and assessment of current therapy including modifications in medication, diet, and

exercise in order to attain the optimal glycemic control (Shrivastava et al., 2013)

Among diabetic patients treated with insulin and either oral medications or diet

and exercise, only 39% and 5% respectively were adhered to daily blood glucose self-

monitoring of at least one blood glucose check per day (Harris et al., 2001). According to

Delamater (2008) study, blood glucose self-monitoring adherence between diabetic

patients treated with insulin and either oral medications or diet and exercise was 70% and

64% respectively and appointment keeping adherence was 71% and 72% respectively.

Medication adherence behaviors. The goal of the medical treatment is primarily

to save life and alleviate symptoms. Secondary goals are to prevent long term diabetic-

related complications and, by eliminating various risk factors, to increase longevity.

Insulin replacement therapy is considered to be one of the cornerstones for the patients

with Type I Diabetes Mellitus while diet and lifestyle modifications are for the treatment

and management of Type II Diabetes Mellitus patients. Oral hypoglycemic agents are

also useful in the treatment of Type II Diabetes Mellitus (Bastaki, 2005).

Diabetes progression can be prevented by adequate glycemic control (Funnell, 2000).

However, unfortunately, diabetic individuals often do not follow their prescribed glucose-

regulating regimen. Considering that 95% of Diabetes Mellitus treatment is by self-care

management (Funnell, 2004), non-adherence to treatment results in significant increase of

the diabetes progression, higher costs to the healthcare system, and frustration in both

patients and healthcare providers.

The results from the study of Diabetes Attitudes, Wishes, and Needs (DAWN)

conducted by Novo Nordisk, the study showed patient-reported medication adherence

rates between Type I and Type II Diabetes Mellitus were 83% and 78% respectively

(Delamater, 2008). Another study using a large national sample of patients with Type II

Diabetes Mellitus showed that only 24% of insulin-treated patients, 65% of oral

medications-treated patients, and 80% of those treated by both diet and exercise alone

either never practiced blood glucose self-monitoring or did so less than once a month

(Harris et al., 2001). Two studies showed that adherence to oral medications in patients

with Type II Diabetes Mellitus were 53% and 67% respectively when measured by

electronic monitoring (Delamater, 2008).

Dietary behaviors. Dietary management is considered to be one of the

cornerstones in treatment of Diabetes Mellitus. It is based on the adherence of healthy

diet behaviors in the context of social, cultural, and psychological influences on food

choices (Ekore et al., 2008). Dietary practice refers to patients’ food intake selections

based on the diabetes nutrition education that provides importance on low fat and sodium

intake, and high fiber intake (Shamsi et al., 2013). Several studies have shown that

healthy diet behaviors could lead to significantly lower glycosylated hemoglobin A1c

levels among diabetic patients (American Diabetes Association, 2008).

Patients newly diagnosed with Type II Diabetes Mellitus have similar diet

behaviors compare to general population groups. Both external and emotional diet

behaviors are linked with high-energy intake and controlled diet behavior with low-

energy intake upon diagnosis. Women with high scores for emotional diet behavior were

seemed to be less able to make initial dietary changes after being diagnosed with

Diabetes Mellitus and having received dietary advice by healthcare providers (Laar et al.,

2006).

Moreover, both external and emotional diet behaviors were linked with increased

energy and fat intake. On the other hand, controlled diet behavior displayed an inverse

relationship between energy and fat intake. External diet behavior, but not emotional diet

behavior, revealed a significantly relationship with a decrease in energy intake in women

and found no statistically significant relationships between diet behavior which was

measured upon diagnosis and changes in energy and fat intake between diagnosis and

four years (Laar et al., 2006). Diet behaviors adherence rates between Type I and Type II

diabetic patients were 39% and 37% respectively (Delamater, 2008).

According to Plotnikoff and colleagues (2009) study, they explored the

relationship between dietary behaviors, body mass index, and exercise. A significantly

relationship was found for both body mass index and exercise for patients who reported

more fruit and vegetable intake. Dietary behavior practice was associated with lower

body mass index and an increase in frequency of physical activity. This study showed

that adherence to dietary behaviors can be related with another health-promoting

behaviors and health outcomes. Study demonstrated that the three types of diet behaviors

distribution including energy fat intake at diagnosis, changes in energy and fat intake

between diagnosis, and both eight weeks and four years were similar in patients with

Type II Diabetes Mellitus and the general population groups.

Exercise behaviors. Exercise has long been considered as essential component of

diabetes care management. Diabetes Mellitus Specialists have established exercise as one

of the four cornerstones of health-promoting behaviors, along with medication, diet and

blood glucose self-monitor. Exercise appears to support in the visceral fat loss. More

recent study suggested that exercise may exert favorable effects on emerging vascular

disease risk factors. Exercise may also play a protective role by increasing patient

resilience to the emotional stress and depression often experienced with Diabetes

Mellitus care management (Zecker, 2004). Irrespective of weight loss, regular physical

activity engagement has beed exhibited to be related with health outcomes improvement

among diabetic individuals. The National Institutes of Health and the American College

of Sports Medicine (NIHACSM) recommend that all adults including those with Diabetes

Mellitus should engage in regular physical activity (Shrivastava et al., 2013).

A weekly 150-minute moderate-intensity exercise can improve glycemic control.

These exercises include cardiopulmonary function-improving activities such as brisk

walking, biking, badminton, tai-chi, and aerobics mediated by repeated exercise

involving large muscle groups (Haskell et al., 2007).

Another study by Diedrich and colleagues (2010), they explored the exercise

program outcomes on weight, body fat, glycosylated hemoglobin A1c levels, and blood

pressure. The participants who completed the program showed a significantly decrease in

weight, body fat, glycosylated hemoglobin A1c levels, and in their diastolic blood

pressure. The participants also showed an increase in their daily steps as indicated by a

pedometer. This study showed that the exercise behaviors can be related with the health

outcomes including glycosylated hemoglobin A1c levels, and the loss of weight and body

fat could be interpreted as an improvement in the health outcome of body mass index.

The exercise behaviors adherence rates between Type I and Type II diabetic patients

were 37% and 35% respectively (Delamater, 2008).

Moreover, in a study conducted by Castillo and colleagues (2010), they explored

the effect of a diabetes empowerment education program on diet, exercise, blood glucose

self-monitoring, depression, and glycosylated hemoglobin A1c levels. A significant effect

was seen on all the variables from the diabetes empowerment program. A significantly

increased in dietary, exercise, and blood glucose self-monitor behaviors were noted while

a significantly decreased in reported depression and glycosylated hemoglobin A1c levels

were seen.

According to Vallis and colleagues (2005) study, they explored the effect of the

diabetes management education program on blood glucose self-monitor, diet, exercise,

and glycosylated hemoglobin A1c levels. A significant effect was seen on all the

variables from the diabetes management education program. A significantly increased in

blood glucose self-monitoring, dietary, and exercise behaviors were noted while

significant decreases in glycosylated hemoglobin A1c levels were seen.

Health Outcomes

Treatment for Diabetes Mellitus involves restoring blood glucose to or near

normal levels in all patients. The American Diabetes Association (ADA) recommends a

treatment target for diabetes that includes a glycosylated hemoglobin A1c (HbA1c) level

less than 7% and a fasting blood sugar (FBS) of less than 120 mg/dl (American Diabetes

Association, 2000). Treatment for Type II Diabetes Mellitus is designed to maximize the

effect of endogenous insulin by decreasing insulin resistance (American Diabetes

Association, 2000). However, significant patient’s key role in self-management is

necessary to achieve the positive overall health outcomes. The following health outcomes

used in this study were body mass index (BMI), lipid profile, fasting blood sugar (FBS)

and glycosylated hemoglobin A1c (HbA1c).

Body Mass Index. Body Mass Index (BMI) is an accurate indicator of fat in

adults. The most commonly used BMI is Quetelet’s Index, which is obtained by dividing

weight in kilograms by height in meters squared (Dillon, 2007). According to the

National Institutes of Health (NIH) interpret BMI values for adults with one fixed

number, regardless of age or sex, using the following guidelines: (1) underweight: below

18.5; (2) normal weight: 18.5 to 24.9; (3) overweight: 25.0 to 29.9; and (4) obese: more

than 30 (Dillon, 2007).

Nearly 90% of individuals with Type II Diabetes Mellitus are overweight or

obese. Both body mass index (BMI) and body fat distribution are considered as strong

predictors of obesity-related health risks, especially the Type II Diabetes Mellitus. The

American Diabetes Association has stated that modest weight loss and reduced energy

intake will help the insulin-resistant individuals to improve their glycemic control

(Boucher et al., 2007).

Achievement of the ideal body mass index has been recommended among

diabetic individuals. Adherence to both diet and exercise behaviors have been considered

to contribute weight loss, which reduces the body mass index (Franz, 2007). Even though

the patient is still considered as overweight, as little as 5% to 10% of weight loss from the

initial weight can help to prevent the weight-related complications such as hypertension,

dyslipidemia, and Type II Diabetes Mellitus. However, weightwatchers may not be

satisfied with such modest goals and sometimes conclude that a desirable weight loss is

unachievable (Kazaks & Stern, 2003). According to Franz (2007) study, he stated that

although a reduction of body mass index has been linked with an improvement in

Diabetes Mellitus is still unclear if the weight loss itself is linked with reduction in

glycosylated hemoglobin A1c levels or if it is from the dietary changes of a decrease in

total energy intake.

Weight loss of more than 3% from the initial weight was linked with glycemic

control improvement in patients who are newly treated for Type II Diabetes Mellitus.

Anti-diabetics medicines associated with weight loss or neutrality were associated with

greater weight loss and glycosylated hemoglobin A1c goal attainment and may facilitate

efforts to co-manage weight and blood sugar in the ambulatory-care setting (McAdam et

al., 2014).

Diabetic control measures. The ideal of diabetic control was mainly assessed

by measuring fasting blood sugar (FBS), glycosylated hemoglobin A1c (HbA1c), blood

pressure and low density lipoprotein-cholesterol (LDL-C) (American Diabetes

Association, 2008). Reduced incidences of diabetes-related complications have been

reported when blood glucose, blood pressure and blood lipid are well controlled

(American Association of Diabetes Educators, 2008).

Lipid abnormalities are common in people with Type II Diabetes Mellitus. Insulin

resistance and central obesity are two closely linked factors that are important in

determining the additional lipid abnormalities found in Type II Diabetes Mellitus

(Brunzell & Hokanson, 1999). The role of insulin resistance in the pathogenesis of Type

II Diabetes Mellitus was recognized by Himsworth (1936) over 60 years ago. According

to Vague (1956) study, central obesity was recognized as a risk factor for the

development of Type II Diabetes Mellitus over 40 years ago and many succeeding

studies have confirmed this relationship.

The measurement of the glycosylated hemoglobin A1c (HbA1c) is a target

indicator suggested by the American Diabetes Association which provides a stable and

longer term measurement of glycemic control status. A glycosylated hemoglobin A1c can

provide a reliable blood sugar history of the previous 120 days, and most accurately

reflects the previous two to three months of glycemic control status. The American

Diabetes Association recommends routine glycosylated hemoglobin A1c testing, two

times per year in diabetic patients maintaining adequate glycemic control, and more

frequently among diabetic patients who have not maintained glycemic control or who

have changed their therapeutic regimen. The American Diabetes Association

recommends the goal of therapy as a glycosylated hemoglobin A1c of less than 7%, and

recommends that treatment be re-evaluated when glycosylated hemoglobin A1c exceeds

8% (American Diabetes Association, 2008).

Overall Summary of the Review

The literature and studies mentioned above provide information on the

determinants of the two variables of this study. The reviews will help bridge the known

from the unknown and as well as give mutual benefits between the patients involved and

the healthcare providers of explaining the possible results of this study.

Chapter III

METHODOLOGY AND PROCEDURES

This chapter presents the methodology involved in the completion of this

undertaking. It describes the processes which will be used to answer the problems of the

present study.

Design

This study utilized a descriptive-analytical research design to examine the

predictors of health outcomes among patients with Type II Diabetes Mellitus. This study

described the characteristics of the population group being studied and further attempted

to describe, explain, and interpret the conditions that already existing in records and

documents.

Environment

This study was conducted in Southern Philippines Medical Center, a tertiary

government retained hospital under the Department of Health, located at the J.P. Laurel

Avenue, Bajada, Davao City. The hospital offers specialty care program in treating adult

patients with Type I and II Diabetes Mellitus and its complications. This is located at the

Mindanao Diabetes Center Clinic at the second floor of Out-Patient Preventive and Care

Center Building every Tuesday and Wednesday from eight in the morning up to twelve

noon.

The Mindanao Diabetes Center Clinic is one of the clinical services offered by the

Department of Internal Medicine. The clinic is also catering pediatric patients and is

manned by a Diabetes Nurse Educator. There are department guidelines and work

instructions followed by the Resident Physicians and Medical Specialists prior they refer

and/or enroll their patients to Mindanao Diabetes Center Clinic. The patient must be

diagnosed with Diabetes Mellitus in any type with supportive health history and diabetic

control measure results including lipid profile, fasting blood sugar and glycosylated

hemoglobin A1c. The patients are instructed when to visit the clinic without fail in as

much as once a month in order to monitor and evaluate their prognosis. Implemented

programs and activities to date are Diabetes Education and Insulin Therapy

Administration.

Respondents

The respondents were the adult patients. The eligibility criteria for the study

participation were as followed: (1) age 18 and above; (2) diagnosed of at least one year

with Type II Diabetes Mellitus; (3) no previous surgeries or hospitalizations from May

2015 up to date of scheduled interview; (4) independent and with little assistance in self-

care activities; (5) able to read, understand and sign informed consent; (6) lives in a home

setting; and (7) currently out-patient status. The non-probability convenience sampling

technique was used in this study. The researcher was allowed to select respondents based

on the above eligibility criteria. There were 128 patients with Type II Diabetes Mellitus

obtained who sought consultation within the period from July 14 to 22, 2015 and were

completely enumerated. A power analysis was performed to determine the acceptable

minimum sample size for this study.

Instruments

Health Interview Questionnaire was used to obtain secondary data from the

respondents. This was adapted-and-modified both from the National Health and Nutrition

Examination Survey (NHANES) and Diabetes Attitudes, Wishes and Needs (DAWN™)

Study.

NHANES is one of the major programs of the National Center for Health

Statistics (NCHS) by the Centers for Disease Control and Prevention (CDC). In early

1960s, the NHANES program was first initiated and had been conducted as a series of

surveys primary focusing on different population groups or health topics. The survey

became a continuous program from 1999 up to date of which it has a changing focus on

health and nutrition measurements variation to meet the emerging necessities of different

population groups (Centers for Disease Control and Prevention, 2015).

DAWN™ Study was first started in 2001 and was introduced by the Novo

Nordisk in partnership with the International Diabetes Federation (IDF) and an

international advisory panel comprising prominent diabetes mellitus specialists and

patient advocates. The first DAWN™ Study was considered to be the largest conducted

study of its kind to explore the psychosocial challenges faced by diabetic individuals and

the people helping them, and search new ways on the improvement of the Diabetes

Mellitus care. In spite of the availability of effective treatments, less than half of diabetic

populations were able to achieve adequate glycemic control; hence, the study was

initiated (Diabetes Attitudes, Wishes and Needs, 2015).

The survey instrument used in this study was divided into five parts: (1) personal

factors; (2) perceived barriers to action; (3) situational influences; (4) health-promoting

behaviors; and (5) health outcomes. The survey instrument was translated from English

version to local dialect version, Cebuano version, in order to understand by the

respondents the questions that were being asked in their own vernacular language. The

Cebuano version of the survey instrument was preliminary developed in this study. Ten

respondents who were not considered to be part of this study were involved for critiques

and pilot trials for content validity of the Cebuano version survey instrument. Reliability

test was also performed using cronbach’s alpha with a grand result of 0.892 interpreted as

very good.

The responses on the survey instrument were treated correspondingly and

interpreted based on the scale below:

Problem Areas in Diabetes Survey Parameter LimitsScale Interpretations Parameter Limits

4 Serious problem 3.21 – 4.03 Somewhat serious problem 2.41 – 3.22 Moderate problem 1.61 – 2.41 Minor problem 0.81 – 1.60 Not a problem 0 – 0.8

Adherence Level to Health-Promoting Behaviors Survey Parameter LimitsScale Interpretations Parameter Limits

5 Always/ Excellent 4.21 – 5.04 Oftentimes/ Very Good 3.41 – 4.23 Sometimes/ Good 2.61 – 3.42 Rarely/ Fair 1.81 – 2.61 Never/ Poor 1.0 – 1.8

Data Gathering Procedure

To be able to fully determine the important details and information, the researcher

devised a systematic approach to fully compensate the time involved therein.

Before the researcher carried out this study, a transmittal letter was addressed to

the Dean of Graduate School Department of University of the Visayas, the Medical

Center Chief of Southern Philippines Medical Center and as well as the informed consent

form for the respondents was considered, seeking approval to conduct this study. The

informed consent form was translated from English version to local dialect version,

Cebuano version, in order to understand by the respondents the purpose of this study in

their own vernacular language before they signed the form. Furthermore, the researcher

sought for permission to the respondents to conduct physical examination to obtain the

body measurements such as weight and height and to review the chart to obtain the

diabetic control measure results such as lipid profile, fasting blood sugar and

glycosylated hemoglobin A1c from the records of Mindanao Diabetic Center Clinic of

Southern Philippines Medical Center within the period from January to July 2015. The

researcher of this study utilized the health interview questionnaires to the respondents to

answer the following questions regarding on the profiles including personal factors, too

many treatments as perceived barriers to action and situational influences, the adherence

level to health-promoting behaviors, and the health outcomes.

Data Analysis

The gathered data were tabulated for the analysis and converted into Statistical

Package for the Social Sciences (SPSS) data files using Statistical Analysis System

(SAS) Version 21 software using the following statistical treatment: (1) frequency,

percentage and weighted mean were used for the profiles of the patients; (2) weighted

mean was used for the adherence level of the patients to health-promoting behaviors; (3)

frequency and percentage were used for the patients’ health outcomes; and (4) logistic

regression analyses were performed for the predictors of health outcomes among patients

with Type II Diabetes Mellitus.

Ethical Considerations

Approvals of the study were obtained from the Office of Dean of Graduate School

of the University of the Visayas and Integrated Research Board of Southern Philippines

Medical Center. The potential respondents were invited to listen to a short discussion of

the study objectives and all the queries were entertained right after the discussion. After

the study objectives discussed and explained very well, selected eligible respondents who

agreed to be part of the study were asked to sign two copies of informed consent form

(one for the researcher’s copy and the other one was the respondent’s copy). The

researcher obtained the informed consent at the Mindanao Diabetes Clinic Center in

Southern Philippines Medical Center. The information from this study was kept as

confidential as possible. The researcher did not reveal information about the respondents

to a third party without their consent or a clear legal reason. All transcripts and

summaries were given codes and stored separately from any names or other direct

identification of the respondents. Study information was kept in locked files at all times.

Only the researcher has the access to the files and essential need to see names had

accessed to that particular file. 

The researcher did not force anybody to participate in this study researcher. If the

respondents did not decide to participate in this research, there was no further

consequence be made. If the respondents decided to participate, the respondents may stop

participating at any time and the respondents may decide not to answer any specific

question. The researcher respected the respondents’ decision if they decided to withdraw

or refuse to participate in the study, and they were not be penalized or given charges for

that matter. The data were encoded in the computer. There was no identifying

information encoded to the computer so that the information cannot be traced back to the

respondent concerned. Only the researcher had the access to the data and the interview

schedule. The interview schedules were kept at the data storage area at the Graduate

School Department of the University of the Visayas. The interview schedule kept for a

period of five years. After five years, the interview schedule disposed of by shredding.

There was no conflict of interest happen in this study. This study did not receive funds or

support from any source.

Chapter IV

PRESENTATION, ANALYSIS, AND INTERPRETATION OF DATA

This chapter presents the data collected from the different respondents of the

study. The presentation and interpretation of data are laid out following the order of the

specific problems, as follows:

Part I listed the profile of the patients with Type II Diabetes Mellitus in terms of

personal factors such as age, sex, civil status, occupation, financial status, length of

disease diagnosis, perceived health status, weight and height; treatments as perceived

barriers to action; and situational influences. The responses were based on the data

gathered from the survey.

Part II showed the adherence level of the patient with Type II Diabetes Mellitus to

health-promoting behaviors in terms of health responsibility, medication adherence,

dietary, and exercise behaviors. The responses were also based on the data gathered from

the survey.

Part III showed the health outcomes of the patient with Type II Diabetes Mellitus

in terms of body mass index, lipid profile, fasting blood sugar, and glycosylated

hemoglobin A1c. The responses were obtained through actual assessment.

Part IV showed the predictors of the health outcomes of the patients with Type II

Diabetes Mellitus. The predictors were computed using the logistic regression.

Lastly, Part V showed the health promotion program that can be developed based

on the findings of the study. The health promotion program is a matrix-based plan that

shows the pre-determined predictors with low indicators.

Profiles of the patients with Type II Diabetes Mellitus

Table 1 shows personal factors of the patients with Type II Diabetes Mellitus such

as age, sex, education, civil status, occupation, financial status, length of disease

diagnosis, perceived health status, and body measurements including weight and height.

In terms of age, more than half of the respondents were 60 years old and above,

comprising 66.4% and the majority of the respondents were females, comprising 68.8%.

Almost half of the respondents obtained at least vocational education, comprising 42.2%

and approximately half of the respondents were married, comprising 52.2%.

Approximately one-third of the respondents were retired, comprising the 29.7% and most

of the respondents live with below-average salaries, comprising 79.7%. The length of

disease diagnosis showed more than 16 years, comprising the 35.9%. Most of the

respondents perceived a good health status, comprising the 40.6%. For the weight, most

of the respondents were less than 50 kilograms, comprising 23.4%. Finally, the average

height of the respondents was within the 1.54 to 1.69 meters range (5’1 to 5’6 feet),

comprising 64.1%.

As noted, age can affect the diabetes treatment care regimen, especially in older

individuals. Older diabetic individuals are often have poor financial status, experience

higher frequency of social isolation and depression, and are often more susceptible to

hypoglycemic episodes (Sinclair, 2006). On the other hand, as noted, health behaviors are

dynamically different between men and women. Women and men also differ in health

care utilization, with men generally utilizing fewer health services (Courtenay, 2000).

Although women are more likely to seek preventive care, extensive research has

documented sex disparities in the care that men and women receive (Bird et al., 2007).

Table 1.

Personal Factors of the patients with Type II Diabetes MellitusProfile Indicators n %

Age 18 to 29 years 6 4.730 to 39 years 4 3.140 to 49 years 12 9.450 to 59 years 21 16.460 years and above 85 66.4

Sex Male 40 31.3Female 88 68.8

Educational attainment Elementary 12 9.4High School 51 39.8Vocational 54 42.2College 3 2.3Post-Graduate 8 6.3

Civil status Single 7 5.5Married 67 52.3Widow/Widower 42 32.8Annulled/Separated 12 9.4

Occupation Unemployed 33 28.5Self-Employed 31 24.2Employed 26 20.3Retired 38 29.7

Financial status Below Average 102 79.7Average 25 19.5Above Average 1 0.8

Length of disease diagnosis 1 to 5 years 9 7.06 to 10 years 29 22.711 to 15 years 44 34.4More than 16 years 46 35.9

Perceived health status Poor 12 9.4Fair 46 35.9Good 52 40.6Very Good 18 14.1

Weight Less than 50 kg 30 23.451 to 55 kg 28 21.956 to 60 kg 15 11.761 to 65 kg 28 21.966 to 70 kg 17 13.3More than 71 kg 10 7.8

Height Less than 1.53 m (5 ft.) 25 19.51.54 to 1.69 m (5’1 to 5’6 ft.)1.70 to 1.84 m (5’7 to 6 ft.)

8221

64.116.4

Note: n=128

The associations between educational attainment and health behaviors are

particularly important in Diabetes Mellitus, given the critical role of health behaviors,

including diabetes self-care management and health-related lifestyle (Mirowsky, 1998).

As noted, lower educational attainment is strongly associated with worse health literacy

(Baker et al., 1998) and inadequate health literacy has been linked to poorer health status

(Street et al., 1993). Diabetic individuals who have inadequate or marginal literacy are

less likely to know the hypoglycemic symptoms (Williams, 1998) and they have higher

results of glycosylated hemoglobin A1c (Schillinger, 2002).

As noted, the influence of wealth on healthcare access and utilization of

healthcare services affects the individual’s adherence to health promoting behaviors.

Even within publicly and universally accessible systems, there is evidence that

individuals from lower financial groups have impaired access to care reflected in longer

wait times and fewer referrals to specialist care (Dunlop et al.; 2002). According to the

study of Rabi and colleagues (2006), they explored the association between financial

status with prevalence and utilization of diabetes care services. Their findings showed

that low income earners have higher prevalence of Diabetes Mellitus than those high

income earners.

According to the study conducted by Rhee and colleagues (2005) explored the

relationship between length of diabetes diagnosis, and glycosylated hemoglobin A1c

levels and the study obtained significant results. The length of diabetes diagnosis was

found to be positively related to glycosylated hemoglobin A1c level. The longer the

diagnosis the higher the glycosylated hemoglobin A1c level.

Perceived health is a subjective assessment that people make about their own

health state and it is an indicator of over-all health status (European Community Health

Indicators and Monitoring, 2010). According to Mitchell and colleagues (2004) study,

they explored the relationship between perceived health status, blood glucose self-

monitor, and glycosylated hemoglobin A1c levels but no significant relationship was

found between these variables.

Table 2 shows treatments as perceived barriers to action of the patients with Type

II Diabetes Mellitus. The 60 respondents (46.88%) with Type II Diabetes Mellitus agreed

that there were too many treatments to manage. The least number of respondents (7.81%)

strongly disagreed on this indicator.

Table 2.

Treatments as Perceived Barriers to Action of the patients with Type II Diabetes MellitusIndicators n %

Strongly Agree 44 34.38Agree 60 46.88Disagree 14 10.94Strongly Disagree 10 7.81

Note: n=128

This may be due to financial or logistical barriers include physical limitations of access to

services, time and locations, financial cost, local availability of services and ongoing support

once people have had self-care management training or guidance. System barriers include

conflicting advice or a lack of collaborative working between healthcare social care professionals

in providing joined up information, services and ongoing support for self-care management

(Diabetes UK, 2009).

As noted, this is due to constraints of time, limited social support and coping skills, the

lack of knowledge related to diabetes management, helplessness and frustration from lack of

glycemic control, and continued disease progression despite adherence. Although some of these

Table 3.

Situational Influences of the patients with Type II Diabetes MellitusIndicators Mean Interpretation

1. Not having clear and concrete goals for your diabetes care.

1.34 Minor problem

2. Feeling discouraged with your diabetes treatment plan.

1.52 Minor problem

3. Feeling scared when you think about living with diabetes.

1.97 Moderate problem

4. Uncomfortable social situations related to your diabetes care (e.g., people telling you what to eat).

1.98 Moderate problem

5. Feelings of deprivation regarding food and meals.

1.99 Moderate problem

6. Feeling depressed when you think about living with diabetes.

1.73 Moderate problem

7. Not knowing if your mood or feelings are related to your diabetes.

1.87 Moderate problem

8. Feeling overwhelmed by your diabetes. 1.95 Moderate problem9. Worrying about low blood sugar reactions. 2.30 Moderate problem

10. Feeling angry when you think about living with diabetes.

2.16 Moderate problem

11. Feeling constantly concerned about food and eating.

2.13 Moderate problem

12. Worrying about the future and the possibility of serious complications.

2.56 Somewhat serious problem

13. Feelings of guilt or anxiety when you get off track with your diabetes management.

2.11 Moderate problem

14. Not accepting your diabetes. 1.88 Moderate problem15. Feeling unsatisfied with your diabetes

physician.1.73 Moderate problem

16. Feeling that diabetes is taking up too much of your mental and physical energy every day.

2.09 Moderate problem

17. Feeling alone with your diabetes. 2.14 Moderate problem18. Feeling that your friends and family are not

supportive of your diabetes management efforts.2.02 Moderate problem

19. Coping with complications of diabetes. 2.55 Somewhat serious problem

20. Feeling burned out by the constant effort needed to manage diabetes.

2.59 Somewhat serious problem

Grand Mean 2.03 Moderate problemNote: n=128. 3.21-4.0 Serious problem; 2.41-3.2 Somewhat serious problem; 1.61-2.4 Moderate problem; 0.81-1.6 Minor problem; 0-0.8 Not a problem

barriers may appear static and not likely to change and many of these perceived barriers can vary

in intensity from day to day.

Table 3 shows situational influences of the patients with Type II Diabetes

Mellitus. Worrying about the future and the possibility of serious complications

(Mean=2.56), coping with complications of diabetes (Mean=2.55), and feeling burned

out by the constant effort needed to manage diabetes (Mean=2.59) were all rated as

somewhat serious problem. The overall situational influences had a grand mean of 2.08,

which means that the respondents considered it a moderate problem.

It is part of a person’s experience of managing diabetes and its treatment in the

social context of family and health-care personnel (Fisher et al., 2012; and Polonsky et

al., 2005). The under recognition of emotional problems, such as depression, anxiety, and

diabetes-specific emotional distress, has been reported (Pouwer et al., 2006), and when

such concerns are recognized, problems might be identified as depression, even in

patients whose problems are directly related to diabetes and its treatment related to

diabetes and its treatment (Gonzales et al., 2011).

Thus, as observed, it became a problem when there is a little support from the

family or peers, particularly financial, emotional, and psychological support. People with

diabetes have to be assessed in partnership with the person as part of the care planning

process. Family relationships play an important role in diabetes management particularly

in communication, regimen, and low conflict levels.

The respondents worry about the future and the possibility of serious

complications (Mean=2.56), which was somewhat a serious problem. Later in life, poor

stress management and coping mechanism have been linked with more adherence

problems (Peyrot et al., 1999). Diabetes-related emotional distress such as anxiety,

depression, and eating disorders has also been associated with worse diabetes

management in both young and adult diabetic population groups (Delameter et al., 2001).

As noted, the respondents did not foresee themselves with a bright future ahead as

patients with Type II Diabetes Mellitus. Coping mechanisms were weak as it had always

been associated with problems. Most of the respondents were stressed and depressed,

thus having eating disorders. The respondents did not see themselves to be healthy in the

future and believed it was only going to get worse; thus, it posed a serious problem to

most respondents.

However, not having clear and concrete goals for diabetes care (Mean=1.34) was

a minor problem. Perceived barriers have an important role in the self-care process

among diabetic individuals. Important barriers are non-awareness of health nutritional

program, lack of social support and self-management perception (Nagelkerk et al., 2006).

Rothman and colleagues (2008) showed inappropriate diet and sport habit in these

patients was related with perceived barriers. In the study of Glasgow and colleagues

(2001), there is a significant but reverse relationship between perceived barriers to action

and self-care behaviors.

As noted, it was only a minor problem for not having clear and concrete goal for

diabetes care because respondents were already aware on how to perform self-care, diet

management and being able to know the importance of sport as part of the day-to-day

activities of the patient with Type II Diabetes Mellitus.

Adherence Level to Health-Promoting Behaviors of the patients with Type II Diabetes Mellitus

Table 4 shows the level of adherence of the patients with Type II Diabetes

Mellitus to health-promoting behaviors in terms of health-promoting behaviors had a

factor mean of 3.44 rated as very good, medication adherence behaviors had a factor

mean of 3.61 rated as very good, dietary behaviors had a factor mean of 3.59 rated as

very good, and exercise behaviors had a factor mean of 2.93 rated as good.

In spite of the remarkable success in improving the lives of those living with

Diabetes Mellitus with technological innovation in biomedical sciences, the management

of Type II Diabetes Mellitus lies largely with those with diabetic individuals. It includes

the practices that must be carried out by the patients themselves. Such practices include

eating a healthy diet, performing physical activity, taking prescribed medications, self-

monitoring of blood glucose level, regular clinic appointments, and stress management,

among other practices (American Diabetes Association, 2002).

Table 4.

Adherence Level to Health-Promoting Behaviors of the patients with Type II Diabetes Mellitus

Indicators Mean InterpretationHealth-Responsibility Behaviors

1. I visit my doctor periodically. 3.47 Very good2. I self-monitor my blood sugar daily. 3.45 Very good3. I have Lipid Profile, Fasting Blood Sugar (FBS)

and Glycosylated Hemoglobin A1c (HbA1c) examined periodically.

3.41 Very good

Factor Mean 3.44 Very goodMedication Adherence Behaviors

1. I take my prescribed medications on time daily. 3.73 Very good2. I never forget to take my prescribed

medications.3.70 Very good

3. Sometimes if I feel worse when taking the prescribed medications, I never stop taking it.

3.52 Very good

4. Even if I feel better, I still take my prescribed medications.

3.51 Very good

Factor Mean 3.61 Very goodDietary Behaviors

1. I control my diet while eating outside. 3.51 Very good2. I avoid high fat, oily and sweet foods intake. 3.55 Very good3. I am concerned with my blood sugar. 3.69 Very good4. I have a balanced diet. 3.55 Very good5. I include fruits and vegetables intake daily. 3.63 Very good

Factor Mean 3.59 Very good

Indicators Mean InterpretationExercise Behaviors

1. I do 150-minutes exercise every week. 3.01 Good2. On bad-weather days, I do exercise. 2.86 Good

Factor Mean 2.93 GoodGrand Mean 3.39 Good

Note: n= 128. 4.21-5.0 Excellent; 3.41-4.2 Very good; 2.61-3.4 Good; 1.81-2.6 Fair; 1.0-1.8 Poor

As noted, the health-promoting behavior was perceived only good because of the

practices of the patients itself. The respondents only sometimes performed exercises,

being responsible for their health, and even daily intake of medicines. Diabetic

individuals are expected to follow a multifaceted set of behaviors to manage their chronic

disease on a daily basis. The respondents must engage in a healthy lifestyle, which

includes meal planning and engaging in appropriate physical activities as well adherence

to medication. However, many respondents still did not follow steps to good health and

continually live an unhealthy lifestyle through binge eating and having a sedentary

lifestyle.

Health-responsibility behaviors had a factor mean of 3.44, which was rated very

good. Successful control of diabetes mellitus requires lifelong adherence to multiple self-

management activities in close collaboration with the healthcare professionals. Lack of

adherence to such activities had been revealed to be linked with negative health

outcomes. For instance, prescription refill adherence to diabetes mellitus medications

correlates with improved glycosylated hemoglobin A1c results (Schectman et al., 2002).

As noted, the patients with Type II Diabetes Mellitus periodically visited their physicians

for check-ups, and monitored their blood sugar on a regular basis. That is why there is

better control of the sugar in the blood to good level.

The respondents visited their doctors periodically (Mean=3.47), which was rated

very good. Successful control of diabetes mellitus requires lifelong adherence to multiple

self-management activities in close collaboration with the healthcare professionals

(Schectman et al., 2002). As noted, continuous collaboration with the healthcare

professionals can aid in the control of the sugar; thus, promoting long life to the patients

with Type II Diabetes Mellitus.

However, the respondents had lipid profile, fasting blood sugar (FBS) and

glycosylated hemoglobin A1c (HbA1c) examined periodically (Mean=3.41) was rated

very good, but the lowest among the indicators. As observed, these medical laboratory

tests were done oftentimes but the lowest in the indicator since these would require

substantial amount of money to take these tests particularly the lipid profile, which is

very expensive.

Medication adherence behaviors had a factor mean of 3.61, which was rated very

good. The goal of the medical treatment is primarily to save life and alleviate symptoms.

Secondary goals are to prevent long term diabetic-related complications and, by

eliminating various risk factors, to increase longevity. Insulin replacement therapy is

considered to be one of the cornerstones for the patients with Type I Diabetes Mellitus

while diet and lifestyle modifications are for the treatment and management of Type II

Diabetes Mellitus patients. Oral hypoglycemic agents are also useful in the treatment of

Type II Diabetes Mellitus (Bastaki, 2005). As noted, the respondents wanted to live a

longer, healthy life; thus, most of the respondents got medical treatment in the event of

secondary symptoms appears.

The respondents took the prescribed medication on time daily (Mean=3.73),

which was rated very good. The results from the study of Diabetes Attitudes, Wishes, and

Needs (DAWN) conducted by Novo Nordisk, the study showed patient-reported

medication adherence rates between Type I and Type II Diabetes Mellitus were 83% and

78% respectively (Delamater, 2008). Another study using a large national sample of

patients with Type II Diabetes Mellitus showed that only 24% of insulin-treated patients,

65% of oral medications-treated patients, and 80% of those treated by both diet and

exercise alone either never practiced blood glucose self-monitoring or did so less than

once a month (Harris et al., 2001). Thus, as observed, the respondents adhered to

prescribed medication on a daily basis by following the medication pattern prescribed by

the healthcare professionals.

However, even if the respondents feel better, they still take the prescribed

medications (Mean=3.51), rated very good. As noted that this was the lowest indicator

because respondents highly regarded the medication instruction given to them by the

medical professionals by attending into detail the prescribed medication to prolong their

lives and live a healthy lifestyle.

For the dietary behaviors, it had a factor mean of 3.59, which was rated very

good. Dietary management is considered to be one of the cornerstones in treatment of

Diabetes Mellitus. It is based on the adherence of healthy diet behaviors in the context of

social, cultural, and psychological influences on food choices (Ekore et al., 2008). As

noted, respondents had control in their diet while eating outside and most of them

avoided high fat, oily and sweet food intake as well as being concerned with their blood

sugar. Most respondents had balanced diet and included fruits and vegetables in their

daily intake.

The respondents were concerned with their blood sugar (Mean=3.69), which was

rated very good. Daily blood glucose self-monitoring is believed to be essential for the

diabetic patients under treatment to detect asymptomatic hypoglycemia and to guide the

patients and healthcare providers’ behaviors toward reaching the adequate blood glucose

control (Harris, 2001). Blood glucose self-monitoring provides detail about current

glycemic status and assessment of current therapy including modifications in medication,

diet, and exercise in order to attain optimal glycemic control (Shrivastava et al., 2013). As

observed that part of medication or self-care involved checking one’s blood sugar on a

regular basis.

However, the respondents controlled their diets while eating outside

(Mean=3.51), although rated very good, was the lowest among the indicators. As noted

that respondents followed the same diet pattern even when eating outside and did not

differ with the general population (Laar et al., 2006).

For the exercise behaviors, it had a factor mean of 2.93, which was rated good.

Exercise has been considered as an essential component of diabetes management.

Diabetes specialists have established exercise as one of the four cornerstones of health-

promoting behaviors, along with medication, diet and blood glucose self-monitoring.

Exercise appears to support in the visceral fat loss. More recent study suggested that

exercise may exert favorable effects on emerging vascular disease risk factors. Exercise

may also play a protective role by increasing patient resilience to the emotional stress and

depression often experienced with diabetes management (Zacker, 2004). However, as

noted, this was only rated good as most of the respondents lived a sedentary lifestyle. The

respondents did not involve much of their time into brisk exercise.

Most respondents did 150-minute exercise every week (Mean=3.01), which was

rated good. A weekly 150-minute moderate-intensity exercise can improve glycemic

control. These exercises include cardiopulmonary function-improving activities such as

brisk walking, biking, badminton, tai-chi, and aerobics mediated by repeated exercise

involving large muscle groups (Haskell et al., 2007). As observed, inactive lifestyles of

the respondents, this really did not involve themselves in exercise like brisk walking,

biking, badminton, and others. However, respondents exercised even on bad-weather days

(Mean=2.86), rated good, was the lowest indicator. As noted, whether on good or bad

weather days, respondents did not have enough exercise.

Table 5 shows the summary of level of adherence of the patients with Type II

Diabetes Mellitus to health-promoting behaviors in terms of health-responsibility,

medication adherence, dietary and exercise behaviors. It had a grand mean of 3.39, which

was rated good.

Table 5.

Summary of Adherence Level to Health-Promoting Behaviors of the patients with Type II Diabetes Mellitus

Indicators Factor Mean InterpretationHealth-Responsibility Behaviors 3.44 Very goodMedication Adherence Behaviors 3.61 Very goodDietary Behaviors 3.59 Very goodExercise Behaviors 2.93 Good

Grand Mean 3.39 GoodNote: n=128. 4.21-5.0 Excellent; 3.41-4.2 Very good; 2.61-3.4 Good; 1.81-2.6 Fair; 1.0-1.8 Poor

Health-responsibility behaviors had a factor mean of 3.44, which was rated very

good. Successful control of Diabetes Mellitus requires lifelong adherence to multiple

self-management activities in close collaboration with the healthcare professionals. Lack

of adherence to such activities has been revealed to be linked with negative health

outcomes. For instance, prescription refill adherence to diabetes mellitus medications

correlates with improved glycosylated hemoglobin A1c results (Schectman et al., 2002).

As noted, the patients with Type II Diabetes Mellitus periodically visited their physicians

for check-ups, and monitored their blood sugar on a regular basis. That is why there is

better control of the sugar in the blood to good level.

Medication adherence behaviors had a factor mean of 3.61, which was rated very

good. The goal of the medical treatment is primarily to save life and alleviate symptoms.

Secondary goals are to prevent long term diabetic-related complications and, by

eliminating various risk factors, to increase longevity. Insulin replacement therapy is

considered to be one of the cornerstones for the patients with Type I Diabetes Mellitus

while diet and lifestyle modifications are for the treatment and management of Type II

Diabetes Mellitus patients. Oral hypoglycemic agents are also useful in the treatment of

Type II Diabetes Mellitus (Bastaki, 2005). As noted, the respondents wanted to live a

longer, healthy life; thus, most of the respondents got medical treatment in the event of

secondary symptoms appears.

For the dietary behaviors, it had a factor mean of 3.59, which was rated very

good. Dietary management is considered to be one of the cornerstones in treatment of

Diabetes Mellitus. It is based on the adherence of healthy diet behaviors in the context of

social, cultural, and psychological influences on food choices (Ekore et al., 2008). As

noted, respondents had controlled in their diet while eating outside, and most of them

avoided high fat, oily and sweet food intake as well as being concerned with their blood

sugar. Most respondents had balanced diet and included fruits and vegetables in their

daily intake.

For the exercise behaviors, it had a factor mean of 2.93, which was rated good.

Exercise has been considered as an essential component of diabetes management.

Diabetes specialists have established exercise as one of the four cornerstones of health-

promoting behaviors, along with medication, diet and blood glucose self-monitoring.

Exercise appears to support in the visceral fat loss. More recent study suggested that

exercise may exert favorable effects on emerging vascular disease risk factors. Exercise

may also play a protective role by increasing patient resilience to the emotional stress and

depression often experienced with diabetes management (Zacker, 2004). However, as

noted, this was only rated good as most of the respondents lived a sedentary lifestyle. The

respondents did not involve much of their time into brisk exercise.

Health Outcomes of the patients with Type II Diabetes Mellitus

Table 6 shows the health outcomes of the patients in terms of the actual

assessment. Most of the respondents had body mass indices that were normal, comprising

73.4%; and, those who were above normal only comprised 26.6%. The lipid results of the

respondents were mostly normal, comprising 78.1%; and, those who were above normal

only comprised 21.9%. The fasting blood sugar of the respondents was mostly normal,

comprising 80.5%; and, above normal comprised 19.5%. Finally, the result in

glycosylated hemoglobin A1c showed more normal diagnoses at 53.1%; and, those above

normal resulted at 46.9% as the least.

Table 6.

Health Outcomes of the patients with Type II Diabetes MellitusIndicators N %

Body Mass Index Normal 94 73.4Above Normal 34 26.6

Lipid Profile Normal 100 78.1Above Normal 28 21.9

Fasting Blood Sugar Normal 103 80.5Above Normal 25 19.5

Glycosylated Hemoglobin A1c NormalAbove Normal

6860

53.146.9

Note: n=128

As noted, the overall health outcomes of the patients with Type II Diabetes

Mellitus were normal. Treatment for Diabetes Mellitus involves restoring blood glucose

to or near normal levels in all patients. The American Diabetes Association (ADA)

recommends a treatment target for diabetes that includes a glycosylated hemoglobin A1c

(HbA1c) level less than 7% and a fasting blood sugar (FBS) of less than 120 mg/dl

(American Diabetes Association, 2000). Treatment for Type II Diabetes Mellitus is

designed to maximize the effect of endogenous insulin by decreasing insulin resistance

(American Diabetes Association, 2000). However, significant patient’s key role in self-

management is necessary to achieve the positive overall health outcomes.

Predictor of Health Outcomes for Body Mass Index

Table 7 shows the predictors of health outcomes of the patients in terms of body

mass index. The perceived barriers to action, situational influences, health responsibility,

medication adherence, dietary, exercise, age, educational attainment, civil status,

occupation, financial status, length of disease diagnosis, and perceived health status had

p-values greater than 0.05. Thus, the aforementioned factors did not predict the health

outcomes for body mass index of the patient with Type II Diabetes Mellitus.

Table 7.

Predictor of Health Outcomes for Body Mass IndexPredictors B p Exp(B) Decision Interpretation

Personal FactorsAge 0.160 0.719 1.174 Accept Ho Not significantSex 2.740 0.022 15.482 Reject Ho SignificantEducational attainment -0.597 0.305 0.551 Accept Ho Not significantCivil status -1.001 0.142 0.368 Accept Ho Not significantOccupation 0.463 0.249 1.588 Accept Ho Not significantFinancial status 1.840 0.109 6.300 Accept Ho Not significantLength of disease diagnosis -0.924 0.147 0.397 Accept Ho Not significantPerceived health status -0.841 0.143 0.431 Accept Ho Not significantWeight 2.493 0.000 12.101 Reject Ho SignificantHeight -3.453 0.001 0.032 Reject Ho Significant

Treatments as Perceived Barriers to Action

0.420 0.388 1.522 Accept Ho Not significant

Situational Influences -0.152 0.775 0.859 Accept Ho Not significantHealth-Promoting BehaviorsHealth-responsibility behaviors 0.305 0.687 1.357 Accept Ho Not significantMedication adherence behaviors 1.561 0.073 4.762 Accept Ho Not significantDietary behaviors -1.877 0.094 0.153 Accept Ho Not significantExercise behaviors 0.080 0.918 1.083 Accept Ho Not significant

(Constant) -4.815 0.429 0.008 Accept Ho Not significantNote: Significant at p < 0.05

The BMI can be predicted using the following model: BMI = 2.740 (Sex) + 2.493

(Weight) – 3.453 (Height). Thus, if sex is female (sex=2), weight is less than 50

kilograms (weight=1), and height is between 1.54 to 1.69 meters (5’1 to 5’6 feet)

(height=2), then BMI = 2.74(2) + 2.493(1) – 3.453(2) then BMI = 1.067. Thus, BMI is

below normal (BMI=1) for a female who weighs less than 50 kilograms and whose height

is between 1.54 to 1.69 meters (5’1 to 5’6 feet).

If sex is a male (sex=1), weight is less than 50 kilograms (weight=1), and height

is less than 1.53 meters (5 feet) (height=1), then BMI = 2.74(1) + 2.493(1) – 3.453(1)

then BMI = 1.78 (approximately 2). Thus, BMI is above normal (BMI=2) for a male

patient whose weight is less than 50 kilograms and whose height is less than 1.53 meters

(5 feet).

However, sex had a p-value of 0.022, which rejected the null hypothesis. Sex was

a predictor for health outcomes for body mass index. The females were 15.48 times more

likely to become obese. Health behaviors are dynamically different between men and

women. While most studies have found that men are more physically active than women.

Women’ exercise patterns are more health-promoting and sustainable relative to those of

men (Dean, 1989). Women and men also differ in health care utilization, with men

generally utilizing fewer health services (Courtenay, 2000). Although women are more

likely to seek preventive care, extensive research has documented sex disparities in the

care that men and women receive (Bird et al., 2007). With this, as observed that since

men had more physically active lifestyle than women, and then it showed that women

tend to become more obese than men.

The weight and height had p-value of 0.000 and 0.001 respectively, which

rejected the null hypothesis. Thus, weight and height were predictors to health outcomes

for body mass index. Respondents with weights less than 50 kilograms are 12.1 times

more likely to have normal body mass index and respondents with heights between 1.54

to 1.69 meters were 0.032 times more likely to have normal body mass index. Body Mass

Index is an accurate indicator of fat in adults. Nearly 90% of individuals with Type II

Diabetes Mellitus are overweight or obese. Body Mass Index and body fat distribution,

which individuals’ weight must be proportionate to their height, are both considered as

strong predictors of obesity-related health risks, especially the Type II Diabetes Mellitus.

The American Diabetes Association has stated that modest weight loss and reduced

energy intake will help insulin-resistant individuals improve their glycemic control

(Boucher et al., 2007). As noted, periodic weight monitoring could help respondents to be

more cognizant about their weight and calculated BMI changes in concordance to health-

promoting behaviors.

Predictor of Health Outcomes for Lipid Profile

Table 8 shows the predictor of health outcomes in terms of the lipid profile. The

perceived barriers to action, situational influences, health-responsibility, medication

adherence, dietary, exercise, age, sex, educational attainment, civil status, occupation,

financial status, length of disease diagnosis, perceived health status, and height had p-

Table 8.

Predictor of Health Outcomes for Lipid ProfilePredictors B p Exp(B) Decision Interpretation

Personal FactorsAge -0.169 0.593 0.844 Accept Ho Not significantSex 0.272 0.719 1.312 Accept Ho Not significantEducational attainment -0.395 0.310 0.673 Accept Ho Not significantCivil status -0.173 0.709 0.842 Accept Ho Not significantOccupation 0.200 0.516 1.221 Accept Ho Not significantFinancial status 0.821 0.268 2.272 Accept Ho Not significantLength of disease diagnosis -0.424 0.279 0.654 Accept Ho Not significantPerceived health status -0.689 0.079 0.502 Accept Ho Not significantWeight 0.713 0.002 2.041 Reject Ho SignificantHeight -1.010 0.110 0.364 Accept Ho Not significantTreatments as Perceived Barriers to Action

0.664 0.064 1.942 Accept Ho Not significant

Situational Influences -0.578 0.147 0.561 Accept Ho Not significantHealth-Promoting BehaviorsHealth responsibility behaviors -0.146 0.781 0.864 Accept Ho Not significantMedication adherence behaviors 0.055 0.919 1.057 Accept Ho Not significantDietary behaviors -0.979 0.131 0.376 Accept Ho Not significantExercise behaviors -0.011 0.981 0.989 Accept Ho Not significant

(Constant) 4.114 0.305 61.172 Accept Ho Not significantNote: Significant at p < 0.05

values more than 0.05. Thus, the aforementioned indicators did not predict the lipid

profile of the patients with Type II Diabetes Mellitus.

The lipid profile can be predicted using the following model: Lipid Profile =

0.713 (Weight).

Weight had a p-value of 0.002, which rejected the null hypothesis. Weight was a

predictor of health outcomes for lipid profile. Those who weighed more were 2.041 times

more likely to have an increase lipid profile result. Lipid abnormalities are common in

people with Type II Diabetes Mellitus. Insulin resistance and central obesity are two

closely linked factors that are important in determining the additional lipid abnormalities

found in Type II Diabetes Mellitus (Brunzell & Hokanson, 1999). The role of insulin

resistance in the pathogenesis of Type II Diabetes Mellitus was recognized by Himsworth

(1936) over 60 years ago. According to Vague (1956) study, central obesity was

recognized as a risk factor for the development of Type II Diabetes Mellitus over 40

years ago and many succeeding studies have confirmed this relationship. As noted,

periodic weight monitoring could help the respondents to be more cognizant about their

weight changes thus help to control eating habits and decrease sedentary lifestyle.

Predictor of Health Outcomes for Fasting Blood Sugar

Table 9 shows the predictor of health outcomes in terms of the fasting blood

sugar. The perceived barriers to action, situational influences, health-responsibility

behaviors, medication adherence behaviors, dietary behaviors, exercise behaviors, age,

sex, educational attainment, civil status, occupation, financial status, length of disease

diagnosis, perceived health status, and height had p-values more than 0.05. Thus, the

aforementioned indicators did not predict the fasting blood sugar of the patients with

Type II Diabetes Mellitus.

Predictor of Health Outcomes for Glycosylated Hemoglobin A1c

Table 10 shows the predictor of health outcomes in terms of glycosylated

hemoglobin A1c. The perceived barriers to action, situational influences, health-

responsibility behaviors, medication adherence behaviors, exercise behaviors, age, sex,

education attainment, occupation, financial status, length of disease diagnosis, perceived

health status, and height had p-values more than 0.05. Thus, the aforementioned

indicators did not predict the glycosylated hemoglobin A1c of the patients with Type II

Diabetes Mellitus.

Table 10.

Predictor of Health Outcomes for Glycosylated Hemoglobin A1cPredictors B p Exp(B

)Decision Interpretation

Personal FactorsAge -0.204 0.632 0.815 Accept Ho Not significantSex -1.113 0.211 0.328 Accept Ho Not significantEducational attainment -0.399 0.350 0.671 Accept Ho Not significantCivil status -1.117 0.028 0.327 Reject Ho SignificantOccupation -0.282 0.398 0.754 Accept Ho Not significantFinancial status 1.886 0.088 6.594 Accept Ho Not significantLength of disease diagnosis -0.061 0.896 0.941 Accept Ho Not significantPerceived health status -0.086 0.837 0.918 Accept Ho Not significantWeight 0.907 0.000 2.477 Reject Ho SignificantHeight -1.106 0.103 0.331 Accept Ho Not significantTreatment as Perceived Barriers to Action

0.458 0.243 1.580 Accept Ho Not significant

Situational Influences 0.387 0.352 1.473 Accept Ho Not significantHealth-Promoting BehaviorsHealth responsibility behaviors 0.344 0.568 1.410 Accept Ho Not significantMedication adherence behaviors -0.425 0.477 0.654 Accept Ho Not significantDietary behaviors -1.606 0.022 0.201 Reject Ho SignificantExercise behaviors -0.101 0.847 0.904 Accept Ho Not significant

(Constant) 8.954 0.066 7737.401 Accept Ho Not significantNote: Significant at p < 0.05

The glycosylated hemoglobin A1c can be predicted using the following model:

HbA1c = 8.954 – 1.606 (Dietary Behavior) – 1.117 (Civil Status) + 0.907 (Weight).

Dietary behavior had a p-value of 0.022, which rejected the null hypothesis.

Dietary behavior was a predictor to health outcomes for glycosylated hemoglobin A1c.

Better dietary behavior was 0.201 times more likely to improve the results for

glycosylated hemoglobin A1c. Dietary management is considered to be one of the

cornerstones in treatment of diabetes mellitus. It is based on the adherence of healthy diet

behaviors in the context of social, cultural, and psychological influences on food choices

(Ekore et al., 2008). Dietary practice refers to patients’ food intake selections based on

the diabetes nutrition education that provides importance on low fat and sodium intake,

and high fiber intake (Shamsi et al., 2013). Several studies have showed that healthy diet

behaviors could lead to significantly lower glycosylated hemoglobin A1c levels among

diabetic patients (American Diabetes Association, 2008). As noted that proper eating

habits could improve or normalize the blood glucose and may reduce the risk of diabetes-

related complications.

Civil status had a p-value of 0.028, which rejected the null hypothesis. Civil status

was a predictor to health outcomes for glycosylated hemoglobin A1c. Married

respondents were 0.327 times more likely to have better results for glycosylated

hemoglobin A1c. As observed, most of the married respondents might had strong spouse

support thus adequate glycemic control in terms of glycosylated hemoglobin A1c levels.

The weight had a p-value of 0.000, which rejected the null hypothesis. Weight

was a predictor for health outcomes for glycosylated hemoglobin A1c. Those who

weighed below 50 kilograms were 2.48 times more likely to have better results for

glycosylated hemoglobin A1c. Nearly 90% of individuals with Type II Diabetes Mellitus

are overweight or obese. Weight loss of more than 3% was linked with glycemic control

improvement in patients who are newly treated for Type II Diabetes Mellitus. Anti-

diabetics medicines associated with weight loss or neutrality were associated with greater

weight loss and glycosylated hemoglobin A1c goal attainment and may facilitate efforts

to co-manage weight and blood sugar in the ambulatory-care setting (McAdam et al.,

2014). With this, as noted, proper weight management in adherence to anti-diabetic

medications may help to improve glucose control of the respondents and thus better

glycosylated hemoglobin A1c results.

Chapter V

SUMMARY OF FINDINGS, CONCLUSION, AND RECOMMENDATIONS

This chapter presents the summary of the findings of this study, the conclusion

that was drawn from the findings, and the recommendations in the areas of theoretical

advancement and practical significance.

Summary of Findings

Most of the respondents were 60 years and above and were females with

vocational education, married, retired, with more than 16 years of diagnosis, with

perceived good health status, mostly weighing less than 50 kilograms, and were within

the 1.54 to 1.69 meters (5’1 to 5’6 feet) height range. In terms of treatments as perceived

barriers to action, 60 respondents with Type II Diabetes Mellitus agreed that there were

too many treatments to manage. Most respondents considered situational influences a

moderate problem. The respondents worried about the future and the possibility of

serious complications, coping with complications of diabetes, and feeling burned out by

the constant effort needed to manage diabetes were viewed somewhat a serious problem.

However, not having concrete goals for diabetes care and feeling discouraged with your

diabetes treatment plan were considered minor problem.

The health-responsibility behavior of the respondents was rated very good.

Oftentimes, the respondents visited their physicians periodically. Although oftentimes,

the respondents had lipid profile, fasting blood sugar (FBS) and glycosylated hemoglobin

A1c (HbA1c) examined periodically. Medication adherence behavior was rated very

good. Oftentimes, the respondents took the prescribed medication on time daily. Although

oftentimes, even if the respondents feel better, they still take the prescribed medications,

was the lowest indicator. Dietary behavior was rated very good. The respondents were

concerned with their blood sugar oftentimes. The respondents also oftentimes controlled

their diets while eating outside, the lowest in the indicators. Exercise behavior was rated

good. Most respondents did 150-minute exercise every week, which was rated

sometimes. The lowest in the indicator showed that respondents exercise even on bad-

weather days, which was rated sometimes. The body mass index, lipid profiles, fasting

blood sugar, and glycosylated hemoglobin A1c among patients with Type II Diabetes

Mellitus had normal results.

Sex was a predictor of health outcomes for body mass index and females were

more likely to become obese. Weight was also a predictor of health outcomes for body

mass index and those respondents who weighed less than 50 kilograms were more likely

to have normal body mass index. Weight was a predictor of health outcomes for lipid

profile and those who weighed below 50 kilograms were more likely to have normal

results. Dietary behavior predicted the health outcomes for glycosylated hemoglobin A1c

and those with better dietary behaviors were more likely to have better glycosylated

hemoglobin A1c results. Civil status predicted the health outcomes for glycosylated

hemoglobin A1c and those who were married were more likely to have better

glycosylated hemoglobin A1c results. Weight predicted the health outcomes glycosylated

hemoglobin A1c and those who weighed below 50 kilograms were more likely to have

better glycosylated hemoglobin A1c results.

The findings of the study rejected the null hypothesis thus the factors that

predicted the health outcomes among patients with Type II Diabetes Mellitus were weight

for BMI, lipid profile and HbA1c, height for BMI, lipid profile and HbA1c, sex for BMI

and civil status and dietary behaviors for HbA1c.

Conclusions

Based on the findings of the study, it is concluded that sex, weight and height

were the predictors of health outcome for body mass index, weight was the predictor of

health outcome for lipid profile and civil status, weight and dietary behaviors were the

predictors of health outcome for glycosylated hemoglobin A1c among patients with Type

II Diabetes Mellitus.

These findings can be used to develop a health promotion program which

affirmed to the Health Promotion Model by Nola J. Pender (1996) for improving the self-

care management among patients with Type II Diabetes Mellitus in order to enhance their

over-all health outcomes.

Recommendations

Based on the findings and conclusion of the study, it is recommended that:

1. Use the health promotion program to improve and prolong the lives of the patients

with Type II Diabetes Mellitus. The patients must live a healthy lifestyle by following

proper diet management, updating his knowledge about the illness, constant contact

with a health professional, following religiously the medication prescribed by the

physician, exercising on a regular basis, and many others.

2. The health care providers must update the patients the necessary knowledge as well

help them not only for their physical needs but for emotional and psychological needs

as well.

3. The health policy makers must ensure that policies on health promotion and the

procedures for control are strictly followed and monitored.

4. The Department of Health must ensure that hospitals and clinics give the up-to-date

information on diabetes control and that they perform community-based immersion

programs in educating the locals about the disease.

5. The researcher must apply the relevant knowledge particularly to patients with

diabetes in order to control and help them attain better health.

6. The future researchers must find other means or factors not only to improve the lives

of the patients with diabetes mellitus but also to propose the following studies that

might be deemed useful in the future such as the following:

6.1. Classification and Diagnosis of Diabetes Mellitus of Glucose Intolerance;

6.2. Predictors of Care Improvement of Geriatric Patients with Diabetes Mellitus;

and

6.3. Influence of Body Fat Distribution on the Incidence of Diabetes Mellitus among

patients in Davao City.

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