Development and evaluation of web-based Self-care Management Health Education e-Learning Program for type 2 diabetes patients: A pilot study

Abstract

Aims

Diabetes mellitus (DM) is an incurable chronic disease that can be controlled by self-care management. Health education assisted by technology can improve self-care management. This pilot study aims to: (a) identify the concerns, issues, and challenges faced by type 2 diabetes mellitus (T2DM) patients and healthcare providers, especially during the COVID-19 pandemic; (b) develop a Self-care Management Health Education e-Learning Program (ScMHEeLP); and (c) pilot whether ScMHEeLP can improve knowledge, self-care management, and glycemic controls of T2DM patients.

Method

This pilot study uses a multiphase mixed-methods design. Twenty-three participants were involved in in-depth interviews as the basis for developing ScMHEeLP, and thirty-seven voluntary participants were recruited for the evaluation phase. The ScMHEeLP was piloted for 3 months to test its effectiveness in improving the knowledge, self-care management, and glycemic controls of T2DM patients. Thematic analysis was used to examine the qualitative data, and the Wilcoxon test was used for quantitative data.

Results

In the development phase revealed patients’ and healthcare providers’ concerns, issues, and challenges regarding diabetic care, especially during the COVID-19 pandemic. Based on these findings, the ScMHEeLP was developed in the form of web-based. ScMHEeLP consists of seven animatic videos, completed with a feature to evaluate patients’ understanding of the disease and treatments. ScMHEeLP was downloadable and accessible anywhere and anytime (online–offline). In the evaluation phase showed a significant difference in the levels of knowledge (Z = −5.306, p = 0.000), levels of self-care activities (Z = −5.139, p = 0.000), and level of fasting blood sugar (Z = −4.282, p = 0.000), before and after the implementation of ScMHEeLP.

Conclusions

ScMHEeLP was able to improve knowledge and self-care activities and able to lower fasting blood sugar levels. ScMHEeLP still needs continuous improvement and further testing for better outcome.

Introduction

The number of cases and the prevalence of diabetes have been increasing steadily over the past few decades. The latest data from the International Diabetes Federation¹ states that there were 537 million people with diabetes mellitus (DM), and Indonesia ranked fifth in the number of DM cases worldwide. Although DM is an incurable chronic disease, it can be controlled by keeping the blood sugar levels within the normal range. Therefore, patients are requested to control their blood sugar level by complying with all medical treatment programs, including a healthy diet, regular physical activities, medication adherence, routine check-ups, foot examination, quitting smoking and alcohol consumption, and seeking treatment for complications.² Thus, patients need sufficient knowledge, self-motivation, self-care management, good support, and access to health care facilities.^3,4

The COVID-19 pandemic has impacted all aspects of human lives and disrupted all sectors, including driving the acceleration of innovation and technological transformation in the healthcare sector. Telemedicine has become a solution that leverages the current technology in delivering healthcare services, including for type 2 diabetes (T2DM) patients. The use of mobile or smartphone-based, computer-based, and digital tools can help improve the knowledge, self-management, and compliance of treatment of patients to control blood sugar levels.⁵

The ADDIE model was used as the theoretical framework in the development of e-learning, that consist of the processes of analysis, design, development, implementation, and evaluation.⁶ These model has been use in some previous studies in developing an e-learning modules or programs.^7,8 For this reason, this study aims to focus on (1) identifying the concerns, issues, problems, and challenges of type 2 diabetes patients and the healthcare providers regarding diabetic care, especially during the COVID-19 pandemic; (2) developing educational and monitoring applications for T2DM patients based on the needs analysis; and (3) piloting whether ScMHEeLP can improve knowledge, self-care management, and glycaemic controls of T2DM patients.

Method

This pilot study uses a multiphase mixed-method design divided into two phases: development phase and evaluation phase. The development phase started by exploring the qualitative data from nine diabetic patients, eight healthcare providers as the bases for need analysis through in-depth interview. These needs analysis findings then discussed with six IT experts to get recommendations in designing and developing web-based ScMHEeLP. ScMHEeLP was developed by professional web development team. ScMHEeLP is a consist of seven animatic videos, has a feature to evaluate patients’ understanding of their disease and their treatment, has a feature for laboratory result test record and can be accessed anywhere and anytime (online–offline). The quality of the first ScMHEeLP prototype was evaluated in terms of the instruction, content, technology, and design for further improvements, by using quality review rubric for digital learning resources developed by the North Carolina Department of Public Instruction and the Friday Institute for Educational Innovation. The assessment test and revision of the ScMHEeLP was continually conducted until the cumulative average value reaches above 80%.

In the evaluation phase, the final prototype of web based ScMHEeLP was piloted to 37 patient-participants. Participants were recruited from Tuminting's community health centre (Puskesmas) in Manado, using a purposive sampling method. The inclusion criteria were: (a) patients diagnosed with T2DM, (b) aged between 46 and 65, and (c) receiving oral hypoglycaemic agents (OHA) only treatment. The exclusion criteria were (a) T2DM patients with DM complications, (b) having comorbidity such as stroke and/or cancer, (c) difficulties in seeing, hearing, and communicating, and (d) having impaired memory. These evaluation phase using one group pre-test and post-test approach. The pre-test assessment focused on the level of knowledge, self-care activities, and glycemic levels (fasting blood sugar level) of participants. The Diabetes Knowledge Test (DKT) scale was used to measure the level of knowledge of T2DM patients regarding their disease and the diabetes treatment program. The Indonesian version of the Summary of Diabetes Self-Care Activities’ (SDSCA) questionnaire was used to measure the patient's daily activities, behaviour, and compliance to their diabetes treatment program as recommended by their physicians. The DKT and ADSCA were tested and proved valid and reliable.^9,10 Glucometer with ISO:15197-2013 was used to measure the fasting blood sugar levels. The intervention (ScMHEeLP) was given for 3 months and the post test was conducted a month after the intervention delivered. The quantitative data was analysed using Wilcoxon to test the effectiveness of the intervention in improving the level of knowledge, the self-care activities, and in lowering fasting blood sugar level.

All stages of this research uphold the ethical principles of research on human subjects. Each participant received an explanation regarding their participation in this study, shown by their willingness to sign an informed consent. This research protocol was approved by the Research Ethics Committee of St. Paul University, the Philippines, received recommendation from the Political National Unity Agency and got approval from the Public Protection of the Manado City Government to be conducted at Tuminting's Puskesmas.

Results

In the development phase, most patients participating in this study were above 61 years old (44.45%). Most were female (66.67%), married (77.78%), had a high school educational background (77.78%), worked as an entrepreneur (44.44%) and were housewives (44.44%). They all suffered DM for one to five years (100.00%). Most healthcare providers were between 25 and 30 years old (37.50%), female (75.00%), from nursing health educational background (62.50%), and had one to five years of work experience (37.50%).

Table 1 shows the participants’ concerns, issues, problems, and challenges related to compliance with the T2DM treatments. Six qualitative themes were identified. From the patients’ perspectives, factors related to non-compliance with T2DM medical treatments included lack of information from the healthcare providers, lack of knowledge, limited access to information, inability to use technology, and patient's physical conditions. Meanwhile, from the health care providers’ perspectives, some issues related to the non-compliance of the patients include lack of knowledge, lack of motivation, and disobedience to the medical treatments. Furthermore, the impact of the COVID-19 pandemic, lack of healthcare workers, and inadequate teaching materials and strategies (contents and methods) were considered factors that made the implementation of diabetes programs inadequate.

Table 1.

Themes and sub-themes of qualitative data.

Group of participants	Sub-theme	Theme
Patients	Lack of information from the healthcare providers	Factors related to non-compliance with T2DM medical treatments
	Lack of knowledge
	Limited sources of information
	Patients’ physical conditions
	Patients’ expectations about information technology for T2DM	Information technology-related factors
	Inability to use technology
Healthcare providers	Disobedience	Non-compliance of the patients
	Patients’ lack of knowledge and self-motivation
	Impact of the COVID-19 pandemic	Inadequate implementation of patients’ education and care
	Lack of healthcare workers
	Inadequate teaching materials and strategies (contents and methods)
	Inability to use technology	The utilisation of technology
	Technology facilitates tasks/work with ease

In the evaluation phase, the majority of DM participants in the evaluation phase aged above 61 (32.43%). Most of them were female (73.00%), married (81.10%), and housewives (51.50%). Most had suffered from T2DM between one and five years (75.70%).

Table 2 displays that the mean rank difference in participants’ level of knowledge before and after the implementation of the ScMHEeLP was statistically significant (Z = −5.306, p < 0.05); thus, the Ho hypothesis was rejected. In other words, the implementation of the ScMHEeLP improved the participants’ knowledge level significantly. Table 2 also shows that the mean rank difference of participants’ level of self-care activities before and after the implementation of the ScMHEeLP was statistically significant (Z = −5.139, p < 0.05); hence, the Ho hypothesis was rejected, indicating that ScMHEeLP can increase the level of self-care activities of participants significantly. Additionally, Table 2 illustrates that the mean rank difference in participants’ fasting blood sugar levels before and after the implementation of the ScMHEeLP was statistically significant (Z = −4.282, p < 0.05); therefore, the Ho hypothesis was rejected.

Table 2.

Level of knowledge, self-care activities, and fasting blood sugar before and after the ScMHEeLP implementation.

Variable	n	Mean	SD	Z	p-Value
Level of knowledge before	37	7.59	3.48	−5.306	0.000
Level of knowledge after		20.55	1.15
Level of self-care activities before	37	36.35	24.55	−5.139	0.000
Level of self-care activities after		51.13	23.07
Level of fasting blood sugar before	37	211.51	90.99	−4.282	0.000
Level of fasting blood sugar after		152.43	65.91

Discussion

The concerns, issues, problems, and challenges of the participants regarding compliance to the T2DM treatments

From patients’ perspective

Compliance is the key to success in diabetes management that affected by many factors. In this study, the factors influenced the compliance of patients including: lack of information from the health care provider, lack of knowledge, limited sources of information, and patients’ physical conditions. Health care providers are the main component of educational resources for patients.¹¹ However, in this study, the participants considered that they did not get enough information about their disease and its treatment program from health care providers both at the hospital and at the Puskesmas. Increasing the knowledge of DM sufferers is the entrance to the active role of DM sufferers in the management and control of DM disease.¹² Many previous studies proved how knowledge is an important factor of compliance of diabetic patients. In this study, the participants expressed the lack of knowledge of the causes of disease and things they should and should not do as part of their type 2 DM disease treatment program. Apart from information from health workers, other sources of information that patients use to obtain information about their illness are via TV, radio, and the internet.¹³ In this study, other sources of information used by patients were broadcasts on TV and from the internet. According to participants, the use of TV is very limited depending on the TV broadcast material, while the use of the internet is very dependent on their family to help them find information. The presence of symptoms caused by DM or other comorbidities also has an impact on patient's adherence to their medical treatment.¹⁴ In this study, it was found that the participants experienced various physical conditions such as weakness and dizziness and it was affecting in doing exercises. Others said that their physical condition (elderly) make them unable to obey some of the treatment program.

Furthermore, the use of information technology in diabetics aims to improve diabetes management.^15–17 In this study, participants hope that current technology could help them obtain more complete and accurate information about their disease and treatment program. Even though the patient has a positive expectation for using new technology for their diabetic care but it is also a fact that low technological knowledge of DM patients, who are generally elderly, is a factor that makes it difficult for them to learning new existing technology skills.¹⁸ In this study, some of the limitations of the participants in accessing and using existing information technology and their dependence on other people in providing information related to their health can be seen.

From health care providers perspective

The success of the DM patient treatment program is very dependent on patient adherence to the entire treatment program. In these study, patients’ disobedience; and patients’ lack of knowledge and self-motivation, become two factor that considered as the main obstacle of patients’ compliance from the health care providers perspective. There was supported by previous study that patient non-compliance was largely determined by the patient's knowledge and skills in controlling blood sugar levels.¹⁹ Therefor providing education for DM patients is the entrance to the implementation of the DM patient treatment program.²⁰

Moreover, in this study, the impact of COVID-19’ pandemic, lack of health workers, and inadequate teaching material and strategy also considered as the factor that cause inadequate implementation of patients’ education and care from the health care provider. COVID-19 not only gives worse results for people with DM. Worse, the impact of the pandemic event has changed the health care system significantly and challenged health workers to innovate in diabetes care.²¹ Based on the results of the interview, it was found that the COVID-19 pandemic had made various T2DM patient service programs unable to run optimally. Limited human resources (health care providers) are one of the inhibiting factors in achieving patient control of blood sugar levels. The large workload and time pressure undermine the ability of health workers to provide services for people with diabetes.¹⁹ In addition, the lack of health workers and health cadres is another factor that causes the implementation of education programs and treatment to control T2DM sufferers to be not maximal. Aside, unmanaged education refers to lack of official planning for patient education and supervising the education process.²² In this study, the lack of facilities, incompleteness of educational materials, and learning strategies/methods are allegedly inhibiting factors for the ineffectiveness of the T2DM patient education and care program.

Furthermore, according to²³ current technological developments provide opportunities for improving the quality of diabetes services and even the quality of life for diabetes patients. The utilization of technology allows more optimal control of blood sugar levels, including reducing the workload of health care providers. In this study, the health care provider considered that there is inability to use technology and hope that technology can easier task/work. In terms of the use of technology, previous research stated that patients prefer the use of technology that is easy to use and easy to understand. However, health care providers pay more attention to the mismatch between the complexity of the content of educational materials and the level of literacy of patients as the target audience. Those who have good health literacy will benefit from the use of that technology.²⁴ In this study, the age factor of patients, who are mostly elderly, is considered the reason for the lack of technological knowledge and skills, like the use of technology such as cellphones and the internet. Integrations of education into workflows and the involvement technology could make it better. That could help them provide information and convince patients of the benefits of treatments. In this study, health care providers expect that technology could facilitate their job and make it easier, including providing education to patients.

Develop a Self-care Management Health Education e-Learning Program (ScMHEeLP)

Based on the participants’ concerns, issues, problems, and challenges regarding compliance with the T2DM treatments, the web based Self-care Management Health Education e-Learning Program (ScMHEeLP) was developed by professional web developer. The web-based (http://penkes.com/) educational and monitoring program for T2DM patients consists of seven animatic videos about (1) diabetes and its treatment, (2) diet for T2DM patients, (3) activities and exercises for T2DM patients, (4) prohibition of smoking and no alcohol for T2DM patients, (5) daily self-care routines, (6) how to prevent diabetes complications, and (7) support systems standardised by WHO and PERKENI for diabetes education. All learning materials can be downloaded as interactive features to ask questions and discussion. ScMHEeLP has a feature to evaluate patients’ understanding of their disease and their treatment. It also has a feature that can monitor patients’ self-care activities weekly and document daily blood sugar levels, vital signs, and other laboratory examinations. ScMHEeLP can be accessed anywhere and anytime (online–offline). Therefore, patients and healthcare providers can use ScMHEeLP not only as an education media but also as a monitoring media for T2DM patients.

The pilot test of the ScMHEeLP's effectiveness in improving knowledge, self-care activities, and fasting blood sugar control of T2DM patients

This study proves that ScMHEeLP significantly able to improve participants’ knowledge levels. The results of this study were supported by previous research conducted by,²⁵ showing that web-based health education could increase the knowledge of diabetes mellitus patients. Another study by²⁶ also suggested that a similar program called Diabetes Interactive Education Programme (DIEP) could improve the knowledge of diabetic patients. It is implied that the use of ScMHEeLP has been proven to increase diabetics’ knowledge about the disease and its management. Nurses at the Puskesmas could use ScMHEeLP as an alternative method of education for DM sufferers, especially during the COVID-19 pandemic.

This pilot study also proves that ScMHEeLP could increase the level of self-care activities of participants significantly. The results of this study are supported by previous research conducted by²⁵ where web-based health education can increase self-management of diabetes mellitus patients. Furthermore, a review of previous studies also concluded that the use of internet media (including web-based) for health education for diabetes patients was able to increase self-management of diabetes patients.²⁷

Moreover, ScMHEeLP was able to lower the level of fasting blood sugar test of participants significantly. Some review of previous studies also concluded that the use of internet media (including web-based) for health education for diabetes patients was able to increase the glycemic control of diabetes patients both HbA1C and fasting blood sugar glycemic control indicator.^27,28

The main limitations of this study are related to the current condition of the COVID-19 pandemic, which has greatly affected the participant recruitment process (number of samples), as well as the technical process of collecting and implementing the ScMHEeLP program. People were advised not to conduct activities outside the home unless they had a critical urgency. This also affected patients’ visits at the Puskesmas. Patients, especially the elderly at the highest risk from COVID-19, were reluctant to come to the Puskesmas for check-ups or control. Consequently, we experienced a problem in obtaining the research samples. In addition, the pandemic also affected the technical data collection and implementation of the ScMHEeLP program. We were required to comply strictly with health protocols in every patient interaction. In the final stages of the research process, participants’ experiences and suggestions for further development of the ScMHEeLP were obtained via telephone interviews. This was done to minimise the interaction when the post-test was carried out.

In conclusion, the concerns, issues, problems, and challenges related to compliance with the T2DM treatments were identified from the patients’ and healthcare providers’ perspectives. The ScMHEeLP program was successfully developed based on the needs of patients and healthcare providers in Puskesmas. The program effectively improved the levels of knowledge and self-care activities and lowered fasting blood sugar levels.

Conflict of interest

The authors declare no conflict of interest.