Hindawi

Journal of Diabetes Research

Volume 2019, Article ID 1073131, 7 pages
https://doi.org/10.1155/2019/1073131

Research Article
Effects of an Outpatient Diabetes Self-Management
Education on Patients with Type 2 Diabetes in China:
A Randomized Controlled Trial

Fan Zheng , Suixin Liu , Yuan Liu , and Lihua Deng

Cardiac Rehabilitation Center of Rehabilitation Department, Xiangya Hospital at Central South University, Changsha, China

Correspondence should be addressed to Suixin Liu; [email protected]

Received 5 August 2018; Revised 7 December 2018; Accepted 26 December 2018; Published 17 January 2019

Academic Editor: Gianluca Iacobellis

Copyright © 2019 Fan Zheng et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective. This study is aimed at assessing the effectiveness of a simple outpatient diabetes self-management education programme.
Methods. In the study, 60 patients with type 2 diabetes mellitus were randomly allocated into the control group (n = 30) and
intervention group (n = 30). Regular and 2-session health education programmes were provided. The summary of diabetes
self-care activity measure, problem areas in the diabetes scale, fasting blood glucose, postprandial 2 h blood glucose, and HbA1c
were measured before and after the intervention to assess the effects of this 2-session diabetes education programme. Results.
The total mean score of the summary of diabetes self-care activities measure was 17 60 ± 6 63 points. The problem areas in the
diabetes scale revealed that the total mean score was 29 82 ± 15 22 points; 27% of the patients had diabetes-related distress,
while 9% suffered from severe emotional distress. Compared with the control group, scores of the summary of diabetes self-care
activities measure and problem areas in the diabetes scale, fasting blood glucose, postprandial 2 h blood glucose, and HbA1c
were significantly improved in the intervention group after the intervention (P < 0 01). Conclusion. This study showed that the
2-session diabetes education programme could effectively improve the level of self-reported self-management, psychological
distress, and glycemic control in patients with type 2 diabetes mellitus.

1. Introductions approaching T2DM and its related complications. The edu-

cational interventions that involved patient collaboration
Diabetes mellitus (DM) is the world’s third-largest, chronic, were more effective than didactic interventions in improving
noninfectious disease after cardiovascular diseases and can- glycemic control [8–13]. Furthermore, a group-based diabe-
cer. DM and its complications threaten individual health tes self-management education programme was showed to
and bring a heavy financial burden to the families and society produce improvements on clinical, lifestyle, and psychosocial
[1–3]. Among the diabetic complications, the psychological outcomes in patients with T2DM [14, 15]. The researches in
disorders are usually neglected by the patients and their fam- China also revealed that the family- and community-based
ilies [4, 5]. The latest Chinese study of 112 patients with type diabetes self-management interventions were effective to
2 diabetes mellitus (T2DM) showed that a general represen- improve the diabetes self-care behaviors in Chinese adults
tation of anxiety, depression, and other psychological condi- with type 2 diabetes [16, 17]. Indeed, the results showed
tions existed among this population [6]. How to effectively that when self-management education was provided, age,
improve the self-management behavior and negative mood education, knowledge, self-efficacy, economic factor, and
of T2DM patients is the key goal of clinic work in China. social support should be considered to offer more appro-
Diabetes self-management is considered as the corner- priate intervention and to improve patients’ behaviors in
stone of T2DM management [7]. In reviewing the literature, China [18, 19]. It is, consequently, suggested to develop a
the effectiveness of the didactic diabetes self-management more comprehensive and participatory education pro-
education programmes was seemed to be rather weak when gramme and concentrate on some significant variables,
2 Journal of Diabetes Research

i.e., self-management behavior and psychological perfor-

60 patients with T2DM
mances [12, 13, 20].
The purpose of this study was to develop an interactive and
participatory educational programme and evaluate the effects
of this programme. An outpatient diabetes self-management General question, SDSCA,
education was subsequently conducted to guide these sub- PAID, FBG, PBG, HbA1C
jects in an appropriate, targeted, self-management manner
and to improve the self-management level.
Control group Intervention group
2. Methods (n = 30) (n = 30)

2.1. Participants. A single-blinded randomized controlled

study, followed by CONSORT 2010 criteria [21], was General education
General education+
approved by the Human Ethics Committee of Xiangya Hos- interventional education
pital at Central South University. This study was conducted
at the Cardiovascular Rehabilitation Clinic, Endocrinology
SDSCA, PAID, FBG, SDSCA, PAID, FBG,
Clinic, and Geriatrics Clinic at Xiangya Hospital, Central PBG, HbA1C PBG, HbA1C
South University, from 2015 to 2017. The inclusion criteria
were as follows: (I) All patients with T2DM should meet Figure 1: Presentation of the research flow chart.
the T2DM diagnostic criteria established by the American
Diabetes Association in 2010 [22]: (1) HbA1c ≥ 6 5%; (2) f a
sting blood glucose FBG ≥ 7 0 mmol/L; (3) postprandial bl education programmes were applied to the control and inter-
ood glucose PBG ≥ 11 1 mmol/L in the oral glucose toler- vention groups, respectively.
ance test (OGTT); and (4) typical hyperglycemia symptoms, Regular education was given to the control group during
such as polydipsia, polyuria, polyphagia, obvious weight loss, their first clinic visit; this included general knowledge on dia-
and random plasma glucose RPG ≥ 11 1 mmol/L; if the betes disease process and treatment options; blood glucose
symptoms were not evident, criteria (1)–(3) should be monitoring; healthy lifestyle; preventing, detecting, and
repeatedly measured. (II) The patients were conscious, with treating diabetes complications; and developing personalized
complete behavior and cognitive ability. (III) The patients strategies for decision-making [23]. The intervention group
were willing to take the follow-up tests after three months. was given 2-session diabetes self-management education
The exclusion criteria were as follows: (1) the presence of besides the regular education programme. Interventional
mental disorders; (2) complications of acute diabetes or education programme consisted of two types of courses: the-
inability to take care of themselves; (3) other serious diseases, ory and practical. For the theory course, there were two tim-
such as severe cardiovascular and cerebrovascular diseases, ings for classes: the first class was given during the first clinic
severe kidney disease, cancer, and visual impairment due to visit same as the control group, while the second class was
complications of T2DM; (4) gestational diabetes; and (5) given during the second clinic visit after 2 days. Each class
already received systematic diabetes education. lasted for 45 minutes. The second class consisted of group
Seventy-two potential participants were identified by the studies using an impressive PowerPoint-incorporated images
clinic physician for the study. However, 12 patients declined and videos, presenting an overview knowledge of diabetes
to take part in this study because of lack of time or inconve- and additional details about self-management strategies, such
nient transportation. Finally, a total of 60 patients with as diet guidance, exercise guidance, and knowledge of hypo-
T2DM were recruited in this study, and informed written glycemia treatment, foot care, medication, and the blood glu-
consents were obtained from all these participants. A cose monitoring.
computer-generated randomization list with permuted, In the practical course, the educational tools were also
variable-size blocks was used to randomize the two groups. culturally designed to be more appropriate and relevant
The allocation ratio of assignments was 1 : 1. The randomiza- for patients, including vivid models and individual practice.
tion and allocation concealment were performed by the stat- This course contains mainly two parts, one-on-one nutri-
istician, and a therapist was in charge of enrollment and tion guidance and individualized exercise guidance. The
assignment of subjects to interventions. Figure 1 shows the one-on-one nutrition guidance was applied by the dietitians
research flow. after the first theory class and lasted for 40 minutes. This
guidance, developed for the Chinese diabetes population
2.2. Two-Group Experimental Design. Two groups, a preex- based on the American Diabetes Association [24], includes
perimental design and a postexperimental design, were used the definition and application of an exchangeable food por-
in this study. 60 patients with T2DM were randomly allo- tion in the diabetes diet planning assisted with the presen-
cated into 2 groups: the control group (n = 30) and inter- tation of food simulation models. One piece of the
vention group (n = 30). A questionnaire was distributed to “exchangeable food portion” is defined as “one serving for
the patients, and all of them were returned. This question- every 90 kcal of food produced.” The same type of the
naire included the general information such as gender, age, exchangeable food portion can be exchanged; the nutri-
and educational background. Regular and interventional tional value is almost the same. The individual total energy
Journal of Diabetes Research 3

required per day is calculated according to the individual After fasting for 12 hours, blood samples were obtained
weight and daily physical activity. Calculate the total indi- from cubital veins of the patients in the morning. HbA1C
vidual servings of exchangeable food portion required per was measured by the low-performance liquid chromatogra-
day = total calories per day divided by 90 (kcal/serving). phy (DiaSTAT Hemoglobin A1C analyzer, Bio-Rad Labo-
Distribute the three nutrients in each serving according to ratories Inc., Philadelphia, USA). FBG concentration of
the total calories: 50%–60% for carbohydrates, 15%–20% the serum was determined by the hexokinase method
for proteins, and 20%–25% for fat. The daily serving is (BS300 biochemistry analyzer, Mindray Inc., Shenzhen,
appropriately distributed into three to six meals, and every China). After 2-hour oral administration of 75 g of anhy-
meal is supplied on time and based on the ration. Each food drous glucose, a blood sample was taken from the cubital
simulation model is marked with weight and calories, which vein again to measure the postprandial 2 h blood glucose
makes the nutrition guidance more clear and vivid. concentration (BS300 biochemistry analyzer, Mindray
Individualized exercise guidance [25] includes making Inc., Shenzhen, China).
a personalized exercise prescription for each patient,
according to the outcomes of cardiopulmonary exercise 2.4. Descriptive Statistics. Qualitative information related to
testing and the Borg scale of perceived exertion (Borg the research sample was presented as frequency and per-
scale). Generally, the exercise training is performed three centage. The quantitative data were described as the mean
times a week and 60–90 min each time. Each training pro- ± standard deviation (SD). SPSS statistical software, version
gramme includes (1) warm-up session: low-intensity aerobic 17.0 Windows (SPSS Inc., Chicago, IL, USA), was used for
exercise for 5–10 min; (2) exercise session: aerobic exercise statistical analysis. The t/χ2 tests were used to compare the
for 30 min at a moderate intensity, i.e., 50%–60% of maximal differences between the demographics and characteristics
oxygen uptake (VO2max) and at a rate of 13–14 (somewhat of two groups. P < 0 05 indicated that the difference was sta-
hard of the Borg scale), and resistance exercise for 30 min at tistically significant.
a moderate intensity, i.e., 50%–60% of 1RM; and (3) relax-
ation session for 10 min. The intervention group experi- 3. Results
enced a complete exercise training programme at the
Cardiac Rehabilitation Center of Xiangya Hospital under 3.1. Baseline Information. The general information gained in
therapist guidance and electrocardiogram monitoring. This this sample was as follows: the percentage of male was 55%,
individualized exercise guidance was applied after the sec- the average age was 52 22 ± 11 32 years, the systolic blood
ond theory class and lasted for 60 minutes. Some instruc- pressure was 134 09 ± 18 17 mmHg, the diastolic blood pres-
tions were mandatory: avoiding exercise on an empty sure was 84 43 ± 11 61 mmHg, and the body mass index was
stomach; knowing the identification and treatment of hypo- 26 33 ± 3 47 kg/m2 . Most of the patients were rural residents
glycemic episodes; and knowing how to adjust the insulin (57%), nonsmokers (94%), physically inactive (87%), with a
dose according to the exercise. poorly controlled glycosylated hemoglobin level (53%), poor
glucose control (52%), and a short disease course of no more
2.3. Outcomes. The SDSCA, PAIDs, FBG, postprandial 2 h than 5 years (52%) (Table 1).
blood glucose, and HbA1c tests were all performed to evalu- The current treatments for T2DM were summarized as
ate the effects of interventions for both groups before and follows: restriction of total calorie intake combined with exer-
after 3 months. The SDSCA scale [26] included five items: cise training, oral antidiabetic agents (OADs), and insulin
dietary behavior, exercise, medication adherence, blood glu- injection. Twelve percent of the sample undertook the restric-
cose monitoring, and foot care. The Likert 7 rating scale tion of total calorie intake combined with exercise training.
was used, with scores ranging from 0 to 7, indicating “Don’t Seventy-three percent of the sample took only OADs, which
do it at all” to “Complete it all.” The ranking method was as includes metformin, sulfonylureas, alpha-glucosidase inhibi-
follows: total points > 28 scores (single item > 5 6 scores) tors, thiazolidinediones, and meglitinides. They were used as
were good, 21–28 was normal, and <21 (single item < 4 2 sc monotherapy or in combinations to arrive at the best individ-
ores) was poor. Cronbach’s α coefficients and the test-retest ualized prescription to achieve treatment goals. Last, fifteen
reliability coefficient of the SDSCA were 0.913 and 0.774 percent of the sample took insulin injection with/without
(P < 0 01), respectively [27]. OADs (Table 1).
PAID [28] was a self-administered, 20-item scale, and
every item was scored from 0 to 4: 0 = no problem at all, 1 3.2. Self-Management Behavior and Mental Health of
= a little problem, 2 = moderate problem, 3 = serious prob- Patients. The present study showed that the average score
lem, and 4 = severe problem. The total score was the sum of of SDSCA was 17.60, and the overall score was low (<21
all item scores multiplied by 1.25, with a range of 0–100 points is poor). The average score of PAID was 29.82 points
points. The higher the score, the more serious the associated (0~33 points are considered as normal), suggesting that the
psychological distress. Scores from 0 to 33 were believed to be overall psychological condition of the sample was good. A
normal, >33 meant that DM was accompanied by a related further stratified analysis of the overall scores revealed that
mental pain, and >44 indicated that the mental problems 27% of the sample had diabetes-related pain and 9% of them
were quite severe. Cronbach’s α coefficients and the were severely emotionally disturbed (Table 2). These severely
test-retest reliability coefficient of PAID were 0.94 and 0.65 emotionally disturbed diabetics were all treated with insulin
(P < 0 01), respectively [29]. injection with/without OADs.
4 Journal of Diabetes Research

Table 1: General information about the sample (n = 60).

Item CG (n = 30) IG (n = 30) t/χ2 P

Age (years) 51 92 ± 12 30 52 52 ± 10 46 0.20 P > 0 05
Disease course (years) 2 33 ± 1 58 2 59 ± 1 89 0.58 P > 0 05
Weight (kg) 72 46 ± 1 96 71 56 ± 1 64 -1.93 P > 0 05
Male : female 17 : 13 16 : 14 0.07 P > 0 05
Education (years) 9 52 ± 4 20 9 38 ± 3 70 -0.14 P > 0 05
Urban : rural 11 : 19 15 : 15 1.09 P > 0 05
Physically active : inactive 5 : 25 3 : 27 0.58 P > 0 05
Smoker : nonsmoker 1 : 29 3 : 27 1.07 P > 0 05
Insulin injection : OADs 4 : 21 5 : 23 0.03 P > 0 05
CG: control group; IG: intervention group; OADs: oral antidiabetic agents.

Table 2: Results of diabetes self-care activities measure and problem areas in diabetes (n = 60).

Stratification percentage
Item Rating scale (points) Mean ± SD (points)
Good (normal, %) Fair (pain, %) Poor (severe, %)
Dietary control 0–7 4 18 ± 1 73 28.5 17.0 54.5
Physical activity 0–7 3 18 ± 2 35 25 9 66.0
Medication adherence 0–7 5 25 ± 1 66 79 2 19
Blood glucose monitoring 0–7 2 44 ± 1 26 19 4 77
Foot care 0–7 2 40 ± 1 02 15 4 81
SDSCA score 0–35 17 60 ± 6 63 8 28 64
PAID score 0–100 29 82 ± 15 22 73 27 9
The ranking method: summary of diabetes self-care activities measure scores: total points > 28 or single item > 5 6 scores was good, 21–28 was normal, and <21
or single item < 4 2 was poor. Problem areas in diabetes scores between 0 and 33 were believed to be normal, >33 points meant a diabetes-related mental pain,
and >44 points indicated severe mental problems.

3.3. Effects of Outpatient Diabetes Self-Management 14% [31] in the diabetic population, the risk of depression
Education Programme. The scores of SDSCA and PAID in T2DM was 24% more than in nondiabetics [32], and more
and blood glucose levels of the two groups were compared than 33% of T2DM had depressive symptoms [33]. In fact,
before and after 3 months to evaluate the effect. It was when those severely emotionally disturbed diabetics were
revealed that the scores of SDSCA and PAID, FBG, postpran- interviewed, they generally responded that they had the “fear
dial 2-h blood glucose, and HbA1c in the intervention group of injection.” These patients were treated with insulin and
were all significantly (P < 0 01) improved after the interven- reported the “injection-related uncomfortable feelings,” such
tion, as compared with those in the control group (Table 3). as anxiety, scarring, sensitivity, pain, and bruising. Injection
was perceived as restricting and interfering with their lives.
4. Discussion They felt embarrassed about injecting in public, particularly
when injecting with meals. They were worried about the
The first finding of this study was that the overall inconvenience when travelling and the increased dependence
self-management behavior score of the sample was rather on others especially when getting older. Based on the above
low, indicating poor self-management behavior of these fears of injection, the patients would rather take more OADs
patients. Compared with a previous study [30], the score in than inject insulin. Thus, they showed a poor adherence to
this study was even lower (17 60 ± 6 63 points vs. 22 0 ± 4 1 injection compared to OADs. These negative emotions, to
points in SDSCA), which might be related to the rural popu- some degree, may have affected the patient’s behavior of gly-
lation with poor education, backward economy, and an cemic control, aggravated disease prognosis, and increased
undeveloped medical health system in the study sample. the patient’s mental burden, forming a “vicious circle” [34].
The second finding of this study was that these patients per- Diabetes is a life-long disease. As the disease progresses,
formed poorly on the psychological status, showing that 27% acute, chronic, and serious complications develop, which
of the patients had negative emotions, of which 9% had greatly weaken patients’ confidence in the recovery. Patients
severe diabetes distress. This was in line with previous stud- gradually slack off in self-management behavior and reduce
ies, indicating that the incidence of anxiety disorder was therapy compliance, which eventually leads to aggravation
Journal of Diabetes Research 5

Table 3: SDSCA score, PAID score, and blood glucose level of the two groups before and after the intervention (mean ± SD, n = 60).

Before After
Item t P t P
CG (n = 30) IG (n = 30) CG (n = 30) IG (n = 30)
SDSCA (scores) 17 72 ± 7 21 17 47 ± 6 11 -0.14 P > 0 05 18 62 ± 1 31 22 80 ± 4 86 4.55 P < 0 01
Dietary control (scores) 4 13 ± 1 86 4 23 ± 1 62 0.22 P > 0 05 4 53 ± 0 86 5 75 ± 0 28 7.39 P < 0 01
Physical activity (scores) 3 25 ± 2 47 3 11 ± 2 27 -0.23 P > 0 05 3 82 ± 1 27 5 37 ± 0 56 6.12 P < 0 01
Medication adherence (scores) 5 25 ± 2 03 5 24 ± 1 21 -0.02 P > 0 05 5 75 ± 2 33 6 52 ± 0 81 1.71 P > 0 05
Blood glucose monitoring (scores) 2 55 ± 1 41 2 33 ± 1 12 -0.67 P > 0 05 2 65 ± 0 55 2 55 ± 1 08 -0.45 P > 0 05
Foot care (scores) 2 52 ± 1 03 2 28 ± 1 01 -0.91 P > 0 05 2 63 ± 1 02 3 43 ± 0 85 3.30 P < 0 01
PAID (scores) 30 72 ± 15 86 28 91 ± 14 76 -0.46 P > 0 05 26 57 ± 12 50 21 15 ± 0 25 -2.37 P < 0 05
FBG (mmol/L) 8 48 ± 1 10 8 35 ± 1 21 -0.44 P > 0 05 7 48 ± 1 10 6 11 ± 0 72 -5.72 P < 0 01
PBG (mmol/L) 13 96 ± 3 72 13 67 ± 1 12 -0.41 P > 0 05 12 16 ± 1 72 9 04 ± 1 40 -7.71 P < 0 01
HbA1c (mmol/L) 8 48 ± 0 40 8 30 ± 1 02 -0.89 P > 0 05 8 53 ± 0 72 6 34 ± 0 87 -10.62 P < 0 01
CG: control group; IG: intervention group; FBG: fasting blood glucose; PBG: postprandial blood glucose; HbA1c: glycosylated hemoglobin. P < 0 05 was
considered statistically significant.

of the disease. Evidence supported the effectiveness of diabe- not a unanimous diabetes self-management education devel-
tes education and self-management programme on the oped by voluntary organizations or community groups [8].
self-management of T2DM, particularly in the short term. Based on the aforementioned considerations, we employed
Thereinto, lifestyle advice on diet and exercise was at the one-to-one dietary guidance and individualized exercise
core of first line. Because of the Chinese traditional view of instruction in the short-term outpatient education pro-
dependence on the treatment with medication, diabetes gramme and investigated the effects on self-management
self-management education in China is still not widely behavior, psychological status, and glycemic control.
accepted and valued by the T2DM patients and their fami- Dietary guidance used the “exchangeable food portion”
lies. The current format of diabetes education in China method presented by the simulation food model. A recent
focuses on a more didactic approach to educate patients study reported [36] that this type of dietary guidance applied
about prescriptions and T2DM-related complications. This more practical experiences and specific skills compared with
makes the diabetes self-management education even some- the traditional Chinese education pattern. Consequently, it
how difficult to execute and sustain by these patients. As was easier for patients to understand and accept, resulting
showed in the present study, most of the patients were with in improved glycemic control and lipid metabolism. This
lower education; thus, the diabetes self-management educa- finding is in line with the results of a previous study, where
tion should be easier to understand and follow in various the patients could make their own food services per day
forms. What is more, the cooperation between patients and according to personal preferences after dietary guidance,
providers should also be strengthened. It showed in the shifting the boring and difficult-to-understand theory of die-
study that the educators could help patients relieve the fears tary theories to concrete and easy-to-use individual practice.
of insulin injection and improve the injection technique to In the exercise section, a combined exercise training pro-
reduce physical discomfort, resulting in a better adherence gramme was applied, i.e., moderate intensity aerobic exercise
to treatment and improved performance of self-management combined with resistance exercise in the present study.
behaviors. Thus, patients should be encouraged to discuss Under the guidance of medical staff and continuous ECG
their own problems, such as injection-related concerns, and monitoring, the patients in the intervention group took a full
providers should offer patients information about tools to set of exercise training programme. This type of exercise
reduce injection-related worries, preferably by directly show- guidance concentrated on individualized exercise education
ing to them. Patients and providers should work together to and guidance.
find the solutions. For the sake of economic issue, the intervention pro-
On the other hand, most diabetes education studies in gramme in the present study took place only over two turns
China are aimed at inpatients and the community population along with the patient’s first visit and return visit to the outpa-
currently, with common patterns of collective instruction or tient department. This intervention programme integrated
individual guidance. These diabetes self-management educa- the advantages of the two education patterns, combining col-
tion interventions usually involved a number of sessions over lective instructions with individual guidance (individualized
a long period and cost a lot of time and energy for the orga- diet guidance and exercise practice). Although taking only
nizer. Hence, they were difficult to be promoted across the two sessions, the effects of the outcomes were significant,
country. Patients were also reluctant to follow a long-term i.e., higher participation and better compliance by the
programme because of the transportation and the uncovered patients, improved self-management behaviors and psycho-
medical insurance; consequently, the rates of participation logical conditions, and lower blood glucose levels. The spot-
and compliance were relatively low [35]. There is currently light of this diabetes self-management education programme
6 Journal of Diabetes Research

was that it approached patients’ own risk factors and [4] J. Guo, R. Whittemore, M. Grey, J. Wang, Z. G. Zhou, and G. P.
encouraged and educated patients to act on the risk factors He, “Diabetes self-management, depressive symptoms, quality
of most importance to them, i.e., lifestyle, diet, and physi- of life and metabolic control in youth with type 1 diabetes in
cal activity. China,” Journal of Clinical Nursing, vol. 22, no. 1-2, pp. 69–
The strength of this study was that it provided new 79, 2013.
ideas and practical experience for diabetes health educa- [5] J. Guo, R. Whittemore, S. Jeon et al., “Diabetes self-manage-
tion in clinic work. As for some undeveloped districts or ment, depressive symptoms, metabolic control and satisfaction
countries, in where patients have poor education and are with quality of life over time in Chinese youth with type 1 dia-
betes,” Journal of Clinical Nursing, vol. 24, no. 9-10, pp. 1258–
under poor economic status, it is important to encapsulate
1268, 2015.
a patient-centered approach to diabetes self-management
[6] L. Ting and Y. Yandong, “The study of mental pain and inter-
to maximize the profits of these patients and greatly
vention methods in 122 patients with type 2 diabetes,” Chinese
improve the participation and adherence to diabetes
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limitations in this study, primarily related to the composition
psychometric testing of a theory-based tool to measure
of the analyzed sample, that is, regionalism, resources of the self-care in diabetes patients: the Self-Care of Diabetes Inven-
patients (limited to outpatients), and so on. Additionally, tory,” BMC Endocrine Disorders, vol. 17, no. 1, p. 66, 2017.
the sample of this study is small. Due to the limited sample
[8] M. C. Portillo, A. Kennedy, E. Todorova et al., “Interventions
in this study, we did not compare the self-management and working relationships of voluntary organisations for dia-
behaviors, psychological condition, glucose control, and the betes self-management: a cross-national study,” International
effects of educational intervention in different types of antidi- Journal of Nursing Studies, vol. 70, pp. 58–70, 2017.
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even the patients treated with insulin seemed to experience self-management pathways for people with diabetes in pri-
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have obvious negative emotions. The short-term diabetes [12] E. T. Adolfsson, B. Starrin, B. Smide, and K. Wikblad, “Type 2
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Data Availability betes education and self management for ongoing and newly
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The data used to support the findings of this study are diagnosed type 2 diabetes: cost effectiveness analysis,” BMJ,
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[14] A. Steinsbekk, L. Ø. Rygg, M. Lisulo, M. B. Rise, and
Conflicts of Interest A. Fretheim, “Group based diabetes self-management educa-
tion compared to routine treatment for people with type 2 dia-
The authors declared that they have no conflicts of interest to betes mellitus. A systematic review with meta-analysis,” BMC
this work. Health Services Research, vol. 12, no. 1, p. 213, 2012.
[15] Y. P. Zheng, L. F. Wu, Z. F. Su, and Q. H. Zhou, “Development
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