The Effect of Diabetes Self-Management Education on Hba1c Level and Fasting Blood Sugar in Type 2 Diabetes Mellitus Patients in Primary Health Care in Binjai City of North Sumatera, Indonesia

AIM: The study aimed to evaluate the effect of short-term diabetes self-management education (DSME) on Hba1and Fasting Blood Sugar in type 2 diabetes mellitus patients attending the Primary Health Care (PHC) in Binjai city of North Sumatera, Indonesia. SUBJECTS AND METHODS: A quasi-experimental (pretest-posttest) study was conducted in 4 PHCs, involving 80 patients with type 2 diabetes mellitus. The patients in received a 3-months intervention, including an 8 week education on self- management of diabetes mellitus and subsequent 4 weeks of practice of the self- management guidelines.The patients received standard advice on diet management. RESULTS: There was a significant reduction in Hba1c levels. The statistical analysis using t-test found that there was a significant difference of Hba1c value between pre and post education among type 2 diabetes mellitus patients (p < 0.005). CONCLUSIONS: Diabetes self-management education in PHC of Binjai city can reduce the Hba1c level in type 2 diabetes mellitus patients.


Introduction
Diabetes mellitus, commonly type 2 diabetes mellitus, is an increasing health problem worldwide. It has been estimated that there will be 552 million patients with diabetes and 300 million people with impaired glucose tolerance in 2030 [1]. Diabetes mellitus is associated with various atherosclerotic complications, including cerebrovascular and cardiovascular diseases, causing significant morbidity and mortality [2].
Diabetes self-management education (DSME) is the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. This process incorporates the need, goals, and life experiences of the person with diabetes and is guided by evidence-based standards. Therefore, it plays an important role in the clinical management of diabetes [3].
Monitoring of metabolic markers, such as blood pressure, body weight, lipid profile, fasting blood sugar and Hba1c, is essential in the clinical management of patients with diabetes because hypertension, obesity and dyslipidemia are wellknown risk factors of atherosclerosis and are common https://www.id-press.eu/mjms/index in diabetic patients [4]. Monitoring of these risk factors also helps in evaluation of treatment response of the patients [5]. As a long-term disease, diabetes mellitus needs lifetime care and management. However, 50-80% of patients with diabetes did not have enough skills and knowledge for self-care of the disease [6]. Previous studies have shown that DSME improves homeostasis of metabolism of the patients, and healthy lifestyle prevents the development of atherosclerosis in patients with type 2 diabetes [7] [8].
This study was undertaken to evaluate the effect of DSME on Hba1c and Fasting Blood Sugar.

Methods
In this study, a total of 80 patients with type 2 diabetes mellitus were recruited from four Primary Health Care in Binaji city, North Sumatera, Indonesia. This is quasi-experimental research with One Group Pretest-Posttest Design. This was conducted from April to September 2017. From each PHC 20 samples were taken. The patients were recruited in accordance with the inclusion criteria, age > 40 years oldcooperative patients and willing to join the research and exclusion criteria (using diuretic and the middle of cancer therapy). Among the 80 patients, two of them did not complete the DSME programme or did not attend the follow-up examination and thus were excluded from the study. This research was approved by Health Research Ethical Committee, Medical Faculty of University Sumatera Utara/H. Adam Malik General Hospital number 591/TGL/KEPK FK USU-RSUP HAM/2016. Patients were informed of the detail of the study, and written consent was obtained from the patients before they participated in the study.
Blood samples were collected (using syringe) twice before and after interventions and transferred to the laboratory immediately to conduct glycosylated haemoglobin test by Alere Afinion as 100 Analyzer. Fasting blood sugar of samples, we examined by using a portable measuring instrument (Gluco DR). We examine blood pressure, weight, and height and waist size as well.
A questionnaire interview method was adopted to collect information about the family history of the disease, education level and type of the job.
The patients in the intervention participated in a DSME programme in which the patients were required to attend a two-hour lesson weekly for eight weeks and to follow the self-management guidelines of the education programme in the daily activities within the study period. For the DSME programme, all the lessons were focused on the skill and knowledge for healthy eating, being active, monitoring, taking medication, problem-solving, reducing risks, and healthy coping [9]. For the samples blood test (fasting blood sugar and HBa1c), height, weight waist size examinations were performed before the commencement of the DSME programme as the baseline and one month after the completion of the DSME programme. The continuous data were expressed as the mean ± standard deviation (SD). Shapiro-Wilk test was used for checking the normality of distribution. If the data were normally distributed, a t-test was used. Otherwise, a nonparametric test was applied.

Results
The number of the samples from the four PHCs were 80 comprising 52 females (65%) and 28 males (35%), achieving the assigned target of interviews before and after the intervention. The demographic data; about gender, age-group, education level, kinds of job, family history and type of treatment are presented in Table 1. We give the education for 3 months only. Two of samples did not complete the DSME programme or did not attend the follow-up examination and thus were excluded from the study. When we did the post-test the number of samples is 78 because two of that are excluded because one of them was is died, and the other did not complete all of the education. We found that there was a significant difference in all variables between pretest and posttest.

Discussion
This study aimed to evaluate the effect of diabetes self-management education on reducing Hba1c levels among the type 2diabetes mellitus patients by measuring glycaemic indexes before and after intervention in primary health care in Binjai city. One of the reasons for diabetic patients' failure to achieve the desired outcomes is their lack of participants in treatment. This participation is an important factor in the treatment of patients who are willing to follow a treatment plan throughout the life [10]. A study by Chuang Yuan ect showed that the patients in the intervention group had significant reduction of the Hba1c level and body weight after receiving the education as compared to the control group, indicating that education had positive effects for improving the health status of patients with type 2 diabetes [11]. Different with us all the patients with type 2 diabetes mellitus we gave diabetes selfmanagement education, and it had a positive effect on improving the health status by reducing Hba1c after the intervention. In spite of the short exposure time to education, our findings suggest that the educational intervention was successful in achieving some significant changes in the lifestyles of participating subjects. Among our target population there was an increase in the number of patients being involved in exercise like bike, aerobic and just walking for 30 minutes, an increase in the proportion of patients using the healthy diet that we suggested, increased vegetable intake, diet soft drinks, and the reason for those changes was the doctor's advice and more personal concern about their health care. This resulted in achieving a good change in the control of diabetes mellitus (mean HbA1c) in the post-educated than the pre-educated group.
Respondents in the two surveys were similar about gender, age, marital status, educational level, the presence of a maternal history of diabetes. On our studying we took the samples at the age > 60 years old is a little compared than < 60 years old, the reason was it make us easy for giving education, for the samples with age>60 years old we gave education besides for the patient we gave to the education for their close family. Most respondents had received some form of health education in the recent past and the follow-up survey. However, the recent health education was well organised and directed mainly to diabetic patients and their close family. All the study participants received the drugs of diabetes mellitus type 2 from PHCs because we included patients diagnosed with type 2 diabetes mellitus. Only one patient received insulin.
The level education was more at the middle level (30 people) than at the low (20 people), the high (25 people) and academic (5 people). We can say that these results are encouraging, considering that the health education intervention was of very short duration and was of limited scope and quality. A largescale, effective and high-quality health education program is likely to have much better results; such a program is expected to reduce the burden of diabetes mellitus in Binjai city, North Sumatera.
The conclusion of this study is that improving the quality of health education in PHC in Binjai city through well-designed programs will improve the awareness and practices among the population in general, but particularly among patients with diabetes mellitus, increasing awareness for diabetes mellitus patients about exercising like aerobic in PHC each week and exercise every day at least for 30 minutes. Several studies concluded that lack of knowledge, self -care skills, and correct information about the treatment programs hinder the improvements. One important problem is non-compliance and adherence to treatment plan [12] however, we must not forget emphasis just on knowledge, because in many cases, people know what to do, but do not put their knowledge in action [13].
There are several limitations in our study: Firstly; the time interval between pre and posttest was relatively short. Secondly; the possibility of bias in the end line survey cannot be excluded (patients exposed to health education and/or a similar interview at the end-line are more likely to give 'adequate' answers to the questions). Thirdly, we recorded data only for pretest and post-test time points. Finally, it is expected that the effect of diabetes self-management education intervention may have been short-lived, as observed in several other studies.