Diabetes knowledge, health beliefs, and health behaviour among type2 diabetes patients in rural area Indonesia- Qualitative and quantitative studies（インドネシアの農村地域における２型糖尿病患者の糖尿病
知識、健康信念、および保健行動 － 定性的および定量的研究）

by
NICE MAYLANI ASRIL

Graduate School of Biomedical and Health Sciences
Hiroshima University
2019SUMMARY OF THE WHOLE DISSERTATION

Indonesia experiences an epidemiological transition with increasing casesof diabetes mellitus every year, especially in Java and Bali. In Indonesia, studies on
diabetes have mostly been oriented on patients in urban areas. The study to explore
the diabetes knowledge and health beliefs in rural areas is important to initiate. The
Health Belief Model (HBM) is the model that has been specifically developed to
explain health behaviour of patients. In this study HBM provides a conceptual
framework to make it possible for the researcher to explore the health behaviour ofthe diabetes patients. According to the model, if the diabetes patients obtain correctknowledge about diabetes risk, then they will perceive diabetes as a serious disease
and decide that it is important for them to take a preventive action. They will also try
to adjust their behaviour to keep healthy by practicing diabetes prevention throughperceived susceptibility, perceived severity, and perceived benefits and barriers.
When they have self-efficacy within themselves that they can practice the diabetes
prevention and overcome every problem, this will lead to a good self-management.
Knowledge and demographic characteristics were also investigated in this diabetes
study because they have implications as a foundation for a person’s decision to
manage the disease.
This study is divided into two stages, namely qualitative and quantitative
studies. This study included a fieldwork to collect the data: i.e., study conducted inlocal community in rural Bali Province, Indonesia. The first study was qualitative
study with aims to explore diabetes knowledge, health beliefs, and health behaviours
among type 2 diabetes patients in rural Indonesia using the theoretical framework of
the HBM. The first study used HBM in applied thematic analysis. The Focus Group
Discussion (FGD) was used to collect data. The FGD guides were developed based on
HBM aspects. The participants were selected through purposive sampling. The
invitees were 32, of whom 20 signed the informed consent document and joined thestudy. This sample size was to ensure sufficient variety of experience needed forsaturation. The participations were voluntary and confidential. The mean age ofparticipants was 49.9 years old, range 33-58. Nine (45%) participants were graduatesfrom elementary school, 9 (45%) were those from high school, 2 (10%) were thosefrom junior high school, and all of them were working (45% of them were sellers).
Mean age when the participants got the diabetes diagnosis was 49.6 ± 6.5 years old.
Mean of random blood glucose level in November 2016 was 184.3 ± 75.7 (mg/dL).
About 60% of the participants did not have a family member suffering from diabetes
and 75%participants had no history of non-communicable disease. The result of thefirst study showed the emergence of three themes, according to HBM. The first theme
was poor diabetes knowledge due to traditional indigenous beliefs and low healthliteracy. The second theme was the perception of diabetes as a life burden related withphysical and psychological conditions. The third theme was the existence of factors
affecting self-efficacy in practicing healthy lifestyle including the perceived barriersand external influence. Further studies on health beliefs in diabetes should be
explored. In the future, there are needs to understand the traditional indigenous beliefs,
burdens, and lacking internal intention as the modifying factors of health beliefs. The
development of integrated health promotion of diabetes should consider the HBM’s
modifying factors in rural areas.
The second study was quantitative study with aims to identify factors
explaining the healthy lifestyle behaviours of type 2 diabetes patients in rural
Indonesia. In this study, Extension Health Belief Model (EHBM) provides aconceptual framework to explore the healthy lifestyle behaviours in the diabetes
patients. It additionally includes locus of control and social support as extension
factors in EHBM. According to this extended model, if the diabetes patients obtaincorrect knowledge about diabetes risk, they will perceive diabetes as a serious disease
and decide that it is important for them to take a preventive action. They will also try
to adjust their behaviour to keep healthy by practicing diabetes prevention throughperceived susceptibility and perceived severity. Furthermore, if the patients
understand the usefulness of new healthy behaviour and its effect of decreasing therisks of developing the complication and the benefit of social support from theenvironment around them, they will believe there is a benefit in adopting these
healthy lifestyle behaviours. When they have an internal locus of control withinthemselves that they can practice the diabetes management and overcome every
problem, this will lead to a good self-management. The participants were selectedvoluntarily by convenience sampling for this study. There were 256 participants
recruited, of whom 203 completed and returned the questionnaires. Informed consent
was obtained from all individual participants included in the study. Each participant

took about 30 minutes to complete the questionnaire anonymously. Demographic
characteristics, clinical and lifestyle factors, knowledge, EHBM, and healthy lifestyle
behaviours as the measurements for this study were measured using a personal
information sheet and standard self-report scales. Means, percentage, and standard
deviations were calculated for descriptive statistics. Pearson’s correlation coefficientswere used to identify the correlations among variables. Predictors of healthy lifestyle
behaviour were identified by hierarchical regression analysis. An alpha level of 0.05
was used to determine statistical significance in all statistical tests.
The mean age of the participants was 54.6 years old (standard deviation, SD
8.99). Notably, 36.9% were senior high school graduates; 61.1% took diabetic
medicine; mean symptom duration was 33.8 months (SD 33.3), and 34.0% consumed
alcohol. About 17.7% of the participants believed that diabetes was associated withblack magic and shamanism. The mean score for diabetes knowledge was 5.41 (SD1.51). The results of the hierarchical regression predicting healthy lifestyle behaviours
from demographic characteristics, clinical and lifestyle factors, diabetes knowledge,
and EHBM. All these factors accounted for 71.8% (0.718) of the variance inparticipants’ healthy lifestyle behaviours. The strongest predictors for healthy
behaviours were demographic characteristics (33.9%), the extended health belief
model (24.3%), clinical and lifestyle factors (12.6%), and the last was diabetes
knowledge (0.9%). The significant predictors of healthy lifestyle behaviours were age,educational level, employment status, traditional belief, symptom duration, diabetic
medicine, alcohol use, perceived susceptibility, perceived severity, family support,
bonding social capital, chance locus of control, and perceived barriers. The findings
from this study indicate that demographic characteristics, clinical and lifestyle factors,
diabetes knowledge, and the EHBM could predict healthy lifestyle behaviours in type2 diabetes patients in the rural areas of Bali. Even though diabetes knowledge is afoundation, the extension factors of EHBM, i.e., social support (family support),
bonding social capital, and chance locus of control are an adequate framework that
could help to predict healthy lifestyles. Healthcare professionals need to consider
EHBM for patient education and disease management in diabetes care.
Based on the results from qualitative and quantitative study, efforts to promotehealthy behaviours of type 2 diabetes patients should not be limited to educating type2 diabetes patients about diabetes. They should also include the consideration of theirhealth beliefs, support from the family and those in the environment around them forreducing the risk of diabetes complications. The following recommendations areoffered for the development of an effective intervention program for patients in ruralarea.
1. At the individual patient level: The EHBM theory can be used as a guide toinclude all suitable aspects in the intervention program. Diabetes education
classes can include important information about the etiology of diabetes and thecomplications of diabetes. The class is more focused on improving diabetes
knowledge, perceived susceptibility, reducing risk factors and the benefits of
behavioural change. The class is a message to give the appropriate view ofdiabetes: i.e., diabetes is a chronic disease that can be controlled, and the risk ofcomplications is significantly reduced by patient decisions and behavior. Classes
are encouraged to share success stories among diabetic patients in the classroom
to make behavioural change more successful. Classes are also expected to
discusses perceived barriers to behavioural change, as one of the key aspects of
HBM.
2. At the level of family, friends and small groups: The study showed that social
support from families could predict healthy lifestyle behaviours. The diabetes
program can intentionally encourage class participants to bring family members
and/or friends ("anyone who helps you manage diabetes") to class and facilitate
the development of a family-like atmosphere in the classroom itself. Diabetes
education classes can be designed with the aim of applying aspects of social
support. The aim is to make participants feel supported, both interpersonally andin a real way, throughout the class. Classes can be introduced as "second
families" and set cultural expectations for emotional support throughout eachsession. Participants in the class are also socially integrated with each other; they
will communicate outside the classroom, calling each other as "buddy" and"family," and rely on each other during class sessions.
3. At the organizational, community and cultural level: Health careorganizations and providers in these organizations can provide infrastructure not
only to improve patient care but also to support patients in making behavioral
changes. For example, nurses as care managers can help to increase social
support, to improve medication adherence, and to facilitate adoption of lifestylebehaviors. A nurse practitioner at a community health center could function as acare manager for high-risk diabetes patients. He/she is also a companion teacher
in the diabetes education class and able to provide a smooth transition among
intensive education, support for behaviour modification, and providing care.