Yearbook on Journal of the Japan Society of Nursing Research 2014

Effects of an Education Program to Promote Behavioral in Working Patients with Type
2 Diabetes
Yoko Yamaguchi1)
Key Words :Theory of planned behavior
diabetes education program
type 2 diabetes
working males

I. Introduction

ABSTRACT
Objective: To evaluate the effects of a patient educational program, in order to promote behavioral intentions
in patients with type 2 diabetes, based on the theory of planned behavior. Methods: The education program
consisting of 3 sessions was implemented for 6 weeks, involving 5 working male patients with type 2 diabetes
undergoing treatment in a clinic. Results: The scores of the Diabetes Self-management and -efficacy Scales
significantly improved during the study period. Conclusion: The education program may be effective topromote behavioral intentions to perform diabetes self-management in patients through approaches tothe 3 concepts of the theory.

rapidly increasing medical costs and those spent on outpatient education.
In our clinic, patient education is provided in a short periodof time during consultation, and has successfully improved
glycemic control in a large number of patients. On the other
hand, as detailed education programs are not yet available,
the contents of this education depend on the needs of individual patients. Considering this situation, in this study, an
education program was developed to promote behavioral
changes toward appropriate self-management in working
male patients with type 2 diabetes. This paper reports its
contents and effects.

The number of diabetic patients is increasing yearly, andthe incidence of diabetes is higher in males1). Among the 30
trillion yen for national medical costs, approximately 1 trillion is spent on the treatment of diabetes complications2). The
maintenance of favorable glycemic control reduces the incidence of diabetes complications3), preventing the occurrenceof diabetes and its advancement and consequently contributing to the reduction of future medical costs. Therefore, it
is important to provide diabetic patients with education to
improve and maintain favorable glycemic control.
Diabetic patients without marked subjective symptoms
have been reported to withdraw from treatment more frequently. Particularly late middle-aged males, who workand play an important role in society, tend to give priority
to work over health-related activities. It is also difficult forthem to visit a hospital for consultation due to the coincidence
between the time zone in which medical services are usuallyprovided and business hours4). In this respect, the provisionof efficient and effective education may be crucial to support
working diabetic patients in the continuous control of thedisease while maintaining their daily lives.
At present, education for diabetic patients is mostly provided during hospitalization. Educational hospitalization has
been reported to improve patients’ glycemic control more
effectively than outpatient education, as it facilitates theobtainment of appropriate knowledge and self-care skills, inaddition to motivating them to improve their inappropriate
lifestyles5).
The period of such educational hospitalization is 1 to 2
weeks in the majority of medical facilities. In recent years,
weekend educational hospitalization services and outpatient
education sessions have been increasingly provided in consideration of late middle-aged patients’ living conditions.
The purposes of today’s diabetes education include:
enhancing the level of self-efficacy6-8), performing foot care9),
and providing telephone or e-mail consultation services10, 11).
However, the number of studies examining diabetes education programs12) has been limited, and none of them wasbased on theories of behavior. Under these circumstances,the development of effective education programs for outpatients with diabetes is urgently required, while considering

II. Methods

1. Conceptual framework for the study

1) BAIK Women’s University

Corresponding author. Tel.: +81 72 643 6221(Ext.472);
Fax: +81 72 643 7687.
E-mail address: y-yamaguchi@baika.ac.jp (Y. Yamaguchi)

29

On the basis of the theory of planned behavior13), a conceptual model14) to promote behavioral intentions in malepatients with type 2 diabetes (Figure 1) was created.
According to the theory of planned behavior, behavioral
intentions as a theoretical base for this conceptual model areunder the direct influence of the following 3 concepts: <attitudes toward the behavior>, <subjective norms>, and <perceived behavioral control>15). Intentions to show appropriate
behavior arise from positive feelings. Behavioral intentions
are promoted, and lead to the performance of a given behavior
when <a positive attitude toward the behavior>, <subjective
norms> to meet surrounding people’s expectations for its performance, and <perceived behavioral control> to perform it
without difficulty are appropriately combined. The theoryof planned behavior defining intentions to show appropriate behavior has been focused on in the field of behavioral
sciences, being regarded as contributing to the prediction ofhealth-related behaviors, as behavioral intentions are promoted in those showing a positive attitude toward the behavior, with highly elaborated subjective norms and increased
perceived behavioral control16).
The conceptual model (Figure 1) aimed to support working
male patients with type 2 diabetes to perform self-management comfortably as a behavior and not to consider it as interfering with their daily lives (work). The diabetes education
program based on it was designed to promote their positive
attitudes toward diabetes self-management, elaboration ofsubjective norms to meet their supporters’ expectations for its
performance, and perception of their own control to perform
it appropriately in their daily lives. These approaches focusedon the nurturing of glycemic self-management behavior as aThis paper was published at “the Japan Society of Nursing Research” Vol.33 No.5 in 2010.

Yearbook on Journal of the Japan Society of Nursing Research 2014

<Attitudes toward the behavior>࣭Understanding of the disease 㸨Listening to patients
Working malepatients with
type 2 diabetes

࣭Recognition of the actual   㸨Provision of knowledge situation

situation
㸨Provision of information
࣭Awareness of problems     and skills<Subjective norms>
࣭Recognition of surrounding  㸨Establishment of relationships
people's expectations

Behavioral
intentions

Glycemic
controlbehavior<Perceived behavioral control>࣭Perception of the ability to  㸨Provision of the knowledge toperform the behavior  make own decisions
࣭Availability of necessary  㸨Provision of skills to execute࣭㸸Patient        ࣭㸸Patient
resources and skills      decisions
㸨㸸Educator

Diabetes education program㸦Ajzen I,1988; Translated by Matsumoto, 2002㸧

Figure 1. A Conceptual Model to Promote Behavioral Intentions in Working Male Patients with Type 2 Diabetes

result of the development of behavioral intentions.

glycemic self-management behavior by guiding them toward
appropriate recognition.
The contents of the education program were determinedbased on the literature on diabetes education17, 18) and theresearcher’s experience of providing health guidance forworkers as an industrial nurse and educating outpatients, aswell as the results of previous studies19, 20), as follows:
1) reducing education-related psychological stress inpatients, 2) providing the maximum information within theminimum time period, 3) personalizing education to meet
individual patients’ needs, and 4) specifying the details of
dietary therapy as part of self-management in daily life. The
education program consisted of 3 sessions and, to enhancepatients’ comprehension of its contents, brochures explaining
the goals of each session were prepared. Table 1 outlines thecontents of the education program, while Table 2 illustrates
the points of nursing commitment based on the 3 concepts
influencing behavioral intentions.

2. Definition of terms

Education programs: Programs to specify policies onpatient education and its details and procedures
Positive attitudes toward the behavior: Positive feelings
based on the belief that a given behavior leads to significant
consequences
Subjective norms: Norms based on the belief that people
important to the individual consider the behavior to be performed and the desire to meet their expectations
Perceived behavioral control: Perception of the individual’scontrol to perform the behavior appropriately using necessary skills and resources
Behavioral intentions: Motivation to perform the behavior
3. Contents of the diabetes education program

The diabetes education program (education program)developed in this study aimed to provide patient education ina short period of time during consultation in clinics, increase
patients’ knowledge necessary for diabetes self-management,
and promote their behavioral intentions to perform the1) Purposes and structure of each session of the education
program (Table 1)
The purposes and structure of each session of the education
program were as follows: The first session aimed to motivate

Table 1. Purposes and Structure of Each Session of the Education Program

Purposes
Title

Content

Session 1

Providing information regarding the pathology and treatment of diabetes andmotivating to improve the lifestyle[Understanding the Mechanism of Diabetes]

Knowledge of diet’s influence on the
blood sugar level

Awareness of the necessity of glycemic
control by examining the lifestyle andchallenges

Session 2
Maximizing the effect of dietary therapy
by reviewing the time and amount offood intake and promoting habitual exercise[Food and Exercise Influencing theBlood Sugar Level]
Knowledge and skills to perform dietary and exercise therapies

Session 3
Providing information to realize the influence of lifestyle (mainly eating habits)on the blood sugar level and continuously perform self-management[To Perform Glycemic Control Continuously]
Necessity and appropriate period of
follow-up to perform glycemic control
continuously
Methods to undergo long-term care
comfortably

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This paper was published at “the Japan Society of Nursing Research” Vol.33 No.5 in 2010.

Yearbook on Journal of the Japan Society of Nursing Research 2014

Table 2. Points of Commitment in the Education Program
Concept

Points of commitment

Attitudes toward the behavior
Subjective norms
Listening to patients and not denying Encouraging patients to express their
their efforts and emotions toward emotions and make efforts to meet surrounding people’s expectations
diabetes self-management
Confirming changes in the results ofProviding patients with knowledge
blood test, body weight, and oral mediof the pathology of diabetes and theircations, with a view to meeting surpathological conditions
rounding people’s expectations
Providing patients with knowledge Establishing favorable relationships
and information to realize their with patients as one of their supporters expecting the behavior
lifestyle-related problems
Providing patients with informationand skills to develop solutions bythemselves

patients to improve their lifestyles, while providing them withinformation regarding the pathology and treatment of diabetes. Its content focused on [Understanding the Mechanismof Diabetes] to lead patients to understand the pathology ofdiabetes and appropriately recognize the influences of theirlifestyle on diabetes control. It also aimed to enhance patients’knowledge of diet, its influence on the blood sugar level, andawareness of the importance and necessity of glycemic control by reviewing their previous life patterns and clarifying
their present challenges.
The second session focused on the appropriate time andamount of food intake, and evaluated patients’ eating habits,with a view to maximizing the effect of dietary therapy. It also
aimed to lead patients to execute habitual exercise effectively.
To help them use their knowledge and skills on dietary andexercise therapies, aiming to control the time and amountof food intake appropriately, explanations regarding <foodand exercise’s influence on the blood sugar level> were also
provided.
The third session aimed to provide patients with information necessary to realize the influences of their lifestyle(mainly eating habits) on their blood sugar levels and continuously perform diabetes self-management, such as the necessity and appropriate period of follow-up <to perform glycemic
control continuously> and methods to undergo long-term care
comfortably.

Perceived behavioral control
Providing the knowledge to make own
decisions and skills to execute them indaily life

Providing skills to perform dietary andexercise therapies in daily life appropriately

Diabetic patient    㸨Blood test and body weight measurement
Period㸨Questionnaire survey
First session : Providing education and㻌collecting statements
Second session : Providing education and6 months
collecting statements
㸨Blood test and body weight measurement
࣭Doctor's explanations regarding test results
Third session㸸Providing education andcollecting statements
㸨Questionnaire survey

Figure 2. Evaluation Design for the Education Program
Table 3. Patient Attributes
Patient
A
B
CD
E

2) Scales used in the diabetes education program

In the education program, the following scales were used:the Diabetes Self-management Scale21), to evaluate glycemic
self-management behaviors related to diet and exercise, andthe Diabetes Self-efficacy Scale21), to measure <perceived
behavioral control>; the latter was adopted, as Ajzen22) considered the components of <perceived behavioral control> torepresent the sense of self-efficacy defined by Bandura23) as
the second determinant of behavior.
The Diabetes Self-management Scale is a self-reported scale
to evaluate the performance of diabetes self-management
related to diet and exercise in daily life, and consists of 22
items: 16 diet- and 4 exercise-related ones, as well as 2 others,with 4 response options from “Never” to “Always”. The Diabetes Self-efficacy Scale is a self-reported scale to evaluate

Duration ofHistory ofthe disease
Age
Complications
educational(years) (approximately,
hospitalization
years)
53
5
AbsentAbsent37
1
AbsentAbsent71
16
AbsentAbsent38
4
AbsentAbsent57
12
AbsentAbsentperceptions of one’s ability to perform dietary and exercise
therapies for diabetes self-management in diverse daily situations. It consists of 8 items, 4 diet- and 4 exercise-related ones,
with 5 response options from “Not appropriately performing”
to “Appropriately performing”.
Furthermore, as part of the treatment, items of periodic
blood tests that patients periodically undergo to examine
the status of glycemic control, such as fasting blood glucose,hemoglobin A1c (Hb-A1c: JDS*), total cholesterol, and triglyceride levels, were adopted, in addition to the BMI and bodyfat percentage.

*JDS (Japan Diabetes Society)
The value for HbA1c (%) is estimated as an NGSP equivalent value (%) calculated by the formula HbA1c (%) = HbA1c (JDS)(%) + 0.4%.

Journal of the Japan Diabetes Society 53(6):450-467,201031
This paper was published at “the Japan Society of Nursing Research” Vol.33 No.5 in 2010.

Yearbook on Journal of the Japan Society of Nursing Research 2014

2. Patients’ views and statements on the education Program

4. Patients

Table 4 lists the participants’ views and statements on the
3 sessions of the education program based on the 3 concepts.

A total of 6 male patients with type 2 diabetes, who visited aclinic monthly or more frequently and met the following criteria, were studied: aged 35 or over, absence of serious diabetes
complications or other diseases possibly interfering with thestudy, and consent to participate in the study.

1) First session

Before the implementation of the education program, periodic test values were shown to the patients. They also underwent measurement of their body fat percentage, followed bycompletion of the 2 questionnaire sheets.
Subsequently, as an approach to <attitudes toward the
behavior>, the patients reviewed their daily life patterns,
while being provided with information regarding the courseof diabetes and eating habits to learn the difference between
the amount of actual daily energy intake and that instructedby the doctor; such a difference was observed in all patients,
indicating their excessive energy intake equivalent to approximately one meal. Provided with such information, the patients
stated the following: Patient B: “Am I supposed to lose
weight?”, C: “My physical strength will decrease if I becomethin”, and E: “I am not eating so much”.
As another approach to <attitudes toward the behavior>,
the patients learned about the pathology of diabetes toenhance their awareness of their own pathological conditions.
Those treated with oral medications were also provided with
explanations regarding their side effects, while those with
sufficient knowledge of diabetes concentrated on important
points. Table 4 lists their statements during this session.
After termination, the following statements on the education program were recorded: Patient A: “I need to be much
more scared”, B: “I want to know what I can expect if I continue this lifestyle”, D: “Explanations regarding pathologicalconditions are absolutely necessary”, and D: “It is interesting to learn the details”. The duration of the first session was
37.0±7.6 minutes.

5. Site and period of the study

The study was conducted for 6 weeks from April 2005
to the end of May --- a sufficient period of time to observechanges in the Hb-A1c level representing the status of glycemic control --- in a clinic located in the business district of acity, specializing in internal medicine.
6. Data collection

Data were collected, as shown in Figure 2. The 3 sessionsof the education program were performed by the researcher
as a diabetes educator. A questionnaire survey was conducted
before and after the implementation of the education programusing the 2 scales to evaluate its effects. Values of biologicalindices, such as the items of periodic blood testing, BMI, andbody fat percentage, were also measured before and after it. In
addition, the patients’ statements were collected during eachsession, and interviews were conducted after termination toclarify their views on its content. Data regarding the patients’attributes were collected from their medical records.
7. Methods of evaluation

1) The patients’ views and statements on the contents ofthe education program were collected to perform narrative
analysis based on the 3 concepts.
2) Changes in the patients’ self-management and motivation were evaluated based on the scores of the 2 scales.
3) Changes in the metabolic status were evaluated based onvalues of objective biological indices, such as the fasting blood
glucose, Hb-A1c, total cholesterol, and triglyceride levels, aswell as the BMI and body fat percentage.

2) Second session

The second session took place approximately 2 weeks
after the first one. The patients’ statements on this session
were as follows: Patients A and B: “I have become aware of
the importance of continuing care”, A: “It was easy to understand, although such information is also available through thedoctor, nurses, and media”, B and C: “In daily life, newspapers
are the main source of information regarding diabetes. Now I
read them more carefully than previously”.
As an approach to <perceived behavioral control>, thepatients’ improvements after the first session were initiallydiscussed to enhance their perception that it is possible toperform self-management simply by controlling the amountof energy intake. During the discussions, the following
statements were recorded: Patient A: “Now I eat a reduced
amount of food more slowly and frequently”, B: “I eat thesame amount for breakfast and lunch, but that for dinner isslightly reduced”, C: “My goal is to limit my daily energy intake
to 1,700 kcal, as instructed by the doctor, not exceeding 2,000kcal”, C: “I eat only half a slice of bread for breakfast now. I
have also reduced the amount of salad dressing”, D: “I have
reduced the amount of rice by half for lunch”, E: “I order half abowl of rice for lunch, and consume reduced amounts of side
dishes for dinner. My body weight has decreased by 1 kg”, E:“On the basis of my calculation, I am limiting my daily energy

8. Statistical analysis

All values were simply totaled, and are shown as means ±standard deviations.
9. Ethical considerations

The patients were provided with written explanations
regarding the study objective, voluntary participation,
unconditional withdrawal, and guarantee of anonymity by
the researcher through the doctor to obtain their consent.
III. Results

1. Characteristics of the patients

The education program was implemented in 6 malepatients with type 2 diabetes, 5 of whom participated in all 3
sessions. Table 3 shows the characteristics of these 5 patients.
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Yearbook on Journal of the Japan Society of Nursing Research 2014

Table 4. Patients’ Views and Statements

A1

I should increase my physicalactivity level.
I need to exercise.

My wife just asks me about theresults after testing.

2

I have slightly reduced theamount of food intake, particularly meat.
I go for a walk at weekends.

She helps me appropriately
dine.

3
1

B

C

2

I may need more exercise.
I am walking at weekends, but
this is not sufficient at all.
I should stop eating my children’s leftovers. I should also
reduce the amount of alcohol
consumption.

She is generally cooperative.

I have to reduce the amount of
She said that she knew what
food intake, particularly at dinwas expected of me.
ner.
I should further reduce the They are cooperative, but, after
amount of food intake.
all, this is my problem.

1

It may be effective to reduce
the amounts of side dishes atdinner.
Wife: I am not so anxious (II am going to reduce the amount like cooking).
of food intake.
I have to be more self-directed.

2

1
D 2
3
1
2
3

Perceived behavioral control:
Perceptions of the ability toperform the behavior

Behavioral intentions: Motivation to perform the behavior

My physical condition is too faMaybe I can walk for about 30
vorable to realize that actually
minutes after dinner on FriI am ill.
days and Saturdays.
I think I can do it.
Should I really improve mylifestyle?
I need to take my situation If so, I have to try all methods
more seriously to make further for such improvement.
efforts.
I am continuously making efforts, although they are absolutely insufficient.
It should be my problem; there
I should do everything I can do
may be a lack of awareness.
if my condition is so poor...
OK, I will try.

My wife does not trust me.
She says that I need further Not so difficult.
control.

3

3E

Attitudes toward the behavior:
Subjective norms: Surrounding
Methods to improve the curpeople’s expectations
rent situation

I will do my best.
It is not so difficult to control
my meals, except for lunch, as I
cannot have dinner until late atnight.
I can continue this if I am doing well.

I will surely do it.

I have stopped eating my children’s leftovers. I am trying
to eat more vegetables thesedays.
I will surely do so.
I had never made so much effort like I am doing now, so I
expected improvement (in test
results)...
I should make further efforts.
I will surely do so.

It is easy to reduce the amounts I will try.
of meals.
Yes, it is possible.

My goal is to limit my daily energy intake to 1,700 kcal, notexceeding 2,000 kcal.
Yes, I am continuing to do this.
I will try to improve them further (test results).
I have just tried small things, This value should decrease toI asked my wife not to cook so
but despite it being early, I see 7%.
much, as I am on a diet.
an effect.
I should avoid excessively eating when I go mountain climbing.

My wife is an easygoing perI have reduced the amounts ofson, and always tells me to eat It is becoming easier.
my meals.
without worry.
I am going to go mountain climbing on my holidays.

I am just living routinely.
I eat less when I am busy working.
Maybe I can change my drinking style (diluting with water).
I noticed that I had been exercising in the wrong way.
I often eat at an inappropriate
time.
I am trying to satisfy myself
with reduced amounts of foodand drink.
I enjoy small amounts of foodand diluted drinks.
I tend to eat excessively atlunch.
I should review the amount.

Now I am eating more carefully.
I am holding on.

There is nobody expecting it(not married).

I am always trying to improve.
I will try as much as I can.

I am going to start from basic
I don’t want to worry my parthings.
ents by talking about my probI don’t eat much when I eat
lems.
with others.
My wife also has hyperlipidemia, so she understands what
I need, and helps me when we
dine.

Yes, I can.

Following my wife’s advice, I
It is easy.
have started eating vegetables.

Moderate.
I know I am not living well. It istime to restart.

I am already on a diet. I am
going to reduce the amountsof meals gradually in consideration of changes in the size of
my stomach.
On the basis of my calculation,
I am limiting my daily energy
intake to about 2,000 kcal.

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Yearbook on Journal of the Japan Society of Nursing Research 2014

intake to about 2,000 kcal”, and E: “Following my wife’s advice,
I’ve started eating vegetables”. Furthermore, to increase theamount of energy consumption, A: “I go for a walk at weekends” and C: “I walk 4,000 to 5,000 steps a day”.
During the second session, the patients reviewed theknowledge they had obtained during the previous session,
while being provided with explanations regarding dietary andexercise therapies as another approach to <perceived behavioral control>. Regarding support from other family members
as <subjective norms>, the patients stated the following: A:“Nothing special. My wife just asks me about the results after
testing” and B: “They are cooperative, but, after all, this is myproblem” (Table 4).
Their learning during this session was as follows: D: “I
noticed that I had been exercising in the wrong way” and A
and D: “I have learned about nutrient absorption”. The duration of the second session was 28.0±4.5 minutes.

D: “It is difficult to comment...”, and E: “I have just started”.
During the third session, the patients reviewed the contentsof the previous 2 sessions, while being provided with explanations regarding points of diabetes self-management. Whenthey were asked about changes in their lifestyles after thesession, they stated the following: A: “I am not exercising so
actively (just walking at weekends). I may still lack awarenessof my problem”, D: “I reduced the amount of rice for lunch assoon as this program started”, and E: “I am consuming reduced
amounts of side dishes (for dinner)”. Regarding the contentsof the 3 sessions, they stated the following: A: “It is very clear
what I have to do, and it should be my problem; it may be alack of awareness if I am not doing it well”, B: “I was shocked
when I learned that diabetes is an incurable disease of theblood vessels, and all I can do now is prevent it from deteriorating”, and A and C: “The sessions were informative andeasy to understand”.
They also expressed their views on medical professionals
as follows: A, B, and D: “It is nice to have someone who cares
about me besides my family”.
At the end of the third session, they completed the diabetes
self-management and -efficacy scale sheets. The duration ofthis session was 26.6±7.6 minutes.

3) Third session

Before the initiation of the third session, the patientswere informed of the results of the test they had undergone
1 month after the first one by the doctor. When they wereasked about their feelings toward the test results, they stated
the following: Patient A: “I did not expect good results, as mylifestyle has not changed much yet”, B: “I had never made somuch effort as I am now, so I expected improvement... The
data are severe”, C: “It is so early, but I see an effect (happily)”,
䠄Score䠅㻤㻜㻌Diabetes selfmanagment

㻣㻜㻌

Dietary selfmanagement

䠄Score䠅㻡㻡㻌

Figures 3-1 and 3-2 show self-efficacy and -management
scale scores before and after the implementation of the
Exercise selfmanagement

䠄Score䠅㻝㻤㻌䠄Score䠅㻥㻌

Other self-㻌 㻌㻌 㻌 management

㻤㻌

㻡㻜㻌

㻢㻜㻌

3. Changes in index values

㻝㻠㻌
㻣㻌

㻠㻡㻌

㻭㻌
㻮㻌
㻯㻌
㻰㻌
㻱㻌

㻝㻜㻌
㻡㻜㻌

㻠㻜㻌

㻠㻜㻌

㻟㻡㻌

㻢㻌
㻢㻌

㻟㻜㻌

㻟㻜㻌
BeforeBefore

After

㻡㻌
㻠㻌

㻞㻌

After

BeforeBefore

After

After

Figure 3-1. Changes in Diabetes Self-management

Exercise self-efficacy

Dietary self-efficacy

Diabetes self-efficacy
䠄Score䠅㻠㻜㻌䠄Score䠅㻞㻜㻌䠄Score䠅
㻝㻤㻌

㻟㻡㻌
㻝㻢㻌

㻞㻡㻌

㻭㻌
㻮㻌
㻯㻌
㻰㻌
㻱㻌

㻝㻠㻌

㻟㻜㻌
㻝㻞㻌

㻝㻜㻌

㻞㻜㻌
㻤㻌

㻢㻌

㻝㻡㻌
㻝㻜㻌
Before

After

㻞㻌

㻠㻌
BeforeAfter

BeforeAfter

Figure 3-2. Changes in Diabetes Self-efficacy

34
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Yearbook on Journal of the Japan Society of Nursing Research 2014
(mg/dl)BMI(kg/m2)

㻝㻥㻜㻌

㻝㻜㻌

㻞㻤㻌

㻝㻣㻜㻌

㻥㻌

㻞㻢㻌

㻝㻡㻜㻌

㻤㻌

㻞㻠㻌

㻝㻟㻜㻌

㻣㻌

㻞㻞㻌

㻝㻝㻜㻌

㻢㻌

㻞㻜㻌

㻥㻜㻌

(%)

HbA1c (JDS䠆)Fasting blood glicose

㻟㻟㻌

㻡㻌

Before㻌 㻌 After session 2(mg/dl)Body fat percentage

Befire㻌 㻌 After session 2㻌

Total cholestrol

㻟㻜㻜㻌

㻝㻤㻌

Before 㻌 Afert session 2(mg/dl)Triglyceride

㻟㻞㻜㻌
㻟㻝㻌

㻞㻢㻜㻌

㻞㻣㻜㻌

㻞㻥㻌
㻞㻣㻌
㻞㻡㻌

㻭㻌
㻮㻌
㻯㻌
㻰㻌
㻱㻌

㻞㻞㻜㻌

㻞㻞㻜㻌

㻝㻣㻜㻌

㻝㻤㻜㻌

㻝㻞㻜㻌

㻞㻟㻌
㻝㻠㻜㻌

㻞㻝㻌
㻝㻥㻌

㻝㻜㻜㻌

Before After session 2

㻣㻜㻌
Before 㻌 After session 2㻌

㻞㻜㻌

Before㻌 After session 2㻌

JDS*(Japan Diabetes Society)㸸HbA1c (NGSP) (%) ‫ ܬ‬HbA1c (JDS) (%) + 0.4

Figure 4. Changes in Biological Index Values

education program. Both scores increased after education.
Figure 4 shows changes in the fasting blood glucose, Hb-A1c,
total cholesterol, and triglyceride levels, as well as the BMI
and body fat percentage.

and Hb-A1c levels, body weights, and oral medications werecompared between the past and the present, while clarifying related changes in their lifestyles, including age-related
metabolic changes, as an approach to <attitudes toward the
behavior> to promote positive glycemic self-management. As
a result, the patients realized their problems, and stated thatthey needed solutions (Table 4).
Behavioral improvement is considered necessary in education24). In the present study, as an approach to <attitudes
toward the behavior>, the patients reviewed their previous
and present lifestyles and self-management to clarify theirproblematic life patterns, and recognized the possibility of
performing glycemic control by changing their behaviors.
Knoweles25) reported that the accumulated experiences of late
middle-aged patients are valuable resources for learning, and
it is necessary to use them effectively in education. In the present study, the patients learned the factors influencing glycemic
control after reviewing their care-related experiences, andthis may have led them to examine methods to improve theirlifestyles during the first session. Furthermore, the reviewof their present lifestyles during the second and third sessions may have guided them toward the effective use of theirpast care-related and present life experiences, consequently
strengthening their positive attitude toward the glycemic
control behavior.
Regarding <subjective norms>, wives provided an

IV. Discussion

1. Details and effects of the education program

On the basis of the durations of the 3 sessions of the education program in the 5 patients, a time frame of 30 minutes
may be feasible for a consultation; considering that interviews were conducted after the termination of each session, the times actually needed to perform them are likely to
be even shorter. The content and structure of each session
were shown to be appropriate to accomplish its purposes.
The appropriateness of the approaches to the 3 concepts,<attitudes toward the behavior>, <subjective norms>, and<perceived behavioral control>, during each session of theeducation program, aiming to promote positive glycemic selfmanagement behavior in patients, is discussed below.
During the first session, almost all patients sufficiently
understood the necessity of decreasing their blood sugar
levels, and showed a positive attitude toward dietary therapy.
On the other hand, they were not fully convinced that they stillneeded control. To address this, their fasting blood glucose
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Yearbook on Journal of the Japan Society of Nursing Research 2014

important normative belief for the male patients in thisstudy. The patients regarded their wives as cooperative, but
considered it necessary to address diabetes management bythemselves (Table 4). In this respect, the availability of support may be important for such patients to recognize theirpathological conditions appropriately, and to perform selfmanagement. In fact, the patients stated that it was nice tohave someone who cared about them besides their families,
highlighting their expectations for support from medical
professionals, including diabetes educators who implement
patient education programs. Donna26) defined patient education as a dynamic process in which medical professionals andpatients exchange information, pointing out the necessity of
establishing social support systems and clarifying social andenvironmental factors that influence the methods of treatment and its provision. As such, it may be necessary for those
who implement patient education programs to identify accurately patients’ varying social and environmental factors andnon-verbal information from them, such as facial expressions
and behaviors, in order to establish favorable relationships
with them during education. Through these approaches, diabetes educators may also provide patients with an important
belief in <subjective norms>.
As an approach to <perceived behavioral control> toprovide a belief in appropriate glycemic self-management
behavior, in the present study, the patients reviewed theirlifestyles and became aware of their excessive energy intake
based on test values; those expected after improvement werealso shown to them. During the second session, they learned
about physical activities to consume energy effectively as an
approach to <perceived behavioral control> to recognize theirability to perform the behavior. Considering the direct influence of <perceived behavioral control> on behavioral intentions as reported by Sheeran27), the approach to <perceived
behavioral control> during each session in the present study
may have led the patients to perceive that it was unexpectedly
easy to change their behaviors (Table 4). In addition, when
they heard about the improvement in their test results andbody weights during the third session (Figure 4), they becameaware of the importance of appropriate daily behaviors to
improve glycemic control. This may have developed a positive
attitude toward the behavior, leading to behavioral intentions
to perform glycemic self-management (Figures 3-1 and 3-2).
Donna26) reported that patient education focuses on knowledge, and one of its goals is supporting the use of information
appropriately by patients. In short, patient education should
not be limited to the provision of information and, in orderto achieve such a goal, it is necessary to identify individual
patients’ needs, experiences, and attitudes, as well as theinformation they need for health management. In line with
this, the education program consisted of 3 sessions withbasic contents to enable patients to perceive that they haveobtained new, useful knowledge, rather than simply providing them with general information and explanations, aiming
to promote behavioral intentions through approaches to the
3 concepts of the theory of planned behavior. As a result,the patients’ diabetes self-management behavior improved(Figure 3-1), with them giving positive statements on the 3
sessions, such as “It was easy to understand” and “I could realize the need for improvement”. On the basis of these results,
the education program is likely to be effective to provide
patients with necessary information in consideration of theirneeds and experiences, and help them to use it appropriately

as a goal of patient education. The availability of brochuresand explanations during the sessions, according to the individual’s level of knowledge, may also have contributed to the
reduction of education-related psychological stress.
Among the 3 concepts to promote behavioral intentions,<subjective norms> was not shown to influence such intentions markedly, while approaches to <attitudes toward the
behavior> and <perceived behavioral control> were effective
to lead the patients to express their behavioral intentions(Table 4) and perform diabetes self-management (Figures
3-1 and 3-2). After objectively examining their lifestyles
through these approaches, the patients actively began to show
a positive attitude toward the behavior as enhanced problemsolving ability and awareness. Therefore, the setting of clear
behavioral goals may strengthen <perceived behavioral control>, consequently enabling patients to realize the positiveeffect of behavioral changes.
While further studies may be necessary to examine the contents of the education program in more detail based on theseresults and in consideration of patients’ reactions, the appropriateness of its structure and procedures was confirmed in
the present study.
The possibility of achieving the goal of each session of theeducation program while promoting patients’ diabetes selfmanagement was also demonstrated.
2. Changes in index values

Before and after the implementation of the education program, a questionnaire survey was conducted using the Diabetes Self-management and -efficacy Scales. After education,
both scale scores improved (Figures 3-1 and 3-2), suggestingthat the approaches to the concepts to promote behavioral
intentions may have led to behavioral changes to performdiabetes self-management. This also suggests the enhanced
sense of diet- and exercise-related self-efficacy. A number ofprevious studies confirmed the direct influence of the 3 concepts on behavioral intentions16, 28).
Furthermore, after the second session, the Hb-A1c level
improved in 4 patients (Figure 4), supporting the effect ofintervention using the education program to promote behavioral intentions and improve glycemic self-management
behavior. The absence of changes in other biological index
values may be explained by the short period of the study, 6months, which was not sufficient to improve such values, as
the study objective was limited to examination of the contents of the education program. However, considering that the
BMI and body fat percentage slightly improved (Figure 4), it
may be possible to improve other biological index values byreviewing the period of its implementation.
On the basis of these results, the education program developed to improve the lifestyles of working males with type 2
diabetes may be effective to promote behavioral intentions.
V. Conclusion

In this study, a diabetes education program was developed
based on the theory of planned behavior to promote behavioral changes toward behavioral intentions, with a view toimproving the lifestyles of working males with type 2 diabetes
undergoing inpatient treatment in a clinic; the following findings were obtained:
1. It may be possible to implement this education program
36

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Yearbook on Journal of the Japan Society of Nursing Research 2014

in a short period of time during consultation, and its contents may meet working male patients’ need for diabetes
self-management.
2. The education program may be effective to promote behavioral intentions and behavioral changes toward appropriate
glycemic self-management, as diabetes self-management
and -efficacy scores increased, and the Hb-A1c level
improved in all patients except 1.

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Acknowledgement

This study was supported by a large number of people. The
author would like to express her sincere gratitude to the diabetic patients undergoing treatment in the study clinic, who
readily gave consent to participate in the study despite theirbusy lives, as well as the clinic director who permitted her to
conduct the study in his facility.
The author also thanks Sachiyo Kinoshita for permitting
the use of the Diabetes Self-management and -efficacy Scales
in the study.
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This paper was published at “the Japan Society of Nursing Research” Vol.33 No.5 in 2010.