Comparison Effect of Physical Health Training and Psychological Training of the Theory of Reasoned Action (TRA) model on the Life Quality of Patient with Diabetes in Tehran, Iran: Utilization of Message Texting

doi:10.21203/rs.3.rs-3626238/v1

Download PDF

Research Article

Comparison Effect of Physical Health Training and Psychological Training of the Theory of Reasoned Action (TRA) model on the Life Quality of Patient with Diabetes in Tehran, Iran: Utilization of Message Texting

https://doi.org/10.21203/rs.3.rs-3626238/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background and Purpose: Providing physical health and mental health training promotion is necessary for a sustainable change in patients with diabetes attitude and way of life. The present study was conducted with the aim of comparison effect of physical health training and psychological training of the theory of reasoned action (TRA) model on thelife quality of patients with diabetes.

Methods: This experimental study was conducted with two intervention groups and one control group in 2022 on 129 diabetic patients referred to Imam Khomeini Hospital in Tehran. During one month, each person in first group was sent 15 text messages on physical health and second group received 15 psychological text messages on the TRA. The data collection tool was the "Audit of Diabetes-Dependent Quality of Life (ADDQoL)" questionnaire, which was completed by the participants before and after the intervention. The data were analyzed using SPSS version 16 software at a statistical level of 0.05.

Results: After the intervention, in first group, life quality score average was 8.51 units (P<0.001) and second group was 19.25 units (P<0.001) more than the control group. The psychological training group had a 17.62 units (P<0.05) lower average fasting blood sugar (FBS) and a 10.74 units (P<0.001) higher average quality of life than the physical training group.

Conclusion: The effectiveness of psychological training of TRA model in improving the life quality and reducing FBS in patient with diabetes is more than physical health training. Future plans to develop mental health education in these patients are recommended.

Diabetes

Training

Physical Health

Reasoned Action

Quality of Life

Diabetes is one of the chronic diseases that cause significant mortality worldwide (1). This disease is a potentially debilitating disorder and has become the fastest growing chronic disease affecting more than 300 million people worldwide, including our country (2, 3). In Tehran, 5–6% of people aged 3–69 and in Iran 12% of adults and 14–23% of people over 30 years old have diabetes (4). Lack of blood sugar control, in addition to physical complications, can cause negative attitude, mental pressure and also reduce the quality of life of sufferers (5, 6). The extent to which a person believes in his abilities to deal with certain situations is related to the quality of his/her health-related life (7). Therefore, the quality of life is considered a main issue in the care and promotion of the health of patients, including those with diabetes (8). Diabetic quality of life refers to the perception and feeling of diabetic patients about their needs, desires and satisfaction from their whole life (9); In such a way that the low quality of life in them causes mental exhaustion, leaving the job, reducing productivity, psychological problems such as depression, anxiety and reduced physical performance (10, 11).

Proper training in terms of physical health and improving mental health will cause a lasting change in the attitude and performance of people and eventually change in their way of life (12). Most of the people with diabetes do not have a good level of quality of life during their illness due to the lack of sufficient knowledge of the complications and consequences of this disease (13); Therefore, the education process is one of the basic needs of these patients (14, 15). Despite all the benefits of education, what is important is the development of new, low-cost and accessible methods such as mobile phone text messages to educate diabetic patients and check their effectiveness (16, 17) to be able to save the resources of the health sector effectively (18). This service provides the possibility of sending instant and direct messages to people at any time and place (19) and does not have the limitations of social networks (requires Smartphone, internet, etc.) (20). Studies have shown that sending text messages as a medium for patient education along with conventional treatment not only improves blood sugar control (21), but also have positive effects on raising awareness, changing behavior, quality of life and other aspects of their self-care (22, 23).

On the other hand, due to the connection between body and mind, the natural and pathological physical changes of diabetic patients can lead to debilitating psychological symptoms (24), which itself is the basis for creating or intensifying disorders such as depression, anxiety, fear, injuries and cognitive distortions of people towards themselves and their surroundings (25, 26). Therefore, in the case of correct psychological training and health-promoting lifestyle to these patients, such problems can be reduced to a large extent (27, 28). In this regard, the study of Eyni et al. (2020) showed that most people with diabetes have a low level of psychological well-being, and training to patients has been able to play an important role in empowering and improving their quality of life (29). Also, researchers are of the opinion that the effectiveness of theory-based interventions is often greater by providing the necessary tools and information about how to teach and evaluate (30, 31). One of the theories that can be used in the mental health education program for patients with diabetes is the theory of reasoned action (TRA) (32). This theory shows that most of a person's behaviors are under his voluntary control. Therefore, they can be predicted based on the intention of the behavior (33). Also TRA assumes that people are usually rational and consider all aspects of a behavior before making a decision about whether or not to do it (34, 35). The TRA has been considered by researchers as a model to improve the compliance of patients with diabetes in the management of this disease in order to achieve therapeutic effectiveness (36). This theory has the advantage of other behavioral theories and has been widely used in studies to predict and explain the tendency to act and the actual behavior of patients with diabetes (37). In this regard, St. Quinton (2022) in a psychological study that aimed to use the approach of TRA and planning to understand diabetes self-management behaviors reported that the willingness to comply with diet and blood sugar monitoring is significantly related to instrumental attitude, command norm and individual capacity (38).

The conducted studies indicate the usefulness of training, but so far no independent research has been conducted regarding the comparison of the effect of general physical health training on the one hand and psychological training on the other hand in people with diabetes. In the present research, the psychological training of patients with diabetes based on the TRA including messages that affected the dimensions of their voluntary and perceptive behavior in relation to the type of disease and the surrounding environment, in comparison with the training of the individual's physical health, performance and effect these two types of training, as well as the comparison of their impact on the quality of life of patients with diabetes referred to the Diabetes Center of Imam Khomeini Hospital in Tehran, were investigated, so that by analyzing the data, appropriate educational policies can be adopted regarding the use of the type and method of more effective training to improve the quality of life, reduce blood sugar and morale in this patients.

Objective:

The objective of this study was to determine the effectiveness of SMS training related to physical health issues and psychological training of the TRA model, as well as comparing the effect of these two trainings on the quality of life of people with diabetes referred to the Diabetes Center of Imam Khomeini Hospital in Tehran.

Study design:

This experimental study was performed with two intervention groups and a control group in order to compare the effect of physical health training and psychological training of the TRA model using text messages on the life quality of patients with diabetes referred to the Diabetes Center of Imam Khomeini Hospital in Tehran.

Study population:

The study population consisted of all patients with type I and type II diabetes, except those with gestational diabetes, referred to Imam Khomeini Hospital in Tehran. Inclusion criteria were at least 6 months from the diagnosis of the disease, being between the ages of 20 and 65, willing to participate in the research, being under medical treatment (pills, insulin injections or both), being literate, having a simple mobile phone was used by yourself or a family member to receive text messages and know how to use it. The exclusion criteria included the inability to understand and answer the questions, the occurrence of medical problems leading to hospitalization, simultaneous suffering from another underlying disease, and the patient's unwillingness to continue the research in any of the stages of the study. In order to take a sample for this research, first, with the coordination of Tehran University's Research and Technology Affairs Department, a request for permission to conduct the study and relevant documents was submitted to the Vice President of Academic Affairs of Tehran Imam Khomeini Hospital Complex, and after obtaining the permission, the list of all patients to the diabetes department of the hospital, from April 2022 to March 2023 was received from the admission department, statistics and medical documents of this hospital. After a comprehensive review of the obtained information, the patients who met the criteria for inclusion in the study were selected. Then, by making phone calls to each of the patients and explaining how to conduct the research process, a list of people who were willing to participate in the study was prepared. To determine the sample size in this research, the following formula was used with a confidence level of 95% and a test power of 90%:

Based on this, the number of samples required in each of the three studied groups was estimated to be 43 people. Then the samples were randomly divided into two intervention groups and one control group, totaling 129 people and the research process was completed by obtaining the informed consent of the patients and ensuring the confidentiality of the received information.

Variables:

In this study, information about demographic factors including age (20 to 40 years, 41 to 55 years and 56 to 65 years), gender (male or female), level of education (under diploma, diploma and postgraduate diploma, bachelor and above), job status (employed, unemployed), duration of disease diagnosis (under 5 years, 5 years and above), type of medical treatment (pills, insulin injection, both) and family history of diabetes were collected. The level of fasting blood sugar (FBS) and glycosylated hemoglobin (HbA1C) of each person, which indicate the clinical effects of proper training, were collected and recorded from the patients.

The data collection tool in this study was the diabetes-dependent quality of life questionnaire, created by Bradley et al. 1999 (39), which are known as "Audit of Diabetes-Dependent Quality of Life (ADDQoL)". This questionnaire shows how important each aspect of life is for the quality of life of diabetic patients and how diabetes affects that aspect of life. The ADDQoL questionnaire has 19 items and is designed for people's perception about the impact of diabetes on the quality of life of sufferers. Each question consists of 2 parts. The scoring method of this tool is that in the first part of each question, the impact of diabetes on people's lives is scored from 1 to 5 (much better or more to worse or less), except for question 17, which is scored in reverse and the second part of the question of the degree of importance of each item is scored on a scale of 1 to 4 (completely unimportant to very important). For normalization and comparability of the raw quality of life score, the rank of each person's effect is multiplied by its importance rank (41). Thus, the final score of this tool measures the quality of life of patients with diabetes. As Cronbach's alpha (85%) shows, there is good internal reliability. Factor analysis and Cronbach's alpha coefficient support the integration of items in one scale (39). This tool is designed for both insulin-dependent and non-insulin-dependent diabetics. The validity of this questionnaire has been examined by Darvishpoor Kakhaki et al. 2005 (40). Cronbach's alpha coefficient of 0.91 in this research indicates good and acceptable internal consistency of this scale. Also, in order to check the reliability of the scale, the questionnaire was re-administered on the same patients with an interval of 5 weeks, and the retest coefficient was 0.69 and the significance level was 0.001. In general, the results show that this questionnaire is a suitable tool for investigating the quality of life of with diabetes in Iran (40).

Data gathering:

The research samples were randomly selected from the patients referred to the diabetes department of Imam Hospital based on the inclusion criteria and placed in two intervention groups and one control group. First, the purpose of the study was explained to the patients and they were asked to follow the ethical standards when answering the questions. The average time allotted to each patient to complete the questionnaire was about 20 minutes. Then the patients signed the informed consent form. Demographic questions, FBS and HbA1C of each person were recorded before the intervention, and the diabetes-related quality of life questionnaire was also administered to each affected person in all groups by phone and according to the relevant protocol was completed.

Then, the training process was carried out for 2 intervention groups during one month in such a way that the first intervention group only received text messages with physical health content every other day. These text messages included things such as following a proper and sufficient diet, preparing a regular meal plan, performing beneficial sports activities in certain time intervals, taking timely and appropriate medicine, observing personal hygiene, taking care of the skin regularly, and visiting the doctor regularly. The draft of the initial content of these text messages was prepared by the researcher and then it was revised and corrected with the help of experienced medical education professors and diabetes education experts.

The second intervention group also received only text messages with psychological content based on the TRA every other day; with the argument that according to this theory, most of the behaviors of these patients are under their voluntary control, and they often act based on their perception of how others think about performing the behavior (32, 37). Therefore, the messages prepared in this direction include accepting responsibility to the extent possible, having enough sleep to improve brain function, controlling anger, calming the mind by regularly planning life affairs, being bold in doing things and accepting mistakes, reducing stress levels by changing habits. The thinking was not comparing oneself with others, accepting the disease and following the treatment, hoping for the future and improving individual self-confidence that these text messages were also prepared and used with the help of the present research team (nursing education expert, medical education expert, and psychiatric nursing expert) and with the help of psychology professor. The proposed text of the text messages for mass sending in terms of structure and number of characters was given to the information technology expert and after checking and applying the necessary corrections; the final text was compiled and used. During the intervention period, no SMS was sent to the third group (control).

Thus, during this study, each person in the first intervention group received 15 text messages related to physical health training and the second intervention group received 15 other text messages regarding their psychological training. During the mentioned period of time, to ensure the receipt of the sent SMS, the researcher made random phone calls to some patients and followed up the training process. The phone number of the researcher was also provided to all patients so that if any of the patients needed further explanation about the submitted materials during the study, they could contact her and fully understand the relevant concepts. Then one month, the patients were given the opportunity to apply the sent messages in their daily life and after the mentioned period, the ADDQoL questionnaire was completed and collected again by phone according to the relevant protocol. The scores obtained by each person were recorded based on the points specified in the questionnaire. The level of FBS and HbA1C of each sample was also collected and recorded from the patients after the intervention.

Statistical Analysis:

Chi-square test was used to check the distribution of samples in intervention and control groups. In order to find the relationship between the quality of life scale and demographic variables, independent t-tests and one-way analysis of variance, In order to check the average scores of the questionnaire, the amounts of FBS and HbA1C among the groups, the independent t-test and within the groups, the paired t-test were used. A P value of < 0.05 was considered significant for all tests. The SPSS software version 16 was used for analysis.

The number of research samples in this study was 129 people whose age range was between 20 and 65 years. Most of these samples are in the age range of 41 to 55 years (41.08%), male (52.71%), have diploma and post-diploma education level (45.74%), unemployed (69.77%), the duration of illness was less than 5 years (57.36%), used oral medications (62.02%) and had a family history of diabetes (69.77%). The demographic information of each group is presented separately in Table 1.

Table 1

Distribution of absolute and relative frequency of demographic information in three groups
		Control			Intervention 1			Intervention 2			Total
Demographic variables		Num		%	Num		%	Num		%	Num		%
Demographic variables		N = 43			N = 43			N = 43			N = 129
Age (years old)	20–40	12	27.91		13	30.23		10	23.25		35	27.13
	41–55	18	41.86		16	37.21		19	44.19		53	41.08
	56–65	13	30.23		14	32.56		14	32.56		41	31.79
Gender	Man	23	53.49		24	55.81		21	48.84		68	52.71
Gender	Woman	20	46.51		19	44.18		22	51.16		61	47.29
Education	Under Diploma	11	25.58		12	27.91		13	30.23		36	27.91
	Diploma & Post-dip.	21	48.84		18	41.86		20	46.51		59	45.73
	Bachelor's & Above	11	25.58		13	30.23		10	23.26		34	26.35
Job	Employed	12	27.91		11	25.58		16	37.21		39	30.23
Job	Unemployed	31	72.09		32	74.42		27	62.79		90	69.77
Duration of illness (years)	< 5	26	60.47		23	53.49		25	58.14		74	57.36
Duration of illness (years)	≥ 5	17	33.54		20	46.51		18	41.86		55	42.64
Treatment	Oral	28	65.12		27	62.79		25	58.14		80	62.02
	Inject	13	30.23		12	27.91		17	39.53		42	32.56
	Both	2	4.65		4	9.30		1	2.33		7	5.42
Family history	Yes	29	67.44		30	69.77		31	72.09		90	69.77
Family history	No	14	32.56		13	30.23		12	27.91		39	30.23

Examining the distribution of samples using the chi-square test showed that the samples were equally distributed in the categories of each demographic variable in the control and intervention groups. Also, the findings indicate that in the research samples in the pre-test, there was no significant relationship between the quality of life and the demographic variables of gender and family history of disease (P > 0.05); however, Employed people and people who had diabetes for less than 5 years had a higher average quality of life score than Unemployed people and those who had been diagnosed with diabetes for more than 5 years (P < 0.05). The results showed that with increasing age, the average score of quality of life in patients decreased and with increasing education level, the average score of quality of life also increased significantly (P < 0.05). In the examination of the type of treatment variable, it was also found that people who used oral drugs for their treatment had a higher quality of life score than those who injected insulin; however, no significant difference was observed between the oral and injectable use of the drug compared to the combination.

Also, the overall study of the effect of training before and after the intervention using the paired t-test showed the effect of training on FBS with an average value of 9.16 (P = 0.000) and HbA1C with an average value of 0.7. 0 (P = 0.000) and quality of life is significant with an average value of 10.28 (P = 0.000) (Table 2). This means that, in general, educational interventions have been able to reduce FBS and HbA1C in patients and increase their quality of life.

Table 2

Evaluation of the overall effect of the intervention (before and after) with paired t-test
				Paired Differences
						95% Confidence Interval of the Difference
			Total mean ± Std. Deviation	Mean Difference	Std. Deviation	Std. Error Mean	Lower	Upper	Sig. (2-tailed)
Pair 1	FBS	Before	177.48 ± 38.60
Pair 1	FBS	After	168.31 ± 39.22	9.16279	11.64500	1.02529	7.13409	11.19149	0.000
Pair 2	HbA1C	Before	9.02 ± 0.88
Pair 2	HbA1C	After	8.95 ± 0.87	0.07085	0.12859	0.01132	0.04845	0.09326	0.000
Pair 3	Quality of Life	Before	74.03 ± 10.05
Pair 3	Quality of Life	After	84.32 ± 11.87	-10.28682	9.73572	0.85718	-11.98290	-8.59074	0.000

In order to explain the objectives of this study regarding the effect of each of the interventions separately compared to the control group, independent t-test was used. The results showed that the average level of FBS, HbA1C and quality of life in the patients of both intervention and control groups were not significantly different before the intervention. After the intervention, as can be seen in Table 3, based on the significance of Levene's test to check the assumption of equality of variances in this study, it was determined that after physical health training in the physical health training group (intervention 1), the amount of FBS and HbA1C compared to the control had no significant differences. But according to the significance value of Levene's test in the quality of life scale, including the significance value of 0.09 in the assumption of equality of variances, since the significance value for the t-test statistic is less than 0.001. Therefore, the average score of the quality of life in both the intervention 1 and control has a significant difference and in the physical health training group it are 8.51 units more than the control group.

Also, according to the significance value of Levene's test to check the assumption of equality of variances in the psychological training of patients based on the TRA (intervention 2), it was determined that the mean of HbA1C in this group did not have any significant difference compared to the control. On the other hand, the inclusion of a significant value of FBS of 0.285 and a significant value for the t-test statistic, which is equal to 0.03, indicates that the equality of the average FBS in the control and intervention 2 is rejected, and the intervention 2 is equal to 18.27 units had a greater effect than the control in reducing FBS. Also, according to the significance value of Levene's test to check the assumption of equality of variances in the quality of life scale with a significance value of 0.164, considering that the significance value for the t-test statistic is less than 0.001, this indicates the existence of a significant difference in control group and intervention 2; In such a way that the average quality of life of psychological training based on the TRA group was 19.25 units more than the control group.

Table 3

Examining the mean of the groups using the independent t-test
		Control	Intervention 1				Intervention 2
		Mean ± Std. Deviation	Mean ± Std. Deviation	Sign. value of Levene's test	Sign. value of t-test	Mean Diff.	Mean ± Std. Deviation	Sign. value of Levene's test	Sign. value of t-test	Mean Diff.
FBS	Before	175.30 ± 36.70	181.83 ± 37.94				175.30 ± 41.54
FBS	After	174.62 ± 36.40	173.97 ± 38.48	0.586	0.936	0.65	156.34 ± 40.77	0.285	0.030	18.27
HbA1C	Before	8.94 ± 0.84	9.12 ± 0.85				9.00 ± 0.96
HbA1C	After	8.93 ± 0.84	9.03 ± 0.82	0.603	0.572	-0.10	8.88 ± 0.96	0.168	0.805	0.048
Quality of Life	Before	74.95 ± 11.25	74.18 ± 10.02				72.97 ± 8.88
Quality of Life	After	75.06 ± 10.87	83.58 ± 7.44	0.090	< 0.001	-8.51	94.32 ± 8.08	0.164	< 0.001	-19.25

Also, to investigate another adjective of this study in relation to the effect of the physical health training group (intervention 1) and the psychological training based on TRA group (intervention 2) on each other, according to Table 4, using the independent t-test, it was determined that the mean HbA1C in these two groups did not have any significant difference. On the other hand, according to the significance value of Levene's test in FBS, including the significance value of 0.594 under the assumption of equality of variances, since the significance value for the t-test statistic is equal to 0.04, it was concluded that the average FBS, there was a significant difference in FBS between the two groups and the group of psychological education based on the TRA has had a greater effect of 17.62 units than physical health education in reducing FBS. Also, based on the significance value of Levene's test to check the assumption of equality of variances in the quality of life scale with a significance value of 0.8, according to the significance value for the t-test statistic which is less than 0.001, this indicates the existence of a significant difference between intervention 1 and 2; In such a way that the average of the psychological training based on the TRA group had an effect on the quality of life score by 10.74 units more than the physical health training group.

Table 4

Comparison of intervention 1 with intervention 2 using independent t-test (checking the assumption of equality of variances)
	Levene's test
	F-test statistic	Sign. amount	T-test statistic	Sign. amount	Mean Diff.
FBS	0.287	0.594	2.060	0.040	17.620
HbA1C	1.090	0.299	0.770	0.438	0.150
Quality of Life	0.060	0.800	-6.400	< 0.001	-10.740

This study was conducted with the aim of determining the effectiveness of training related to physical health issues and psychological training of the TRA model, by SMS, as well as comparing the effect of these two training on the quality of life of people with diabetes referred to the diabetes center of Imam Khomeini Hospital in Tehran. In this regard, outcomes such as FBS and HbA1C were also evaluated, which indicate the clinical effects of appropriate training. The overall study of the effect of training before and after the intervention showed that the effect of training on FBS, HbA1C and also the quality of life of people with diabetes are significant. That is, in general, training interventions have been able to reduce FBS and HbA1C in patients and improve their quality of life. In this context, researchers have found that increasing the level of awareness of patients with diabetes through education related to proper and adequate diet, timely and appropriate use of prescription drugs, appropriate physical activities, compliance with personal hygiene, reducing stress levels, controlling anger and accepting responsibility in power limit can improve general health, increase quality of life, reduce FBS and ultimately reduce treatment costs of diabetic patients (41, 42).

In line with the explanation of one of the objectives of the present study to investigate the effect of physical health training on the quality of life of patients with diabetes, the findings showed that the patients who received physical health training via SMS in intervention groop, had a significant increase in the average quality of life score compared to had a control group; However, no significant difference was observed in their FBS and HbA1C. In this regard, Peimani et al. (2016) in their study trained 150 diabetic patients through mobile phone short messages. These messages were prepared and sent to patients in four main areas related to diet plan, physical activities and exercise, blood sugar control with glucometer and correct use of prescription drugs. The findings of this research showed that sending educational messages regularly and at a certain time can control blood sugar, improve self-care and life satisfaction in patients. However, as in the present study, no significant change was observed in the amount of their HbA1C (20). Karamooz et al. (2022) also implemented their training protocol in a study using new educational models, based on the level of knowledge of people, on 30 patients with diabetes for 12 weeks. In this study, people with different levels of literacy received understandable concepts in the field of diabetes in a group with the help of educational media. Finally, compared to the control group, patients in the intervention group reported a significant increase in their quality of life, which is consistent with the present study. But HbA1C in the intervention group of this study showed a significant decrease compared to the control group (43), which is not consistent with the findings of the present study. The reason for this could be the longer duration of the training provided and also the more diversity of the training methods conducted in that research compared to the present study.

In a study conducted by Hanauer et al. (2009) to investigate the effect of an automatic reminder system through e-mail and mobile phone text messages on the management of diabetes in 40 teenagers and young adults with diabetes, they found that the users of the mobile phone group compared to the mail electronics group had a better performance in managing their diabetes. The findings of this research showed that the use of mobile phone text messages can be significant effective in monitoring and controlling the blood sugar of the studied population from life (23). Arora et al. (2012) also conducted a prospective trial to evaluate a mobile intervention program using mobile text messages for low-income patients in the emergency department of diabetes (TExT-MED). The participants in this study received daily text messages for 3 weeks in educational/motivational areas, drug reminders, healthy life challenges, and proper use of simple diabetes management tools. The results showed that after the intervention, the patients had more adherences to taking medicines on time, following a proper diet and improving self-efficacy with the diabetes empowerment scale (44). Since the motto of the World Health Organization is to provide full health care to all patients, especially people with chronic diseases (45), considering the penetration of electronic communication in most countries, it is possible to create a suitable communication channel between patients and health care providers. The use of electronic technologies such as mobile phone text messages by eliminating time and place limitations and also quick access is a cost-effective method in the education and management of chronic diseases such as diabetes, which has led to conducting studies on the use of this service to improve the quality of care in diabetic patients (46).

Also, in order to investigate another objective of this study regarding the effect of psychological training based on the TRA model on the quality of life of people with diabetes, the results showed that the patients who received psychological training based on the TRA in the form of text messages in intervention 2, had a significant difference in the amount FBS and average score of quality of life compared to the control group. This means that patients in this group had a lower average FBS and a higher quality of life score after the intervention. On the other hand, no significant difference was observed in their HbA1C compared to the control group. In line with the present study, Mohammadi et al. (2022) studied the effect of positive psychological training on the quality of life of 30 patients with diabetes. The participants in this research received psychological training in the main areas of positive thinking, empowerment based on capacity, avoiding stress, optimism, hope for life, and responsibility. The results of this study showed that this training had a significant effect on the components of quality of life such as physical health, mental health, health of social relations and environmental health in patients with diabetes (47). In this regard, Ghafarzadeh Almasi et al. (2021) also conducted a study with the aim of determining the effectiveness of stress management psychology training and treatment based on acceptance and commitment on blood sugar control and quality of life of patients with diabates. The participants in the research received educational content related to the determination of stressful factors, the need to deal with these factors, healthy lifestyle, anger control and relaxation training. The results showed that, like the present study, the psychological interventions performed in the research had a significant effect on the quality of life and blood sugar of the patients (48).

Jeihooni et al. (2020) also evaluated the effect of a training program based on the TRA on 100 women with diabetes. The results of this research showed that this educational intervention had a significant effect on improving self-care behaviors, quality of life and blood sugar of patients (49). In this regard, St Quinton (2022) conducted a study to investigate the effect of using psychological training provided based on the TRA on self-care behaviors of diabetic patients. The results of this research showed that appropriate physical activity, willingness to follow a healthy and sufficient diet, and regular control of blood sugar are significantly related to instrumental attitude, command norms and patients' capacity. Also, along with the present study, it was determined that psychological training of patients with diabetes based on the TRA can be effective on the proper control of blood sugar and their level of satisfaction with life (38). Kusnanto et al. (2017) also evaluated the effect of the TRA with the variables of adherence to diet, adherence to physical activity and blood glucose level. The results of this study showed that the implementation of the TRA can effectively and significantly improve the adherence to diet and physical activity in patients with diabetes. Also, in line with the present study, a significant decrease in average blood sugar was observed in the intervention group compared to the control group. These researchers believed that applying the TRA can change individual attitudes towards behaviors that include beliefs about a behavior, evaluation of behavior results, subjective norm, normative beliefs, and compliance motivation (37).

Also, in line with explaining the purpose of comparing the effect of physical health training and psychological training based on the TRA in this study, the results showed that psychological training based on the TRA model is significantly more effective than physical health training in improving the quality of life and reducing FBS has been more effective in patients with diabetes. This means that in this study, the people who received psychological training messages based on the TRA model had a higher quality of life and lower FBS than the people who received physical health training; however, the average HbA1C in two groups was not significantly different. Since there has been no study comparing the effect of general education on physical health on the one hand and psychological education on the other hand in people with diabetes, this finding cannot be compared with the results of other studies. The conducted researches in the field of the effect of training related to personal health in diabetic patients have shown that although increasing the level of physical awareness of people about diabetes and its treatment methods is necessary, it does not seem to be sufficient (44, 46, 47). In this regard, the study of Didarloo et al. (2012) shows that it is important to provide adequate information to patients in order to improve the performance of self-management and improve the quality of life of patients with diabetes, however, individual beliefs and other psycho-social factors should also be considered in the treatment of this disease (50). Among the many researches that have been conducted in recent years regarding the etiology, course, prognosis and treatment of diabetes, psychological factors have been given more attention (51). In addition, more than 20–40% of diabetic patients experience psychological problems, which include worries caused by the disease (such as fear of the symptoms of the disease) to more general symptoms such as worry, stress, anxiety and depression (52). Therefore, psychological training can be useful as a desirable solution in controlling the disease, reducing the physical, mental and social complications of this disease (53). Because the effectiveness of theory-based interventions, due to the provision of appropriate tools to change patients' behavior, is often said to be more appropriate than non-theoretical interventions (31); Therefore, in the present study, psychological training based on the TRA and its comparison with physical health training of patients with diabetes were discussed.

The results of a meta-analytic study by Hagger et al. (2018) in the context of the TRA approach applied to the health behavior of individuals showed the premise of this theory is that people make a rational choice when deciding whether or not to engage in a behavior. According to these researchers, the most important factor determining the patient's behavior is his/her "behavioral intention" which is determined by "the person's attitude towards the behavior" and "the influence of abstract norms" that are significant in the person's life (54). The purpose of the psychological training presented in the present study based on the TRA was that factors such as accepting responsibility to the extent possible, anger control, boldness in doing things, reducing the level of stress by changing the way of thinking, not comparing one with others, hope to strengthen the future and improve individual self-confidence in patients. Because if patients feel that their behavior leads to positive consequences in health, they will adopt and maintain that behavior. The findings obtained from the present study showed that this training model is more effective than the awareness only related to physical health issues. In explaining this issue, Kueh et al. (2017) stated in their study that increasing the knowledge and awareness of patients with diabetes through modifying the pattern and lifestyle, the way of thinking and changing behavior, increases the efficiency and improves their living conditions and helps people in control many complications of diabetes help. These researchers believe that teaching patients with diabetes how to control blood sugar, diabetes complications, exercise, diet, and practical training of related skills alone is not enough, but together with adjusting lifestyle, reducing anxiety, changing thinking, reducing the amount of stress and increasing the client's independence can increase the satisfaction with the living conditions of patients with diabetes and improve their quality of life (55).

The results of the present study showed that training interventions based on physical health and promoting mental health using mobile phone text messages were effective on the quality of life of patients with diabetes. Also, the findings indicate that the effectiveness of psychological training messages based on the TRA model was higher than that of physical health training in improving the quality of life and reducing FBS in patients with diabetes. The results show that if the patients learn, in addition to observing the points related to physical health such as proper diet, regular physical activity and blood sugar control, can improve their mental health with a rational attitude towards the disease, changing the mental norm and abstract behaviors such as changing the way of thinking, daring, hoping for the future and improving individual self-confidence, they can have a better quality of life. In other words, psychological intervention based on the TRA is more practical to improve the health-oriented living conditions of patients and the stability of the obtained results. Therefore, health care policy makers, specialists and health care workers can act to improve the characteristics related to personal health, especially reducing blood sugar and increasing the quality of life of patients with diabetes by using training through mobile phone text messages, especially with psychological content based on the TRA.

In the current research, it can point out the limitations and obstacles such as the research community being limited to those who refer to Imam Hospital in Tehran, which makes it difficult to generalize the results to other communities. Also, in this study, a one-month intervention in the matter of training was used with a one-month opportunity for its effectiveness. Future studies can cover a wider range of society, such as multiple medical centers and more cities, so that the results can be generalized more reliably and the long-term effects of the intervention can also be examined. On the other hand, it was possible for patients to receive training other than the interventions performed in this study through other media (social networks, television, etc.), which could affect the results of this research; of course, they were asked to consciously avoid doing it during the study. Also, due to the Corona virus pandemic and the increase in issues related to personal, social, economic and health limitations, the possibility of the influence of environmental factors on the variables measured in this study was another limitation of this study, which is better to explain the validity of the results, researchers in Post-Corona, repeat it with more subjects.

TRA

Theory of Reasoned Action

ADDQoL

Audit of Diabetes-Dependent Quality of Life

FBS

Fasting Blood Sugar

HbA1C

glycosylated hemoglobin

Ethics approval and Consent to participate:

The objectives of study were explained in detail to the study participants. The collection of demographic information and data obtained from all patients participating in this research was done after obtaining informed consent and willingness to participate in the study. Also, all the information remained confidential with the researchers and the results were published anonymously and only statistically. Ethical approval for the study was obtained from the Ethics Committee of Tehran University of Medical Sciences (Ref No: IR.TUMS.IKHC.REC.1401.180). The authors confirm that all experiments were performed following the relevant Declaration of Helsinki.

Consent for publication:

Not applicable.

Availability of data and materials:

Data is available on request from the authors. If someone wants to request the data from this study should be contacted Donya Sadeghi ([email protected]).

Competing interests:

The authors declare that they have no competing interests.

Funding:

Tehran University of Medical Sciences vice-chancellor for Research has financial support in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Authors' contributions:

Study conception and design: DS, MK, and MD

Designed and prepared the text messages: DS, MK, MD, and AD

Performed the analysis: AM, and PM

Wrote the Manuscript: DS, and MK

Collected the data: DS, MD, AD and EM

All authors reviewed the results and approved the final version of the manuscript.

Acknowledgments:

The authors are grateful to Tehran University of Medical Sciences vice-chancellor for Research for approving and financing this research, and research development office, Imam Khomeini Hospital Complex in Tehran for their support and providing constructive comments, and also to all the patients participating in the study.

- Soleimani Z, Barati H, Mozafari Join A, Ershadi Moqadam H, Mohammadi M. The Quality of life of patients with diabetes from the city of Sabzevar during year 2016. Military Caring Sci. 2017;3(4):264–71.
- Aalaa M, Tabatabaei Molazi O, Sanjari M, Mohajeri Tehrani MR. Investigating the nurse's role in the prevention and care of diabetic foot (a review study). Iran J Diabetes&Lipid. 2011;10(5):372–80.
- Jafar Beglu S, Mehdad A. Effectiveness of self-care training on perceived job stress and perceived self-efficacy among type II diabetic patients. J Diabetes Nurs. 2020;8(2):1105–18.
- Al-Taie N, Maftei D, Kautzky-Willer A, Krebs M, Stingl H. Assessing the quality of life among patients with diabetes in Austria and the correlation between glycemic control and the quality of life. Prim Care Diabetes. 2020;14(2):133–8.
- Jeon HJ, Ku EJ, Oh TK. Dapagliflozin improves blood glucose in diabetes on triple oral hypoglycemic agents having inadequate glucose control. Diabetes res and clinical pract. 2018;142:188–94.
- Fall E, Chakroun-Baggioni N, Bohme P, Maqdasy S, Izaute M, Tauveron I. Common sense model of self-regulation for understanding adherence and quality of life in type 2 diabetes with structural equation modeling. Patient Edu and Counsel. 2021;104(1):171–8.
- Palamenghi L, Carlucci MM, Graffigna G. Measuring the quality of life in diabetic patients: A scoping review. J Diabetes Res. 2020;3:1–19.
- Khoshraftar Roudi E, Ildarabadi E, Behnam Voshani HR, Emami Moghaddam Z. The effect of peer education on the mental aspect of quality of life of elderly patients with hypertension. J North Khorasan Univ Med Sci. 2016;7(3):585–95.
- Bak E, Nowak-Kapusta Z, Dobrzyn-Matusiak D, Marcisz- Dyla E, Marcisz C, Krzeminska SA. An assessment of diabetesdependent quality of life (ADDQoL) in women and men in Poland with type 1 and type 2 diabetes. Annals of Agricultural and Environmental Medicine: AAEM. 2019;26(3):429–38.
- Rasoul AM, Jalali R, Abdi A, Salari N, Rahimi M, Mohammadi M. The effect of self-management education through weblogs on the quality of life of diabetic patients. BMC Med Inf Decis Mak. 2019;19:1–12.
- Cutruzzola A, Irace C, Parise M, Fiorentino R, Tripodi PFP, Ungaro S, et al. Time spent in target range assessed by self-monitoring blood glucose associates with glycated hemoglobin in insulin treated patients with diabetes. Nutr Metabolism Cardiovasc Dis. 2020;30(10):1800–5.
- Azizi M, Arsalani N, Mohammadi Shahboulaghi F, Hosseinzadeh S, Rajab A. The effect of self-care education on the control of diabetes complications, medications and HbA1C in adolescents with type 1 diabetes. J Hayat. 2017;22(4):350–61.
- Heidari A, Isfahani P, Sarani M, Rezaei- Kahkha M. Impact of education on quality of life of diabetic patients in Zabol. J Diabetes Nurs. 2020;8(4):1250–9.
- Aghakhani N, Torabi M, Alinejad V, Broomand A, Nikoonejad A. The effect of education on quality of life in patient with diabetic foot in educational hospital of Urmia. J Urmia Nurs and Midw. 2016;14(4):380–8.
- Daneshvar S, Khodamoradi A, Ghazanfari Z, Montazeri A. Quality of life in diabetic patients: A comparative study. Payesh. 2018;17(5):541–50.
- Yahyapour N. Adoption of the mobile messaging service: an empirical study of Iran context. Networks and Systems: IADIS International Telecommunications; 2008.
- Hussein WI, Hasan K, Jaradat AA. Effectiveness of mobile phone short message service on diabetes mellitus management; the SMS-DM study. Diabetes Res and Clinical Prac. 2011;94:e24–26.
- Baji Z, Zamani Alavijeh F, Nouhjah S, Ghodratollah Shakerinejad Gh, Payami SP. Comparing gain- and loss-framed message texting (SMS) on foot self-care behaviors among women with type 2 diabetes. Payesh. 2016;6:695–705.
- Darvish A, Khodadadi-Hassankiadeh N, Abdoosti S, Ghapandar Kashani M. Effect of text messaging-based psychiatric nursing program on quality of life in veterans with post-traumatic stress disorder: A randomized controlled trial. IJCBNM. 2019;7(1):52–62.
- Peimani M, Rambod C, Omidvar M, Ghodssi-Ghassemabadi R, Tootee A, Nasli Esfahani E. Effectiveness of short message service-based intervention (SMS) on self-care in type 2 Diabetes. Iran j Diabetes Metabolism. 2016;15(4):251–8.
- Harris LT, Tufano J, Le T, Rees C, Lewis GA, Evert AB, et al. Designing mobile support for glycemic control in patients with diabetes. J Biomed Inform. 2010;43:37–40.
- Lee BJ, Ock GUM. Comparison of the effects between positive message and negative message in diabetes mellitus education. Korean Diabetes J. 2009;33:344–52.
- Hannauer DA, Wentzell K, Laffel n, Laffel LM. Computerized automated reminder diabetes system (CARDS): e.mail and SMS cell phon text messaging reminders to support diabetes management. Diabetes tech and therap. 2009;11:99–106.
- Hofmann M, Dack C, Barker C, Murray E. The impact of an internet-based self-management intervention (help-diabetes) on the psychological well-being of adults with type 2 diabetes: a mixed-method cohort study. J Diabetes Res 2016; 1476384.
- Cefalu WT, Kaul S, Gerstein HC, Holman RR, Zinman B, Skyler JS, et al. Cardiovascular outcomes trials in type 2 diabetes: where do we go from here? reflections from a diabetes care editors’ expert forum. Diabetes Care. 2018;41(1):14–31.
- Silverstein MP, Miller JA, Xiao R, Lubelski D, Benzel EC, Mroz TE. The impact of diabetes upon quality of life outcomes after lumbar decompression. Spine J. 2016;16(6):714–21.
- Polonsky WH, Hessler D, Ruedy KJ, Beck RW, DIAMOND Study Group. the impact of continuous glucose monitoring on markers of quality of life in adults with type 1 diabetes: further findings from the DIAMOND randomized clinical trial. Diabetes Care. 2017;40(6):736–41.
Ghane'i R, Golkar F, Aminpoor E. Foot care in depressed and non-depressed diabetic patients. Mod Care Sci Q Birjand Nurs Midwifery Fac. 2013;10(2):124–31.
- Eyni S, Hashemi Z, Ebadi Kasbakhi M. Psychological Well-Being of Patients with Type 2 Diabetes: The Role of Psychological Hardiness, Sense of Cohesion, and Coping Strategies. Health Psychol. 2020;9(2):121–36.
- Massey CN, Feig EH, Duque- Serrano L, Wexler D, Moskowitz JT, Huffman JC. Well- being interventions for individuals with diabetes: A systematic review. Diabetes Res and Clinical pract. 2019;147:118–33.
- Babazadeh T, Mokammel A, Moradil F, Shariat F, Banaye Jeddi M. The effect of educational intervention based on the extended theory of reasoned action on self-care behaviors in patients with type 2 diabetes. J Health. 2017;8(3):256–67.
- Mahyarni M. Theory of Reasoned Action dan Theory of Planned Behavior (Sebuah Kajian Historis tentang Perilaku). J Ekon Univ Islam Negeri Sultan Syarif Kasim-Riau. 2014;4(1):13–23.
Anna-Maija H, Mirca C, Matti LE. The teory of reasoned action in describing tooth brushing, dental cariers and diabetes adherence among diabetic pattents. Jl Clin Pediont. 2002;29:427–32.
- Chang MK. Predicting Unethical Behavior: A Comparison of the Theory of Reasoned Action and the Theory of Planned Behavior. J Bus Ethics. 1998;17(16):1825–34.
- Tabatabaei Nasab SM, Saeida Ardakani S, Nikzad F. Analytical comparison of the technology acceptance model and the theory of reasoned action in relation to the acceptance of mobile advertising. Mod Mark res. 2013;4(11):181–96.
- Goodarzi F, Araban M, Eslami A, Zamani-Alavijeh F. Development and psychometric evaluation of the diabetic menʼs dietary behaviors inventory based on the theory of reasoned action. Archives of Public Health. 2019;77:3.
- Kusnanto K, Kurnia ID, Rama JA. The effect of theory of reasoned action implementation on dietary and physical activity adherence in patients with diabetes mellitus type 2. Advances in Health Sciences Res. volume 3, 8th International Nursing Conference (INC 2017) 233–236.
- St Quinton T. Applying the reasoned action approach and planning to understand diabetes self-management behaviors. Behav Sci. 2022;12:375.
- Bradley C, Tood C, Gorton T, Symonds E, Martin A, Plooright R. The development of an individualized questionnaire measure of perceived impact of diabetes on quality of life: the ADDQoL. Qual life res. 1999;8:79–91.
Darvishpoor Kakhaki A, Abed Saeedi ZH, Yaghmaei F, Alavi Majd H. Instrument development to measure diabetic clients quality of life (DCQOL). Iran J Endocrin Metab. 2005;7(2):149–55.
- Salary S, Roshan R, Poursharifi H, Farahani H, Hosseini MS. Effectiveness of an integrated web-based self-care protocol on mental well-being, quality of life, and blood sugar in patients with type 2 diabetes. North Khorasan Univ Med Sci. 2022;14(3):59–69.
- Soheili S, Firoozi F. Investigation of the effect of lifestyle training on the quality of diabetic patients’ life. J Diabetes Nurs. 2021;9(4):1728–38.
- Karamooz A, Gholam Reza Poor MR, Kazemi M, Vaziri Nejad R. Evaluation of the impact of education intervention on the life quality measure of type 2 diabetic patients at the Rafsanjan university of medical science in Rafsanjan, Iran. J Diabetes Nurs. 2022;10(2):1819–28.
- Arora S, Peters AL, Agy C, Menchine M. A mobile health intervention for inner city patients with poorly controlled diabetes: Proof-of-concept of the TExT-MED program. Diabetes technol & therap. 2012;6:492–6.
- Hussein WI, Hasan K, Jaradat AA. Effectiveness of mobile phone short message service on diabetes mellitus management; the SMS-DM study. Diabetes Res and Clinical Pract. 2011;94:e24–26.
- Ramachandran A, Snehalatha C, Ram J, Selvam S, Simon M, Nanditha A, et al. Effectiveness of mobile phone messaging in prevention of type 2 diabetes by lifestyle modification in men in India: a prospective, parallel-group, randomised controlled trial. Lancet Diabetes & Endocrin. 2013;1:191–98.
- Mohammadi S, Fathi A, Sharifi Rahnemo S, Pahang E. Effectiveness of teaching positive psychological skills on the quality of life of patients with diabetes. J Health and Care. 2022;24(2):145–55.
- Ghafarzadeh Almasi N, Hajializadeh K, Tajeri B. Comparison of the effectiveness of stress management and acceptance and commitment-therapy on blood sugar control and quality of Life in patients with type II Diabetes. J Diabetes Nurs. 2021;9(2):1367–84.
- Jeihooni AK, Khiyali Z, Faghih F, Harsini PA, Rahbar M. The effect of educational program based on the extended theory of reasoned action on self–care behaviors in women with type 2 diabetes. Indian J Endocr Metab. 2019;23:609–15.
- Didarloo AR, Shojaeizadeh D, Gharaaghaji Asl R, Habibzadeh H, Niknami SH, Pourali R. Prediction of self–management behavior among Iranian women with type 2 diabetes: Application of the theory of reasoned action along with self–efficacy (ETRA). Iran Red Crescent Med J. 2012;14:86–95.
- Helgeson VS, Orchard TJ, Seltman H, Becker D, Libman I. Psychosocial predictors of diabetes risk factors and complications: an 11-year follow-up. Health Psychol. 2019;38(7):567.
- Billimek J, August KJ. Costs and beliefs: understanding individual-and neighborhood-level correlates of medication nonadherence among Mexican Americans with type 2 diabetes. Health Psychol. 2014;33(12):1602–5.
- Rassart J, Luyckx K, Berg CA, Bijttebier P, Moons P, Weets I. Psychosocial functioning and glycemic control in emerging adults with Type 1 diabetes: a 5-year follow-up study. Health Psychol. 2015;34(11):1058.
- Hagger MS, Polet J, Lintunen T. The reasoned action approach applied to health behavior: Role of past behavior and tests of some key moderators using meta-analytic structural equation modeling. Soc Sci Med. 2018;213:85–94.
- Kueh YC, Morris T, Ismail AA. The effect of diabetes knowledge and attitudes on self-management and quality of life among people with type 2 diabetes. Psychol Health Med. 2017;22(2):138–44.

No competing interests reported.

Download PDF

Editorial decision: Revision requested
08 Jan, 2024
Reviews received at journal
20 Dec, 2023
Reviewers agreed at journal
20 Dec, 2023
Reviewers agreed at journal
15 Dec, 2023
Reviewers invited by journal
15 Dec, 2023
Editor invited by journal
21 Nov, 2023
Editor assigned by journal
21 Nov, 2023
Submission checks completed at journal
18 Nov, 2023
First submitted to journal
17 Nov, 2023

You are reading this latest preprint version

Comparison Effect of Physical Health Training and Psychological Training of the Theory of Reasoned Action (TRA) model on the Life Quality of Patient with Diabetes in Tehran, Iran: Utilization of Message Texting

Status:

Version 1

Abstract

Introduction:

Methods:

Objective:

Study design:

Study population:

Variables:

Data gathering:

Statistical Analysis:

Results:

Discussion:

Conclusion:

Limitations:

Abbreviations

Declarations

Acknowledgments:

References

Additional Declarations

Status:

Version 1