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Table of Contents   
ORIGINAL ARTICLE  
Year : 2017  |  Volume : 10  |  Issue : 5  |  Page : 1184-1188
Investigating the relationship between the number of care provided and changes in the variables associated with diabetes in health homes and health centers affiliated to Lamerd Healthcare Network


1 Faculty Member of Kermanshah University of Medical Sciences, School of Paramedical Sciences, Department of Anesthesiology, Kermanshah, Iran
2 Department of Emergency Medicine, Faculty of Paramedics, Kermanshah University of Medical Sciences, Kermanshah, Iran
3 Department of Nursing, School of Nursing, Larestan University of Medical Sciences, Larestan, Iran
4 Psychiatric Nursing Department, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
5 Department of Paramedical School, Gerash University of Medical Sciences, Gerash, Iran

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Date of Web Publication6-Nov-2017
 

   Abstract 


Introduction: Diabetes influences the quality of life and the life expectancy of affected people and is an expensive disease to treat that imposes a heavy burden on the health and economy of each country. There have been few studies performed on the effectiveness of diabetes care in the clinical setting in Iran. Therefore, the aim of this study was to investigate the effectiveness of care in the clinical setting. Materials and Methods: This is a descriptive research, as an analysis of available data. Information about patients was extracted from the reports that submitted to Lamerd Healthcare Network. The criteria of the effectiveness of achieving the desired indicators in this study were in accordance with the goals of treatment of diabetes in country (Iran) about diabetic patients. Descriptive statistics and analytical statistics including Pearson's correlation coefficient and t-test were used to analyze the data. Results: About 59.7% of glycated hemoglobin (HbA1c) participants had <7% and 40.3% HbA1c >7%. About 45.3% of body mass index (BMI) participants had <25 and 54.7% of BMI >25. There was a significant relationship between the level of care and changes in hemoglobin glycolysis (r = 0.243, P < 0.05). Conclusion: In terms of achieving therapeutic goals for diabetes, blood pressure and BMI were within the acceptable range, but levels of fasting blood glucose and HbA1c were not in this range. Since there is a relationship between the changes of HbA1c and the number of physician care and health worker, it can be achieved by increasing the number of care for the purpose of treatment. Planning for weight loss in diabetic patients and increasing the number and quality of care for controlling blood glucose in Lamerd is recommended.

Keywords: Blood glucose, blood pressure, body mass index, diabetes, hemoglobin

How to cite this article:
Ezzati E, Goodarzi A, Bazrafshan MR, Faraji F, Rahmati M, Mansouri A. Investigating the relationship between the number of care provided and changes in the variables associated with diabetes in health homes and health centers affiliated to Lamerd Healthcare Network. Ann Trop Med Public Health 2017;10:1184-8

How to cite this URL:
Ezzati E, Goodarzi A, Bazrafshan MR, Faraji F, Rahmati M, Mansouri A. Investigating the relationship between the number of care provided and changes in the variables associated with diabetes in health homes and health centers affiliated to Lamerd Healthcare Network. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Dec 6];10:1184-8. Available from: http://www.atmph.org/text.asp?2017/10/5/1184/217525



   Introduction Top


In 2013, 382 million people were diagnosed with diabetes and are expected to reach 592 million by 2015. The number of people with diabetes is increasing in all countries of the world and 80% of people with diabetes live in the middle- and low-income countries (International Diabetes Federation). Warning for diabetes is not only due to its high prevalence but also due to serious complications, which lead to medical assistance and even death.[1]

Diabetes is a costly illness that affects people's quality of life and life expectancy and imposes a heavy burden on the national health and economics budget as a loss of living.[2] Diabetes is thought to be a systemic disease with well-known ocular, renal, and neurological complications.[3] Diastolic disorder of the left ventricle is more common in patients with diabetes.[4] Complications of diabetes, also called microvascular and macroscopic complications, are also categorized. Long-term dyslipidemia and hyperglycemia, increased oxidative stress, inflammation, and vascular, the sum of these lead to vascular dysfunction and are associated micro- and macro-vascular complications. Microalbuminuria is a primary marker of nephropathy and an independent marker for cardiovascular disease. Diabetic nephropathy is the most common cause of end-stage renal disease in developing countries and its prevalence is increasing.[5] It seems that inadequate control of blood glucose leads to activation of inflammatory cytokines, increasing environmental nephropathy and reducing bone mass.[6] Now, HbA1 is a reliable and necessary tool for care routine and diagnosis of diabetes.[7]

In patients with type 2 diabetes, there is a baseline for glycated hemoglobin (HbA1c) levels so that by increasing the HbA1c level from the threshold of 7%; the magnitude of complications and the threshold of 6.5% increase the risk of microvascular complications so that every 1% increase of the threshold leads to an increase of 38% in macrovascular complications, 40% in microvascular complications, and 38% in the likelihood of death.[8] HbA1c concentration as a long-term control of blood glucose and predictor of risk is considered as an irreplaceable part of routine diabetes care. According to the American Diabetes Association, the usual goal in treating diabetes is HbA1c below 53 mmol/mol equivalent to 7%, and when the HbA1c is over 64 mmol/mol equivalent to 8%, treatment should be strengthened.

HbA1c concentrations include a spectrum that is <40 mM/mol, equivalent to 5.8%, indicating a low risk for diabetes, while >46 mM/mol, equivalent to 4.6%, indicates diabetes. HbA1c concentrations ranging from 40 to 46 (4.6%–8.5%) indicate a high risk of diabetes.[7] In 2012, the International Federation of Diabetes also changed the target HbA1c concentration from <6.5% previously proposed to <7% because of sufficient evidence for the efficacy and cost-effectiveness of treatment. There is no additional reduction in HbA1c below 7%.[8]

Several studies have examined the effectiveness of diabetes care. In a study by Farzadfar et al. in 2012, with the title of the effectiveness of diabetes and hypertension care in rural areas by health workers, it was found that the effectiveness level of diabetes care is higher in rural areas than in urban areas. Although this difference in blood pressure care was lower, care in urban areas than in rural areas was a little better. Furthermore, there is a direct relationship between the number of primary care workers and lower level fasting blood sugar (FBS).[9]

In a study by Vatankhah et al., to examine the effectiveness of foot care in diabetic patients, it was concluded that a simple face-to-face training method is a practical and effective way to increase the knowledge of learners in foot care and also to increase motivation and change the behavior of individuals. Obese people with diabetes need more attention and strong care plans.[10] In a cross-sectional study conducted in patients with diabetes in Switzerland, it was found that 64.4% of the patients had type 2 diabetic and 59% of them were women. In this study, screening of the risk of diabetes, flu vaccinations, physical activity, and dietary recommendations were less reported, and these items were mentioned as items that can be used to increase diabetes care.[11]

In the study of Mansour-ghanaei et al. there was no statistically significant relationship between demographic data (age, sex, education level, occupation, marital status, duration of disease, family history, and where they live) and knowledge, health beliefs, and personal control center. Most of the participants in this study had poor hygiene knowledge and belief. Furthermore, there was not found a significant relationship between knowledge, health belief, personal control center, HbA1c level, number of reference, and personal care. Based on the study findings, it was concluded that the personal locus of control, health beliefs, and knowledge of diabetic patients have no practical impact on diabetes self-care or patient behavior and outcomes.[12]

Little studies have done on the efficacy of care in the clinical area, and more research was conducted in a controlled environment for the effectiveness of a proposed method or a method of treatment or care; therefore, this study examines the effectiveness of routine care of diabetic patients in Lamerd.


   Materials and Methods Top


This study is a cross-sectional analysis of existing data. The data contained in the two periods were compared. Information on patients from the reports submitted to health network Lamerd city was given that the aim of the research was to study the effectiveness of diabetes care for patients. One hundred and eighty-six patients have more detailed information in the first stage, HbA1c tests were performed in two time periods from December 2011 to June 2012, and these data were in the final analysis.

This information includes patient information at two times and the number of care provided at this interval for patients. The reason for choosing these test periods (HbA1c) at these times is for patients free of charge, which allows comparisons. Measuring of the effectiveness of care was in terms of achieving to the national goals of treatment of diabetes, therefore if the patients achieve the desired therapeutic goals, care is also effective. For example, Farzadfar et al. have used fasting blood glucose as an effective measure in their research.[13] All coded and unnamed data were analyzed. Descriptive statistics were used to determine the extent of each of the variables at the beginning of the study and its subsequent changes. The relationship between the variables using the coefficient correlation between Pearson's correlation and t-wave was investigated. Data analysis was performed using SPSS 20 software IBM Corp. Released 2011. IBM SPSS Statistic for Windows, version 20.0. Armonk, Ny: IBM corp.


   Results Top


The average age of the studied individuals was 54.36 (standard deviation [SD] =12.17). In terms of gender, 53 (28.8%) and 131 (72.2%) persons, respectively, were male and female. Five people (2.7%) were with diabetes type 1 and 178 (97.3%) with diabetes type 1. Average numbers of care taken by health workers were 4.69 (SD = 1.16), and the average number of visits by doctors was 1.8 (SD = 0.63) within 6 months.

In terms of smoking, 64 of the participants (34.6%) were smokers, and 121 participants were not smokers (65.4%). In the initial period, 111 of the participants (59.7%) had HbA1c level <7% and 75 of the participants (40.3%) had HbA1c level >7%. About 45.3% of the participants had body mass index (BMI) <25 and 54.7% of the participants had BMI >25.

According to [Table 1], average changes in HbA1c, FBS, and BMI were positive; on the other hand, average changes in systolic and diastolic blood pressure were negative.
Table 1: Average changes in variables in the first and in the second time point (within 6 months)

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Paired t-test results [Table 2] show the changes in HbA1c from baseline after 6 months are statistically significant (P < 0.01) as well as changes in body mass index from baseline after 6 months were meaningful (P < 0.01). However, changes in systolic blood pressure, diastolic blood pressure, and fasting blood glucose from baseline value were not statistically significant (P > 0.05).
Table 2: The results of paired t-test and variables changes in two time periods (baseline and 6 months later)

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   Discussion Top


The results of this study showed that the mean of HbA1c from the early levels (7.22 ± 1.48) at the initial time is reached to 6.86 ± 1.04 at the secondary [Table 1] and this reduction is statistically significant using paired t-test (P < 0.01) [Table 2].

On the other hand, the results of study showed that there was a significant relationship between the numbers of care provided in general and changes in HbA1c levels in this two different periods (P < 0.05, r = 0.243), and also, this relationship was separately for the number of care provided by health worker (P < 0.05, r = 0.192) and the number of visits by physician (P < 0.05, r = 0.175). This means that by increasing the number of care provided by health workers and physician, average HbA1c level in this two time periods has changed. Given that in the second stage, the HbA1c level was dropped; therefore, this change means that with the increase in the number of care provided, the HbA1c level has fallen in patients.

In the research done by Tien et al.,[14] the BMI of the research units ranged from 25.7 ± 4.2 to 26.1 ± 4.3, which according to the significance of the t-test indicated an increase in the mass index body care is complete after 1 year. The results of this study are similar to those of the present study. The average reduction in HbA1c in care provided carried out in the city Lamerd was higher than of this study, while in the study of Tien et al., a planned care with complete accuracy had been done, but the care taken in this study only includes the care routine although this care had sufficient consistency. According to the mean of HbA1c, in this study, initially, it was also lower than the study of Tien et al., and studies have shown that diabetes care in patients with high HbA1c is more effective. Therefore, the rate of decline in this study can be considered.

The mean systolic blood pressure in patients at the initial time was 122.43 ± 16.79 and after 6 months at the secondary time was 123.62 ± 17.28, which indicates that the mean systolic blood pressure in patients at these two periods of time. Since the average blood pressure of the patients under study is generally close to normal, it does not decrease after 6 months of normal. At both times, the results are acceptable in the diabetic patients approved in a country with an equal or elevated systolic blood pressure of ≤120 in terms of therapeutic goals for controlling blood pressure.

Average of fasting blood glucose of patients in the early period of 158.1 ± 56.42 reached to 144.12 ± 46.33 after 6 months. Using t-test showed, there was no statistically significant difference between the two values [Table 2].

Average of fasting blood glucose of patients was higher than the maximum limits with regard to approved therapeutic goals in the National Programme for Prevention and Control of Diabetes that is ≤140 mg/dl. This indicates that patients were not achieved to the therapeutic goal of the national program in control of FBS. In a conducted study of Tien et al.,[14] a comprehensive care of diabetes after 1 year leads to lower average fasting blood glucose from baseline 164.6 ± 60.4 in the amount of 137 ± 37.5.

In a study carried out by Farzadfar in 2012, it was found that diabetes treatment led to a decrease in fasting blood glucose levels of 1.34 mM in rural areas and only 0.21 mM in urban areas per thousand. Adult (as the patient) reduces the fasting blood glucose level by 0.9%, which is different from the results of the present study.[13]

[Table 1] shows that the BMI at the initial time interval was 25.64 ± 4.34 and after 6 months was 25.68 ± 0.32, indicating an increase of ± 0.50. The change in the BMI of the patients in the acceptable range according to the goals of diabetic patients approved by the standard t-test (P < 0/01), according to [Table 2], is statistically significant (P < 0.01).

[Table 3] shows that there was a significant relationship between the number of care provided by health workers and the HbA1c changes (r = 0.192, P < 0.05) as well. There was a significant relationship between the number of care by physician and the HbA1c changes (r = 0.175, P < 0.05), and in general, there was a significant relationship between the number of care and the HbA1c changes (r = 0.19, P < 0.05).
Table 3: The correlation between the number of care and rate of changes of variables

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Normally, by increasing the number of care, HbA1c changes also increased; however, there was not a significant relationship between the number of care by physician and health workers, and in general, between total care changes in systolic blood pressure, diastolic blood pressure, and fasting blood glucose (P > 0.05). Changes in BMI and the number of care between health workers (r = −0.277, P < 0.05) and total care in general (r = −0.225, P < 0.05). There has been a negative correlation means that increasing the number of care changes reduced BMI. The mean age of patients and significant changes in BMI has been negative (r = −0.164, P < 0.05). This means that changes in BMI decreased with increasing patient age. BMI is that older people have fewer changes.


   Limitations of the Study Top


One of the research constraints is the use of existing data. These data are based on a report from health houses and health centers. Since these reports are sent to the healthcare network for other purposes, the defect is the required information. However, the advantages of using existing data are easy access to data and cost savings. Therefore, if the reports submitted are compatible with the therapeutic goals of the disease, the amount of money for the goals can be achieved without spending too much examined. Data defects are also the results of data recording. Therefore, efforts to register a computer and an electronic data collection system are recommended. Considering that this study only examines the data of patients who have more complete information, it should be noted that these patients tend to have more referrals than other patients, and therefore, other patients may be different that should be considered as a result of the research.


   Conclusion Top


Blood pressure and BMI of patients were in acceptable range, but fasting blood glucose and HbA1c levels were away from this area. Given that there is a correlation between hemoglobin glycosylated changes and the number of physician and healthcare attendants, the number of targeted care was achieved in this area.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Agarwal AS, Fuladi AB, Mishra G, Tayade BO. Spirometry and diffusion studies in patients with type-2 diabetes mellitus and their association with microvascular complications. Indian J Chest Dis Allied Sci 2010;52:213-6.  Back to cited text no. 3
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Alpaydın MS, Aksakal E, Erol MK, Simşek Z, Açıkel M, Arslan S, et al. Assessment of regional left ventricular functions by strain and strain rate echocardiography in type II diabetes mellitus patients without microvascular complications. Turk Kardiyol Dern Ars 2011;39:378-84.  Back to cited text no. 4
    
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Mansour-Ghanaei R, Joukar F, Soati F, Khanegha AG. Association between knowledge, locus of control and health belief with self-management, hb A1c level and number of attendances in type 1 diabetes mellitus patients. Int J Clin Exp Med 2013;6:470-7.  Back to cited text no. 12
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13.
Farzadfar F, Murray CJ, Gakidou E, Bossert T, Namdaritabar H, Alikhani S, et al. Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: A nationally representative observational study. Lancet 2012;379:47-54.  Back to cited text no. 13
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Correspondence Address:
Afshin Goodarzi
Department of Emergency Medicine, Faculty of Paramedics, Kermanshah University of Medical Sciences, Kermanshah
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_368_17

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