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Asmat K, Sivarajan Froelicher E, Dhamani KA, Gul R, Khan N. Effect of patient-centered self-management intervention on glycemic control, self-efficacy, and self-care behaviors in South Asian adults with type 2 diabetes mellitus: A multicenter randomized controlled trial. J Diabetes 2024; 16:e13611. [PMID: 39264007 PMCID: PMC11391380 DOI: 10.1111/1753-0407.13611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 06/28/2024] [Accepted: 07/29/2024] [Indexed: 09/13/2024] Open
Abstract
BACKGROUND This study aimed to test the efficacy of patient-centered self-management intervention (PACE-SMI) to improve HbA1c, self-efficacy, and self-care behaviors in adults with type 2 diabetes mellitus (T2DM). METHODS In this multicenter, parallel two-arm randomized controlled trial, 612 adults with T2DM and HbA1c ≥ 7% were enrolled and assigned to the control group (n = 310) and the intervention group (n = 302) using stratified permuted block randomization. The control group received usual care, whereas the intervention group received usual care plus nurse-led, theory-driven, culturally tailored PACE-SMI, comprising eight weekly sessions of individualized education, counseling, behavioral training, and home visit. Outcomes were assessed at baseline, postintervention, and 3 months follow-up. RESULTS Data at 3 months were provided by 583 participants (control: n = 295, intervention: n = 288). Per-protocol analysis showed that the intervention group had a lower mean HbA1c (8.49% [standard deviation (SD), 1.58]) than the control group (8.74% [SD, 1.62]), with small yet statistically significant mean difference of 0.25% (95% confidence interval [CI], -0.01 to 0.51; Cohen's d = 0.16; p = 0.03). Self-efficacy and self-care behaviors significantly improved in the intervention group (116.89 [SD, 25.50] and 70.01 [SD, 17.97]) compared to the control group (75.43 [SD, 18.99] and 51.54 [SD, 12.04]), with mean differences of 41.48 (95% CI, 37.83-45.13; Cohen's d = 1.84; p < 0.0001) and 18.56 (95% CI, 16.08-21.04; Cohen's d = 1.22; p < 0.0001), respectively. Linear regression analysis indicated the effect of PACE-SMI on HbA1c was significantly mediated by improvements in self-efficacy and self-care behaviors (R2 = 0.232, p < 0.001). CONCLUSION PACE-SMI led to modest but significant improvement in HbA1c and substantial enhancements in self-efficacy and self-care behaviors in adults with T2DM.
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Affiliation(s)
- Kainat Asmat
- Faculty of Nursing and MidwiferyShifa Tameer‐e‐Millat UniversityIslamabadPakistan
| | - Erika Sivarajan Froelicher
- Faculty of Nursing and MidwiferyShifa Tameer‐e‐Millat UniversityIslamabadPakistan
- Department of Physiological Nursing, School of NursingUniversity of CaliforniaSan FranciscoCaliforniaUSA
- Department of Epidemiology & Biostatistics, School of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | | | - Raisa Gul
- Faculty of Nursing and MidwiferyShifa Tameer‐e‐Millat UniversityIslamabadPakistan
| | - Nazeer Khan
- The Office of Research, Innovation and Commercialization (ORIC)Shifa Tameer‐e‐Millat UniversityIslamabadPakistan
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Chowdhury HA, Harrison CL, Siddiquea BN, Tissera S, Afroz A, Ali L, Joham AE, Billah B. The effectiveness of diabetes self-management education intervention on glycaemic control and cardiometabolic risk in adults with type 2 diabetes in low- and middle-income countries: A systematic review and meta-analysis. PLoS One 2024; 19:e0297328. [PMID: 38306363 PMCID: PMC10836683 DOI: 10.1371/journal.pone.0297328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 01/01/2024] [Indexed: 02/04/2024] Open
Abstract
Diabetes mellitus (DM) poses a significant challenge to public health. Effective diabetes self-management education (DSME) interventions may play a pivotal role in the care of people with type 2 diabetes mellitus (T2DM) in low- and middle-income countries (LMICs). A specific up-to-date systematic review is needed to assess the effect of DSME interventions on glycaemic control, cardiometabolic risk, self-management behaviours, and psychosocial well-being among T2DM across LMICs. The MEDLINE, Embase, CINAHL, Global Health, and Cochrane databases were searched on 02 August 2022 and then updated on 10 November 2023 for published randomised controlled trials (RCTs) and quasi-experimental studies. The quality of the studies was assessed, and a random-effect model was used to estimate the pooled effect of diabetes DSME intervention. Heterogeneity (I2) was tested, and subgroup analyses were performed. Egger's regression test and funnel plots were used to examine publication bias. The risk of bias of the included studies was assessed using the Cochrane risk-of-bias tool for randomized trial (RoB 2). The overall assessment of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. A total of 5893 articles were retrieved, and 44 studies (n = 11838) from 21 LMICs met the inclusion criteria. Compared with standard care, pooled analysis showed that DSME effectively reduced the HbA1c level by 0.64% (95% CI: 0.45% to 0.83%) and 1.27% (95% CI: -0.63% to 3.17%) for RCTs and quasi-experimental design studies, respectively. Further, the findings showed an improvement in cardiometabolic risk reduction, diabetes self-management behaviours, and psychosocial well-being. This review suggests that ongoing support alongside individualised face-to-face intervention delivery is favourable for improving overall T2DM management in LMICs, with a special emphasis on countries in the lowest income group.
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Affiliation(s)
- Hasina Akhter Chowdhury
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Centre for Injury Prevention and Research, Bangladesh (CIPRB), Dhaka, Bangladesh
| | - Cheryce L. Harrison
- Monash Centre for Health Research and Implementation–MCHRI, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Bodrun Naher Siddiquea
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sanuki Tissera
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Afsana Afroz
- Department of Biochemistry and Pharmacology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Liaquat Ali
- Pothikrit Institute of Health Studies (PIHS), Dhaka, Bangladesh
| | - Anju E. Joham
- Monash Centre for Health Research and Implementation–MCHRI, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Departments of Endocrinology and Diabetes, Monash Health, Melbourne, Australia
| | - Baki Billah
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Dietary habits are associated with the prevalence of type 2 diabetes: a study among a middle eastern population. J Nutr Sci 2022; 11:e78. [PMID: 36304825 PMCID: PMC9554423 DOI: 10.1017/jns.2022.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/17/2022] [Indexed: 12/14/2022] Open
Abstract
Worldwide type 2 diabetes (T2D) prevalence is increasing dramatically. The present study aimed to evaluate the association between dietary habits and T2D in an Iranian adult population using a cross-sectional analysis of the Shahedieh cohort study. Participants were adults aged 35-70 years (n 9261) from Zarch and Shahedieh, Yazd, Iran, who attended the baseline phase of the Shahedieh cohort study. Dietary habits including meal frequency, fried-food consumption, adding salt to prepared meals and grilled-food consumption were assessed by a standard questionnaire. T2D was defined as fasting plasma glucose (FPG) ≥126 mg/dl according to the American Diabetes Association. Multiple logistic regression assessed the association between dietary habits and T2D. Individuals who consumed a meal more than six times per day compared to three times per day had greater odds for T2D (OR 2⋅503, 95 % CI 1⋅651, 3⋅793). These associations remained significant in a fully adjusted model. There was a significant association between greater intakes of fried foods and prevalence of T2D (OR 1⋅294, 95 % CI 1⋅004, 1⋅668) in the adjusted model. No significant associations were observed between other dietary habits (adding salt to prepared meals and grilled-food consumption) and odds of T2D in all crude and adjusted models. In conclusion, we have highlighted the association between meal and fried-food consumption frequencies with risk of T2D. Large longitudinal studies in different ethnicities are needed to confirm these associations.
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Shiferaw WS, Akalu TY, Desta M, Kassie AM, Petrucka PM, Aynalem YA. Effect of educational interventions on knowledge of the disease and glycaemic control in patients with type 2 diabetes mellitus: a systematic review and meta-analysis of randomised controlled trials. BMJ Open 2021; 11:e049806. [PMID: 34887271 PMCID: PMC8663073 DOI: 10.1136/bmjopen-2021-049806] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 10/29/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Globally, type 2 diabetes has continued to increase, now accounting for over 90% of all diabetes cases. Though the magnitude of uncontrolled glycaemic levels in patients with type 2 diabetes is steadily rising, evidence showed that effectively controlled glycaemic levels can prevent complications and improve the quality of life of these patients. As little is known about the effect of educational interventions on this population, this systematic review and meta-analysis evaluated the effectiveness of educational interventions versus standard care on glycaemic control and disease knowledge among patients with type 2 diabetes. METHODS PubMed, Google Scholar, Cochrane Library, Scopus, African Journals Online and Wiley Online Library were searched. Two authors independently assessed within-trial risk of bias in each included study using revised Cochrane risk-of-bias tool for randomised trials. A random-effects model was employed to estimate combined effect sizes. Subgroup analyses were employed to investigate possible sources of heterogeneity between studies. The overall certainty of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS A total of 19 trials with 2708 study participants were included in the review. Primary outcomes (glycaemic control) were reported in 18 trials. The pooled estimated impact of educational intervention on glycaemic levels using the random-effects model was -0.83 (95% CI: -1.17 to -0.49, p<0.001). Subgroup analyses revealed greater A1c reductions in those studies with intervention duration of up to 3 months and with empirical intervention designs. Educational interventions led to significant increases in participants' knowledge of type 2 diabetes (standardised mean difference: 1.16; 95% CI: 0.71 to 1.60; I2=93%). CONCLUSION In the current review overall, educational interventions can potentially lead to improved glycaemic control levels in patients with type 2 diabetes despite heterogeneity across the studies. Besides, the findings showed that educational interventions could increase disease knowledge among patients with type 2 diabetes. PROSPERO REGISTRATION NUMBER CRD42020205838.
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Affiliation(s)
| | | | - Melaku Desta
- Midwifery, Debre Markos University, Debre Markos, Amhara, Ethiopia
| | | | | | - Yared Asmare Aynalem
- Pediatric and Child Health, Debre Berhan University, Debre Berhan, Amhara, Ethiopia
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Batalha APDB, Ponciano IC, Chaves G, Felício DC, Britto RR, da Silva LP. Behavior change interventions in patients with type 2 diabetes: a systematic review of the effects on self-management and A1c. J Diabetes Metab Disord 2021; 20:1815-1836. [PMID: 34900827 PMCID: PMC8630317 DOI: 10.1007/s40200-021-00846-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/23/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE This study aimed to identify the characteristics of interventions employed to promote behavior change in people with type 2 diabetes mellitus (T2DM) and their impact on disease self-management and glycated hemoglobin (A1c). METHODS The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to guide the protocol development for this systematic review. Randomized controlled clinical trials which compared behavior change interventions to controls in adults with T2DM and investigated disease self-management and glycated hemoglobin (A1c) measured by validated methods were eligible for this study. The risk of bias and quality of evidence was assessed respectively by Cochrane's tool and grading of recommendations, assessment, development, and evaluation (GRADE). RESULTS A total of 27 studies were included involving 4464 participants. Behavior change was mainly promoted by education sessions on diabetes care delivered face-to-face, monthly, or every other month, lasting more than 60 min, involving blood glucose monitoring, healthy eating, exercise, and medication. Four studies showed significant improvement in both disease self-management and A1c. The risk of bias was classified as high in most studies. A meta-analysis could not be performed for A1c and self-management due to the high differences in intervention parameters (delivery mode, number, duration, and frequency) and self-management assessments. CONCLUSION Low evidence of improvement in disease self-management and A1c considering only validated assessment methods were found for behavior change interventions, mainly promoted by education sessions on diabetes care. The quality of studies and probably the differences in intervention protocols contributed to this finding. PROSPERO NUMBER CRD42020161162.
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Affiliation(s)
- Ana Paula Delgado Bomtempo Batalha
- Graduate Program in Rehabilitation and Physical-Functional Performance Sciences, Federal University of Juiz de Fora (UFJF), Juiz de Fora, MG Brazil
| | - Isabela Coelho Ponciano
- Graduate Program in Rehabilitation and Physical-Functional Performance Sciences, Federal University of Juiz de Fora (UFJF), Juiz de Fora, MG Brazil
| | | | - Diogo Carvalho Felício
- Graduate Program in Rehabilitation and Physical-Functional Performance Sciences, Federal University of Juiz de Fora (UFJF), Juiz de Fora, MG Brazil
- Faculty of Physical Therapy, UFJF, Juiz de Fora, MG Brazil
| | - Raquel Rodrigues Britto
- Graduate Program in Rehabilitation and Physical-Functional Performance Sciences, Federal University of Juiz de Fora (UFJF), Juiz de Fora, MG Brazil
- Graduate Program in Rehabilitation Science, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG Brazil
| | - Lilian Pinto da Silva
- Graduate Program in Rehabilitation and Physical-Functional Performance Sciences, Federal University of Juiz de Fora (UFJF), Juiz de Fora, MG Brazil
- Faculty of Physical Therapy, UFJF, Juiz de Fora, MG Brazil
- Cardiovascular Research and Exercise Physiology Unit, University Hospital, UFJF, Juiz de Fora, MG Brazil
- Faculty of Physiotherapy, Federal University of Juiz de Fora, Av. Eugenio do Nascimento S/N Bairro Dom Bosco, Juiz de Fora, MG CEP: 36038-330 Brazil
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Azmiardi A, Murti B, Febrinasari RP, Tamtomo DG. The Effect of Peer Support in Diabetes Self-Management Education on Glycemic Control in Patients with Type 2 Diabetes: A Meta-Analysis. Epidemiol Health 2021; 43:e2021090. [PMID: 34696569 PMCID: PMC8920738 DOI: 10.4178/epih.e2021090] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/22/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Diabetes self-management education (DSME) programs are a strategy to maintain healthy behaviors. Nevertheless, limited evidence has been reported from systematic evaluations of the effects of DSME integrated with peer support on glycemic control. This study aimed to review the effectiveness of DSME interventions integrated with peer support on glycemic control in patients with type 2 diabetes. METHODS A systematic search was carried out in electronic databases, including PubMed, Cochrane Library, ProQuest, SpringerLink, ScienceDirect, Scopus, and Google Scholar, for English-language articles published from 2005 until 2020. The effect size was estimated as the standard mean difference (SMD). The Cochrane Collaboration’s Risk of Bias tool was employed to assess the risk of bias. RESULTS Twelve studies were included in this study. DSME integrated with peer support effectively reduced glycated hemoglobin A1c (HbA1c) levels, with a statistically significant effect (SMD, -0.41; 95% confidence interval [CI], -0.69 to -0.13; p<0.001). Programs with a sample size <100 (SMD, -0.45; 95% CI, -0.79 to -0.11; p=0.009), duration of intervention ≤6 months (SMD, -0.52; 95% CI, -0.96 to -0.07; p=0.020), baseline HbA1c <8.5% (SMD, -0.42; 95% CI, -0.77 to -0.07; p=0.020), delivery by group (SMD, -0.28; 95% CI, -0.51 to -0.06; p=0.010), and high frequency of contact (SMD, -0.29; 95% CI, -0.48 to -0.10; p=0.003) had statistically significant effects on reducing HbA1c levels in patients with type 2 diabetes. CONCLUSIONS DSME integrated with peer support effectively enhances glycemic control in patients with type 2 diabetes. Programs with smaller participants groups, shorter interventions, weekly meetings, and closer group sessions improved glycemic control in patients with type 2 diabetes.
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Affiliation(s)
- Akhmad Azmiardi
- Doctoral Program on Public Health, Universitas Sebelas Maret, Surakarta, Indonesia, Surakarta, Indonesia
| | - Bhisma Murti
- Doctor of Public Health Program, Universitas Sebelas Maret, Surakarta, Indonesia, Surakarta, Indonesia
| | - Ratih Puspita Febrinasari
- Department of Pharmacology, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia, Surakarta, Indonesia
| | - Didik Gunawan Tamtomo
- Doctor of Public Health Program, Universitas Sebelas Maret, Surakarta, Indonesia, Surakarta, Indonesia
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Azhdari Mamaghani H, Jabbarzadeh Tabrizi F, Seyedrasooli A, Sarbakhsh P, Badri Gargari R, Zamanzadeh V, Zanboori V. Effect of Empowerment Program with and without Telenursing on Self-efficacy and Glycosylated Hemoglobin Index of Patients with Type-2 Diabetes: A Randomized Clinical Trial. J Caring Sci 2021; 10:22-28. [PMID: 33816381 PMCID: PMC8008233 DOI: 10.34172/jcs.2021.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 02/10/2020] [Indexed: 01/07/2023] Open
Abstract
Introduction: Developing new training methods for improving the health of diabetic patients has always been a concern for nurses. The present study aims to investigate the effects of empowerment-based interventions with or without telenursing on self-efficacy and HbA1c level in diabetic patients. Methods: In this randomized clinical trial, 156 patients with type-2 diabetes were randomly assigned into two intervention groups (empowerment with/without telenursing) and one control group. All subjects in the intervention groups participated in two sessions of the empowerment program. However, only the group of empowerment with telenursing received telephone counseling for 12 weeks. The patients in the control group did not receive any intervention programs. Self-efficacy was measured by diabetes-specific self-efficacy scale. The HbA1c level was measured using Bionic kit. Data were analyzed using SPSS Statistics for Windows, version 13.0 (SPSS Inc., Chicago, Ill., USA). Results: After 14 weeks, while the changes in self-efficacy scores of the control group were not statistically significant, they were significant in the two intervention groups. Comparison of the two intervention groups showed that self-efficacy was higher in the group of empowerment with telenursing. It was only in the empowerment with telenursing group that the reduction of HbA1 c was significant. Conclusion: Training based on empowerment models and emphasis on the strengths of clients in solving their own problems can play a major role in increasing self-efficacy and reduction of HbA1c level. In addition, a continuous training program, along with telephone follow-ups can result in higher self-efficacy and lower HbA1c level.
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Affiliation(s)
- Hadi Azhdari Mamaghani
- Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Faranak Jabbarzadeh Tabrizi
- Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alehe Seyedrasooli
- Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parvin Sarbakhsh
- Department of Statistics and Epidemiology, Faculty of Health Science, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Vahid Zamanzadeh
- Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Vahdat Zanboori
- Endocrine and Diabetes Center,Sina Medical Research & Training Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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Machado CCDS, Malaguti C, Trevizan PF, Ezequiel DGA, Seixas MB, da Silva LP. Psychometric validation of the Brazilian Portuguese version of Bandura's exercise self-efficacy scale in diabetes patients. J Diabetes Metab Disord 2021; 19:925-932. [PMID: 33520812 DOI: 10.1007/s40200-020-00581-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022]
Abstract
Purpose The management of diabetes comprises diet, pharmacological therapy, lifestyle counseling, patient education, and physical exercising, to achieve change in health behavior and control of the disease. However, a large proportion of diabetes patients does not adhere to treatment recommendations, mainly in the lifestyle aspect, which remains sedentary. Considering that self-efficacy is an essential determinant of health behaviors such as exercise practicing, the objective of the study was to investigate the psychometric properties of the Brazilian Portuguese version of Bandura's Exercise Self-Efficacy Scale (BESES) to be used in diabetes patients. Methods The BESES was initially completed by thirty diabetes patients to confirm the feasibility of the answers be provided by themselves. The psychometric properties (i.e., internal consistency, test-retest reproducibility, convergent validity, and ceiling and floor effects) were tested in other two-hundred diabetes patients (≥18 years old). Results The BESES achieved significant internal consistency (Cronbach's alpha coefficient = 0.92), substantial test-retest reproducibility (intraclass correlation coefficient = 0.83). The convergent validity was confirmed by negative correlations between BESES total scores and barriers to exercise total scores (ρ = -0.333; P = 0.018) and rate of perception exercise corrected by distance covered in the incremental shuttle walking test (ρ = -0.426; P = 0.002). Ceiling and floor effects were not found. In addition, physically active patients had BESES total scores higher compared to sedentary (56.8 ± 21.4 vs. 47.9 ± 20.0; P = 0.003). Conclusion The Brazilian Portuguese version of the BESES showed adequate psychometric properties and proved to be valid for assessing the exercise self-efficacy in diabetes patients in Brazil.
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Affiliation(s)
- Carla Cristina da Silva Machado
- Faculty of Physiotherapy, Universidade Federal de Juiz de Fora (UFJF), Eugênio do Nascimento, s/n - Dom Bosco, Juiz de Fora, MG CEP: 36038-330 Brazil.,Cardiovascular Research Unit and Exercise Physiology of the University Hospital of the UFJF, Eugênio do Nascimento, s/n - Dom Bosco, Juiz de Fora, MG CEP: 36038-330 Brazil
| | - Carla Malaguti
- Faculty of Physiotherapy, Universidade Federal de Juiz de Fora (UFJF), Eugênio do Nascimento, s/n - Dom Bosco, Juiz de Fora, MG CEP: 36038-330 Brazil
| | - Patrícia Fernandes Trevizan
- Cardiovascular Research Unit and Exercise Physiology of the University Hospital of the UFJF, Eugênio do Nascimento, s/n - Dom Bosco, Juiz de Fora, MG CEP: 36038-330 Brazil
| | - Danielle Guedes Andrade Ezequiel
- Faculty of Medicine, Universidade Federal de Juiz de Fora (UFJF), Eugênio do Nascimento, s/n - Dom Bosco, Juiz de Fora, MG CEP: 36038-330 Brazil
| | - Mariana Balbi Seixas
- Faculty of Physiotherapy, Universidade Federal de Juiz de Fora (UFJF), Eugênio do Nascimento, s/n - Dom Bosco, Juiz de Fora, MG CEP: 36038-330 Brazil.,Cardiovascular Research Unit and Exercise Physiology of the University Hospital of the UFJF, Eugênio do Nascimento, s/n - Dom Bosco, Juiz de Fora, MG CEP: 36038-330 Brazil
| | - Lilian Pinto da Silva
- Faculty of Physiotherapy, Universidade Federal de Juiz de Fora (UFJF), Eugênio do Nascimento, s/n - Dom Bosco, Juiz de Fora, MG CEP: 36038-330 Brazil.,Cardiovascular Research Unit and Exercise Physiology of the University Hospital of the UFJF, Eugênio do Nascimento, s/n - Dom Bosco, Juiz de Fora, MG CEP: 36038-330 Brazil
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