1

Chapter 1

THE PROBLEM AND REVIEW OF RELATED LITERATURE

Introduction

The latest global estimates from the International

Diabetes Federation forecast that by 2040, 642 million

people will be living with diabetes (The Lancet, 2017).

World Health Organization (2017) stated the number of

people with diabetes has risen from 108 million in 1980 to

422 million in 2014. The global prevalence of diabetes

among adults over 18 years of age has risen from 4.7% in

1980 to 8.5% in 2014.

In addition, the patients who have diabetes then,

patient can confirm that there is a problem with blood

sugar levels that are experiencing hyperglycemia.

Therefore, patients should be able to control blood sugar

in order not to increase or experience hyperglycemia. One

way to be able to control blood sugar in patients with

diabetes is counseling.

This is due to the fact that the patient needs the

delivery in controlling patient’s own blood sugar.

According to the American Counseling Association,

counseling is defined as, a professional relationship that

empowers diverse individuals, families, and groups to

 2

accomplish mental health, wellness, education, and career

goals (Austin, 2017).

Based on data from the Indonesian Central Bureau of

Statistics in 2003, it is estimated that Indonesians aged

over 20 years are 133 million. With a DM prevalence of

14.7% in urban areas and 7.2%, in rural areas, it is

estimated that in 2003 there were 8.2 million people with

diabetes in urban areas and 5.5 million in rural areas

(Mayasari et al, 2014).

South Sulawesi provincial health data showed that

patients with diabetes mellitus treated at community health

clinic in 2010 were 9.61%, 2011 was 9.32%, increased in

2012 by 12.6%. The data of Makassar City health office

diabetes mellitus patients in 2012 as many as 14,067 cases,

increased to 14,604 cases in 2013, and in 2014 increased by

21,452 cases (Syatriani, 2017).

Records of hospital medical records Labuang Baji

Hospital and Pelamonia Hospital Makassar, obtained data on

the number of people with diabetes mellitus is still very

much happening. In Labuang Baji Hospital Makassar in 2010

the number of diabetes mellitus cases as many as 476 cases,

in 2011 as many as 672 cases, and in 2012 as many as 682

cases (Mayasari et al, 2014).

 3

In addition, data of diabetes mellitus in Pelamonia

Hospital Makassar in 2012 about the number of 1,375 people,

in 2013 about the number of 1,568 people, year 2014 about

the number of 1,792 people (Usman, 2017).

According to Schmitt et al. (2013) stated patients

with good glycaemic control reported significantly more

glucose management, dietary control, physical activity, and

health-care use than those with poor control.

WHO projects that diabetes will be the seventh leading

cause of death in 2030. Healthy diet, regular physical

activity, maintaining a normal body weight and avoiding

tobacco use are ways to prevent or delay the onset of type

2 diabetes (WHO, 2017).

A retrospective cohort study conducted by Franklin

(2012) claimed that regularly scheduled lifestyle

counseling in real-world settings motivates patients with

diabetes to achieve targeted average blood glucose more

quickly than scenarios in which patients receive physician

advice less frequently.

One of the factors of a treatment failure is non-

adherence to planned therapy, one of the most important

attempts to improve patient adherence to therapy is by

providing comprehensive, accurate, and structured

counseling about the therapy. The existence of this

 4

counseling is very important because diabetes is a disease

associated with patient lifestyle. Therefore, the purpose

of this study is to come up assess the self care behavior

of patients with diabetes mellitus.

Related Literature and Studies

This will present the related literature and studies

after the through and in-depth search done by the

researcher, as follows:

Diabetes. Diabetes is a serious life-long health

condition that occurs when the amount of glucose (sugar) in

the blood is too high because the body can’t use it

properly. If left untreated, high blood glucose levels can

cause serious health complications. There are two main

types of diabetes: Type 1 and Type 2. Patients are

different conditions, caused by different things, but

patients are both serious and need to be treated and

managed properly (Diabetes UK, 2017).

Diabetes mellitus is a descriptive term for a family

of disorders that are characterized by chronic carbohydrate

intolerance (fasting and/or post-prandinal hyperglycemia)

and the development of long-term medical complications.

Diabetes is of great concern to health-care providers. All

specialties of medicine, including family practitioners,

pediatricians, internists, obstetricians, gynecologists,

 5

surgeons, cardiologists, nephrologists, neurologists, and

ophthalmologists, treat patient with diabetes. The clinic

chemistry laboratory plays a central role diagnostically

and therapeutically in the management of diabetes (Winter

&Signorino, 2002).

Insulin is a hormone produced by the pancreas that

plays a very important role in our bodies. After we eat, we

begin to digest carbohydrates, breaking them down into

glucose. The insulin released by the pancreas moves glucose

into our cells, where it is used as fuel for energy. It may

help to understand that insulin is often described as a

key, which open the doors to the cells, allowing glucose to

enter (Diabetes UK, 2017).

Table 1. Blood sugar levels in diagnosing diabetes

Plasma glucose test Normal Prediabetes Diabetes

Random Below 200 Not 200 mg/dl

mg/dl available or more

Fasting Below 108 108 to 125 126 mg/dl

mg/dl mg/dl or more

2 hour posts-prandial Below 140 140 to 199 200 mg/dl

mg/dl mg/dl or more

According to Nemours (2018) claimed a blood glucose

meter is a small, portable machine that's used to measure

 6

how much glucose (a type of sugar) is in the blood (also

known as the blood glucose level). People with diabetes

often use a blood glucose meter to help them manage their

condition.

DM patients experienced the highest number of cases

occurred in the age range of the elderly by age group based

on the Ministry of Health Republic Indonesia (2009) ranging

from 46 years to 55 years as many as 22 people respondent

(50%)(Depkes RI, 2008). This data is consistent with

statements from the American Diabetes Association (ADA),

that age above 45 years is one of the risk factors for type

2 diabetes (ADA, 2008).

According to Perkeni (2006) the risk of developing

type 2 diabetes mellitus increases with age. In addition, a

number of changes will occur with age, including anatomy,

physiology, psychology and sociology. Califano suggests

that age is one of the risk factors for health problems

such as DM disease. Incidence of DM disease increases with

age.

Rochmah (2006) explained that the prevalence of DM

disease is more prevalent in adulthood, whereas in adults

(30 years) blood glucose levels increase 1 - 2 mg / year

during fasting and will rise about 5.6 to 13 mg at 2 hours

after meal. DM patients in Indonesia are mostly between 45

 7

and 64 years old. In addition, Sucipto& Rosa (2014) stated

respondents in study consisted 9.1% were aged 36-45 years,

50% were aged between 46-55 years, and 40.9% were aged 56-

65 years.

Results of research conducted by Koja Hospital stated

that the prevalence of type 2 diabetes mellitus that occurs

in women is 62%, greater than the prevalence in men

(Santoso et al, 2004). According Joshlin (1985) that women

are more susceptible to type 2 diabetes mellitus with a

ratio of women and men were 1.8: 1. This is in line with

the research presented by Azrul Azwar which stated that

there are variations in the prevalence of type 2 diabetes

mellitus among men and women in some areas (Azwar, 1985).

Furthermore, Sucipto & Rosa (2014) stated respondents

consisted of 59.1% female sex and 40.9% male sex.

In addition, according to American Cancer Society

(2016) stated body mass index, or BMI, is a way to help

patient figure out if patient are at a healthy weight for

patient’s height. BMI is a number based on patient’s weight

and height. In general, the higher the number, the more

body fat a person has.

BMI is often used as a screening tool to decide if

patient’s weight might be putting patient at risk for

health problems such as diabetes, heart disease, and

 8

cancer. BMI is used to broadly define different weight

groups in adults 20 years old or older. The same groups

apply to both men and women, such as (American Cancer

Society, 2016):

1. Underweight : BMI is less than 18.5

2. Normal weight : BMI is 18.5 to 24.9

3. Overweight : BMI is 25 to 29.9

4. Obese : BMI is 30 or more

Patient can calculate patient’s own BMI. The actual

formula to determine BMI uses metric system measurements:

weight in kilograms (kg) divided by height in meters,

squared (m2). Doctors and nurses often use BMI to help find

out if a person might have a weight problem. BMI gives a

good estimate of total body fat for most people, but it

doesn’t work well for everybody (American Cancer Society,

2016).

According to Guyton's theory, obesity is a

predisposing factor for the rise in blood sugar levels,

this is because the Langerhans island beta cells become

less sensitive to stimuli or as a result of elevated levels

of sugar and obesity will also suppress the amount of

insulin receptors in cells whole body (Guyton & Hall,

2007).
 9

Purwandari (2014) claimed obesity in employees at RS

Level IV Madiun showed that almost half (42%) are obese I

is 17 respondents. In addition, blood sugar levels in

employees at Madiun Hospital showed that almost half (35%)

had between 111-140 mg / dL of 14 respondents. Furthermore,

there is an association of obesity with blood sugar levels

in the employees of RS Level IV Madiun, in other words the

higher the value of body mass index (obesity), the higher

the level of blood sugar.

In accordance with Hillson (2015) claimed people with

diabetes who smoke have at least the same risk of morbidity

and mortality as non-diabetics who smoke, probably greater.

Give smokers support in stopping-stop smoking

groups/courses. Vigorously discourage young people with

diabetes from starting smoking. Nicotine may alter the rate

of insulin absorption, so monitor glucose after stopping.

If patients have diabetes, patients have to work hard

enough already to keep patient’s blood sugar in check.

Smoking can make that task even more difficult. Smoking may

make patient’s body more resistant to insulin, which can

lead to higher blood sugar levels (Pletcher, 2016).

In addition, according to Patja et al (2005) examined

the association of cigarette smoking with the risk of type

2 diabetes and to find out whether the association is

 10

modified by obesity and physical activity. Smoking had a

graded association with the risk type 2 diabetes, and it

remained significant after controlling for age and major

risk factors. Smoking increased the risk of type 2 diabetes

at all levels of BMI and physical activity.

Smoking is a risk factor for type 2 diabetes

independently of BMI and physical activity. Prevention of

smoking should be encouraged as a part of efforts to reduce

the risk of type 2 diabetes, and it will result in other

health benefits, too (Patja et al, 2005).

Self Care Theory. There are instances wherein patients

are encouraged to bring out the best in them despite being

ill for a period of time. This is very particular in

rehabilitation settings, in which patients are entitled to

be more independent after being cared for by physicians and

nurses. Through these, the self-care nursing theory or the

Orem model of nursing was developed by Dorothea Orem

between 1959 and 2001. It is considered a grand nursing

theory, which means the theory covers a broad scope with

general concepts that can be applied to all instances of

nursing (Wayne, 2014).

Orem’s theory defined Nursing as “The act of assisting

others in the provision and management of self-care to

maintain or improve human functioning at home level of

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effectiveness.” It focuses on each individual’s ability to

perform self-care, defined as “the practice of activities

that individuals initiate and perform on their own behalf

in maintaining life, health, and well-being (Wayne, 2014).”

This theory of self-care focuses on the performance or

practice of activities that individuals initiate and

perform on their own behalf to maintain life, health and

well-being. In addition as follows (Wayne, 2014):

1. Self-care Requisites

Self-care Requisites or requirements can be defined

as actions directed toward the provision of self-care. It

is presented in three categories:

2. Universal self-care requisites

Universal self-care requisites are associated with

life processes and the maintenance of the integrity of

human structure and functioning.

2.1. The maintenance of a sufficient intake of air

2.2. The maintenance of a sufficient intake of water

2.3. The maintenance of a sufficient intake of food

2.4. The provision of care associated with elimination

process and excrements

2.5. The maintenance of a balance between activity and

rest
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2.6. The maintenance of a balance between solitude and

social interaction

2.7. The prevention of hazards to human life, human

functioning, and human well-being

2.8. The promotion of human functioning and development

within social groups in accord with human potential,

known human limitations, and the human desire to be

normal

Normalcy is used in the sense of that which is

essentially human and that which is in accord with the

genetic and constitutional characteristics and the

talents of individuals.

3. Developmental self-care requisites

Developmental self-care requisites are “either

specialized expressions of universal self-care requisites

that have been particularized for developmental processes

or they are new requisites derived from a condition or

associated with an event.”

4. Health deviation self-care requisites

Health deviation self-care requisites are required

in conditions of illness, injury, or disease or may

result from medical measures required to diagnose and

correct the condition.

4.1. Seeking and securing appropriate medical assistance

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4.2. Being aware of and attending to the effects and

results of pathologic conditions and states

4.3. Effectively carrying out medically prescribed

diagnostic, therapeutic, and rehabilitative measures

4.4. Being aware of and attending to or regulating the

discomforting or deleterious effects of prescribed

medical measures

4.5. Modifying the self-concept (and self-image) in

accepting oneself as being in a particular state of

health and in need of specific forms of health care

4.6. Learning to live with the effects of pathologic

conditions and states and the effects of medical

diagnostic and treatment measures in a lifestyle

that promotes continued personal development

In addition, the theory of nursing system is the

product of a series of relations between the persons:

legitimate nurse and legitimate client. This system is

activated when the client’s therapeutic self-care demand

exceeds available self-care agency, leading to the need for

nursing. In addition as follows (Wayne, 2014):

1. Wholly compensatory nursing system

This is represented by a situation in which the

individual is unable “to engage in those self-care

actions requiring self-directed and controlled ambulation

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and manipulative movement or the medical prescription to

refrain from such activity. Persons with these

limitations are socially dependent on others for their

continued existence and well-being.” Example: care of a

new born, care of client recovering from surgery in a

post-anesthesia care unit.

2. Partial compensatory nursing system

This is represented by a situation in which “both

nurse and perform care measures or other actions

involving manipulative tasks or ambulation [Either] the

patient or the nurse may have the major role in the

performance of care measures.” Example: Nurse can assist

postoperative client to ambulate, Nurse can bring a meal

tray for client who can feed himself.

3. Supportive-educative system

This is also known as supportive-developmental

system, the person “is able to perform or can and should

learn to perform required measures of externally or

internally oriented therapeutic self-care but cannot do

so without assistance.” Example: Nurse guides a mother

how to breastfeed her baby, Counseling a psychiatric

client on more adaptive coping strategies.

Counseling. Counseling is an individualized

relationship between the individual i.e. counselor who is

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an older, more experienced and wiser and the younger (the

counselee) who is less experienced and less wise. The

latter has a problem for which seeks the help of the

former. In the process, the counselee feels free to express

self fully (Pal, 2011).

The counselor helps the counselee to understand

patients’ self and prevents trouble rather than merely

remedying it after it has gained headway. Thus counseling

has the following main elements: 1) counseling is a face to

face relationship; 2) counseling aims at assisting the

counselee to solve patient problem; and 3) counseling is a

job of professionally trained person (Pal, 2011).

And then, according to the American Counseling

Association, counseling is defined as, "a professional

relationship that empowers diverse individuals, families,

and groups to accomplish mental health, wellness,

education, and career goals” (Austin, 2017).

Counseling involves helping people make needed changes

in ways of thinking, feeling, and behaving, and is a goal-

based collaborative process, involving a non-judgmental,

supportive counselor who works with a client in telling his

or her story, setting viable goals, and developing

strategies and plans necessary to accomplish these goals.

For some people this process takes a small amount of time,

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in some cases as little as one or two sessions; for others,

the process may last longer (Austin, 2017).

The role of the counselor is to assist people to grow

and solve their own problems. Most people who need help

have within patients’ own self some resources for coping

which counselors can bring out. The process of counseling

as follows: 1) interview; 2) the process; 3)

interpretation; 4) developing insights and putting them to

work; and 5) termination of the contact. The following

types of interview for counseling are mentioned: 1)

introductory interview; 2) fact finding interview; 3)

informative interview; and 4) treatment interview (Pal,

2011).

In addition, procedures of interview included

preparation. Interviewing is an art that requires careful

planning and preparation for satisfactory performance and

good results. Before the interview the counselor needs to

work out the entire interview (Pal, 2011).

The counselor needs to be sure how counselor is to

initiative it, what responses are responsible to

counselor’s opening statement, which one of these

counselor’s wants, how came eliminate the unwanted

responses and achieve define objective. The following hints

can prove useful: 1) decide what is to be accomplished; 2)

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know the interviewee; 3) make appointment; 4) period of

privacy; 5) practice taking the interviewee’s point of

views; 6) know your own personality (Pal, 2011).

Furthermore, the process counseling after interview is

talked about establish rapport, help the interviewee feel

at ease and ready to talk, help the interviewee obtain and

organize into a meaningful pattern the information

counselor needs in counselor’s choice making activity, ask

unambiguous questions, learn to listen, keep control of the

interview, and at the close of the interview, watch for

additional information or new leads on the casual remarks

of the interview (Pal, 2011).

Moreover, the next hints can prove useful that

interpretation. What the interviewee says is often a

mixture of facts, counselor’s view of the situations or

counselor sees if and counselor’s feelings. Unless the

interviewer has information from other sources, counselor

is often unable to distinguish between fact and fiction

(Pal, 2011).

There is another difficulty arising out of the

interviewer counselor’s own self counselor’s tendency to

project counselor’s ideas and attitudes upon the

interviewee. Without interpretation, the counselee may

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remain on a superficial level of the self understanding

(Pal, 2011).

Sucipto & Rosa (2014) indicated that counseling is

very effective in improving diabetes diet compliance,

control and pill count and post prandial blood sugar

compliance and are not effective in improving exercise

compliance of patients.

In accord with Adepu et al (2007) declared study was

carried out to assess the influence of pharmacist provided

patient counseling on patients' perception about the

disease management and quality of life in type 2 diabetes

mellitus patients. Pharmacist provided patient counseling

has an impact in improving the perception about disease,

diet and life style changes and in turn on glycemic control

and overall quality of life in diabetic patients.

Pharmacist provided patient counseling might be considered

as an important element in implementing the disease

management program.

According to Schmitt (2013), to assess self-care

activities associated with glycaemic control was developed,

based on theoretical considerations and a process of

empirical improvements that is four subscales, glucose

management, dietary control, physical activity, and health-

care use.
 19

The goal of blood glucose management is to keep

patient’s blood glucose levels in the target range that

prevents complications and helps patient feel the best.

Therefore, it is important to know how to identify blood

glucose problems, respond appropriately, and take action to

prevent in the future (May & Fletcher, 2012).

Furthermore, the beneficial effect of the dietary

pattern on diabetes mellitus and glucose metabolism in

general and traditional food pattern was associated with a

significant reduction in the risk of developing type-2

diabetes. The dietary pattern emphasizes a consumption of

fat primarily from foods high in unsaturated fatty acids,

and encourages daily consumption of fruits, vegetables, low

fat dairy products and whole grains, low consumption of

fish, poultry, tree nuts, legumes, very less consumption of

red meat (Bannard et al, 2005).

In accordance with Suhaema et al (2010) stated the

prevalence of diabetes mellitus (DM) is increasing

globally, including in Indonesia. Studies by Diabetes

Control and Complication Trial (DCCT) and U.K. Prospective

Diabetes Study Group (UKPDS) prove the benefit of medical

nutrition therapy (MNT) to glycemic control. Intake of

nutrient, nutrition status, blood glucose level and blood

pressure of type 2 DM patients that got MNT was more

 20

controllable than of those that got conventional nutrition

counseling.

Furthermore, physical activity includes all movement

that increases energy use, whereas exercise is planned,

structured physical activity. Exercise improves blood

glucose control in type 2 diabetes, reduces cardiovascular

risk factors, contributes to weight loss, and improves

well-being (Lin et al, 2015).

In addition, increasing physical activity can reduce

the risk of type 2 diabetes. The protective effect of

physical activity was observed in subjects with an

excessive BMI and elevated glucose levels. Physical

activity and weight control are critical factors in

diabetes prevention in subjectswith both normal and

impaired blood glucose regulation (Hu et al, 2004).

Moreover, in accordance with Williams et al (1998)

applied the self-determination theory of human motivation

to examine whether patient perceptions of autonomy

supportiveness (i.e., patient centeredness) from patient’s

diabetes care providers related to improved glucose control

over a 12-month period. Support the prediction of the self-

determination theory that patients with diabetes whose

health care providers are autonomy supportive will become

more motivated to regulate patient’s glucose levels, feel

 21

more able to regulate patient’s glucose, and show

improvements in patient’s HbA1c values.

In addition, Perhimpunan Edukator Diabetes Indonesia

(PEDI) is Educator Diabetes Association of Indonesia who is

giving education through counseling or health promotion

concern diabetes. The head of PEDI, Dr.dr.ArisWibudi, SpPD,

KEMD said practitioners must to aware about diabetes

education. Furthermore, PEDI held training and give

education toward step by step to control diabetes. This

learning used continually basic training level until next

training level for educator diabetes candidate. Moreover,

PEDI instructors always held education diligently as a

daily activity in their own places.

PEDI held Diabetes Conversation Map in 2013 which is

made by Healthy Interactions together with International

Diabetes Federation (IDF) and health practitioners

professional. This program held to train the trainers for

aware health practitioners implement managing diabetes

through education. The trainers facilitated by diabetes

educator for discuss and exchange knowledge concern

diabetes, fake or fact diabetes, or perception about

diabetes. Through interactive discussion in games form, the

trainers share success story and problem solving when

trainers with diabetes patients. This method will be aware

 22

patients that they are not alone suffering diabetes and it

could be inspired patients to manage diabetes better.

Synthesis

Diabetes is a serious life-long health condition that

occurs when the amount of glucose (sugar) in the blood is

too high because the body can’t use it properly (Diabetes

UK, 2017).

If the patient has diabetes, then we can confirm that

there is a problem with blood sugar levels that are

experiencing hyperglycemia. Therefore, patients should be

able to control patient’s blood sugar in order not to

increase or hyperglycemia. One way to be able to control

blood sugar in patients with diabetes is intensive

counseling. This is due to the fact that the patient needs

the delivery of complaints and mistakes in controlling

patient’s own blood sugar. According to the American

Counseling Association, counseling is defined as, "a

professional relationship that empowers diverse

individuals, families, and groups to accomplish mental

health, wellness, education, and career goals" (Austin,

2017).

World Health Organization (2017) stated the number of

people with diabetes has risen from 108 million in 1980 to

422 million in 2014. Based on data from the Indonesian

 23

Central Bureau of Statistics in 2003, it is estimated that

Indonesians aged over 20 years are 133 million (Mayasari et

al., 2014).

South Sulawesi provincial health data showed that

patients with diabetes mellitus treated at community health

clinic in 2010 were 9.61%, 2011 was 9.32%, increased in

2012 by 12.6%. The data of Makassar city health office

diabetes mellitus patients in 2012 as many as 14,067 cases,

increased to 14,604 cases in 2013, and in 2014 increased by

21,452 cases (Syatriani, 2017).

Records of hospital medical records LabuangBaji

Makassar, obtained data on the number of people with

diabetes mellitus is still very much happening. In 2010 the

number of diabetes mellitus cases as many as 476 cases, in

2011 as many as 672 cases, and in 2012 as many as 682 cases

(Mayasari et al., 2014).Data of diabetes mellitus in

Pelamonia Hospital Makassar in 2012 about the number of

1,375 people, in 2013 about the number of 1,568 people,

year 2014 about the number of 1,792 people (Usman, 2017).

WHO projects that diabetes will be the seventh leading

cause of death in 2030. Healthy diet, regular physical

activity, maintaining a normal body weight and avoiding

tobacco use are ways to prevent or delay the onset of type

2 diabetes (WHO, 2017).

 24

In addition, to those already described by Schmitt et

al. (2013), as a result to self-care activities diabetes

associated with glycaemic control, such as glucose

management, dietary control, physical activity, and Health-

Care Use. Furthermore, the patient must know how to control

hyperglycemia come again and again.

Seeing from the above exposure, the researcher is

interested to come up assess the self-care behavior of

patients with diabetes mellitus. The hope by assess the

self-carebehavior, it will be useful for the diabetes

mellitus patients especially for considering counseling

program.

In accordance with Redman (2013) stated in contrast to

traditional patient education, which has limited teaching

to information and technical skills, patient self-

management (PSM) is problem-focused and action-oriented and

emphasizes patient-generated care plans.

In addition, according to Heni (2012) stated diabetes

mellitus (DM) is a chronic disease characterized by blood

glucose levels that exceed normal values. It can be

concluded that factors related to successful management of

DM type 2 is knowledge, regularity of sport, diet and

compliance to take medicine.

 25

In pursuance of Kruse (2013) claimed the best foods

for diabetes are most often whole foods that are not

processed, such as fruits and vegetables. In this case it

will be seen how the problem is managed and solved

depending on patient compliance in blood sugar control.

According to Ziemer et al (2003) declared compare a

simple meal plan emphasizing healthy food choices with a

traditional exchange-based meal plan in reducing HbA1c

levels in urban African Americans with type 2 diabetes.

In addition, the ability to control blood sugar as one

of them also is a regular physical activity by National

Institute of Diabetes and Digestive and Kidney Diseases

(2016) stated aerobic exercise, strength training, and

stretching exercise.

In accordance with Williams et al (1998) applied the

self-determination theory of human motivation to examine

whether patient perceptions of autonomy supportiveness

(i.e., patient centeredness) from patient’s diabetes care

providers related to improved glucose control over a 12-

month period. Support the prediction of the self-

determination theory that patients with diabetes whose

health care providers are autonomy supportive will become

more motivated to regulate patient’s glucose levels, feel

 26

more able to regulate patient’s glucose, and show

improvements in patient’s HbA1c values.

Furthermore, ability to control blood sugar as one of

those too is a maintaining normal body weight by American

Cancer Society (2016) claimed normal bodyweight same with

body mass index (BMI).

According to Hu et al (2004) asserted sedentary

lifestyle, obesity, and impaired glucose regulation are

associated with the risk of type 2 diabetes. Increasing

physical activity can reduce the risk of type 2 diabetes.

The protective effect of physical activity was observed in

subjects with an excessive BMI and elevated glucose levels.

Physical activity and weight control are critical factors

in diabetes prevention in subjects with both normal and

impaired blood glucose regulation.

Moreover, ability to control blood sugar as one of

them also is avoiding tobacco use by Centers for Disease

Control and Prevention (2017) knew that smoking causes type

2 diabetes. In fact, smokers are 30–40% more likely to

develop type 2 diabetes than nonsmokers.

In addition, according to Patja et al (2005) examined

the association of cigarette smoking with the risk of type

2 diabetes and to find out whether the association is

modified by obesity and physical activity.

 27

However, the researcher will use glucose meter to

measure blood sugar of patients. According to Nemours

(2018) claimed a blood glucose meter is a small, portable

machine that's used to measure how much glucose (a type of

sugar) is in the blood (also known as the blood glucose

level). People with diabetes often use a blood glucose

meter to help them manage their condition.

In accordance with Suhaema et al (2010) stated the

prevalence of diabetes mellitus (DM) is increasing

globally, including Indonesia.

One of the factors of a treatment failure is non-

adherence to planned therapy, one of the most important

attempts to improve patient adherence to therapy is by

providing comprehensive, accurate, and structured

counseling about the therapy. The existence of this

counseling is very important because diabetes is a disease

associated with patient lifestyle.

Conceptual/Theoretical Framework

The conceptual framework in this research shows the

following below:
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Input Process Output

Assessment of
the self-
management
 Profile of behaviors:
Diabetes  Glucose
Mellitus management Proposed
patients counseling
 Dietary
 Self- program
control
management
 Physical
questionnaire
activity
 Health-care
use

Figure 1. The conceptual framework

The study utilized the Input-Process-Output design.

The inputs of the study will include the profile of

diabetes mellitus patients and self-management

questionnaire.

The study will undergo the process that is assessment

of the self-management behaviors, such as glucose

management, dietary control, physical activity, and health-

care use. The output is proposed counseling program for

diabetes mellitus patients in LabuangBaji Hospital and

Pelamonia Hospital Makassar, South Sulawesi, Indonesia.

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Statement of the Problem

This study aims to come up assess the self-care

behavior of patients with diabetes mellitus. This study

will specifically to answer the following problems:

1. What is the profile of the participants in terms of:

1.1. Age;

1.2. Gender;

1.3. Blood sugar levels;

1.4. Body Mass Index (BMI); and

1.5. History of smoking?

2. What is the degree of manifestation of the self-

management behaviors of the participants in terms of:

2.1. Glucose management;

2.2. Dietary control;

2.3. Physical activity; and

2.4. Health care use?

3. Is there a significant difference in the self-management

behaviors of the participants when grouped according to

profile variables?

4. What counseling program can be purposed to enhance self-

management behaviors?

Scope and Limitation

This study is conducted to come up assess the self

care behavior of patients with diabetes mellitus. Self-

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management includes glucose management, dietary control,

physical activity, and health care use.

In addition, the data will be collected from the

diabetic patients in Labuang Baji and Pelamonia General

Hospital Makassar, South Sulawesi, Indonesia. Furthermore,

this study covers the population of diabetic patients who

are hospitalized in these 2 hospitals and who are aged 18 -

60 years old. Moreover, the period for gathering the data

for this study will take 2 months from February 12 - April

12, 2018.

Although this research was carefully prepared, the

researcher is still aware of its limitations and

shortcomings. First of all, the research will be conducted

in 2 hospitals which have many cases of diabetes mellitus

during hospitalization. After which that, the researcher

will assess the self-management behaviors participants

during two months. Second, the population of the research

will be conducted to diabetes mellitus patients who are

hospitalized only and with the exclusion of out-patients on

the 2 hospitals.

Third, since the questionnaire is designed to measure

the diabetes patients’ ability to control blood sugar which

may give useful information; and not to provide enough

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evidence of the diabetes patients’ actual ability to

control blood sugar.

Significance of the Study

Department of Health. The results of this study are

expected to be an input for the preparation of health

development policies and programs. In addition, the results

of this study also shall be used as input for the

development of science.

Hospital. The hospital would be adherence training

diabetes mellitus education for the health worker which the

training held by Association of Diabetes Indonesia or

Persatuan Diabetes Indonesia. And then, the health worker

will be more aware toward counseling approach for diabetes

mellitus patients.

Nursing Education Institution. Science schools that

apply the recommended approach derived from the results of

this study will be able to train the students better than

before which concerns counseling especially about diabetes

mellitus patients.

Diabetic Patients. The contribution of this study will

be beneficial for people with diabetes who need counseling

to control blood sugar in diabetes mellitus patients. In

other words, the findings of this study will redound to the

benefit of patients considering that ability to control

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blood sugar for diabetes mellitus patients is an important

role in having a healthy lifestyle. The greater demand for

diabetes mellitus patients with diabetes mellitus theory

background justifies the need for more effective and life-

changing approaches.

Researcher. The result of this study will be more

valuable to ascertain and improve cognition to the

researcher concerning counseling of diabetes mellitus

patients. In addition, the study will help future

researchers discover critical areas in the educational

diabetes counseling process in which researchers were not

able to explore yet in general hospitals.

Definition of Terms

Body Mass Index. According to American Cancer Society

(2016), the terms body mass index is normal body weight

which calculate with the actual formula uses metric system

measurements: weight in kilograms (kg) divided by height in

meters, squared (m2).

Counseling Program. A method used by health

professionals who are experts in the field of diabetes

mellitus in which health workers have attended training

organized by the Perhimpunan Edukator Diabetes Indonesia

(PEDI) or Educator Diabetes Association of Indonesia.

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Diabetes Mellitus. A disease suffered by patients who

have uncontrolled blood sugar.

History of Smoking. It is calculated by multiplying

the number of packs of cigarettes smoked per day by the

number of years the person has smoked (National Cancer

Institute, 2017).

Plasma Glucose Level. The amount of blood sugar in the

human body.

Self-Care Behavior. It is a patient's essence

management actions in keeping blood sugar within normal

limits.