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Pre-diabetes and Diabetes Early Awareness Education and Its Effects on BMI

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Nancy L. Gee Comment by Pamela Love: Looks like an interesting project, Nancy.Very good start! Be sure whenever you submit your manuscript that you change wording from “study” to “project” and avoid referring to the project as research. Review carefully for grammar, punctuation, sentence structure, format, or APA errors. Pay close attention to the reviewer’s comments as you continue on this DNP journey. Stay focused &be sure to follow the DPI template as you prepare for IRB submission.“For I know the plans I have for you, declares the Lord, plans to prosper you and not to harm you, plans to give you hope and a future.” — Jeremiah 29:11 (NIV).Blessings, breathe, and believe,Dr. Love

Direct Practice Improvement Project Proposal

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

Running head: EARLY AWARENESS

EARLY AWARENESS

February 14, 2018 2/14/18

Table of Contents

List of Figures…………………………………………………………………………….iv Comment by Maria Thomas: ??

Chapter 1: Introduction to the Project……………………………………………………..1

Introduction……………………………………………………………………………1

Background of the Project………………………………………………………………2

Problem Statement………………………………………………………………………5

Purpose of the Project……………………………………………………………….......7

Clinical Question………………………………………………………………………..8

Advancing Scientific Knowledge……………………………………………………….9

Significance of the Project……………………………………………………………..11

Rationale for Methodology…………………………………………………………….13

Nature of the Research Design for the Project………………………............................14

Definition of Terms…………………………………………………………………….16

Assumptions, Limitations, Delimitations……………………………………………...17

Summary and Organization of the Remainder of the Project…………………………19

Chapter 2: Literature Review……………………………………………………………21

Introduction to the Chapter and Background to the Problem…………………………21

Theoretical Foundations and Conceptual Framework………………………………..23

Review of the Literature……………………………………………………………….29

Theme 1……………………………………………………………………………..29

Theme 2……………………………………………………………………………..43

Summary………………………………………………………………………………56

Chapter 3: Methodology…………………………………………………………………58

Introduction………………………………………………………………………….58

Statement of the Problem………………………………………………………………59

Clinical Question………………………………………………………………………60

Project Methodology…………………………………………………………………...61

Project Design………………………………………………………………………….62

Population and Samples Selection……………………………………………………..66

Instrumentation ………………………………………………………………………..67

Validity…………………………………………………………………………………68

Reliability………………………………………………………………………………69

Data Collection Procedures…………………………………………………………….71

Data Analysis Procedures……………………………………………………………...73

EthicalConsiderations…………………………………………………………………74

Limitations…………………………………………………………………………….75

Summary……………………………………………………………………………….76

Appendix A………………………………………………………………………………96

List of Figures

Figure 1: Health Belief Model Conceptual Framework…………………………………27

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EARLY AWARENESS

Figure 2: Graphics of Research Process Onion………………………………………….59

Chapter 1: Introduction to the Project

In society today, obesity is a serious comorbidity with the prevalence in the United States (US) continuing to increase (Jarolimova,Tagoni, &Stern, T. A., 2013). Obesity is a leadingcause of increased risks for developing many health problems such as an excessive rise in bodyweight. Furthermore, it isone of the most essential and changeable risk factors within the pathogenesis of health are complications problems like type-1 diabetes (T1D) andtype-2 diabetes (T2D). These problems are well, thus, is documented in most biochemical studies as well as cross-sectional research (Piven, 2014). In current times, there are many all-important biochemical studies in the inter-relationship amid body mass index (BMI) and its connection with the advancement of diabetic issues (Innocent, Oweh, Sandra & Josiah, 2013). Comment by Thomas, Maria: Space Comment by Thomas, Maria: Remove and change all tracking changes before submission for AQR Clarify this. Check for sentence flow so it is easy for the reader to follow your logic

The Center for Disease Control (CDC) anticipates that nearly thirty-three percent of adults may have diabetes by the year 2050 (CDC, 2010; Robert Wood Johnson Foundation, 2016); as presently, more than twenty-nine million adults in America have been diagnosed with diabetic issues, and an additional eighty-six million have pre-diabetes (Statistics about Diabetes, n.d; Robert Wood Johnson Foundation, 2016).

Pre-diabetes is a diagnosis where blood sugar levels are elevated, however lesser than the established inception of diabetes (Kowall et al., 2012). Kowallet al. (2012) write “pre-diabetes is a result of Impaired Fasting Glucose (IFG), Impaired Glucose Tolerance (IGT), or perhaps a mixture of IFG and IGT” (p. 828). Moreover, diabetes has numerous effects which might consist of several health disorders and, in a few instances, failure of bodily organs (Tabák, Herder, Rathmann, Brunner, & Kivimäki, 2012; Brown, 2017). Thus, T2D puts individuals at risk for a variety of ailments like cardiac conditions, amputations, renal malfunction, vision loss, as well as obesity. Weight reduction has been seen to stop the triggering of T2D and morbid obesity in individuals having pre-diabetes (Brown & Kuk, 2015). As a result, “early diagnosis and management of pre-diabetes can avoid its crossover to complete onset diabetes and thus reduce the related problems” (Brown & Kuk, 2015, p. 79).

Little is known about how patients respond to Diabetes Self-Management Education (DSME). Thus, the goal of this project study will be to measure the awareness and knowledge of pre-diabetes and diabetic risk factors among obese patients in a family practice clinic. The project study adopts a quantitative approach using a descriptive method and pre-post tests to determine subjects' understanding and knowledge of pre-diabetes and T2D. The pretests will establish current knowledge ,and gaps about diabetes awareness, and post-test will determine the knowledge the participants’ gained from the Diabetes Self-Management Education (DSME) intervention. The results will state the advancement of the pre-diabetes and diabetes informative and knowledge-based programs. Comment by Pamela Love: Project, not study. Correct throughout paper.

This chapter focuses on a particular target audience while describing the idiosyncrasies of this Direct Patient Improvement (DPI) project such as background of the study, problem statement, purpose of the study, clinical question(s), advancing scientific knowledge, significance of the study, rationale for methodology, nature of the study, definition of terms, assumptions, limitations and delimitations and lastly, summary and organization of the remaining chapters.

Background to the Project

The frequency of identified diabetic issues amid U.S. adults has gone up twofold within the past four decades and seventy-five percent in the past twenty-five years (NCD Risk Factor Collaboration, 2016; Gregg et al., 2004; Centers for Disease Control and Prevention, 2006). The lifetime danger of acquiring diabetes within the U.S. in 2000 had been 33% for males and 39% for females,and this had been even greater amid U.S. minority communities (Narayan et al., 2003).

BMI is a highly reliable, yet a controllable risk element for diabetes (American Diabetes Association, 2017; Ford, Williamson and Liu, 1997; Diabetes Prevention Program Research Group, 2002). Nevertheless, the link between pre-diabetes, diabetes,and BMI has notbeen extensively examined (Arayan, James, Theodore,et al., 2007). Medical experts use BMI to determine whether a person is overweight, obese, normal or underweight. It is a determination of the ratio of a person’s weight and their height (Lo, Wong, Khalechelvam and Tam, 2016).

The following are details of the findings from research, about the relationship between the BMI ratio, pre-diabetes, and diabetes. It was found by Narayanet al. (2007) that one’s risk of developing diabetes in their lifetime is one in three, at the point of birth. He further noted that the risks of developing the condition across the categories of BMI over a lifetime are still unclear. The study sought to demonstrate the specific lifetime risks for the various BMIs for people in the US, based on sex, ethnicity, and age subgroups (Narayan et al., 2007).

The survey data from the National Health Interview n=780, 694, from 1997 to 2004 was the basis for indicating race, sex, age, ethnicity, and the prevalence of BMI-linked occurrence of diabetes in the US in 2004 (Narayan et al., 2007). The data from the US Census Bureau including age, sex-specific mortality, population rate projections, and race were used along with two earlier studies relating to mortality, to project the mortality rates related to BMI ratios (Narayan et al., 2007).

The findings and estimates informed the Markov Model projection of the lifetime risks of diabetes diagnosed by race, sex baseline age, and BMI. According to the results, the lifetime risk of developing diabetes at the age of eighteen for underweight people was 7.6,and those who were obese was 70.3%. The figures also increased from 12.2 to 74.4 for women in the same weight categories. The difference in lifetime risk was lower at advanced ages. For example, at age 65, healthynormal weight males had their lifetime risk difference rise from 3.7 to 23.9 points in percentages between overweight people and the ones regarded as very obese. The figure increased by 8.7 percentage points to 26.7 for women (Narayan et al., 2007a). It was also determined that the effect of BMI on the duration of diabetes compounded with an increase in one’s age (Narayan et al., 2007b).

The risk of developingdiabetes was investigated in case-control research by Ganzet al. (2014) by studying its incidence versus BMI ratios. The rising effect of BMI, based on BMI categories was assessed. Those who recorded weights between 25 and 29.9 were considered overweight. Moreover, then there was the Obesity Class I who measured between 30 and 34.9. Class II Obesity group registered BMI index from 35 to 39.9. Obesity Class III on its part recorded figures equal to or over 40(Ganz et al., 2014).

Relative risks and ratios regarding the odds were calculated from a range of logistic regression outcomes. Age, cardiac history, sex, and hyper-inflammatory were used to select group subjects (Ganz et al., 2014). Measures of BMI were taken a year preceding the first diagnosis of T2D. BMI was obtained from dates that were randomly assigned for those that were in control group. The relationship between BMI and the incidence of diabetes is strong with the risk increasing with higher BMI (Ganz et al., 2014).

There is a significant correlation between diabetes and being overweight. Some studies have established a compelling link between the two factors. In one study, for instance, Akbari et al. (2017) found that patient education regarding T2D can help reduce barriers. The core aim of the study was to establish the impact of an education program intervention, using the beliefs, attitudes, subjective norms and enabling factors model (BASNEF) on awareness barriers, adaptation, lifestyle and support for patients living with T2D (Akbari, 2017). Comment by Thomas, Maria: Spell out first time use

Removing the barriers associated with pre-diabetes and diabetes is a reasonable step towards empowering patients with diabetes to manage their lives with the condition and to recognize what affects the barriers (Akbari, 2017). The findings indicated that there was a clear difference between a score derived from living barriers such as lifestyle, awareness, protection and adaptation components, and the BASNEF model variable, i.e., enabling factors, attitude, subjective norm, knowledge, and behavioral intention (Akbari, 2017).

Problem Statement

T2D also referred to asnon-insulin-dependent diabetes (NIDDM), makes up most cases of diabetes mellitus globally. In 2000 there had been roughlyone hundred and fifty million people with the illness and that this quantity is most likely to increase twofold by the year 2025 (Kaveeshawar & Cornwall, 2014; King, Aubert, & Herman, 1998). T2D will be the fourth or perhaps the fifth prominent cause of demise in many developed nations and there's expanding proof that this has attained epidemic dimensions in quite a few developing and recently industrialized nations (Amos, McCarty, &Zimmet, 1997). All-time low levels of T2Dare found in places where individuals retain a traditional lifestyle (Gray, 2015; Bennett, 1999). Dramatic modifications in the frequency ofthe occurrence of T2D is found in places where there have already been significant changes in the kind of foods utilized. The food choices range from the conventional native diet plan to a standard “western” diet plan (Hu, 2011; Bennett, 1999; Lako and Nguyen, 2001; Hetzel and Michael, 1987). Changing illness levels are revealed by modifications in some dietary elements along with modifications in other lifestyle associated elements, notably a decrease in physical exercise (Sami, Ansari, Butt, Rashid, & Hamid, 2017; Steyn et al., 2004). Comment by Maria Thomas: Space

It is not known if and to what degree these facts are known to diabetes patients. Therefore, Because of these facts, the purpose of this project study is to assess the awareness and knowledge of diabetes amongst patients with prediabetes in a family practice clinic. After carrying out DSME pre-intervention assessments on patients with prediabetes, gaps will be recognized in awareness and understanding of prediabetes and diabetes amongst diabetes patientsthe subjects. Measurement of BMI will be completedpre-test and eight weeks after post-test to assess the effects of the DSME intervention related to weight loss. Comment by Thomas, Maria: Present a clear declarative statement that begins with “It is not known if and to what degree/extent...,” or “It is not known how/why and….” Comment by Thomas, Maria: Include the broad population affected by the problem

Absent from the literature is information on how patients respond to self-management methods that should be adopted to attain the preferred benefits, and precisely what they will do with the knowledge they gain from DSME educational interventions. There's an expanding demand for interventions that enhance patients’ understanding and knowledge of pre-diabetes and diabetes (Islam et al., 2014). The “substantial population at an increased risk for or with diabetes is actually within the age bracket of 25 - 65 years. Insufficient steps to decrease theoccurrence of pre-diabetes might result in a considerable boost in health investment, morbidity, as well as other associated health circumstance” (National Diabetes Statistics Report, 2014, para 8).

For healthcare providers managing an increased incidence of diabetes diagnoses, health interventions will be essential to avoid diabetic issues or postpone their development (Islam et al., 2014). Such endeavors can consist of acompletelifestyle change for all those at an increased risk for pre-diabetic issues and timely treatment for patients suffering from the disorder. An ambitious method focusing on individuals at an increased risk of diabetes is a significant public health strategy targeted at reducing the threat elements for pre-diabetes and diabetes (International Diabetes Federation, 2013).

Purpose of the Project

The purpose of this Direct Practice Improvement (DPI) project is to evaluate awareness and understanding concerning pre-diabetes and diabetes in pre-diabetic individuals and the effects of the DSME on BMI. To determine if the patients qualify for the study and are pre-diabetic, the researcher will utilize patients’ healthcare records to choose individuals with increased fasting glucose (IFG), and hypertension in the family practice clinic. The potential study participant will be recognized as obese if they have aBMI of more than 30kg/m2. Obesity and hypertension are both related to diabetes and may be considered as inclusion criteria.

The independent variables will be the DSME intervention plan,and the dependent variable will be patients’ awareness level about the threat of acquiring T2D and awareness concerning risk lowering habits and treatments, and these factors will be assessed utilizing the Diabetic Knowledge Test 2 (DKT2), a close-ended questionnaire. The DKT2 was designed and developed by the Michigan Diabetes Research Training Center (MDRTC). Its purpose is for testing common knowledge of diabetes in pre-diabetic and diabetic patients.Thuspatients. Thus, the study uses a quantitative descriptive research design. Another dependent variable will be BMI assessment. The BMI will be measured by weighing the patient before awareness education and eight weeks after receiving the DSME intervention. Additional independent variables are how awareness and understanding levels amongst individuals differ based on education level,andlastly, the health belief model will be the theoretical foundation for this study.

This project will make use of diabetes associated queries in the pre-assessment to evaluate and classify individuals according to their understanding and knowledge of diabetic issues. Theseinclusion criteria for this study will be adults of both sexes with a BMI of more than 30kg/m2. Moreover, the results might be helpful in the advancement of future interventions towards decreasing pre-diabetes and diabetes risk in communities with ahigherrisk of acquiring T2D.

Clinical Question:

The clinical question is: Among pre-diabetic patients with a BMI > 30kg/m2in a family practice clinic to what extent does providing diabetic education using Diabetic Self-Management Education (DSME) compared to providing no education result in improvement in patient awareness and knowledge of pre-diabetes and diabetes and a decreased BMI over an eight week period?

When promoting interventions to assist with prevention and control of diabetes, awareness is an essential resource (Demaio et al., 2013). There's a connection amid individuals with reduced levels of health understanding and increased diabetic problems (Maina, Ndegwa, Njenga, &Muchemi, 2011). Patients’ understanding of their health could be helpful in the assessment of the risks associated with developing diabetes, DSME interventions to reduce the risk, and their control over lifestyle changes including weight reduction. Consequently, outcomes of this research will promote stakeholders, within the healthcare sector to plan, create, and implement complete health campaigns focused on pre-diabetes-related DSME interventions.

The project will analyze the understanding and awareness of diabetes amongst patients with prediabetes in a family practice clinic with a BMI >30kg/m2. The research project query is: among pre-diabetic patients with a BMI > 30kg/m2in a family practice clinic to what extent does providing diabetic education using Diabetic Self-Management Education (DSME) compared to providing no education result in improvement in patient awareness and knowledge of pre-diabetes and diabetes and a decreased BMI over an eight week period.The independent variable will be the DSME intervention plan,and the dependent variable is patients’ awareness level about the threat of acquiring T2D and awareness concerning risk lowering habits and treatments, and these factors will be assessed utilizing a quantitativedescriptive research design and the DKT2. The DKT2will be used to assess participants knowledge pre-DSME and post-DSME.

Other dependent variables will be BMI assessment. The BMI will be measured by weighing the patient before pre-diabetes awareness education and eight weeks after receiving the intervention. Additional dependent variables are how awareness and understanding levels amongst individuals differ based on education level,and lastly, the health belief model will be used as the theoretical foundation for the projectstudy.

Advancing Scientific Knowledge

There is a controversy inexistence, relating to the BMI mortality diabetes paradox in which the BMI optimal category is higher in patients that are non-diabetic.Bayset al. (2007) noted that not all obese or overweight cases develop diabetes and that not all with diabetic conditions were necessarily obese or overweight (Bays et al., 2007). A paradox regarding BMI ratios and diabetes still exists and needs a solution.

Controversy is still rife related to the relationship between BMI and the occurrence of pre-diabetes and diabetes. Physicians will be empowered to minimize the risk factors for diabetes sooner if there is afull understanding of the relationship between the two. Modern day is well known for the diabetes epidemic. Numerous pre-condition indicators have been identified for medics to use to reduce the risk factors. It is irresponsible to wait to treat pre-diabetes and/or diabetes when there are ways topreventitsoccurrence. These potential populations need education about the risks and how they can self-manage them to reduce symptoms and avoid its inception.

Tabak, Herder, Rathmann, Brunner & Kivimäki et al. (2012) wrote one can find an increase in thefrequency of pre-diabetes as well as obesity within the U.S. Additionally; there happens to be a higher chance of further advancement to T2D for individuals with pre-diabetes (Tabak et al., 2012). T2D raises the danger of acquiring other problems like high blood pressure, kidney issues, and loss of sight along with growing the price of therapy, and loss of efficiency. Thus, undoubtedly there is a need for a DSME intervention method to improve the levels of understanding and knowledge concerning pre-diabetes, diabetes, and weight problems amongst patients and to assure higher levels of successful Self-Managed cases. Comment by Maria Thomas: APA format for 3-5 authors, first time in text

This project utilizes the Health Belief Model (HBM) that is undoubtedly one of the most frequently utilized theories in health learning and health intervention campaigns (Glanz, Rimer, & Lewis, 2002; National Cancer Institute, 2003). HBMwas designed during the 1950s to describe the reason why healthcare screening programs proposed by the U.S. Public Health Services, especially for tuberculosis, just were not successful (Hochbaum, 1958). The root notion of the initial HBM was that health conduct is independent of individual beliefs or views with regards to a disorder as well as the methods accessible to reduce its prevalence (Hochbaum, 1958). Individual insight is affected by the complete array of intrapersonal elements impacting health conduct (Jones and Bartlett, 2008).

The results from this study can assist in realizing public awareness gaps and practices concerning pre-diabetes, diabetes,and obesity, which may help in the creation of obesity and diabetes self-management campaigns. Medical care services and professionals will find the outcomes of this study essential forproviding assistance to obese prediabetic patients. It will also contribute to knowledge already existing in the literature by increasing health care providers’ awareness of the extent to which diabetic patients are aware of their condition.

Significance of the Project

The occurrence of clinically diagnosed diabetes amongst U.S. adults has increased twofold within the past four decades and 75% in the past twenty-five years (Gregget al., 2004; Centers for Illness Control and Prevention, 2007). The lifetime danger of diabetes within the U.S. in the year 2000 had been 33% males and 39% females and was even higher amongst U.S. minority communities (Narayan et al., 2003). BMI is known as reliable, yeta changeable risk element related to diabetes (Ford, Williamson, &Liu, 1997; Diabetes Prevention Program Research Group, 2002). Nevertheless, the link between pre-diabetes, diabetes, and BMI has not been extensively examined (Arayan, James, Theodore,et al., 2007).

The growing urbanization, westernization, and mechanization happening practically in every area around the globe are associated with modifications in the eating routine to one of higher fat, higher energy-packed meals, and an inactive way of life resulting in increased degrees of BMI (World Health Organization, 2000; Popkin, 2001). This change is further linked to the present rapid modifications in childhood as well as adult weight problems. Even in several low-income nations around the world weight problems are now dramatically rising, and frequently coexists within the same populace with persistent under-nourishment (Popkin, 2001). Life-span has risen because of improvement in nourishment, cleanliness, and the control over thecontagious ailment. Transmittable illnesses and nutritional insufficiency diseases are, consequently, being substituted in developing nations by unique health risks similar to obesity, cardio disorder and diabetic issues (World Health Organization, 2000;2 Swinburn, Caterson, Seidell & James, 2004). Comment by Maria Thomas: The citation must match the reference and vice versa Comment by Maria Thomas: Follow APA citation and reference format. Review and change for all citations and references

Even though treatment of diabetic subjects is costly, medical care establishments face a far more complicated problem in dealing with issues because of T2D like heart disease, cardiac arrest, stroke, and kidney malfunction that also hinders economic efficiency and boosts the price of medical treatment (C3 Collaborating for Wellbeing, 2011). Awareness and knowledge are vital assetsin controlling and preventing pre-diabetes and diabetes (Demaio et al., 2013). Lack of understanding and awareness about diabetes increases the chances of acquiring this disease (Maina, Ndegwa, Njenga, &Muchemi, 2011). Patients’ awareness assists in risk assessment of developing diabetes. Therefore, DSME interventions can reduce the risk in conjunction withlifestyle changes including weight reduction.

Consequently, knowledge of pre-diabetes and diabetes along with effective DSME strategies amongst overweight pre-diabetic individuals are essential strategies for lessening the damaging influences of the disorder to both people and the community.Thus, this project will use a quantitative descriptive design to measure the knowledge andunderstanding concerning pre-diabetes and diabetes in pre-diabetic individuals and their response to DSME using a pre-posttest closed-ended questionnaire. Participants will be weighedeight weeks after completing the post-test to analyze the effects of DSME on BMI, i.e., weight reduction. The study results will be integrated into campaigns to assist in the management of obesity and diabetic issues for the exact purpose of developing a tradition of understanding/increasing awareness about pre-diabetes and diabetes amongst overweight people within society.

The effectiveness of such an educational intervention might lead to considerable self-control over morbid obesity, BMI, and diabetes that would improve the standard/quality of life for diabetic individuals. Additionally, it might decrease health treatment expenses. By creating knowledge and providing awareness, the study's results might affect the local community favorably. For example, the results might also be utilized to teach the neighborhood about the risks of weight problems and just how individuals can handle prediabetes as well as T2D. For the public, the details on understanding and knowledge about diabetic issues will be utilized to organize public health guidelines targeted at preventing and managing diabetes.

Rationale for Methodology

The purpose of this DPI project is to measure the effects ofknowledge and awareness related to pre-diabetes and diabetes amongst overweight people who are at risk or have diagnoses ofprediabetes who happen to be patients in a family practice clinic. The project makes use of a quantitative descriptive research method to determine subjects’ understanding and knowledge of prediabetes and T2D while measuring the effects on BMI.

A descriptive study offers information for analyzing and monitoring policies and plans. This type of study model focuses on the best way to respond to these kinds of queries as: How much? How many? How effective? How successful? How sufficient? (Indiana University, n.d.). Furthermore, descriptive study designs are an approach that offers a description of the subjects. The critical methods for conducting a study utilizing a descriptive investigation design and style are acCase study, sSurvey along with observational scientific studies (Shawyer et al., 2014).

This projectuses a descriptive design to focus on the effectiveness of DSME intervention programs. The study will monitor the efficiency of DSME plans and provide recommendations for improvement of future DSME programs. Hence this study adopts a quantitative approach using a descriptive method utilizingthe DKT2 for pre-post tests to determine subjects' understanding and knowledge of prediabetes and T2D and the effect of DSME on BMI. Comment by Thomas, Maria: Use citations from textbooks or literature on the research methodology to justify the use of the selected methodology

The pretests will establish current knowledge,and gaps about diabetes awareness and post-test will determine the information they gained from the intervention (DSME) and how they plan to use that information in their life, i.e., reduction of BMI. The results will assist in the advancement and improvement of the prediabetes self-management intervention programs.

The quantitative method is the best method for this project and set of data because it provides much needed statistical information that can help close the gaps on this specific subject (Knight, Hickman, Gibbons & McIntyre, 2016). Statistical evidence is missing relating to this precise population. The quantitative method provides the means for this gap to be filled.

Nature of the Research Design for Project

This project will use adopt a quantitative descriptive design and use the DKT2 closed-ended questionnaire to carry out DSME pre-assessment and post-assessment on patients suffering from prediabetes. This study uses a descriptive design to measure the effectiveness of the DSME intervention program. Moreover, the study will monitor DSME’s efficiency and provide recommendations for improvement of future DSME programs.

A quantitative measurement of BMI will also be used to test the effectiveness of the DSME intervention. The patients will be weighedbefore the pre-test and eight weeks after awareness education.Initially, subjects will be requested to be weighed to determine if their BMI is >30 and then take part in the pre-assessment and post-assessment once they sign a consent form. The pre-assessment queries will use the DKT2 in such a manner that respondents can comprehend and fully grasp the questions (Shawyer et al., 2014; Indiana University, n.d.; Michigan Diabetes Research Center, n.d.). The DKT2 will be carried out to measure the degree of knowledge and understanding concerning diabetes from the subjects. Making use of outcomes from the pre-assessment, the researcher will customize the educational intervention program to meet the requirements of the subjects. After the participants' DSME educationintervention has been completed; a post-assessment is going to be carried out utilizing the easy to understand questionnaire to ascertain the efficiency of the educational intervention.

One of the most productive approaches supporting this type of research is the

survey approach. The survey method has, through the years, established itself to be possibly the most efficient way of measuring any social research. Survey methodsassist the researcher to come up with, distribute, and ask relevant queries from the targeted subjects or sample. It enables the researcher to select from two different and all-encompassing strategies: 1) interviews and 2) questionnaires (Trochim, Donnelly,and Arora (2015). Trochimet al., (2015) explains in his research that a survey has the versatility to vary from a short-scaled easily written response to an all-inclusiveface-to-face extensive interview that is the thing that makes the survey such an essential research fragment. The standardized and closed-ended structure of survey,the,i.e., thequantitative DKT2 closed-ended questionnaire will be most valuable for this form of study.

This study compares the strategies and theories that were developed and verified by previous studiesabout the research matter. In this study, the connectionis amid awareness concerning diabetic issues in pre-diabetic individuals and the way it impacts their willingness to self-manage diabetes, i. e. weight reduction. After awareness-level and knowledge-level assessment of pre-diabetes and diabetes amongst the subjects utilizing quantitative methods, the researcher will use an educational intervention program for patients with prediabetes. These types of interventions can be carried out to enhance clinical results amongst individuals, as well as, theprogression of more efficient educational intervention models (Funnel et al., 2010).

Definition of Terms

Diabetes knowledge.: For this project, the researcher will use the definition employed by Fonseca et al. (2012) who state that diabetes knowledge represents having abilities, data, and details concerning diabetic issues learned via experience or education.

Diabetes self-management education (DSME): For this project, the researcher will assume the definition put forward by ADA (2010) which states that DSME is are the ongoing process for facilitating knowledge and skills focusing on goals and life experiences guided by evidence-based standards, which supports self-care behaviors, problem-solving and promotes collaboration with the healthcare team. Comment by Thomas, Maria: Term.Write the definition of the word. This is considered a Level 3 heading. Definitions are supported with citations from scholarly sources

Risk factors. For this project, the researcher will assume the definition put forward by the Diabetic Council (2017) who state that risk factors are anything that increases your risk—your chances—of developing a particular disorder such as diabetes.

Pre-diabetes: For this project, the researcher will assume the definition put forward by ADA, (2013) which classifies prediabetes as a medical problem in which the degree of blood sugar is higher than the normal degree, although not enough to be classified as T2D.

Type II diabetes: For this project, once again, the researcher will assume the definition put forward by the ADA, (2013) classifies T2D as a disorder in which the body does not take advantage of the insulin released through the pancreas, resulting in higher blood sugar levels.

Body mass index (BMI): For this project, the researcher will assume the definition put forward by the Centers for Disease Control (CDC) (2016) which adult over-weight and obesity as a person’s weight in kilograms (kg) divided by his or her height in meters squared.

Obesity: The researcher will use the definition put forward by Haas and his colleagues (2013) who state that this is a health disorder where there's excessive unwanted fat that may be established when BMI, calculated by dividing a person’s weight from the height, which is powered square, exceeds 30 kg/m2.

Diabetes knowledge test 2: The researcher will use the definition put forward by Fitzgerald et al.(2016) who represents the DKT2 test by stating it hastwenty-three knowledge test items and developed by the Michigan Diabetes Research Training Center (MDRC). These twenty-three items represent a test of general knowledge of diabetes.

Assumptions, Limitations, and Delimitations

This project will concentrate on the belief that individuals with prediabetes might have less understanding and knowledge of diabetes. Consequently, the DSME intervention program will undoubtedly enhance the patients’ understanding of diabetic issues. Additionally, there is a presumption that growing awareness concerning diabetic issues as well as its associated challenges might lead to enhanced benefits when managing the health disorder. The sample for this study will be patients inside a family practice clinic. Consequently, the opportunity to make use of the results to the general populace at an increased risk of acquiring T2D is restricted (Stommel&Wills, 2004).

Results generalization is reasonably limited because of the small volume of subjects and the absence of a control group. Because of the target populace, the obstacles to registering more subjects will include individuals traveling, working, or experiencing other scheduling restrictions, along with issues in reaching out to a few subjects. The limitations to acquiring all after-intervention information may include lapses in subject's insurance coverage, and absence of insurance coverage to get a two-month BMI measurement. However, this project still has a fair degree of generalizability as the information obtained from it may serve as a foundation for better understanding the awareness of diabetes patients with regard to their condition.

Project impact might be understated because of the timing involved in the awareness education intervention that will take place during the February-March after winter month’s sedentary activity related to determents of winter weather and participating in holiday season festivities and parties where people might be much more likely to drink alcoholic beverages and avoid eating healthy foods. The subjects may well improve their health indicators much more if this DSME intervention takes place at another time.

The independent variables will be the DSME intervention plan,and the dependent variable will be patients’ awareness level about the threat of acquiring T2D and awareness concerning risk lowering habits and treatments, and these factors will be assessed using a quantitative descriptive research design and employing the DKT2 closed-ended questionnaire. Other dependent variables will be BMI assessment. The BMI will be measured by weighing the patient before pre-assessment and awareness education and eight weeks after receiving the intervention.

This project will make use of diabetes associated queries in the pre-assessment to evaluate and classify individuals according to their understanding and knowledge of diabetic issues. Dedication towards increasing their understanding and awareness of diabetes as well as their risk of acquiring T2D might encourage them to alter their lifestyle and embrace new treatments to decrease the threat of diabetes.

Summary and Organization of the Remainder of the Project

Increasingly, diabetes is becoming a health problem which could potentially overload the existing healthcare system. Additionally, diabetes can be the cause of various other health problems making it a verycomplicated disease. There is undoubtedly a need for effective initiatives such as early awareness to assist with prevention or slowing down the incidences of the disease focused on slowing the progression (Brown, 2017). The achievements of a health intervention programs are partially affected by the people’s degree of understanding concerning the health disorder. Understanding and knowledge lead to obesity and diabetes cognizance, and as a result,therapy and control of this disorder (ADA, 2017). This projectexamines knowledge of pre-diabetesand diabetes in pre-diabetic subjects. The results of this project could assistlawmakers and Healthcare providers in creating and applying obesity and diabetes programs (Brown, 2017).

The project isdividedintofour additional chapters. The review makes up chapter two and will consist of the theoretical fundamentals. The methodology will make up chapter three. The fourth chapter will highlight all of the outcomes. The fifth and final chapter will offer evaluation and dialogue of the results.

Chapter 2: Literature Review

Introduction to the Chapter and Background to the Problem

This chapter explores specific and general literature on the management of diabetes and how to control it. The body of information is arranged as (1) Background of the study; (2) Themes Relevant to the PICOT Question; (3) Theoretical Foundations and/or Conceptual Framework; (4) (4a) HBM’s Seminal Source (4b) The foundational, historical, current and relevant literature in the field (5) Theme One: prediabetes’ and obesity (5a) Subtheme 1: Prediabetes, Obesity and Type II Diabetes (T2D) (5b) Subtheme 2: Insulin-Resistance and Obesity (5c) Subtheme 3: Weight-loss (6) Main theme 2: Diabetic Education (6a) Subtheme 1: Evaluation of education (6b) Subtheme 2: Effectiveness of education (6c) Subtheme 3: Cost-Efficiency of Diabetic education (7) Summary of the literature review.

Consequently, to access the sources of literature review, PubMed, Medline, Embase, Cochran Central Register of controlled trials, also referred to as CCTR, Bioline International, Database of Abstracts of Reviews (DARE), The Cochran Database of Systematic Reviews (CDSR) and Google Scholar. Apart from making use of libraries online, journal articles from Grand Canyon University that contained related information were also explored. Comment by Thomas, Maria: Cochrane

The search terms below are used in the project: prediabetes, obesity, T1D, T2D. A hand/manual search of selected journals from cover to coveris conducted following successful identification of the relevant studies. The references contained in the eighteen research studies were re-examined to pick out relevant studies that may have been missedduring the electronic search effort. The process of inclusion was meticulous. The study only reviewed journals published between 2009 and 2018. English language articles, quantitative and qualitative studies, and the latest articles published between 2009 and 2018 were included. The criterion for exclusion was that any non-English language articles, thesis, published abstracts, dissertations and articles published after 2000.

A review of therecent literature revealed thatdiabetic issues have doubled in their frequency in the past four decades. In the past 25 years, the frequency has gone up by 75% (NCD Risk Factor Collaboration, 2016; Gregg et al., 2004; Centers for Disease Control and Prevention, 2006). The risk of acquiring a diabetic condition in the United States in the year 2000 was 39% for females and 33% for men. These figures increased minority communities in the US (Narayan et al., 2003).

While BMI is a valid risk index for diabetes (ADA, 2017; Ford, Williamson & Liu, 1997; Diabetes Prevention Program Research Group, 2002), there is a gap in the literature regarding knowledge of diabetes based on BMI has not been carefully studied (Arayan, James, Theodore et al, 2007). BMI is an indicator of the ratio between one’s weight and height (Lo, Wong, Khalechelvam&Tam, 2016). It is used to indicate whether one is underweight, normal,overweight, or obese.

According to estimates, there were over one hundred and fifty million individuals suffering from T2D in 2000. The number is predicted to double by the year 2025 (Kaveeshawar& Cornwall, 2014; King, Aubert, & Herman, 1998). It is projected that the condition is slated to become the fourth or fifth most common cause of death in developed countries. Indeed, there isincreasing evidence that T2D has reached epidemic proportions in several developed countries (Amos, McCarty, &Zimmet, 1997). Low levels of T2D occurrences are noted in communities where traditional and simplelifestylesareis maintained (Gray, 2015; Bennett, 1999). The situation is the opposite in communities where there is extensivepansive food modification to a western type food plan (Hu, 2011; Bennett, 1999; Lako and Nguyen, 2001; Hetzel &Michael, 1987). Illness levels change, based on amodification of lifestyle-related activities and habits, including physical exercise (Ansari, Butt, Rashid, & Hamid, 2017; Steynet al., 2004). Comment by Maria Thomas: APA citation

A gap in the literature exists regarding patients’ response to DSME that ought to be applied to acquire the advantages; and, on what these patients plan to do with the newfound knowledge gained via DSME intervention(Brown, 2017; Islam et al., 2014). The demand for interventions aimed at enhancing patients’ understanding about diabetes is increasing (Islam et al., 2014). The population that stands the most significant risk of developing diabetes is between the ages of 25 to 65 years. If there are no proper interventions to reduce pre-diabetes occurrence,there is a possibility that the lack of educational interventions may lead to a more significant financial burden in the health sector including a rise in morbidity (National Diabetes Statistics Report, 2014, para 8).

Thus,this DPI project focuses on establishing the knowledge and awareness of pre-diabetes, diabetes,and obesity among patients that have pre-diabetes with a BMI >30 in a family clinic. This study will utilize the DKT2 quantitative closed-ended questionnaire for pre-post testing and DSME to achieve these goals.

Theoretical Foundationsand Conceptual Framework

The PICOT question is an essential component of the research process. It provides the basis for establishing the research topic and appropriate themes. For this literature review the PICOT of interest is as follows:among pre-diabetic patients with a BMI > 30kg/m2in a family practice clinic to what extent does providing diabetic education using Diabetic Self-Management Education (DSME) compared to providing no education result in improvement in patient awareness and knowledge of pre-diabetes and diabetes and a decreased BMI over an eight week period.Further, the following will address the central problem, the intervention, the comparison, and the outcome. Thus:

Problem. The central problem is the need to establish the knowledge and awareness levels about the diabetic condition among those with pre-diabetes in a family practice clinic. The following will be used to answer the question:

· Intervention: a quantitative survey to conduct pre-assessment and post-assessment on pre-diabetic obese patients. It will include a quantitative BMI measurement after eight weeks following awareness campaigns. The subjects will be asked to take a measure of their weight and proceed to participate in pre and post DSME after signing a consent form. The assessment questions are crafted to make sure that respondents can will easily follow the content (Shawyer et al., 2014; Indiana University, n.d.).

· Comparison: The DKT2 will seek to establish the extent to which respondents understand pre-diabetes and diabetes issues related to DSME.After presenting participants with self-management education, a post-assessment will be completed by use of the DKT2. The outcomes of pre and post assessments will be examined to show how efficient the educational intervention is.The post-assessment will measure their DSME knowledge and also measure their willingness to apply the newfound information in their lives.

· Outcome: the desired results relate to improving clinical outcomes among patients and continuation and development of better DSME intervention models of education. The PICOT question forms the basis of two important themes. These are examined later in this chapter. The theoretical foundationis as follows.

Conceptual framework. Attitudes, beliefs related to health and knowledge are essential concepts of health behavior practice models. In particular, effects and control are included in socio-cognitive models because they represent health behavior, respond to change, intervene in related risk factors, and are the objectives for intervention (Jones, Smith, & Llewellyn, 2014). The health belief model (HBM) shaped the project. HBM(Hochbaum, 1958; Rosenstock, 1974) is an intrapersonal model laced around one’s knowledge theory and beliefs in the promotion of health (Jones, Smith, & Llewellyn, 2014). Applying HBM was meant to examine people’s behavior via observing their awareness responses, attitudes and perceptions one may hold towards given ailments and the effects of specified actions.

HBM’s seminalsource. HBM is a significantly most commonly applied theory in health promotion and education (Glanz, Rimer, & Lewis, 2002; National Cancer Institute [NCI], 2003). This model was crafted in the 1950sby social psychologists Irwin M. Rosenstock, Godfrey M. Hochbaum, S. Stephen Kegeles, and Howard Leventhal at the U.S. Public Health Service. The model was developed to demonstrate why medical screening for tuberculosis in the US was notmostlargely successful (Hochbaum, 1958). The basic concept in the HBM model is that people’s health behavior is influenced by personal perceptions, attitudes,and perceptions regarding illness and the available strategies to reduce the occurrence of such illness (Hochbaum, 1958). Moreover, perception at the personal level is determined by a wide range of factors that have to do with a person at theindividual level and affecting their health behavior. The centralconstruct of the model is shaped by the following four factors, which include perceived susceptibility, perceived seriousness, perceived barriers and perceived benefits (Jones & Bartlett, 2008). Each of the perceptions can be applied singly or in combination to demonstrate health behavior. Using the model as a theoretical basis can assist to enhance public awareness and understanding regarding pre-diabetes, diabetes, and issues of weight. In turn, pre-diabetes, diabetes,and obesity awareness campaigns may be improved. The health fraternity will find thebroad application of the study in approaching obese and pre-diabetes cases (Jones and Bartlett, 2008).

Perceived seriousness. Perceived seriousness has to do with one’s belief regarding how severe a disease is. Although such perceptions are widely and commonly influenced by medical information, it may be spurred by one’s beliefs regarding disease difficulties in their life (Jones and Bartlett, 2008).

Perceived susceptibility.Perceived susceptibility is a substantial perception that commonly influences people’s health behaviors. The perceived risk tends to be directly proportional to behaviors that reduce such risk (Jones and Bartlett, 2008).

Perceived benefits. Perceived benefits relate to one’s belief of the helpfulness of new behavior in reducing the risk of contracting a disease. When people believe that their new way of behaving will reduce the chance of developing a disease, behaviors such as quitting smoking, using sunscreen, adopting a diet filled with fruit servings and vegetables are results of perceived benefits (Jones and Bartlett, 2008).

Perceived barriers. Because change is often resisted, perceived barriers relate to one’s evaluation of the barriers/ obstacles that prevent them from pursuing a new behavior (Orji, Vassileva, &Mandryk, 2012). Indeed, the perceived barriers are most responsible for thechange in behavior.

According to the HBM framework, perceived susceptibility relates to one’s belief about the possibility of the disease developing as a result of the behavior they engage in, and how such behavior will lead to an adverse health outcome (Orji, Vassileva, &Mandryk, 2012). Perceived threat examines the possibility of a disease developing. Risk of thediseasecould be determined by environmental factors and demographics including race, ethnicity and one’s status, socioeconomically (Jones and Bartlett, 2008).

HBM is a practicaln effective framework for shaping this project by examining knowledge and beliefs which is summarized in the Conceptual Model by Ganz et al., 2002(figure1).

FIGURE 1: Health Belief Model (Glanz et al., 2002, p. 52)

The foundational, historical, current, and relevant literature. As specified

above, three aspects influence the chance that a person will adopt a specific behavior in HBM. a. There is perceived severity and susceptibility where one realizes that there is enough reason to prioritize a health concern. b. The perceived threat in which someone understands that he or she might be at the risk of developing a disease. Alternatively,an adverse health effect and c. Perceived barriers and benefits where one realizes that change in behavior can be positive and that the gains related to the change override the costs of doing it (Bayat et al., 2013).

HBM shows that a cue or trigger is central to encourage engaging in behaviors that are positive to health. Befitting cues may be internal or external. Pain symptoms are some of the internal cues. External cues include information and events from the media, friends, healthcare practitioners participating in behaviors related to health and family (Zareban et al., 2013). Cues that signal action include reminders emanating from medical staff, family and friends’ experiences and health product labels. Speedy action depends on the strength of the cues. It varies from between person to person based on perceived susceptibility, benefits, significance, obstacles and benefits. The model also insists self-efficacy which refers to one’s perception of their competence to engage in a particular behavior (Brown, 2017).

Knowing about thedisease and people’s attitude towards the disease influences the chance of the action happening. After being aware of the possibility of a disease occurring, if there is no behavior change, it is essential to examine both benefits and barriers of taking action and pointing out which affect someone’s life more (Julinawati, Cawley, Domegan, Brenner, & Rowan, 2013). The likelihood of actionis determined by perceived gains including the quality of life. All behavior changes initiatives encounter barriers, and they contribute towards the outcome.

The HBM model showed that it supports the basic understanding regarding the psychological and environmental mechanisms of patients for approval. It is used in diabetes to simplify the awareness and understanding of the health condition behavior. The knowledge may “mitigate the short and long-term diabetic effects and give instructions for investigators to develop suitable training methods” (Bayat et al., 2013, p.45). The education improves acceptance and patient adherence to behaviors that are applicable such as nutritional plans that lead to long-term management of blood sugar levels and weight reduction in people with pre-diabetes and diabetes.

Review of the Literature

Theme 1-prediabetes, diabetes, and obesity. Deepa et al. (2014) carried out cross-sectional research in rural and urban areas of India. The study involved subjects from four geographical regions in India. Deepa et al. (2014) used 6,607persons as a sample. The researcher sought to establish diabetes awareness and the level of knowledge regarding the factors that cause it, including accompanying complications of the condition. He used a questionnaire administered by an interviewer. Deepa et al. (2014) realized a response rate of 8 percent from the participants. The researcher discovered that diabetes awareness levels in India were notably low in the rural places compared to urban areas (Deepa et al., 2014). Only 43.2% of the subjects were aware of diabetes. Urban residents, on the other hand, were well aware of the diabetes condition. The rate of awareness among urbanites stood at 58.4 compared to a relatively lower 36.8% by the rural dwellers. The researchers underscored the need for enhancing awareness and knowledge about the disease. Such awareness and understanding will enhance control and prevention of the condition (Deepa et al., 2014).

Given the fast developments occurring in China, the incidence of pre-diabetes is on the rise. Zhuanget al. (2015)argue in the same way. Zhuang et al. (2015)say that missing out on awareness may have cost a chance to prevent T2D. The study sought to establish the prevalence ofthe diabetes condition, and the level of awareness among the Southern Chinese community of Suzhou between the years 2012 and 2013. The researchers collected self-reporting questionnaires which included disease awareness index, demographics and a willingness to change lifestyle for curing diabetes. The study results indicated that 1.8% of the subjects were pre-diabetic while 38.5 percent of

the group were aware that they had the condition.

Factors including not smoking, a higher level of education, low levels of BMI, and access to advisingrelated to pre-diabetes, diabetes, and obesity from providers were pointed out as reasons for a lower chance of developing diabetes among adults in China. It was also noted that a small number (less than one third) of the reported cases knew that pre-diabetes are a precursor to developing T2D and cardiovascular complications (Zhuanget al. 2015). Further, less than one-third of the pre-diabetes reported cases were likely to take precautionary measures to stop developing diabetes. The need for enhancing awareness regarding diabetes and promoting healthy behavior cannot be overemphasized in the fight to prevent the occurrence of pre-diabetes among adult Chinese (Zhuang et al. 2015).

In a study completed by the Finnish Diabetes Prevention Group, it was concluded that patients with glucose tolerance impairment could forestall the occurrence of diabetes by readjusting the risk factors relating to sedentary ways of life and obesity (Woodbury, Botros, Kuhnke, & Greene, 2013). In the research, “522 patients with glucose intolerance were assigned to a control group or an intervention set, arbitrarily. The intervention sought to achieve a weight loss of at least 5%, and to attain physical exercise running for at least an hour each day” (Woodbury et al., Botros, Kuhnke& Greene, 2013, p. 703). After the comparison between the intervention set and the control regarding the general incidence of diabetes, it was found that there was a reduced probability of 58 percent of developing the diabetes condition. The results based on gender varied significantly too. The reduction rate was noted as 54 percent among women while that of men stood at 63 percent (Woodbury et al., 2013). The study demonstrated how lifestyle changes have a significant role in reducing the incidence of T2D. Comment by Maria Thomas: For Work by Three to Five Authors. In subsequent citations, only use the first author's last name followed by "et al."

In yet another study conducted by Evert et al. (2013), it was demonstrated that changes in lifestyle could significantly reduce the possibility of developing diabetes type 2. In the study, a sample of 84,941 female nurses was tracked for 16 years. 3, 300 new diabetes cases were reported during the study. The study revealed that being overweight and obese, as measured using BMI was a clear indicator of developing diabetes down the course of time (Evert et al., 2013). When the BMI was adjusted, though, other precipitating factors including smoking, alcohol intake and a sedentary lifestyleare associated with a higher chance of developing diabetes. Conversely, it was noted that limiting alcohol intake, a healthy diet,regularexercising, and maintaining a recommended weightarereasonable steps to decrease the chance of developing T2D (Evert et al., 2013).

In another study, 19 participants were engaged from three practices of general nature. It was an assessment of a self-management intervention based on an internet site calledHeLP Diabetes) by Hoffmanet al. (2016). Collection of data was done at the onset and followed in six weeks interval. Accessing the online service showed a linkto reduced diabetes associated distress. As far as emotional distress and self-efficacy are concerned, there was no notable difference. According to the qualitative data, those that participated reported better self-efficacy, support, higher levels of awareness of diabetes and improved mood management (Hoffman, 2016).

Nevertheless, there were also some negative experiences linked to the use of the intervention. They included feeling guilty for not making use of the intervention as proposed or not successfully changing behavior. There were navigational,and other technical frustrations reported. It was determined that Internet-based diabetes interventions have the potential to reduce the incidence of the condition of T2D. Indeed, the qualitative study points to the possibility of internet interventions positively influencing behavioral and psychological outcomes of adult patients with T2D (Hoffman, 2016).

Further research also links lifestyle change to better chances of preventing the occurrence of T2D. The Diabetes Prevention Research Group compared diabetes incidence in people that changed their ways of life and patients who were on metformin as their primary remedy (Knauper et al., 2014). Metformin augments cell sensitivity to insulin effect and thus reducing resistance to insulin (Knauper et al., 2014). Three clusters with a total of 3234 patients with diabetes were studied. They included control group, the intensive lifestyle change group and the metformin group. The lifestyle change group aimed at achieving a weight loss of at least 7% and complete a minimum of150 minutes of physical exercise every week. The group that was on metformin took the medication twice every day. They also got lifestyle commendations. The control group on its part tool placebos twice every day and received a standard lifestyle commendation. The results of the research indicated that lifestyle change and the metformin reduced one’s chances of developingT2D. Nevertheless, the lifestyle change cluster indicated a 58% reduction, compared to 31 percent elicited by metformin (Knauper et al., 2014).

Moreover, to manage diabetes efficiently, there is a level of awareness, understanding,and knowledge through education that must be taught to patients and their families. It is imperative, therefore, if success is to be achieved in prevention, management,and control of diabetes to educate patients and all people at risk of developing the condition (Deepa, 2014). These measures must be well-thought-out and planned. Past literature on the subject bears evidence that when there is increased knowledge about diabetes among patients, their families and the general population, there is a high chance of patients complying to treatment and treatment recommendations including physical exercise programs (Deepa et al., 2014). It is clear, therefore, that healthcare institutions, including health centers, caregiving organizations, nursing staff and other medical staff should facilitate awareness and education programs regarding predisposing causes of diabetes, and the need for lifestyle change in the population where they operate. Such efforts are more likely to yield positive outcomes as far as management, prevention and control of diabetes are concerned. Only then, will countries begin to see significant gains in the fight against diabetes; a condition that has reached epidemic status in many developed countries (Brown, 2017).

Subtheme 1.- oObesity and its link to pre-diabetes and type 2 diabetes.

Project 1. While the number of diagnosed diabetic cases has increased over the last decade, undiagnosed diabetes incidence has been regular in its occurrence (Cowie, 2010). Moreover, the chance of occurrence of central diabetes increases in tandem with an increase in the size of the ratio of the waist to the hip, the circumference of the waist and visceral fat. A cross-sectional study involving 35 subjects and another 317 for prospective research in people aged between 18 and 74 was completed. It was noted that two factors, i.e., the circumference of the waist or the Body Mass Index successfully predicted the occurrence of type 2 diabetes separately (Qiao, &Nyamdorj, 2010). Mohammed et al. (2016) also carried out a research study that involved 40 patients. The study reviewed the occurrence of a gene called TLR2 found in pro-inflammatory cytokline IL18 and in blood monocytes. The gene occurs in diabetic type 2 and obese patients.

TThe researchers sought to demonstrate a possible link of pathophysiological nature between inflammation that causes resistance to insulin and obesity. The study group was divided into three groups as follows: 15 obese patients that were diabetic, 15 obese but non-diabetic patients and a control group consisting of 10 people of normal weight. The study groups were exposed to examinations clinically and in the laboratory. The study established that there was a positive correlation between insulin and TLR2 MFI, and BMI and IL18 in patients that were non-diabetic but obese. The research served to show that the occurrence of TLR-2 on CD14+ was controlled in patients that were obese but non-diabetic and those who were both obese and diabetic. The increased IL18 serum levels assessment showed a link with aninflammatory response.

Project 2. The relationship between obesity with a higher BMI and the prospect of developing T2Daremore likely to occur in younger people compared to older adults (Malik, Popkin, Bray, Despres, & Hu, 2010).Further, the chance of developing the T2D condition increases in tandem with both inflammation and BMI. Mussaet al. (2016) discovered in yet another study that obesity and hypertension are significant precipitates for the occurrence of diabetes T2DM in the long term. The research was observational and retrospective. The researchwas conducted within the Rashid Center for Diabetes and Research (Ajman, UAE). 510 patients from Emirates were examined. The observations concluded that there was a strong correlation between age, systolic blood pressure and the duration of diabetes. On the other hand, it was also observed that diastolic blood pressure showed an inverse relationship between age and diabetes duration. Hypertension and obesity prevalence among the diabetes T2D patients of Emirates origin was notably high. Diabetes duration and age manifest countercurrent effects on diastolic and systolic blood pressure.

Project 3. Further research evidence demonstrates that overweight pre-diabetic patients are at high risk (49%) for developing diabetes in ten years if they gain of one kilogram each year (Wilding, 2014). In the same way, observations have concluded that for every single kg of weight loss per year, there is an accompanying 33 percent chance of not developing diabetes in the decade that follows. Elsewhere, research by Kivimäki, (2017), seeks to show that while obesity and overweight have been a subject of research about cardiometabolic diseases for individuals, there is still inadequate understanding when it comes to cardiometabolic multimorbidity.

According to the study, the researcher sought to find out the incident risk for cardiometabolic morbidity from T2D, stroke and coronary heart disease in overweight and obese adults relative to those with ahealthy weight (Kivimäki, 2017). 16 prospective studies from Europe and USA were pooled. The analysis included subjects ofwith 35 years and above and had the criticalimportant BMI data available at the onset oft andfor coronary heart disease, T2D,and stroke at the onset and on follow up. Those with adiabetes diagnosis, stroke,and coronary heart disease patients were not included before or at the baseline point. The data wereereanalyzed by applying logistic regression thethen pooled estimates that were specific to cohorts through the random effects meta-analysis. It was observed in the study outcome that the cardiometabolic multimorbidity increases positively with BMI. It leaps from twice in people who are overweight to tenfold in people with severe obesity; pitted against normal weight individuals with a healthy BMI. The findings point to the need for health professionals to conduct diabetes-screening widely; especially for overweight and obese patients suffering from vascular disease complications.

Project 4. Several studies have linked obesity with the occurrence of diabetes (Bullon, Newman & Battino, 2014; Klil-Dori, Azoulay & Pollak, 2017). Obese people have significant amounts of adipose tissue. Studies show that fatty tissue in some parts of the body secrets hormones that play a part in the development of IRS. Indeed, with inadequate body insulin response mechanism, the breakdown of glucose is severely inhibited. Indeed, the weight dynamics have been shown to be essential variables in the prediction of the occurrence of diabetes. While not all obese people have diabetes, obesity is a predictor of the occurrence of diabetes after some time; therefore, obesity has a solid connection to our study wherein we seek to investigate the knowledge and awareness of pre-diabetes and diabetes among patients that are pre-diabetic in a family clinic.

Subtheme 2.- iInsulin resistance and obesity.

Project 1. Insulin Resistance Syndrome (IRS) refers to a wide range of abnormalities observed commonly in people with insulin resistance. Insulin resistance is the failure by body organs to respond appropriately to insulin action. It has been determinedthat overweight women that are also barren and suffering from Polycystic Ovary Syndrome, also known as PICOS, and visit an infertility clinic show a relatively higher IRS and pre-diabetes than normal-weight women with PICOS (Reyez-Munoz, 2016).

A cross-sectional study carried out retrospectively by Reyez-Munoz, et al. (2016) observed the relationship between overweight and obesity with the occurrence of IR, pre-diabetes and biochemical characteristics among women of Mexican origin suffering from PCOS. The research was conducted at an infertility clinic in Mexico City. Subjects included infertile women of Mexican origin diagnosed with PCOS. They were grouped using the Rotterdam criteria, i.e. 1) normal weight (n=83) with BMI of 18.5 to 24.9 kg/m2 2) (n=217), BMI 25 to 29.9 kg/m2 and 3) (n=238); these were obese patients with BMI equal or greater than 30kg/m2. Since the study subjects showed high resistance to insulin, it was suggested that therapeutic interventions should incorporate women that showed improved metabolic functioning before trying to become pregnant among the women groups.

Project 2. The above scenarios all reflect a need to institute effective awareness and educational programs towards patients at risk of developing T2D. It is imperative that women become aware of the need to reduce or keep their weight low and cut down on body fat (Wilcox 2005). Earlier studies have suggested that obesity is a primary cause of resistance to insulin among other human disorders. More studies show that fatty tissue in some parts of the body secretes hormones that have been implicatedin insulin resistance and other problems (Wilcox, 2005). In another study Kabadi (2017), points out that reducing the body mass index to 25kg/m2 to define the onset of obesity by ADA proposes resistance to insulin as the main complication of faulty metabolism of glucose (IGM) among Asian people.

Project 3. Nevertheless, glimepiride delayed the start of T2D after pre-diabetes, signaling a decline in thesecretion of insulin as an important factor in (L; BMI, 27 kg/m2) IGM subjects. The study observed insulin secretion and resistance in obese and L euglycemia subjects (N), pre-diabetic patients and those freshly experiencing diabetes type 2 (Kabadi, 2017). Kabadi (2017) selected men and women aged between 36 and 75 years for the study. He split his subjects into six cohorts, i.e.,LPreDM, LN, ObPreDM, LDM2, ObN, and ObDM2. The researcher discovered that insulin secretion and insulin resistance indices were lower in the L cohort relative to the corresponding Ob cohorts. Reduction of IS and an increase in IR progressed from N to pre-diabetes to type 2 diabetes mellitus. It was noted, however, that the reduction in IS levels was higher than increases in IR in LPreDm and LDM2. The IR rise was noted to be higher compared to the reduction in IS in ObDM2 and ObPreDM (p. e279).

It is imperative to understand how the body handles insulin and how IR arises. The breakdown of glucose in the human body maintains a balance between insulin secretion and sensitivity towards the hormone using other tissues such as the liver and the adipose muscle tissue. The TD2 pathogenesis observed among adults contains two major components, i.e., a decline in sensitivity to insulin and function impairment of ? – cells (Kaiser & Leibowitz, 2009). Indeed, the central connection between type II diabetes and obesity is resistance to insulin (Ali, 2011).

Project 4. According to Hossain et al. (2016),there is scarce data touching on the resistance to insulin related to nonalcoholic fatty liver disease, also shortened as NAFLD, in a state of pre-diabetes. NAFLD is a known metabolic ailment with a strong link to obesity, inflammation,and T2D. All the mentioned conditions and symptoms are viewed asinsulin resistance syndrome features. Hossain researched to establish how the relationship occurs among the population under study (Hossain et al., 2016).

An analytical cross-sectional design consisting of 140 females and males (77:63) spanning a range of years in their age, and 45 patients between 25 and 68 that were pre-diabetic after confirmation with the 75-oral tolerance test for glucose was completed. The NAFLD diagnosis was made using ultrasonic liver examination (Hossain et al. 2016). The studywas divided into groups with no NAFLD n=63 and NAFLD of n=77. The study found that NAFLD subjects elicited higher levels of hsCRP and HOMA-IR among the subjects of NAFLD relative to those without NAFLD. NAFLD was significantly determined by hsCRP and HOMA-IR, after adjusting potential confusing factors of BMI and triglyceride (Hossain, 2016).

Project 5. The researchers observed that insulin resistance and inflammatory condition were more of independent factors in the relationship between pre-diabetes and NAFLD. Moreover, the data showed that IR and inflammatory condition were interlinked. They are subsequently influenced by dyslipidemia and adiposity levels in subjects with pre-diabetes (Hossainet al., 2016).

Obesity is a precipitating IRS factor. Insulin Resistance Syndrome (IRS) refers to the failure of the body organs to synthesize glucose because they do not respond appropriately to the action of insulin (Hossainet al. 2016). Studies show that the connection between T2D and obesity is resistance to insulin. About obesity, the need to keep one’s body weight within certain perimeters is underscored in many studies including one involving infertile Mexican women attending infertility clinics. There is also a connection between pre-diabetes and insulin resistance. NAFLD is also stronglyassociated with T2D and insulin resistance. Non-Alcoholic Liver Disease (NAFLD) is commonly associated with obesity and is a pre-diabetes symptom NAFLD. Obesity and insulin resistance can significantly increase the chances of acquiring diabetes and therefore has a strong connection to our study wherein we seek to investigate the knowledge and awareness of diabetes among patients that have been diagnosed with pre-diabetes in a family clinic.

Subtheme 3. -wWeight loss.

Project 1. According to scholars, weight loss proves beneficial to pre-diabetic, overweight/obese individuals. Losing between five and fifteen percent of one’s weight has the potential to appreciably decrease obesity and associated ailments’ risk factors (Kim et al., 2013). Study findings by White and Huntriss (2016) reveal that losing weight is a favorable diabetes treatment strategy with numerous testified advantages such as enhanced insulin sensitivity, improvement in mortality rates, better glycemic control, decreased medicine dependency, and restored ?-cell functioning. Clinical results of an initiative for losing weight spanning twelve weeks among pre-diabetic and T2DM -diagnosed multi-ethnic individuals were assessed (White &Huntriss, 2016). A total of thirty-four individuals signed on; of these, twenty-one individuals remained on the initiative until the end,i.e., twelve weeks. The initiative proved clinically efficient; patients who sought additional support attained more superior clinical results. Patients from the South-Asian ethnic group pose treatment challenges related to compliance with initiative and clinical results. Additional studies need to take into account the ideal intervention to serve this cluster of patients (White &Huntriss, 2016).

Project 2. Losing weight proves advantageous for obese T2D-diagnosed patients regarding improving their glycemic control and cardiovascular risk factors. Clinical researchers provide evidence of enhanced therapeutic advantages when a 0.45 kg- 4 kg weight loss is achieved; for instance, such levels of weight loss positively affect cardiovascular risk, metabolic control, and mortality rates (Unwin & Unwin, 2014). Weight loss impacts on diabetes and associated ailments’ incidence suggests that the ideal initiative ought to encompass comprehensive behavior management, pharmacotherapy, diet changes and bariatric surgery exercises (Unwin & Unwin, 2014). Twenty-one orlistat, sibutramine,and other widely prescribed medicines lead to moderate weight loss, accompanied by obvious improvements in T2D comorbidities. Kimet al.(2013) assessed liraglutide’s capability of improving insulin resistance, inflammation,and cardiovascular risk and boosting weight loss among high-risk cardiovascular ailment and T2D individuals. Sixty-eight pre-diabetics, obese/overweight older adults (aged, averagely, 58 ± 8) were randomized for the purposes of their fourteen-week double-blind research of placebo vs. 1.8 mg liraglutide.

Project 3. Participants received a recommendedfor a daily calorie consumption reduction of 500 kcals.Quantificationinfluences BMI post-Diabetes Self-Management Education/ intervention of peripheral insulin resistance (PIR) was facilitated through the measurement of SSPG (steady-state plasma glucose) concentrations when examining insulin suppression. Authors discovered that calorie reduction and liraglutide combined resulted in appreciable improvements in insulin resistance, blood glucose, blood pressure, triglyceride concentration and weight loss among high-risk cardiovascular ailment and T2D individuals (Kimet al., 2013).

Researchers conducting observations and initiatives on the subject revealed that everyday behavior, e.g., decreased energy intake for promoting ongoing, reasonable weight loss and necessary dietary alterations can facilitate T2D prevention and onset delay. (Fujioka, 2010; Unwin & Unwin, 2014). According to Wilding (2014), the obesity outbreak has been a critical force influencing the rise in T2D incidence.

Project 4. Obesity is linked to cardio-metabolic complication risks that are primarily responsible for T2D-linked mortality and morbidity. The author analyzed evidenceabout weight loss impacts among pre-diabeticcs and T2D-diagnosed individuals (Wilding, 2014). Study findings suggested that weight loss among pre-diabetics evidently delays T2D onset or reduces disease development risks; meanwhile, for T2D-diagnosed individuals, weight loss leads to better glycemic control and severe calorie reduction proving potent enough to reverse disease progression (Wildling, 2014).

Project 5. Observational researchers provide evidence supporting reduced cardiovascular risk among T2D-diagnosed persons who have achieved weight loss (Wing, 2011). However, the findings of the randomized trial dubbed ‘Look AHEAD’ indicate rigorous weight loss’s inability to decrease cardiovascular disease development among obese/overweight T2D diagnosed adults (Look AHEAD Research Group, 2007). Moreover, secondary examinations of sizeable cardiovascular result trials by other researchers fail to provide any conclusive results. However, aside from cardiovascular risk factors, other recorded advantages of losing weight for T2DM patients areimproved mobility, sexual functioning and overall quality of life. Doctors were advised to urge every over-weight individual whether pre-diabetic or diagnosed with T2D to lose weightwhile selecting the best glucose-reducing treatments (Wilding, 2014).

Overall, weight loss has proven advantages for overweight/obese individuals suffering from T2DM or at elevated risks of developing the disease in the near future (Wilding, 2014). These advantages, assimilated through the findings of various researchers, include: enhanced insulin sensitivity, improvement in mortality rates, better glycemic control, improvements in insulin resistance, better metabolic control, decreased medicine dependency, T2D prevention and onset delay, improvements in cardiovascular risk factors, restored ?-cell functioning and improved mobility, sexual functioning and overall quality of life (Wu, Ding,Tanaka & Zhang, 2014, et al). Patient weight loss benefits can significantly assist in curbing the impact of diabetes and therefore have a strong connection to our study wherein we seek to investigate the knowledge and awareness of diabetes among patients that have been diagnosed with pre-diabetes in a family clinic. Comment by Maria Thomas:  Work by Three to Five Authors: List all the authors the first time you cite the source.

TMain theme 2- diabetic education. Experts have, earlier, come up with self - management diabetes education initiatives for assisting patients when it comes to informed decision-making and expedition of self – care actions (Mulcahy et al., 2003). Lifestyle modifications, including reducing risks and engaging in more physical activity proves highly crucial in DSME initiatives. The American Association of Diabetes Educators (AADE) claims learnable actions which may help achieve self - management. The DSME’s initiatives areaimed at cultivating the most effective behaviors and capabilities for diabetes and related risk management (Woodburyet al., 2013). For ensuring DSME approaches prove successful in their patient self - management education objective, there is a need for successful modification of patient behaviors (Woodbury et al., 2013). Woodburyet al.(2013) studied and evaluated the self-management peer-headed initiative labeled “PEP Talk: Diabetes, Healthy Feet and You,” targeted at dealing with the issue of increased diabetes and complications incidence and the scarcity of healthcare funds. The research appraised the initiative, how to place it in the context of public health, and likely avenues for implementing it within Canadian communities and across the globe. The initiative included workshops organized by peer volunteers and healthcare practitioners within a dozen communities in ten provinces in the nation. Volunteer support was ensured via discussion boards, monthly mentoring-focused teleconferences, and online tips. An online portal was created for use by volunteers, community members and team members (Woodburyet al., 2013).

The workshop’s syllabus was designed on the basis of best-practice recommendations for diabetes self-management and foot care. Participating community members were requested to answer questions pertaining to awareness revealed by more correct answers before and after the workshop. They provided positive feedback with regard to the workshops organized. Follow-up interviews were carried out via the telephone, with interview results indicating 97 percent of participants had brought about modifications to their foot care-related self-management behavior (Woodburyet al., 2013). Site visits suggested that concerned parties widely utilized the portal; however, it was less than expected when it came to community member registration. It was suggested that the initiative should become extensively available and customized to individual communities’ unique requirements (Woodbury et al., 2013). A need for additional assessment was also identified.

Likewise, Sagario-Abood (2015) asserts that diabetes incidence has, at present, reached epidemic levels. Roughly 1.4 million adult individuals are diagnosed with the disease per annum. Overall, approximately 9.3 percent of America’s populations, i.e., 29.1 million individuals are suffering from the disease. T2D rates are higher among rural communities as compared to urban communities; making matters worse, the former are faced with more obstacles when it comes to availing themselves of healthcare (Sagario-Abood, 2015). Innumerable diabetics within different rural localities are unable to enjoy established diabetic care standards including foot complication prevention awareness and foot screenings that subsequently result in thedevelopment of foot ulcers and eventual amputation (Hobizal&Wukich, 2012).

Diabetes mellitus is a complexex chronic ailment whose treatment necessitates a multidisciplinary strategy. These multidisciplinary strategies aremostly unavailable in several rural health centers. Fragmented education of diabetes patients results in non-adherence, theformation of foot ulcers and ultimate growth in therate of lower-limb amputated patients (Habizal&Wukich, 2012). Inadequate implementation of diabetes care standards in desperate populations may be dealt with through implementing evidence-based diabetes foot education programs. Woodbury, et al. (2013) aimed at ascertaining the efficacy of a client-focused diabetes foot education program targeted at improving patient awareness, proven by better Patient Interpretation of Neuropathy (PIN) scores after program participation, as compared to scores prior to participation (p. 703). A quasi-experimental research design was employed with study findings establishing the efficacy of client-focused foot ulcer development prevention education as an instructive means to increase patient knowledge about foot ulcer development prevention (Woodburyet al., 2013).

Despite its established efficacy, only roughly 50 percent of US citizens suffering from diabetes engage in formal disease related education. Authorities and experts aim to achieve growth in this figure to over 70 percent this year (Duncan et al., 2009). But in order to ensure patients participate, firstly, there is a need to implement a DSME initiative within the community. Also, this sort of initiative ought to aim at achieving success in prevention of pre-diabetes progression to T2D and reduction of complication risks among diabetics. Chrvalaaet al. (2016) looked into how glycemic control was affected by diabetic self-management support and education, contact time, professionals and duration among T2D-diagnosed adult patients. The PsycINFO, MEDLINE, EMBASE, CINAHL, and ERIC databases were scrutinized for programs that incorporated aspects for improving participant information, capabilities and skills when it comes to goal establishment, making informed decisions and performing self-management activities. A total of 118 distinct programs were identified after analysis; of these, 61.9 percent reported significant A1C changes. Findings indicate delivery mode, baseline A1C,and participation duration may impact the possibility of attaining clinically and statistically significant A1C improvements (Chryalaa, 2016).

DSME initiatives will go a long way towards facilitating informed patient decision-making, risk reduction, and engagement inphysical activity, thereby facilitating diabetes onset prevention and delay (Philis-Tsimikas& Gallo, 2014). Such initiatives can also ensure A1C improvements and asuccessful modification of everyday patient behaviors such as lifestyle modifications, including diet and exercise.

Lastly, diabetes education can ensure foot ulcer development prevention and reduction in subsequent lower-limb amputations among diabetes patients (Woodburyet al., 2013). DSME can significantly assist in curbing the impact of diabetes and therefore have a strong connection to our study wherein we seek to investigate the knowledge and awareness of diabetes among patients that have been diagnosed with pre-diabetes in a family clinic.

Subtheme 1. -eEvaluation of education.

Project 1. A standard curriculum is encompassing modern evidential methods and practice, and outcome evaluation standards, functions as the DSME initiative’s framework. Pre-diabetic and diabetic individuals’ evaluated requirements guide the content matter that will be provided (Funnell et al., 2010). According to Standard 10, National DSME Standards, the DSME initiative will assess diabetes education efficacy and describe developmental prospects through adopting a consistent standard quality improvement approach which delineates and records a systematic assessment of entity progression and resultant information (Funnell et al., 2010). Beck, Haas, Maryniuk, Cox, Duker, et al.and colleagues (2017) analyzed DSMES literature for making sure National DSME Standards are in line with contemporary adoption trends and evidence-based practice. Comment by Maria Thomas: Use APA citation

The researchers’ technique entails division of a score of interdisciplinary experts, followed by making them comb latest diabetes support and education, healthcare atmosphere, organizational, behavioral health, reimbursement, technical, and clinical practice literature to attain the soundest evidence guiding Standards amendment. It was established that DSME supports the knowledge, abilities,and skills vital to diabetes self-management and care, in addition to activities aiding individuals in the implementation and maintenance of behaviors critical to ongoing diabetes management Woodbury, et al., 2013). Evidence reveals diabetics and health practitioners are accepting and supporting technology. This positively affects DSME accessibility, application,and results.

Project 2. Establishing effectiveness is necessary to assess outcomes. A diabetes mentor may use core metrics for establishing efficiency with individual patients, groups and communities, link performance to established standards, and ascertain the unique effect DSME has within the overall diabetes care framework (Woodbury et al., 2013). Brunisholzet al. (2014) ascertained the effect DSME has on improving diabetes care results and processes as gauged via HbA1C and a five-element diabetes bundle, among T2D-diagnosed persons. A retrospective examination for adult diabetics was performed; subjects were diabetics who were recipients of DSME training during 2011–12 from a recognized Intermountain Healthcare American Diabetes Association (ADA) facility, with an HbA1c test in the last three months and between two and six months following completion of their foremost DSME appointment (Brunisholz et al., 2014).

The control cluster constituted patients chosen randomly from case-patients’ facilities for attaining a 1:4 ratio. The DSME cluster revealed a major difference in five-element diabetes bundle accomplishment and HbA1c in comparison to the control cluster. Furthermore, study authors discovered that standardized diabetes self-management education provided in an Intermountain Health ADA facility is linked closely to an appreciable improvement in T2D patients fulfilling every diabetes bundle component and decreased HbA1c levels beyond ordinary care (Brunisholzet al., 2014). Considering the DSME initiative’s low operational expense, the above research outcomes soundly support this initiative’s value-adding advantage in T2D treatment.

Project 3. The AADE (2010) describes the DSME process as being of a collaborative nature, with diabetics or pre-diabetics acquiring requisite knowledge and skills for effecting behavioral modifications and successfully self – managing diabetes and related illnesses. To support outcome measurement and guaranteeing DSME initiative success, the AADE delineated standards to be achieved by all initiatives for evaluating what it has accomplished efficiently and delivered (Roumie et al., 2014). Behavioral modification, in this context, represents a unique DSME outcome metric. Diabetic self – care conduct processes ought to determine DSME efficacy at the level of respondents, individuals, groups and overall communities. Moreover, it is recommended to evaluate self- care behaviors at abaseline level, followed by their evaluation at systematic intervals following completion of the DSME intervention (Roumieet al., 2014).

Further, the AADE suggests assessment of an array of relevant consequences, including behavioral, clinical, educational, and health status-related consequences for corroborating the linkage between DSME and behavioral modifications in the context of diabetes care. Moreover, individual patient outcomes are appliedto guiding medication and improving patient care. Cumulative population outcomes help guide programmatic outcomes and ensuring continuous quality improvement activities to aid patients, providers and the initiative (AADE, 2010).

Project 4. Evaluation of outcomes allows diabetes educators to determine initiative effectiveness, initiative impacts on participants, and areas for improvement (Evert & Boucher, 2014). Frequent, consistent outcome assessment in many instances is imperative, in addition to applying the information gleaned in the areas of instructional and clinical decision- making. These

Rresearch scholars have identified the need for establishing standards for measuring the outcomes of DSME initiatives. It is imperative to assess outcomes to establish effectiveness. Evaluation of outcomes allows diabetes educators to determine initiative effectiveness, initiative impacts on participants, and areas for improvement. Diabetic self – care conduct processes ought to determine DSME efficacy at the level of respondents, individuals, groups and overall communities.

A diabetes mentor may use core metrics for establishing efficiency with individual patients, groups and communities, link performance to established standards, and ascertain the unique effect DSME has within the overall diabetes care framework. Behavioral modification, in this context, represents a unique DSME outcome metric. Individual patient outcomes are applied for guiding medication and improving patient care while cumulative population outcomes help guide programmatic outcomes and ensuring continuous quality improvement activities to aid patients, providers,and the initiative. Frequent, consistent outcome assessment in many instances is imperative, in addition to applying the information gleaned in the areas of instructional and clinical decision- making.

Subtheme 2. E- effectiveness of education.

Project 1. Self-management education related to T2D is core to minimize the complications associated with the condition. However, there are barriers in the educations programs that are yet to be addressed such as ethnicity, personality, age,social,and economic conditions of the patients (Kaye, 2017). Despite national healthcare systems incorporating an educational program, the cost-benefit ratio must prove cost-effectiveness. Provider-initiated self-management education empowers patients and communities where it is conducted efficiently improving diabetes care and prevention of T2D in the community in general (Kaye, 2017). However, the programs put in place for these purposes have to be economically viable for program administrators, patients and reduce the clinical risk factors (Jalilianet al. 2014). For instance, Jalilianet al. (2014) conducted literacy research with an objective to evaluate the efficiency of an educational program among the diabetic, the health belief model (HBM) and the intervention program in Iran.

The participants were 120 T2D patients who were in referred to two rural health centers in Gachsaran. They were randomly divided into two health intervention groups based on their location. The study as designed as a longitudinal pre and post-intervention tests. They executed a behavioral modification plan based on intervention strategies to improve self-management among the patients. The health conditions of all the patients who participated were compared before and after the test and proved that indeed the programs were significantly effective. Barriers that contributed poor self-management had significantly been alleviated among the two intervention groups. Patients were more responsive to factors causing susceptibility, signs of severity and general personnel management. The education on the health benefit model was found to be highly effective in improving the self-management among the participant patients and the prevention of diabetes complications.

Project 2. An alternative approach to craft an educational program based on the cultural foundation of a community is being used in some communities in the U.S. The approach is used to educate communities related to using local languages to communicate an understanding by addressing at-risk lifestyle practices that are promoted by the community’s culture (Kim et al., 2015).Kim et al. (2015) conducted a similar but randomized controlled test (RCT) with a comparison relying on the: “Predisposing, Reinforcing, Enabling Constructs in the Environmental Diagnosis and Evaluation (PRECEDE), Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development” (PROCEED) and self-help models.”

The research was conducted for a period of three years between 2010 and 2013 with comprehensive data collection in the twenty-eight-member states of the European Union. The research projected sampled participants withT2D. The analysis of the data deduced that health workers based in the community are equipped with the ethnic and linguistic insight of the culture in the region which makes them effective trainers of community groups on the management of diabetes (Kimet al., 2015). Thus, this research recognized that health-care professionals have the ability to facilitate elements“influencingself-management and provide direction for registered nurses and other health professionals involved in supporting self-management programs” (Parket al., 2015, p. 1620).

Project 3. Thus,sSelf-management education empowers patients and communities where it is conducted improving diabetes care and prevention of T2D in the community in general (Kaye, 2017). National programs and non-governmental campaigns have been instrumental purveyors of self-management education,but international bodies such as the European Commission on Healthcare are yet to be established. Contribution by such international bodies makes it possible to solicit for support internationally and allocation of funds by international organizations suchas the World Health Organization (WHO), making it possible to advance the training programs further (Van den Brouckeet al., 2014).

Project 4. Patients with limited literacy face numerous barriers and limit the effectiveness of self-management cases in such instances. Participation by international bodies such as the European Health Commission would contribute significantly to such areas that require improvement. Development of Diabetes Literacy programs would make it easier to reach the community members who are less literate (Wallace, 2010). As established by Kim et al. (2015) implementation of such a program would best be done by physicians from this ethnicity that would break the linguistic barrier, culture conflict and affect an overall better understanding of the ethnicity (p. 3278).

Diabetes is a chronic disease and if not well managed may result in serious complications and in extreme cases may result in death. However, awareness among the patients on risk factors, quality of life psychology, self-care, glycemic control and cardiovascular disorders helps the patients manage their health more responsibly. The optimum health status of the patients is easily deterred by indulging in foods they should avoid or making unhealthy choices possibly negatively impacting their health condition. Creating awareness among such patients through education programs is deemed to create awareness among T2D patients promoting informed decisions regarding possible health consequences or what routines they should observe to lead a healthy life.

Subtheme 3. C3-cost-efficiency of diabetic education.

Project 1. Research conducted by Evert and Boucher (2014), EU, US, Taiwan and Israel national diabetes programs were accessed to evaluate the cost incurred in the education per person. A comparison of the four nations care pathways was made to deduce the cost-effective diabetes self-management methods. The moderating role health literacy plays, the manner the organization of health services, and the implementation reliability of the programs were also considered. This would contribute to the formulation of cost-effective self-management programs that were suitable for the different dynamics in different regions. They found that an economic assessment must be done on the health results to establish the cost-benefit ratio of health services rendered.

Consequently, it is possible to establish intervention strategies that are effective with a high-cost benefit ration based on information gathered from the economic assessment and subject population’s opinion. The importance of education diabetes patients on self-management cannot be underestimated,and thus it should not be assumed. However, the program put in place for these purposes has to be economically viable for the program administrators, the patients, and as well as present an effective solution.

Project 2. Suseelalet al. (2017) conducted an RCT program to evaluate the effectiveness of home-based programs educating diabetes patients on self-management practices. The randomized controlled trial was conducted in an experiential design was employed in the research program. Diabetic subjects under treatment for not less than three months were considered for research in MaraiMalai Nagar among other nine villages at Mamandoor. Therefore, aA simple random sampling technique was employed to choose the 200 subjects of the research program. 200 more participants were selected for the control program. The results of the research found that there was a close correlation between the cost-effectiveness and housing of the patient, monthly payments, and age of the patient.

Analysis of the findings indicated that home-based education was cost-effective and significantly reduced diabetes-associated complications and the cases of hospitalization. Health professionals that are participating in home education programs make it possible to control the cost incurred in the management of the diabetes epidemic. Home-based education also increases the awareness of diabetes in the community significantly reducing the cases diabetes besides more effective management among the people who already have the condition. Suseelalet al. (2017) deduced that home-based self-management education of patients with diabetes is cost effective especially when some educational interventions are employed.

Project 3. Lian and McGhee (2017) conducted a review on the cost-effectiveness of education on self-management programs on T2D and the associated clinical risk factors. The review was on PubMed, Cochrane, and PsycINFO databases on the papers published between 2003 and 2015. Further, research was completed on the references on the papers. The total papers they found useful were 777 among which 12 we included in the review project. Eight educational programswere identified,and an RCT analysis was conducted. Four among the eight programs of the effective analysis found a reduction in the clinical risk factors between the US $491 TO to US$7723. The cost incurred for every glycaemicglycemic symptom contributed to a cost saving of up to US$39. However, analysis of cost per QALY gained in the lifetime model the cost was less than US$50,000. The degree of cost-effectiveness in the analysis was negligible despite gaining QALYs in the following year. The clinical risk factor control based on the self-management education is modest in the levels of cost-effectiveness in the short term but proves significant in the long term.

As illustrated above, diabetes self-management programs are cost effective hence should be incorporated into the health system. Additional research completed by Carey et al. (2014) aimed to establish if educators of T2D can be effective in educating diabetes mellitus patients. The research also focused on establishing if lay persons can contribute to the education of either T2D or diabetes mellitus patients.

The researchers derived that it was possible for a joint education between diabetes mellitus and T2D patients making it possible for the development of a more comprehensive education program for patients of either of the conditions. The research also found that after a lay person has undergone training, they can educate the patients under the supervision or guidance of a healthcare professional. Following these deductions, it is, therefore, possible to craft a program that increases the capacity of the patients in a single program and maintain professional standards while simultaneously remaining cost-effective. These strategies are purposed to increase and diversify access to self-management education.

Summary

This literature review chapter concentrated on assessing current literature on themes and issues related to creating DSME awareness among prediabetes patients. The results of the analysispoint towards the significance of DSME and consider it paramount in controlling diabetes. Additionally, the literature points towards the effectiveness of DSME in controlling diabetes.

Moreover, the literature also reveals the cost efficiency of DSME in controlling diabetes. Additionally, the literature has gaps particularly in the efficiency of diabetes educational interventions,and therefore, this DPI projectfocuses on establishing the knowledge and awareness of diabetes among patients with pre-diabetes in a family clinic.

The independent variables will be the DSME intervention plan,and the dependent variable will be patients’ awareness level about the threat of acquiring T2D and awareness concerning risk lowering habits and treatments, and these factors will be assessed using a quantitative descriptive research design whileemploying a closed-ended questionnaire. Other dependent variables will be BMI assessment pre-test and eight weeks after DSME intervention.

Additional dependent variables found in the data collection are how awareness and understanding levels amongst individuals differ based on education level,andlastly, the health belief model will be used as the theoretical foundation for this study. This project will make use of diabetes associated queries in the pre-assessment to evaluate and classify individuals according to their understanding and knowledge of diabetic issues.

Dedication towards increasing their understanding and awareness of diabetes as well as their risk of acquiring T2D might encourage them to alter their lifestyle and embrace new treatments to decrease the threat of diabetes. The inclusion criteria for this study will be adults of both sexes with a BMI of more than 30kg/m2. Further, the results might be helpful in the advancement of future interventions towards decreasing diabetes risk, i.e., obesity in communities with ahigher risk of acquiring T2D.

Chapter 3: Methodology

Introduction Comment by Pamela Love: delete

The purpose of this chapter is to evaluatethe methodology employed to assess awareness and understanding of DSME intervention concerning pre-diabetes and diabetes in pre-diabetic individuals and the effects on BMI. The independent variables will be the DSME intervention plan,and the dependent variable will be patients’ awareness level about the threat of acquiring T2D and awareness concerning risk lowering habits and treatments, and these factors will be assessed adopting a quantitative method and using a descriptive design. Other dependent variables will be BMI assessment. Lastly, the health belief model is used as the theoretical foundation for this study.

This chapter will serve two primary functions; firstly, it is going to offer the strategy being utilized to undertake this project research; subsequently, reasons for selecting this methodology are going to be presented. This chapter is divided into the following subsections: Comment by Pamela Love: project, not research

Statement of the Problem

Clinical Question(s)

Project Methodology

Project Design

Population and Sample Selection

Instrumentation

Validity

Reliability

Data Collection Procedures

Data Analysis Procedures

Ethical Considerations

Limitations

Summary

The methodology chapter is divided into subsections tosystematically present the content. Also, by dividing this chapter, this DPI project has been transformed into functionalfuncinvestigative research stagesas described in the “research process onion” model proposed by Saunders , Lewis and Thornhill et al. (2015) (Figure 1). Comment by Thomas, Maria: Follow APA citation for three authors. First citation in text

FIGURE 1: Research Process Onion (Saunders et al., 2010, p.83)

Statement of the Problem

There are mixed results in the literature on how patients respond to diabetes self-management education that should be adopted to attain the preferred benefits, and precisely what they will do with the understanding they develop from educational interventions. There's an expanding demand for interventions that enhance patients’ understanding and knowledge of pre-diabetes, diabetes, and the effects of obesity (Islam et al., 2014). The substantial population at an increased risk for or with diabetes is actually within the age bracket of 25 - 65 years. Insufficient steps to decrease theoccurrence of pre-diabetes might result in a considerable boost in health investment, morbidity, as well as other associated health circumstance” (National Diabetes Statistics Report, 2014, para 8).

Because of these facts, the purpose of this DPI project is to assess the awareness and knowledge of pre-diabetes and diabetes amongst obese patients in a family practice clinic. Pre-intervention assessments on patients with pre-diabeteswill be carried out to comprehend their current awareness state. The pre-assessment outcomes will be utilized to enhance and modify the DSME educational plan to satisfy the individual requirements of patients with prediabetes.

Health interventions will be essential in the management of the increased incidence of diabetes diagnoses to avoid diabetic issues or postpone their development (Islam et al., 2014). Such endeavors can consist of acompletelifestyle change for all those at an increased risk for pre-diabetic and/or diabetic issues and timely treatment for patients suffering from the disorder. An ambitious method focusing on obese individuals at an increased risk for pre-diabetes and diabetes is a significn important public health strategy targeted at reducing the threat elements for diabetes (International Diabetes Federation, 2013).

Clinical Questions and/or Hypotheses

The project study will analyze the understanding and awareness of pre-diabetes and diabetes amongst obese patients with prediabetes in afamily practice clinic with a BMI >30(P); The research projectquery is: among pre-diabetic patients with a BMI > 30kg/m2in a family practice clinic to what extent does providing diabetic education using Diabetic Self-Management Education (DSME) compared to providing no education result in improvement in patient awareness and knowledge of pre-diabetes and diabetes and a decreased BMI over an eight week period?. Comment by Pamela Love: project

Further, to answer the clinical question, the study uses a descriptive design as the focus is on the effectiveness of DSME intervention programs. The study will monitor the efficiency of DSME plans and provide recommendations for improvement of future DSME programs. Hence this study adopts a quantitative approach using a descriptive method and pre-post test to determine subjects' understanding and knowledge of prediabetes, and T2D.

The pretests will establish current knowledge and gaps about diabetes awareness and post-test will determine the information they gained from the intervention (DSME) and how they plan to use that information in their life. A BMI will be measured pre-test and eight weeks after the DSME intervention to evaluate theeffectiveness of the education related to weight loss. The results will help in the advancement and improvement of the prediabetes and diabetes self-management intervention programs.

Project Methodology

In research, a methodology most often is divided into two primary categories; (1) inductive method and (2) deductive method. “In induction, initially information is collected,and after that,it is analyzed to ensure that a theory/hypothesis may be formed about that situation/phenomenon” (Saunders, et al., 2015. 95). In deduction, a “theory is utilized to develop hypotheses; after that, a research method is developed to either validate or refute the hypotheses” (Saunders et al., 2015, 97). These methods both involve distinctive methodologies and offer various explanations/results of different scenarios. Research signifies that occasionally meaningful simplification via data analysis cannot be made. However, this outcome is not based on themajority of the research studies (Saunders et al., 2015).

In the backdrop of this DPI project, the idea of understanding and awareness associated with prediabetes and diabetes is a relativelynovel principle,andit is gradually acquiring its place within the American healthcare system. For that purpose, the present literature does notentirely disclose sound theoretical frameworks for this phenomenon. In light of the abovementioned details, this project will attempt an inductive method and make an effort to come up with a complete intervention model of understanding and awareness associated with prediabetes.

The study uses an inductive approach and adopts a quantitative design method using a descriptive method with a DKT2 pre-post test to determine subjects' understanding and knowledge of prediabetes and T2D. The pretests will establish current knowledge and gaps about diabetes awareness and post-test will determine the information they gained from the educational intervention and how they plan to use the information in their life. A post-test BMI will be measured eight weeks after the DSME intervention to evaluate the effectiveness of the intervention related to weight loss.The results will help in the advancement and improvement of the prediabetes self-management intervention programs. Comment by Thomas, Maria: Arguments are supported by citations from articles and books on project methodology or design.

Project Design

The purpose of the project design is to measure the effects of knowledge and awareness related to pre-diabetes and diabetes amongst overweight people who are at risk or have been diagnosed with prediabetes who are patients in a family practice clinic. The study makes use of a descriptive design to determine subjects’ understanding and knowledge of prediabetes and T2D and the effects on BMI. Comment by Pamela Love: Very good! Well stated!

A descriptive study offers information for analyzing and monitoring policies and plans. These type of study models focuses on the best way to respond to these kinds of queries as: How much? How many? How effective? How successful? How sufficient? (Indiana University, n.d.). Furthermore, descriptive study designs are an approach that offersa description of the individuals getting involved in the study. The crucial methods for conducting a study employing a descriptive investigation design and style are aCase study, Survey along with observational scientific studies (Shawyer et al., 2014).

This study uses a quantitative descriptive design,and the focus is on the effectiveness of DSME related to weight loss. The DKT2 pre-posttestwill be administered to determine subjects' understanding and knowledge ofprediabetes and T2D. The pretests will establish current knowledge and gaps about diabetes awareness and post-test will determine the information they gained from the DSME intervention and how they plan to use that information in their life. The study will monitor the efficiency of the DSME plan and provide recommendations for improvement of future DSME programs.Thus, the results will help in the advancement and improvement of the prediabetes and diabetes self-management intervention programs.

Research strategy.The primary elements of a research strategy structure, based on Saunders et al. (2015), are “detailing the technique which will be utilized in the study that will allow the researcher to achieve his goals, describing all of the backup and instruments which will be used in the collection of the needed data as well as the weak points and obstacles throughout the data collection procedure” (p. 116). The most fruitful technique to conduct this type of study is the survey approach. Moreover, “surveys are useful in that a researcher is able to gather information that is not likely to be to be available from another source and the information gathered usually provides an unbiased representation of the target population” (Bernard & Bernard, 2012).

The survey approach has, over time, confirmed itself to be among the most effective techniques for just about any social analysis. This approach assists the researcher to come up with, deliver and/or ask appropriate questions from the potential audience or sample. It enables the researcher to select from two distinctive and all-encompassing techniques: 1) interviews and 2) questionnaires (Trochim et al., 2015). Trochimet al., (2015), in his research”, clarifies that a survey has got the versatility to vary from a short-scaled easy composed response to an all-inclusive face-to-face deep interview that is what tends to make the survey such an essential fragment of basic research” (p. 26). The standardized and exploratory structure of the survey is going to be most beneficial for this type of study.

In the study, participants will be given a Diabetes Knowledge Test 2 (DKT2), aclosed-ended questionnaire developed by the Michigan Diabetes Research Center (MDRC). TheDKT2 will be implemented in both pre-assessment and post-assessment. The DKT2offers questions that are simple and easy to understand (Fitzgeraldet al., 2016). The DKT2 will aim to establish awareness levels about pre-diabetes and T2D among the subjects. Such awareness and understanding levels may be influenced by numerous factors. The participant will receive the education individually after receiving informed “informed consent,” and completing the pre-assessment closed-ended questionnaire; then a post-assessment will be done to establish the effectiveness of the intervention. A quantitative measurement ofBMI will be completed before pre-assessment and eight weeks after post-assessment toevaluate the effectiveness of DSME awareness on weight-loss.

The measurement of BMI, pre-post assessments, and DSME intervention will be completed once evaluation and approval arereceived from the family practice clinic. A quantitative approach has excellent data facilitation potential. Such data is used for statistical purposes (Creswell, 2014). Hence, this study decided to use the descriptive quantitative approach. The central focus of this design is to identify the connection between one independent variable and dependent variables in the chosen population (Creswell, 2014).

Once the researcher assesses the understanding levels related to diabetes amid the subjects through quantitative approaches, the researcher will initiate the DSME and use effective intervention strategies proposed by The American Diabetes Association (ADA) to enhance the awareness levels of pre-diabetes patients and those suffering from obesity. The ADA guidelines encourage education about diabetes for the purpose of improving clinical outcomes, implementing programs that include psychosocial methods for better patient treatment and support strategies that are more effective to DSME (Funnel et al., 2010).

The DSME intervention will be accomplished by using an educational plan approved by the American Diabetes Association and promoted by the Robert Wood Johnson Foundation’s Diabetes Initiative: Diabetes Self-Management curriculum.The initiative focused on improving self-managementeducation for adults with diabetes in clinics and communities” (Robert Wood Johnson Foundation, 2009, para. 1). The DSME curriculum focuses on Self-Management behaviorsutilizing evidence-based practice. The relevantcontent of the DSME will be utilized based onthe patients’ educational needs.

Before the administration of DSME intervention, a pre-assessment will be carried out. Using the responses from the closed-endedquestionnaire, lapses and gaps will be understood in the diabetes knowledge and awareness among the subjects. Thereafter, the education program will be administered. However, before the implementation, adjustments will be made based on the gaps in awareness and knowledge revealed in the pre-assessments. After the intervention education, a post-assessment will be completed. Using the responses from theDKT2, diabetes knowledge,and awareness gains will be evaluated in the subjects (Brown, 2017).

Population and Sample Selection

Consistent with Saunders et al. (2015) the “majority of the research within the backdrop of social research makes use of non-probability sampling. This is because non-probability sampling provides a wide variety of techniques established on subjective reasoning” (Saunders, 2015, p. 82). For this study, to be able to “satisfy the goals of this study and respond to the research inquiries, the researcher is going to take an intensive description focusing mainly on a small sample size that will be selected purposively” (Saunders, 2015, p. 89).

As a result, the study will make use of “purposive” or “judgmental” sampling method that will “permit the researcher to select the most appropriate subjects which can most effectively help in fixing the research questions and goals of this research” (Saunders et al., 2015, p. 91). This sort ofPurposive sampling, additionally, aids in creating certain that the conditions are different and filled with data, and, consequently, the setup of the sample will probably be decided only following the researcher entering the field. However, in line with Saunders et al. (2015), the “whole population cannot be regarded as a statistical representation of this sample” (p. 59). The sample will be selected from patients at a family practice clinic nearby.

In addition, because the “survey is going to be a significant source of the verification that will be established on human affairs; they'll be accounted and perceived with tremendous attention, and skilled respondents who can provide important insights to the phenomenon will be of huge benefit to the study” (Saunders, et al., 2015, p. 92).

The DPI project is going to be completed at a family practice clinic where the weight measurement of obese patients will be carried out. Given the timeframe available for this project study and the resources available, asample of 30 affected individuals who are obese and pre-diabetic will be utilized.

Since the clinic is in close proximity to the subjects under focus and accessible to the researcher, a purposive sampling technique was selected. Prediabetic obese participants are easily recruited, thus, will be recruited because of their accessibility. The advantage of purposive sampling is that it is cost-effective, simple, and uses fewer resources.Moreover, the patients will have to be: a) of 18 years of age; b) understand written and spoken English; c) free from ailments such as severe stroke, visual impairment or kidney disease; and d) diagnosed with obesity and prediabetes to take part in the project. The rationale for the use of this population is that it helps to rule out other health factors augmenting the presentation of the patient. Comment by Thomas, Maria: Provide rationale for the use of this population

The informed consent process requires the patient to be informed of the purpose of the study and their participation in it. The patient must give approval for their being included in the project. Confidentiality measures are adopted to ensure that patient rights are protected. These measures include applying a patient ID number to the data that is recorded in lieu of the patient’s name so that anonymity is preserved. Project participation requirements ensure that the project is overseen by a competent authority and that participants’ rights are not violated. Geographic specifics ensure that the participants are from the sample identified and not from any other population. Comment by Thomas, Maria: Include the informed consent process, confidentiality measures, project participation requirements, and geographic specifics

Instrumentation

The Diabetes Knowledge Test 2 (DKT2), a closed-ended questionnaire will be used for the collection of data from pre-diabetic patients who are obese. The participants’ awareness related to the risks of developing T2D and awareness/knowledge regarding risk behavior reduction and interventions will be assessed using theDKT2. The DKT2 will be used to assess DSME. The DKT2 was designed and developed by the Michigan Diabetes Research Training Center (MDRTC). Its purpose is for testing commonknowledge of diabetes in pre-diabetic and diabetic patients. The questionnaire contains questions on (a) description of the diabetes diet, (b) measure of glucose levels in blood, (c) methods for home glucose testing, (d) signs associated with diabetes, (e) reactions based on insulin intake, and (f) causes of blood glucose reaction (Michigan Diabetes Research Center, nd). The DKT2 is not restricted and is open for public use. Thus, there is not a requirement to request permission to use this instrument.

The DKT2 is an approved questionnaire/survey and employs simple questions to minimize the time each respondent would take to answer. Thirty minutes will be allowed for the subjects to complete the questionnaire. Once the questionnaires are completed, the researcher will collect them for subsequent analysis using frequency and distributions in excel sheet (Brown, 2017). Measurement of BMI using a standard weighing scale will be completed pre-testing and eight weeks after DSME intervention with subsequent comparison evaluation using excel sheet.

Validity

Conversely “validity and generalizations handle “how precisely a variable matches a concept” and is usually higher in the creation of the questions to establish a person’s behaviors, ideals,and/or values” (Bouma & Carland, 2016, p.85). Considering the result of this research, Yin (2013) suggests that it is “conceivable to make generalizations from case studies to hypothetical propositions; nevertheless, not to populations” (p. 24). In addition, the objective of the studies is to connect and create theories but not disclose the frequencies (Bouma & Carland, 2016). However, the researcher “interprets that social sciences do not have static rules and that there are plentiful variables which impact the result of a specific study, and for that purpose it's near unattainable to pledge that forthcoming researchers on the same subject will generate identical outcomes” (Yin, 2013, p. 41). Consequently, the outcomes from this research study will not be generalized and this scenario will be appropriately applied in the study.

This project will use the DKT2 for pre-post-testing of awareness. To validate the DKT2, Fitzgeraldet al., (2016)conducted a study to review the validity of the DKT2. The study concluded that “validity of the Diabetes KnowledgeTest 2 was supported by the analyses of the combinedsamples and the preponderance of the combinedsample analyses suggests that the DKT2 is valid and a reliablemeasure of diabetes knowledge” (Fitzgerald, 2016, pp. 183-183).

Reliability

With the aim of decreasing the odds of obtaining incorrect answers, Saunders et al. (2015) suggest researchers give special consideration to both reliability and validity of the study's research design.

Reliability deals with the possibility of various other researchers arriving at the exact same final result when calculating with similar devices. The truth is that issues of reliability symbolize problems and issues within the precision as well as the accuracy of the measuring/calculating instruments (Bouma & Carland, 2016).

Thus, sticking to this notion, Saunders et al. (2015) identify the issues of “biases which may be related to reliability and so are divided into two types (p. 56). The very first type is the researcher’s bias whereby the format, tone or non-verbal behavior of the researcher generates bias in the way that subjects react to the queries being sought after (Saunders et al., 2015). Thus, for this study,

In this study, special consideration is going to be offered on the designing and preparing of the questions to ensure that they are not going to inflict the individual values and viewpoint.Additionally, theresearcherwill make an earnest effort is made to build the trust of the subjects to avert an upswing of doubts with regards to both validity and reliability of the collected information.

The second type of bias is the subject’s bias that is mainly induced by views concerning the researcher where the researcher is likely to examine events/proceedings and search for answers (Saunders et al., 2015). In this situation, regardless of the reality that the researcher will try to obtain the trust of the subjects before the survey, however, it is evident that the subjects will probably be mindful towards the thorough investigation of special subjects and may choose not to disclose and submit specific attributes of the subject. Additionally, it could be believed that the subjects do not respond to the questions with neutrality and try to reflect an inaccurate image of the scenario.

For this study, the DKT2 will be utilized for pre-post DSME awareness assessment. Completing the DKT2 is going to take roughly twenty to thirty minutes. Notwithstanding its practicality, the usefulness of the DKT2 isdependent on the objectivity of the clinician, researcher. The DKT2 is aconvenient,low-cost questionnaire that is used for generalawareness of diabetes and diabetes self-care.

Fitzgerald (2016) conducted a study to test the reliability of the DKT2. It was concluded that both the 14-question general test and the 9-question insulin use sub-scalehad a Cronbach's coefficient ? ? 0.70, thus, the coefficientalphas demonstrated reliability for both the general testand the insulin use subscale for the combined sample; indicating that the questionnaire is reliable.

Completing the DSME questionnaire is going to take up roughly thirty minutes. A Cronbach's Alpha test will be carried out before the pre-assessment to ensure that the questionnaire is reliable.

Data collection procedure

There will be acontinuous formative evaluation to make sure that the activities of the project will be not only effective but completed efficiently. Formative evaluation is used to enhance a project process and delivery through evaluation of the implementation quality and eventual delivery (Geonnotti, Peikes, Wang, and Smith, 2013). Once the researcher secures permissions from the Family Practice clinic, she will send the invitations, through posters, to the patients at the Family Practice clinic to take part in this study.

Before participating in the study, “patientsmust give their permission to be part of a study, and they must be given pertinent information to make an informed consent to participate” (Siegle, 2017).The patients will be given a consent form that provides and lists all elements of the study, which include the type of DSME they will receive and that they will be weighed pre-post testing. The consent form will also include:

· The consent will inform the participants what they are being asked to do, by whom, and for what purpose. The participants will be informed of the identity of the researcher, the affiliations with Grand Canyon University, and be provided with contact information to forward any questions and/orproblems with the research process.

· The participant’s rights to confidentiality, anonymity, and maintaining dignity will be addressed in the “informed” consent.The consent will include protection from physical or psychological harm, psychological, and emotional harm

· The participants of will be informed of any risks they might be taking by participating in the research.This will include protection from physical or psychological harm.

· The participants will be informed of their rights regarding the research process, such as the right to review the material and the right to withdraw from the research study.

· The participants will be informed that their full names will not be used in the study, and they will be given a correlating number for identification.

· The participants will be informed of how the results of the study will be disseminated.

· The participants will be informed that they are free to participate or not participate in the research (Center for Innovation in Research and Teaching, 2017).

After consent has been received the participants will be given an identification code to ensure their anonymity is protected.The data collection process will be facilitated by the investigator herself who will weigh the participant, thendistribute the DKT2 questionnaire. Subsequently, the patients will receive the DSMEintervention. Thereafter, the post-assessment test will commence,and the investigator herself will employ the questionnaire and distribute it for completion by the participants. The researcher will collect the questionnaires after 30 minutes. The questionnaires will be checked for satisfactory completion. Questionnaires that are half completed will be excluded from the study to avoid results that are biased (Brown, 2017).

The questionnaires/data will be placed in a locked filing cabinet in a locked/secure room. The participants will return in eight weeks for a post-test BMI. After collecting BMI measurements from the participants, the pre-posttest scores and BMI measurements of each individual will be analyzed. After project completion, data has been analyzed;data will be stored for 6 months. The paper records/data will be destroyed by shredding it. Electronic data will be destroyed byusing DBAN software that overwrites the data by incorporating a fixed sequence or patterns of letters , numbers,andsymbols.The flashdrive will be destroyed by shredding it.

Data Analysis Procedures

The purpose of this research is to evaluate DSME intervention concerning prediabetes and diabetes in pre-diabetic individuals and the effects on BMI. The independent variable will be the DSME intervention plan,and the dependent variable will be patients’ awareness level about the threat of acquiring T2D and awareness concerning risk lowering habits and treatments, and these factors will be assessed adopting a quantitative method and using a descriptive design. Other dependent variables will be BMI assessment. The BMI will be measured by weighing the patient before awareness education and eight weeks after receiving the intervention. Lastly, the health belief model is the theoretical foundation for this study.

Descriptive statics and Demographic info will be computed using Microsoft Excel. Descriptive statistics will include frequencies and percentages. Both techniques will be used to assess the subjects’ demographic information. Moreover, frequencies and percentages will also be used to calculate awareness and knowledge in both pre and post-tests. Descriptive statistics has been chosen because it can determine the connection amid independent and dependent variables within a chosen population and both percentages and frequencies align well with quantitative research designs (Creswell, 2014).

Results from the questionnaire and pre-posttest BMI measurements will be inserted manually into the excel sheet. After that frequency and percentage formulas will be used to derive the results.The knowledge scores will be arranged from 0 to 23 with 0 to 10 signifying poor knowledge; 11 to 17 signifying average knowledge, and 18 to 23 signifying higher knowledge levels. Scores for awareness will be classified along the same lines (Brown, 2017). The impact of the DSME intervention-relatedto changes in BMI, i.e., reduction of BMI will be measured with the level of statistical significance for the quantitative analyses being p value < 0.05. Comment by Maria Thomas: Include the level of statistical significance for quantitative analyses as appropriate.

Ethical Considerations

The researcher must first seek the consent of the participants before involving them in the study (Felzmannet al. 2010). The DPI project’s goal and the subject’s roles will be made clear in the consent form. It will also highlight the dangers and benefits of participating in the project related to confidentiality, anonymity and maintaining dignity.

The ethical consideration for this project will adhere to the fundamental principles of the Belmont Report by providing respect for persons, justice, and beneficence in the design and sampling procedures. These ethical considerations can be accomplished by:

· Respect for persons where the participants will be treatedautonomouslyand individuals with diminished autonomy will be entitled to additional protections.

· Justice will be achieved by ensuring reasonable, non-exploitative, and well-considered sampling method, choosing an appropriate research design, explaining the purpose of the research while finding an answer to the research question.Further, DSME interventions and measurement of BMI will be administered fairly. The DPI project results will be disseminated by ensuring reasonable methods.

· Beneficence will be achieved by minimizing risks and maximizing benefits to participants and society (U.S. Department of Health and Human Services, 2016).

Participants’ privacy and anonymity will be emphasized and wholly explained so that participant rights are observed for this project. Recruitment will only include participants that sign the consent form (Hammersley &Traianou, 2012). Physician to client privacy privileges will be fully granted to the subjects. Personal identification details will not be publicized (Brown, 2017). The questionnaires will be coded and stored in a secure room where only the researcherhas access to maintain participants confidentiality.

Limitations

The aim of this DPI project is directed towards assessing awareness and knowledge levels about pre-diabetes and diabetes among people with pre-diabetes and obesity at a Family Practice clinic. One limitation has been the approach wherein this study only uses induction rather than a mixed method design. The use of induction will assist in evaluating the knowledge gained and the effectiveness of DSME intervention. Another limitation has been the small sample size of 30 obese patients. This is due to the timeframe available for this study and the resources available to the researcher. Moreover, to meet the goals of this study, the researcher is going to select the sample using thepurposive method as it will permit the researcher to select the most appropriate subjects which can most efficiently and effectively assist in answering the research questions with accuracy and precision. In addition, the population has been limited to one Family Practice clinic.

A third limitation is the use of the DKT2 only to gather data instead of interviews and questionnaire or interviews together to obtain the data. The use of the DKT2, aclosed-ended questionnaire is in sync with the goals of this study and the chosen quantitative method of analysis and therefore will assist in producing accurate results. Given the simplicity of the data, another limitation is that the researcher will use descriptive statistics to analyze data as it can determine the connection amid independent and dependent variables within a chosen population and both percentages and frequencies align well with quantitative research designs.

Given the goals of this DPI project, the timeframe and resources available to the researcher, the selected methodology is the most appropriate strategy to answer the research question. Thus, despite the limitations of the study, awareness,and knowledge related to effects on BMI will be appropriately assessed.

Summary

This chapter presents a descriptive quantitative approach in evaluating obese pre-diabetic patients’awareness and understanding of DSME concerning pre-diabetes and diabetes in obese pre-diabetic individuals and its effects on BMI in an urban family practice clinic.

Further, the data collection uses the DKT2 as the primary tool for the collection of data; while using a standard weighing scale to measure BMI. Data collection will involve30 obese participants with a BMI >30 diagnosed with pre-diabetes that will be selectedfrom the Family Practice clinic. Purposive sampling will be the favored approach. It means that only patients who meet the standards will be chosen.

Data analysis will use percentages and frequencies that willbe applied as descriptive statistical tools to establish the knowledge and awareness variation regarding diabetes among the participants. As stated previously, descriptive statistics havebeen chosen because it can determine the connection amid independent and dependent variables within a chosen population and both percentages and frequencies align well with quantitative research designs (Creswell, 2014). Additionally, there will be formative evaluation throughout the study’s process so that research activities will be carried out in accordance with the approved approaches and in an effective and efficient manner; including ethical considerations such as respect for persons, justice and beneficence ((U.S. Department of Health and Human Services, 2016).

There will be limitations to this study which include the assumed research philosophy, approach wherein this study only uses induction rather than a mixed method design, and only usingthe DKT2 to assess patient knowledge levels and understanding. Moreover, lastly, the population has been limited to one Family Practice healthcare center, while utilizing a small sample size. Thus, the results cannot always represent the actual occurring, in a generalized form. Also, the respondents have limited options of responses, based on the selection made by the researcher

Finally, after completing the data collection, chapter 4 will present the “Data Analysis and Results.” The chapter will briefly present the problem statement, methodology, and the clinical question. In this chapter, the collected data will be summarized, a description of how it was analyzed will be described, and the results will be presented.

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