Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11918 The impact of structured education on knowledge and self-efficacy in type 2 diabetes mellitus patients Erlin Sayuti,1,2 Hema Malini,3 Devia Putri Lenggogeni3 1Faculty of Nursing, Universitas Andalas, Padang; 2Universitas Andalas Hospital, Padang; 3Medical Surgical Department, Faculty of Nursing, Universitas Andalas, Padang, Indonesia Abstract Patients diagnosed with Type 2 Diabetes Mellitus (T2DM) need to acquire knowledge and self-confidence to effectively engage in self-care activities. A structured education program has the potential to influence knowledge, self-efficacy, and self-care behavior. This study aimed to investigate the impact of education on the knowledge, self-efficacy, and self-care of individuals with T2DM. The research employed a quasi-experimental non-equiva- lent control group design with purposive sampling. The total sam- ple size consisted of 60 participants, with 30 in each group. The intervention group attended a four-session T2DM structured edu- cation program conducted by internal medicine specialists, nurses, nutritionists, and pharmacists, while the control group continued with their usual monthly check-ups. The results of the independent t-test revealed differences in knowledge, self-efficacy, and self- care between the intervention and control groups in the post-test assessment. Education for T2DM patients was found to be effec- tive in enhancing knowledge (p=0.000), self-efficacy (p=0.000), and self-care (p=0.000), making it a recommended component of self-management education to prevent complications. The impli- cations of this study may assist hospitals in developing Standard Operating Procedures (SOPs) for implementing structured educa- tion programs for individuals with Type 2 Diabetes Mellitus as a means of enhancing patients’ management skills for T2DM. Introduction Diabetes Mellitus (DM) remains a global problem,1 and its prevalence has increased in developing countries.2 Type 2 Diabetes Mellitus (T2DM) is one of the non-communicable dis- eases that continues to rise in prevalence and mortality rates over the years.3,4 T2DM is a chronic condition characterized by decreased responsiveness to insulin and reduced insulin produc- tion by pancreatic β cells resulting in long-term hyperglycemia.5 The International Diabetes Federation (IDF) estimates that there are currently 463 million people with diabetes, and this number is expected to rise to 700 million by 2045, with 90% being T2DM.6 The IDF also predicts a substantial increase in T2DM cases from 10.7 million in 2019 to 13.7 million in 2030.5 With 10 million adults diagnosed with diabetes, Indonesia ranks seventh in the prevalence of diabetes, following China, the United States, Brazil, Russia, and Mexico. The rising prevalence of T2DM is a signifi- cant global concern, and if left unmanaged, it can lead to various complications, including vascular issues, neuropathy, and other related problems.7,8 A previous study found that 76.4% of T2DM patients suffer from at least one complication.9 Meanwhile, in West Sumatra province, out of 19 municipalities, Padang is one of the cities that has a high prevalence of T2DM, with a prevalence rate of 2.47%.10 Effective prevention of long-term complications necessitates a strong foundation of knowledge to support self-care activities.11 A structured education program is crucial to ensuring that T2DM patients have the knowledge and abilities necessary for self-care.12 Self-management for type 2 diabetes treatment includes dietary regulation, physical activity/exercise, blood glu- cose monitoring, medication adherence, and self/foot care. A structured education program has been created and tested mul- tiple times in Indonesia called the Indonesian Group-Based Diabetes Education Program (InGDEP).13 Malini, Copnell, and Correspondence: Hema Malini, Faculty of Nursing, Universitas Andalas, Padang, Indonesia. E-mail: hemamalini@nrs.unand.ac.id Key words: education class, type 2 diabetes mellitus patient, knowledge, self-care. Contributions: ES, article writing; conceptualization; methodology; investigation; formal analysis; data curation; implementation of research protocols. HB, DPL, work concept; supervision; conceptualization; final approval of the version to be published, writing review and editing; final approval of the version to be published. Conflict of interest: the authors declare no potential conflict of interest. Ethical approval and consent to participate: To safeguard the welfare and human rights entitlement of the subjects, this study has undergone ethical review. The Research Ethics Committee of the Faculty of Nursing at Andalas University in Padang has approved this study under number 029.laiketik/KEPKFKPUNAND. Informed consent: all patients participating in this study signed a written informed consent form for participating in this study. Availability of data and material: data and material are available upon request to the authors. Funding: thesis Research Scheme, DRTPM, Higher Education Number 115/E5/PG.02.00.PL/2023 Acknowledgment: I would like to thank all parties who took part in this research, the patients who agreed to be part of this research, the supervi- sors and families who always encouraged me to complete this research. Received: 5 October 2023. Accepted: 20 December 2023. Early access: 2 February 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:11918 doi:10.4081/hls.2024.11918 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:11918] [page 237] Non -co mmerc ial us e o nly Moss (2017) created this concept.14 The high prevalence of type 2 DM is caused by unchangeable risk factors, such as gender, age, and genetic factors. The second is modifiable risk factors, such as smoking habits, education level, occupation, physical activity, alcohol consumption, Body Mass Index (BMI), waist circumfer- ence, and age.15 There are 4 pillars of DM management: education, medical nutrition therapy, physical activity, and pharmacological therapy. Education about knowledge of T2DM is crucial for con- trolling risk factors and preventing complications.16 Positive knowledge and mindset have been shown to improve the self-care practices of T2DM patients.17 Knowledge is the result of sensory perception and leads to the acquisition of new knowledge, particu- larly about T2DM.18 Knowledge plays a vital role in enhancing self-efficacy, enabling individuals to perform proper self-care activities.19 Several studies have demonstrated that education pro- grams for T2DM patients are effective in boosting self-efficacy, which, in turn, significantly influences self-management.9 Self- efficacy refers to an individual’s belief in their capacity to initiate, motivate themselves, and act, with potential effects on cognitive, motivational, affective, and selection processes.20 In the context of T2DM, self-efficacy relates to an individual’s confidence in their ability to manage their blood sugar effectively and serves as a valuable framework for understanding and predict- ing the behavior and commitment of T2DM patients.21,22 There is a clear connection between self-efficacy and T2DM self-care, with self-efficacy significantly impacting a patient’s ability to engage in self-care activities positively or negatively. Increased self-efficacy has been linked to improved self-care.23 Self-care encompasses active practices by patients aimed at improving their physical con- dition and maintaining health through measures such as dietary choices, physical exercise, blood sugar monitoring, and preventive healthcare services.11 T2DM patients require ample support in terms of resources, information, and self-confidence to effectively implement self-care.24 Effective management of T2DM through self-care can be facil- itated through structured and continuous education, aligning with the principles of the social learning theory, which emphasizes cog- nitive components and promotes understanding and evaluation of learned material.25 Data from medical records of University hospi- tal revealed an increasing number of T2DM patients in the Outpatient Internal Medicine ward, with a total of 364 patient vis- its during that period. Among these patients, four had less than 50% knowledge about T2DM, one had knowledge above 50%, and none had an excellent level of knowledge. Some patients were uncertain, while two were confident in their ability to manage dia- betes self-care activities. Regarding self-care, a small number of patients demonstrated poor self-care, while none exhibited good self-care behavior. Nurses at the outpatient ward noted the absence of a structured and continuous education program for T2DM patients, with only occasional counseling and information provid- ed through QR barcode scanners and leaflets. Based on the prelim- inary study, researchers identified that there is a need for providing an education program that suit with the hospital situation. Lack of self-care management of T2DM patients could increase complica- tions and a reduced quality of life for T2DM patients. A viable solution involves implementing a health education program, which is part of the development of the InGDEP method. This includes applying simulation or demonstration methods in regular educa- tional classes for T2DM patients in the outpatient setting. The edu- cational class will be based on adapting the InGDEP concept to hospital conditions, modifying learning methods, and enhancing interactions in educational sessions. The educational program will follow the social learning theory, emphasizing the cognitive com- ponent of individuals’ minds, leading to better understanding and evaluation of the learned material. Moreover, educational materials will align with the pillars of management (diet, physical activity/exer- cise, medication, and lifestyle) established by the Indonesian Endocrinology Association (2017).7 The method will involve employing an active learning approach in educational classes, foster- ing cohesion between participants and educators. To address this gap and enhance the knowledge, self-efficacy, and self-care of T2DM patients, the researchers proposed a solution. The suggestion involves incorporating simulation or demonstration using the InGDEP tech- nique into routine teaching for T2DM patients at the outpatient clinic.13 The research question guiding this study was: What is the effect of educational classes on the knowledge, self-efficacy, and self- care of T2DM patients in Outpatient University Hospitals? Thus, this study aimed to investigate the impact of an educational program for T2DM patients on their knowledge, self-efficacy, and self-care. Materials and Methods Study design This study employs a quantitative quasi-experimental non-equiv- alent control group design to establish a cause-and-effect relationship. It utilizes a pre-test and post-test with a control group design, focusing on a structured education program provided to T2DM patients to assess its impact on knowledge, self-efficacy, and self-care. Intervention Researchers divided respondents into two groups: a control group with 30 participants and an intervention group with 30 participants. The intervention group was further subdivided into two educational classes, each consisting of 15 respondents. The educational classes spanned four weeks, with two sessions held per week, covering the same material. The provided material included concepts related to diabetes management and lifestyle, dietary practices, food organiza- tion, physical activity, and medication management. Each session was conducted by healthcare professionals, including doctors, nutri- tionists, and nurses. Sample size and sampling method The study included T2DM patients from the Internal Medicine Outpatient Clinic at University Hospital in Padang. There was an average of 121 patient visits per month from June to August 2022, totaling 364 visits over three months. The study involved 30 partici- pants in the intervention group and 30 in the control group, deter- mined using the Slovin formula. Purposive sampling was employed with specific inclusion and exclusion criteria. Inclusion criteria included T2DM patients proficient in reading and speaking without cognitive deterioration. Exclusion criteria encompassed patients with communication problems, psychiatric issues, diminished hearing, kidney dysfunction, cardiovascular problems, and poor eyesight. Study tools To measure participants’ knowledge, the DKQ-24 Diabetes Knowledge Questionnaire: A 24-question survey assessing knowl- edge of diabetes mellitus with options of true, false, or don’t know answers.19 The questionnaire used for this study has previously been translated and validated by Malini et al., with a Cronbach alpha for the Indonesian version of DKQ-24 of 0.603. For measuring self-effi- cacy, this study used Self-Efficacy for Diabetes Scale: an eight-item survey graded on a Likert scale of 1 to 10 to evaluate self-efficacy, with a higher score indicating greater confidence This questionnaire Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [page 238] [Healthcare in Low-resource Settings 2024;12:11918] Non -co mmerc ial us e o nly has been adopted previous study which underwent reliability and validity tests, with a Cronbach alpha value of 0.87.26 Meanwhile, Summary of Diabetes Self-Care Activities (SDSCA) questionnaire was used, and consists of 17-question survey, originally created by Toobert, Hampson, and Glasgow in 2000 and modified by Agrimon (2014), used to assess self-care practices over the past seven days fol- lowing education. The Cronbach alpha value for the Indonesian ver- sion is 0.474.27 Research ethics Ethical approval for this study, ensuring subject welfare and human rights, was obtained from the Research Ethics Committee of the Faculty of Nursing at Universitas Andalas in Padang under approval number 029.laiketik/KEPKFKPUNAND. Data analysis The analysis employed both univariate and bivariate techniques. Univariate analysis assessed the knowledge, self-efficacy, and self- care levels of T2DM patients during pre-test and post-test in both the intervention and control groups. It included descriptive statistics such as distribution, presentation, maximum and minimum values, stan- dard deviation, and mean with a 95% Confidence Interval. Bivariate analysis examined the mean differences and the impact of education on T2DM patients’ knowledge, efficacy, and self-care before and after the intervention, as well as between the intervention and control groups to support the research hypothesis. Normality was checked using the Shapiro-Wilk test, and parametric tests such as paired-sam- ple T-tests and independent T-tests were applied to pre-test and post- test data for knowledge, self-efficacy, and self-care in both groups. Results The purpose of this study was to determine how structured edu- cation affects knowledge, self-efficacy, and self-care in the manage- ment of Type 2 Diabetes Mellitus. Based on Table 1, all characteris- tics of respondents in the intervention and control groups are homo- geneous (p value >0.05). Respondents in the intervention group were predominantly pre-elderly (45-59 years old, 70%), had secondary education (40%), worked as IRT (40%), suffered from T2DM for ≤5 years (57%), and had a family history of T2DM (87%). Table 2 shows the average knowledge, self-efficacy, and self-care of T2DM patients in outpatient University Hospital Padang in the intervention and control groups before and after education classes. In the intervention group, the average value of knowledge after being given educational classes increased (9.73). Likewise on self- Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Characteristics of intervention and control group respon- dents (n=60). Characteristic Group Homogeneity test intervention control n=30 (%) n=30 (%) Gender Man 11 (37) 14 (47) Woman 19 (63) 16 (53) Age Adults (20-44 years) 2 (7) 3 (10) Pre-elderly (45-59 years) 21 (70) 13 (43) Senior (60 years or older) 7 (23) 14 (47) Education Lower education 6 (20) 5 (17) Secondary education 12 (40) 18 (60) Higher education 12 (40) 7 (23) Work Teacher 0 (0) 1 (3) IRT 12 (40) 13 (43) Merchant 2 (7) 2 (7) Pensioner 0 (0) 4 (13) Farmer 0 (0) 2 (7) Civil servants 7 (23) 4 (13) Self-employed 9 (30) 4 (13) Duration of T2DM Diagnosis ≤5 years 17 (57) 16 (53) >5-10 years 9 (30) 10 (33) >10-15 years 3 (10) 4 (13) ≥15 years 1 (3) 0 (0) Family history of T2DM Exist 26 (87) 25 (83) None 4 (13) 5 (17) Table 2. The effect of educational classes on knowledge, self-efficacy, and self-care (n=60). Variable Group Mean Mean Mean difference Pretest Post-test Knowledge Intervention 10.00 19.73 9.73 Control 9.10 7.43 -1.66 Self-efficacy Intervention 4.23 7.54 3.31 Control 4.46 4.36 -0.10 Self-care Intervention 3.15 5.14 1.98 Control 2.98 3.00 0.02 Table 3. Differences in knowledge, self-efficacy, and self-care between intervention and control groups of T2DM patients during the post- test (n=60). Variable Group Mean difference Sig (2 Tailed) t Knowledge (Post) Intervention 12.300 16.077 0.000 Control Self-efficacy (Post) Intervention 3.183 17.289 0.000 Control Self-care (Post) Intervention 2.133 15.536 0.000 Control Non -co mmerc ial us e o nly efficacy (3.31), and self-care (1,98). After being given education, there is an increase in the mean value, it can be seen where the mean difference has increased. While in the control group, the trend was to experience a decrease in the average value for knowl- edge (-1.66), self-efficacy (-0.10) during the post test. Meanwhile, for self-care (0.02) , there is only a slight difference from the aver- age value during the post-test. Meanwhile, Table 3 shows the results of the Independent Samples T Test on the intervention and control groups obtained knowledge (p=0.000), self-efficacy (p=0.000), and self-care (p=0.000). This means that there are differences in knowledge, self-efficacy, and self-care in the intervention and control groups during the posttest at University Hospital Outpatient ward. Discussion In this study the class education that adopted from structured health education program, conducted by having an interpersonal collaboration between health professionals. The team consist of healthcare teams (doctors, nurses, nutritionists, pharmacists) who collaborate to deliver educational materials on various health top- ics.13 Collaboration between the presenters and nurses, when pre- senting the topic, served as an elaboration in this study. For instance, the nurse instructed the class on pharmacology on how to administer insulin therapy. Educators encourage patients to partic- ipate in the learning process through group discussions and prac- tices based on learning objectives. Active involvement of educa- tional participants and demonstrations/simulations can maximize learning, creating cohesion between educational participants and educators.28 According to Leo et al. (2022), there is a significant positive relationship between educational linkage behavior and affecting participants’ motivation in achieving goals. Based on the results of this study, there was an influence from the provision of educational structure on knowledge, self-efficacy, and self-care.29 The increased knowledge in the intervention group was attributed to continuous education over four weeks, the provision of pocketbooks for Type 2 Diabetes Mellitus, and the use of simu- lation/demonstration methods in delivering material. The results align with Hailu’s research on the influence of education on increasing knowledge.19 The education in this study comprised six sessions lasting 1-1.5 hours each, focusing on T2DM concepts and intervention behaviors. Significant improvements were noted in knowledge regarding dietary recommendations and foot care prac- tices. The decline in knowledge levels in the control group was due to not receiving the same treatment, namely ongoing education on the concept of T2DM. These patients only underwent routine inter- nal medicine poly check-ups. While they received information about their health from internal medicine specialists, detailed explanations about T2DM and structured self-care management were lacking. Information in short-term memory can be transferred to long-term memory through effort and practice in a conscious state with repetitive processes. Another reason for declining knowledge levels is forgotten information. According to cognitive theory, information is processed by the reasoning system and stored in permanent memory. However, real-world experiences sometimes contradict theory, making it challenging to recall dili- gently learned information. Boredom can also lead to a sense of redundancy in one’s actions.30 Meanwhile, self-efficacy in T2DM patients represents an indi- vidual’s self-confidence in their ability to manage blood sugar lev- els.21 The study found significant differences in self-efficacy between the intervention and control groups. These results are related to the patient’s mastery of self-care, increasing their confi- dence in correctly performing self-care. Self-efficacy positively contributes to improved self-care. Increased self-efficacy in self- care is influenced by the education provided.23 The results of this study align with similar research, which indicates the effect of edu- cation on increasing self-efficacy.31 In addition to education, patients received health information through leaflets and videos. Another study also reported an influence on self-efficacy levels after education in Discharge Planning.32 Thus, it can be concluded that patients with Type 2 Diabetes Mellitus can increase their knowledge about T2DM management through education provided in a structured education program. This process involves adding information, sharing positive experiences in T2DM management, and increasing confidence to control blood sugar levels, live better, and avoid T2DM complications. Self-care behavior in T2DM patients was assessed by asking respondents about diabetes self-care activities in the last seven days after receiving education. These routine activities included diet, physical activity (exercise), foot care, blood glucose monitor- ing, and medication. In this study, the intervention group reported more frequent dietary adjustments (6 days a week) compared to the control group (4 days a week). Align with similar study, where the intervention group performed dietary self-care for an average of 6 days a week, while the control group did so for 4 days a week.33 Dietary regulation in the intervention group resulted from the respondents’ ability to adjust their food intake based on their needs. However, the control group had lower dietary self-care because they lacked understanding in setting their diet according to their requirements. For Physical Exercise: The intervention group engaged in physical self-care more frequently, averaging 5 days a week, com- pared to the control group, which averaged 3 days a week. These results are consistent with similar a study which the intervention group participated in physical activity 5 days a week.33 The differ- ence occurred because the intervention group, after attending T2DM education classes, tried to be more physically active than the control group. Respondents in the intervention group engaged in physical activities more effectively than the control group. There was no significant difference in self-care related to medica- tion use. Both the intervention and control groups had an average medication self-care routine of 3 days a week. This lack of improvement in medication adherence was because both groups struggled with proper medication usage. Patients often forgot to take their medication the required number of times per day (two or three times), resulting in suboptimal adherence.34,35 Both the inter- vention and control groups monitored their blood sugar levels an average of 2 times a week during post-tests. However, most respondents checked their blood sugar levels the day before their routine internal medicine poly check-ups. This indicates that respondents did not have the necessary tools to check their blood sugar levels regularly on their own. The intervention group report- ed better diabetic foot self-care, averaging 6 days, compared to the control group’s 3 days. These results are consistent with Indaryati’s study,33 which found that the intervention group performed diabet- ic foot self-care for an average of 6 days, while the control group did so for 3 days. The improvement in diabetic foot self-care in the intervention group was due to a better understanding of the risks associated with diabetic feet and how to care for them among the patients. Most respondents failed to dry the areas between their toes after wetting their feet, unaware that moisture in these areas could increase the risk of fungal growth and foot infections.7 Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [page 240] [Healthcare in Low-resource Settings 2024;12:11918] Non -co mmerc ial us e o nly Limitations This study has several weaknesses, namely the limited research time, which prevented the examination of long-term effects and follow-up activities. Additionally, the sustainability of this education program relies on the commitment of health work- ers, emphasizing the importance of their dedication to implement- ing health education programs. Conclusions In summary, the study highlights the positive impact of struc- tured educational interventions on the knowledge, self-efficacy, and self-care practices of patients with Type 2 Diabetes Mellitus. These findings underscore the significance of patient education as an integral component of diabetes management. The results of this study can contribute to the hospital’s efforts in providing education to T2DM patients. Implementing educational class programs is a viable alternative based on the research findings. This study serves as evidence for the management of T2DM patients in hospitals, particularly in the development of health education programs. Therefore, it is recommended that the hospital establish a policy for creating standardized operational procedures for the implemen- tation of educational classes for T2DM patients. Additionally, con- sideration should be given to the development and application of the role of educators among health workers, fostering collaboration in healthcare services. References 1. Ong KL, Stafford LK, McLaughlin SA, et al. Global, regional, and national burden of diabetes from 1990 to 2021, with pro- jections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 2023;402:203- 34. 2. Awang Jihadi MH, Yuda A, Sukorini AI, et al. Drug-related problems in hospitalized patients with type 2 diabetes mellitus: A systematic review. Explor Res Clin Soc Pharm 2023;12:100348. 3. Dewi EU, Widari NP, Nursalam, et al. The relationship between diabetes self-care management and blood glucose level among type 2 diabetes mellitus patients. Int J Publ Health Sci 2023;12:1165-70. 4. Kusnanto K, Arifin H, Pradipta RO, et al. Resilience-based Islamic program as a promising intervention on diabetes fatigue and health-related quality of life. PLoS One 2022;17:1- 16. 5. IDF. IDF Diabetes Atlas 2021. International Diabetes Federation. 2021. Available from: https://idf.org/e-library/epi- demiology-research/diabetes-a t las .h tml%0Ahttp: / / www.idf.org/about-diabetes/facts-figures%0Ahttps://diabete- satlas.org/upload/resources/material/20200302_133351_IDFA TLAS9e-final-web.pdf 6. Zairina E, Nugraheni G, Sulistyarini A, et al. Factors related to barriers and medication adherence in patients with type 2 dia- betes mellitus: a cross-sectional study. J Diabetes Metab Disord 2022;21:219-28. 7. PERKENI. Guidelines for the Management and Prevention of Type 2 Diabetes Mellitus Adults in Indonesia 2021. Global Initiative for Asthma. 2021;46. Available from: www.ginasth- ma.org 8. Mboi N, Syailendrawati R, Ostroff SM, et al. The state of health in Indonesia’s provinces, 1990–2019: a systematic anal- ysis for the Global Burden of Disease Study 2019. Lancet Glob Health 2022;10:e1632-45. 9. Qiu T, Huang J, Wang W. Association between Diabetes Knowledge and Self-Efficacy in Patients with Type 2 Diabetes Mellitus in China: A Cross-Sectional Study. Int J Endocrinol 2020;2020. 10. Riskesdas. Riset Kesehatan Dasar Provinsi Sumatera Barat Tahun 2018. Laporan Riskesdas Nasional 2018. 2019. 1-478 p. 11. AADE7TM. American Association of Diabetes Educators. Encyclopedia of Child Behavior and Development, 2020; p. 1307. 12. Darma Karingga D, Efendi F. Effect of mobile structured edu- cational applications on self-care management in diabetes mel- litus patients. Gac Med Caracas 2023;131:278-86. 13. Malini H, Yeni F, Saputri DE. The Effect of InGDEP on Type 2 Diabetes Patients’ Knowledge and Self-Care. Jurnal Keperawatan Padjadjaran 2018;6:235-42. 14. Malini H, Copnell B, Moss C. Considerations in adopting a culturally relevant diabetes health education programme: An Indonesian example. Collegian 2017;24:183-90. 15. Rokhmad K, Supriyanto S. Analysis of PROLANIS activities on controlling type-2 diabetes mellitus at Puskesmas Tulungagung in 2022. J Public Health Afr 2023;14:2617. 16. Purwanto CR, Sukartini T, Bakar A, Devy SR. Increasing self- care of patients with type-2 diabetes through implementation of nursing agency based on the health promotion model. J Pak Med Assoc 2023;73:S130-4. 17. Shawahna R, Samaro S, Ahmad Z. Knowledge, attitude, and practice of patients with type 2 diabetes mellitus with regard to their disease: a cross-sectional study among Palestinians of the West Bank. BMC Public Health 2021;21:472. 18. Heriani P, Nauli FA, Woferst R. The relationship of the level of knowledge about DM disease to the coping mechanism of type 2 DM patients. 2020;2030. 19. Hailu FB, Moen A, Hjortdahl P. Diabetes self-management education (DSME) – Effect on knowledge, self-care behavior, and self-efficacy among type 2 diabetes patients in Ethiopia: A controlled clinical trial. Diabetes Metab Syndr Obes 2019;12:2489-99. 20. Bandura A. Self�efficacy. The Wiley Encyclopedia of Personality and Individual Differences. 1994;1994:387-91. 21. Adinata Ach A, Minarti M, Kastubi K. Relationship between Self-Efficacy, Compliance and Family Support with Self- Management of Type 2 Diabetes Mellitus Sufferers in Surabaya. Jurnal Ilmiah Keperawatan Stikes Hang Tuah Surbaya 2022;17:6-15. 22. Anandarma SO, Asmaningrum N, Nur KRM. The Relationship between Self-Efficacy of Type 2 Diabetes Mellitus Patients and the Risk of Readmission at Dr. Regional General Hospital. Harjono, Ponorogo Regency. Jurnal Keperawatan Sriwijaya 2021;8:39-49. 23. Tharek Z, Ramli AS, Whitford DL, et al. Relationship between self-efficacy, self-care behaviour and glycaemic control among patients with type 2 diabetes mellitus in the Malaysian primary care setting. BMC Fam Pract 2018;19:1-10. 24. Kalonga N, Mukwato PK, Wahila R. Nursing & Primary Care Self- Efficacy and Self- Care Practices, In Glycemic Control among Adults with Diabetes Mellitus Receiving Care at Kitwe Teaching Hospital, Kitwe, Zambia. Nursing a & Primary Care 2023;7:4-8. 25. Harmiardillah S. The Effect of Mindfulness-Based Eating Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2024;12:11918] [page 241] Non -co mmerc ial us e o nly Training Using a Social Cognitive Theory (SCT) Approach on Self-Efficacy, Diet Compliance and Blood Glucose Levels in Type 2 Diabetes Mellitus. Ir-perpustakaan Universitas AIR- LANGGA. 2018;1-478. 26. Sabil FA. Relation of Health Literacy and Self Efficacy to Self Care Management Relationship of Health Literacy and Self Efficacy to Self Care Management of Type 2 Diabetes Mellitus Patients in Makasar City Community Health Centers Type 2 Diabetes Mellitus Patients. Bitkom Research 2018;63:1-3. 27. Agrimon OH. Exploring the Feasibility of Implementing Self- Management and Patient Empowerment through a Structured Diabetes Education Programme in Yogyakarta City Indonesia: A Pilot Cluster Randomised Controlled Trial. The University of Adelaide. 2014;1-24. 28. Fitria, Y, Indra W. Pengembangan model pembelajaran PBL berbasis digital untuk meningkatkan karakter peduli lingkun- gan dan literasi sains. Deepublish; 2020. 29. Leo FM, López-Gajardo LG, Rodríguez-González P, et al. How class cohesion and teachers’ relatedness support/thwart- ing style relate to students’ relatedness, motivation, and posi- tive and negative outcomes in Physical Education. Psychol Sport Exerc 2023;65:102360. 30. Nofindra R. Memory, forgetting, and transfer in learning and learning. Journal of Economic Education and Economic Sciences. Jurnal Kajian Pendidikan Ekonomi dan Ilmu Ekonomi 2019;2:1-19. 31. Susanti., D, Marselin. A. ncreased self-efficacy of diabetes militus patients during the pandemic. Journal of Primary Health (Jurnal Kesehatan Primer) 2021;6:23-31. 32. Nurjanah. U. The Effect of Self Care Management Education in Discharge Planning on the Self Efficacy of Type 2 Diabetes Mellitus (DM) Patients in Inpatient Bayu Asih Purwakarta Hospital. Phys Rev E 2018;8:24. 33. Indaryati S. The effect of diabetes self management education (DSME) on the self-care of diabetes mellitus patients in Palembang city hospital. 1. Jurnal Ilmiah Kesehatan 2018; 1:44-52. 34. Suprapti B, Izzah Z, Anjani AG, et al. Prevalence of medica- tion adherence and glycemic control among patients with type 2 diabetes and influencing factors: A cross-sectional study. Glob Epidemiol 2023;5. 35. Rochmah N, Hisbiyah Y, Perwitasari RK, et al. Quality of Life, Medication Adherence, and Glycemic Control in Type 1 Diabetes Mellitus Children with Basal Bolus Regimen During COVID-19 in Limited Resources Setting. J Comprehensive Pediatr 2023;14:e134561. Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions [page 242] [Healthcare in Low-resource Settings 2024;12:11918] Non -co mmerc ial us e o nly