Hrev_master Healthcare in Low-resource Settings 2024; volume 12:11984 The impact of the Le-Diabet application on self-efficacy and blood glucose levels in diabetes mellitus patients Lina Erlina,1 Widi Hastuti2 1Department of Nursing, Politeknik Kesehatan Kementerian Kesehatan Bandung; 2Department of Nutrition, Politeknik Kesehatan Kementerian Kesehatan Bandung, Indonesia Abstract Le-Diabet is an Android mobile application developed for dia- betes management whose effectiveness has remained unknown. This research aimed to investigate its impact on self-efficacy and blood glucose levels in patients with diabetes. Employing a quasi- experimental approach, the study utilized a pretest and posttest control group design. The sample included 28 respondents in the control group and 34 in the intervention group, selected through purposive sampling based on criteria such as diagnosed diabetes, smartphone usage, and 6 weeks of using the Le-Diabet applica- tion. Self-efficacy was measured using the Diabetes Management Self-Efficacy Scale, while blood glucose levels were monitored with a glucometer. Data analysis involved paired and unpaired t- tests. The results revealed a significant increase in self-efficacy scores by 3.1 points [p=0.000, 95% confidence interval (CI) = - 6.006 to -1.876] in the intervention group, whereas the control group experienced a decrease of 1.9 points. Both groups exhibited an increase in blood glucose levels, with a significant rise of 35.6 mg/dL (p=0.035, 95% CI = -68.578 to -2.636) in the control group and a non-significant increase of 3.59 mg/dL (p=0.076, 95% CI = -22.759 to 15.582) in the intervention group. The research con- cludes that the use of the Le-Diabet application enhances self-effi- cacy and maintains blood glucose level stability; however, it has not shown an impact on metabolic syndrome indicators in diabetic patients. Further research is needed, utilizing a larger and more diverse sample from various age groups and extending the dura- tion of the study to evaluate the long-term impact of the applied intervention. Introduction The prevalence of diabetes mellitus in Indonesia is estimated to continue to increase both at the national and global levels.1 The World Health Organization estimates that by 2030 the number of diabetes sufferers in Indonesia will increase threefold since 2000. In 2000, there were around 8.4 million diabetes sufferers, while in 2030, the estimate will reach 21.3 million people.2 This prediction shows a significant upward trend. The results of Basic Health Research in 2018 show that the prevalence of diabetes in Indonesia reached 8.5%.3,4 This shows that more than 8% of Indonesia’s population suffers from diabetes. This data highlights the importance of efforts to prevent and manage diabetes in Indonesia. The Indonesian Endocrinology Association states that there are five pillars of diabetes management, namely education, diet, physical activity, medication, and blood sugar monitoring.2 The five pillars of diabetes management cannot be separated because they are continuous with one another. Of the five pillars, education is the key to the success of the other four pillars. Insufficient edu- cation will result in a lack of knowledge, thereby triggering a high prevalence of diabetes and high complications due to diabetes itself.5,6 Diabetes is a chronic disease that needs to be controlled throughout life, so the patient’s role in managing the disease is very important.7-9 The patients’ ability to control and reduce the impact of the disease they suffer from affects the process and results of diabetes management.10-12 This ability is known as dia- betes self-care management, which can help patients control their blood sugar, thereby reducing the risk of complications.13 Self- care management can prevent morbidity, long-term complications and even death.14 Correspondence: Lina Erlina, Department of Nursing, Politeknik Kesehatan Kementerian Kesehatan Bandung, Bandung, Indonesia. E-mail: linahiar2@gmail.com Key words: blood glucose, Le-Diabet, self-efficacy. Contributions: LE, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing - original draft, review and editing; WH, conceptualization, resources, supervision, and writing - review and editing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: this research has received eth- ical approval from the Health Research Ethics Commission, Politeknik Kesehatan Kemenkes Bandung, Indonesia with ethics approval number No. 44/KEPK/EC/IV/2023. During the study, the researchers paid atten- tion to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research did not receive external funding. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 15 October 2023. Accepted: 16 May 2024. Early access: 1 July 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; 12:11984 doi:10.4081/hls.2024.11984 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;12:11984] [page 507] Non -co mmerc ial us e o nly Many ways can be used to provide education to patients and families regarding diabetes and self-care management, namely by utilizing digital information technology, which is currently contin- uing to develop.15-17 There are 90.54% of households in Indonesia that use cellular telephones.18,19 This allows cellular phones, which are now better known as smartphones, to be used as an educational medium for diabetes sufferers.20 There are several smartphone soft- ware that can be used as a health education medium, such as web- sites and mobile applications. Several studies on mobile applications have been carried out. The research results stated that the e-diary mobile application was effective for use as an educational medium in increasing diabetes sufferers’ diet compliance. The results of the study showed that there was an increase in the average diet compliance of diabetes patients by 0.80. The results of the Wilcoxon rank test analysis obtained a p-value of 0.006. This shows that implementing the mobile e-diary application is meaningful and significantly effec- tive in increasing dietary compliance in diabetes mellitus patients.20 This is in line with research results that state that educa- tion based on the mobile application “Teman Diabetes” has been proven to be effective and has a clinically significant positive effect on the knowledge and attitudes of diabetes sufferers.21 The Le-Diabet application, the latest Android-based innova- tion developed by researchers, stands out as distinctive software with its unique features. Integrated with a comprehensive diabetes management concept, Le-Diabet comprises five main pillars: edu- cation, dietary patterns, physical activity, self-blood glucose mon- itoring, and diabetes therapy. The education provided by Le-Diabet includes up-to-date information on diabetes and its management, directly linked to the website of the Ministry of Health of the Republic of Indonesia. Designed with attractive and user-friendly features, the application facilitates ease of operation for patients. Users can input their current data, and Le-Diabet provides relevant recommendations, covering aspects such as dietary needs with sample menus, physical activity, healthcare management, and required therapies.22 Le-Diabet also offers statistical features to monitor trends in examination results, including blood glucose levels, glycated hemoglobin (HbA1C), blood pressure, cholesterol, and other examinations. With its alarm features, Le-Diabet assists users in remembering medication, appointment times, and other necessary tasks. With Le-Diabet, users can independently monitor their con- ditions, receive recommendations tailored to their health status, and acquire in-depth knowledge about diabetes.22 Education through Le-Diabet is expected to enhance the self- efficacy of patients, aiding in achieving optimal glucose control. However, the effectiveness of implementing Le-Diabet in diabetes patients still requires further investigation. Therefore, this research aimed to evaluate the extent to which Le-Diabet contributes to the improvement of self-efficacy and the management of blood glu- cose levels in diabetes patients. Materials and Methods Research design This study employed a quasi-experimental method with a pretest and posttest control group design approach. In the pretest phase, before the intervention was implemented, both groups, namely the intervention group and the control group, underwent measurements of relevant variables to assess their initial condi- tions. Subsequently, the intervention group received the interven- tion, while the control group did not undergo any intervention. The posttest phase was conducted on both groups after the intervention was completed to evaluate the impact of changes that may occur due to the intervention. Study participants The total sample was 62 respondents, comprising 28 patients in the control group and 34 diabetes patients in the intervention group. Sampling was taken using a purposive sampling technique with inclusion criteria: patients with a medical diagnosis of dia- betes mellitus, owning and using a smartphone either alone or with their family, and willing to use the Le-Diabet application for 6 weeks. Variable, instrument, and data collection The measured variables involved self-efficacy and blood glu- cose levels before and after intervention in both the control and intervention groups. Additionally, other variables serving as indi- cators of metabolic syndrome are also measured, including systolic and diastolic blood pressure, blood cholesterol, uric acid, and the respondent’s body weight. All measurements were taken twice, both before and after the 6-week intervention period, in both the control and intervention groups. Self-efficacy was assessed using the Indonesian version of the Diabetes Management Self-Efficacy Scale, comprising 20 items. The instrument employs a 4-point Likert scale: very incapable = 1, incapable = 2, capable = 3, and very capable = 4. Self-efficacy scores range from 20 to 60. The instrument’s validity was tested on 30 respondents, yielding a Cronbach’s α value of 0.939 [95% con- fidence interval (CI)].23 Blood glucose and metabolic syndrome indicator measure- ments are conducted using peripheral blood samples after patients have fasted for a minimum of 10 hours and only consumed water before the examination. The examination tools used have consis- tent brands and types for all respondents, and the results are pre- sented in mg/dL. Blood pressure is measured using an electric sphygmomanometer in mmHg, while respondents’ body weight is measured using an electric scale in kilograms (Kg). All instruments have undergone a calibration process, including instrument cali- bration, results calibration, and battery calibration, performed at the Laboratory of Health Polytechnic of the Ministry of Health in Bandung, Indonesia. Data analysis Univariate analysis was used to analyze respondent demo- graphics, including age, gender, occupation, and nutritional status, which were presented in the frequency distribution table. Bivariate analysis was used to determine the effect of the intervention and the differences between the control and intervention groups. Before carrying out bivariate analysis, a data normality test was carried out, which resulted in normally distributed data. On this basis, the anal- ysis was carried out using the paired and unpaired t-test. Ethical clearance This research received ethical clearance from the Health Research Ethics Committee of Politeknik Kesehatan Kemenkes Bandung, Indonesia, with approval number No. 44/KEPK/EC/IV/2023. During the research, the researchers paid attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 508] [Healthcare in Low-resource Settings 2024;12:11984] Non -co mmerc ial us e o nly Results The characteristics of respondents based on age, gender, occu- pation, and nutritional status are presented in Table 1. The results from Table 1 indicated that the majority of respondents in both groups were in the late-elderly age category (67.6%). Most respon- dents were female (70.3%), the majority of whom were not employed (67.6%), and their nutritional status predominantly fell into the overweight and obese categories in both groups (53%). The effectiveness of the Le-Diabet application was measured against the respondents’ self-efficacy variables and blood glucose levels. Metabolic syndrome indicators were also measured in this study, such as blood pressure, blood cholesterol, uric acid, and the respondent’s body weight, which were also analyzed considering that these factors are closely related to changes in the respondent’s blood glucose. All measurements were carried out twice with an interval of 6 weeks in both the control and intervention groups. The average measurement results pre- and post-intervention in the two groups can be seen in Table 2. Table 2 indicated that at pre-intervention, it was observed that among the seven variables investigated, only two exhibited a sig- nificant mean difference between the two groups: systolic blood pressure (p=0.015, 95% CI=3.030-27.129) and diastolic blood pressure (p=0.048, 95% CI=0.067-13.685). The remaining vari- ables (self-efficacy, blood glucose, total cholesterol, respondents’ uric acid, and body weight) showed no significant mean difference between the two groups. However, this pattern changed in the post- intervention data, which revealed alterations in the mean values of all variables in both groups. Nevertheless, only three variables demonstrated significant differences between the two groups: self- efficacy (p=0.000, 95% CI= -8.179 - -2.799), blood glucose (p=0.001, 95% CI=23.785-90.497), and systolic blood pressure (p=0.028, 95% CI=0.919-15.509), while the other variables showed no significant mean differences (p>0.05). The effectiveness of using the Le-Diabet application on dia- betes management indicators, namely self-efficacy, blood glucose, blood pressure, cholesterol, uric acid, and respondents’ body weight, can be seen in Table 3, which depicts the research findings, recording the average changes before and after the intervention in both groups for all variables. In the control group, there was a decrease in average self-efficacy by 1.9 post-intervention. Meanwhile, the intervention group exhibited a significant increase in average self-efficacy by 3.1 after the intervention compared to before (p=0.000, 95% CI= -6.006 - -1.876). The average blood glu- cose increased in both groups after the intervention. However, the increase in average blood glucose in the control group was signif- icantly higher than in the intervention group. The control group experienced a significant increase in blood glucose by 35.6 mg/dL (p=0.035, 95% CI= -68.578 - -2.636). Meanwhile, the intervention group showed a stable increase in the average blood glucose, only by 3.59 mg/dL, and the statistical test indicated a non-significant increase (p=0.076, 95% CI= -22.759-15.582). Table 3 also shows changes in metabolic syndrome indicators, such as systolic and diastolic blood pressure, which decreased in both groups after the intervention. Other variables, like cholesterol, uric acid, and body weight, showed changes in averages in both groups, but these changes were not significant (p>0.05). Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions Table 1. Characteristics of respondents. Variables Control group Intervention group n=28 % n=34 % Age Early old age 6 16.6 9 24.3 Late old age 22 59.5 25 67.6 Gender Man 5 13.5 8 21.6 Woman 23 62.2 26 70.3 Work Work 3 10.7 9 24.3 Does not work 25 89.3 25 67.6 Nutritional status Normal 12 42.8 16 47 Overweight and obese 16 57.1 18 53 Table 2. Description of the mean self-efficacy, blood glucose, blood pressure, cholesterol, uric acid, and body weight of respondents in the control and intervention groups pre- and post-intervention Variable Intervention Control group Intervention group p 95% CI Lower Upper Self-efficacy Pre 45.286 44.941 0.871 -3.902 4.591 Post 43.393 48.882 0.000* -8.179 -2.799 Blood glucose Pre 157.857 142.647 0.194 -7.999 38.420 Post 193.464 136.324 0.001* 23.785 90.497 Systolic blood pressure Pre 151.786 136.706 0.015* 3.030 27.129 Post 138.714 130,500 0.028* 0.919 15.509 Diastolic blood pressure Pre 92.464 85.588 0.048* 0.067 13.685 Post 83.714 82.353 0.566 -3.352 6.074 Total cholesterol Pre 213.714 201.882 0.228 -7.599 31.263 Post 222.250 208.147 0.091 -2.325 30.531 Gout Pre 5.879 6.359 0.309 -1.417 0.456 Post 5.689 5.927 0.484 -0.911 0.436 Weight Pre 59.346 61.566 0.471 -8.344 3.904 Post 58.705 61.146 0.435 -8.651 3.770 CI, confidence interval; *significant. [Healthcare in Low-resource Settings 2024;12:11984] [page 509] Non -co mmerc ial us e o nly Discussion Self-care management using digital information technology is currently in development. Technological advances support the acceleration of increasing knowledge and disseminating informa- tion, especially regarding diabetes mellitus. Cellular telephones, which nowadays have become a necessity in daily activities, can be used as an educational medium for diabetes patients.20 The results of the study showed that there was a significant increase in mean self-efficacy of 3.1 in the intervention group, whereas, in the control group, there was a decrease in self-efficacy. The research results show that using the Le-Diabet application can significantly increase respondents’ self-efficacy. The results of this study are in line with Marbun et al. (2012), who state that smartphone applica- tions can influence self-efficacy in diabetes patients so that appli- cations can facilitate the process of self-management and treatment adherence and increase blood glucose control in diabetes patients.23 Self-efficacy has a positive relationship with the self- care of diabetes patients, and self-care is needed to maximize dia- betes self-management.13 Self-efficacy is a person’s belief in their ability to organize and carry out actions that support their health, which is very necessary for diabetes patients to increase their inde- pendence in managing their disease.24 Blood glucose examination is the main indicator in diabetes management. Blood glucose levels are important in monitoring the success of diabetes management. The results of the study showed that in both groups, the mean blood glucose of respondents was above normal both pre- and post-intervention. Post-intervention blood glucose showed results that did not match expectations, in Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 510] [Healthcare in Low-resource Settings 2024;12:11984] Table 3. Effects of using the Le-Diabet application. Variable Mean Standard deviation p 95% CI n Lower Upper Self-Efficacy Control group Pre 45.286 9.610 0.220 -1.203 4.988 28 Post 43.393 4.954 Intervention group Pre 44.941 6.237 0.000* -6.006 -1.876 34 Post 48.882 5.515 Blood glucose Control group Pre 157.857 52.175 0.035* -68.578 -2.636 28 Post 193.464 81.518 Intervention group Pre 142.647 34.811 0.706 -22.759 15.582 34 Post 146.235 54.756 Systolic blood pressure Control group Pre 151.786 23.776 0.008* 3.783 22.359 28 Post 138.714 16.608 Intervention group Pre 136.706 23.464 0.142 -2.191 14.603 34 Post 130,500 12.066 Diastolic blood pressure Control group Pre 92.464 14.393 0.002* 3.474 14.026 28 Post 83.714 10.359 Intervention group Pre 85.588 12.409 0.100 -0.656 7.126 34 Post 82.353 8.198 Total cholesterol Control group Pre 213.714 37.507 0.328 -26.132 9.060 28 Post 222.250 33.861 Intervention group Pre 201.882 38.514 0.247 -17.082 4.553 34 Post 208.147 30.741 Gout Control group Pre 5.879 1.864 0.504 -0.385 0.763 28 Post 5.689 1.409 Intervention group Pre 6.359 1.809 0.133 -0.138 1.003 34 Post 5.927 1.242 Weight Control group Pre 59.346 10.307 0.174 -0.302 1.584 28 Post 58.705 11.095 Intervention group Pre 61.566 13.220 0.587 -1.138 1.979 34 Post 61.146 12.978 CI, confidence interval; *significant. Non -co mmerc ial us e o nly which the mean blood glucose level increased in both groups. In the control group, there was a significant mean increase of 35.6 mg/dL, and in the intervention group, blood glucose was relatively stable; there was a slight increase of 3.59 mg/dL but not signifi- cant. This shows that the Le-Diabet application can be used as a diabetes education medium to facilitate independent diabetes man- agement so that respondents’ blood glucose control becomes bet- ter. The research results are in line with other research, which states that Android-based applications increase knowledge about diabetes self-management so that they can help diabetes patients adhere to their therapy so that glycemic control becomes better.25 Other metabolic syndrome indicators, such as blood pressure, total blood cholesterol, uric acid, and body weight, demonstrated non-significant changes. Effective diabetes control is not only reflected in the stability of blood glucose levels but also in main- taining blood pressure, lipid profile, and body weight within the normal range according to predefined targets.2 Although the research results indicate changes in intervention outcomes in both groups, these changes are not statistically significant. This finding suggests that the use of the Le-Diabet application has not yet yield- ed a significant impact on regulating metabolic syndrome indica- tors. Long-term research is necessary to assess the intervention’s impact on metabolic syndrome as a long-term outcome. The respondents in this study were all elderly patients, most of whom were women; almost all of them did not work, and their nutritional status fell into the overweight and obese categories. Apart from that, both respondents also had a mean of systolic and diastolic blood pressure that was higher than normal, a high mean of cholesterol, and a relatively high mean of uric acid. This data shows that respondents have high-risk factors, so efforts are need- ed to manage glycemic and metabolic control to avoid diabetes complications. Therefore, it is important to increase knowledge and attitudes regarding diabetes, adopt a healthy lifestyle and bal- anced diet, exercise regularly, and avoid smoking to reduce the development of diabetes.2,26 This study has several limitations. The limited sample size, along with a focus on the elderly in sample selection, inhibits the generalization of results to a broader population. Confounding variables such as lifestyle and adherence to medication need spe- cial attention to ensure more accurate results. Additionally, the variability in the sample’s ability to use the Le-Diabet is also a cru- cial factor that needs to be considered. Time constraints in the study also serve as a limiting factor in evaluating the long-term impact of application usage. Therefore, this study emphasizes the importance of carefully addressing these factors to ensure more valid and applicable results. Conclusions The study concludes that utilizing the Le-Diabet application in diabetic patients can enhance self-efficacy and help maintain stable blood glucose levels. However, the intervention did not signifi- cantly impact metabolic syndrome indicators. Further research over an extended period is recommended to fully understand the intervention’s effects on these indicators. Improving the research quality could involve using a larger and more diverse sample across different age groups. Additionally, factors such as patients’ lifestyle and medication adherence should be considered in future research designs. Proficiency in using the Le-Diabet application should also be taken into account, as it may influence intervention outcomes. 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