E:\IBUK\NERS DESEMBER 2021\15-- 360 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 360–367 The Effect of Behavioral Therapy with Modeling Techniques on Changes in the Adherence of Diabetes Mellitus Patients Caturia Sasti Sulistyana1, Rina Budi Kristiani2 1,2Nursing Department, STIKes Adi Husada Surabaya, Indonesia JURNAL NERS DAN KEBIDANAN (JOURNAL OF NERS AND MIDWIFERY) http://jnk.phb.ac.id/index.php/jnk JNK History Article: Received, 26/09/2021 Accepted, 02/11/2021 Published, 15/12/2021 Keywords: Behavioral Therapy, Modeling Tech- niques, Adherence, Diabetes Melli- tus Article Information Abstract Diabetes Mellitus (DM) is a disease whose prevalence is not infectious increases with changes in lifestyle. If not managed properly, it will cause various complications that reduce quality of life, increase morbidity and mortality, and harm the economy. The success of DM management is strongly influenced by the patient’s adherence to medication and diet. One of the interventions to improve the adherence of DM sufferers is Behavior Therapy with modeling techniques. The purpose of this study was to analyze the effect of behavioral therapy with modeling techniques on changes in adher- ence of DM patients. The design of this study was quasy-experimental with pretest posttest and control group, on a sample of 40 DM patients with consecutive sampling technique. The intervention was carried out in 4 ses- sions for 2 weeks. The results of the statistical test paired sample t-test and independent sample t-test obtained p <0.5 (0.000), which meant that there was an effect of behavioral therapy with modeling techniques on changes in adherence DM patient. Changes in compliance that occurred between be- fore and after the intervention was 16.95 points. Modeling technique is be- havioral learning through observation of a model who has successfully con- trolled his illness to emphasize changes in mindset, beliefs, and commitment to a person’s new positive behavior. Modeling has an impact not only on imitating, but also adding or subtracting the observed behavior, so that it can be applied to obtain new behavior, leave old negative behavior, and maintain the desired behavior. © 2021 Journal of Ners and Midwifery 360 Correspondence Address: STIKes Adi Husada Surabaya – East Java, Indonesia P-ISSN : 2355-052X Email: caturia@akper-adihusada.ac.id E-ISSN : 2548-3811 DOI: 10.26699/jnk.v8i3.ART.p360–367 This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/) https://crossmark.crossref.org/dialog/?doi=10.26699/jnk.v8i3.ART.p360-367&domain=pdf&date_stamp=2021-12-26 361Sulistyana, Kristiani, The Effect of Behavioral Therapy with Modeling Techniques on ... INTRODUCTION Diabetes Mellitus (DM) is a disease whose prevalence is not infectious increases with changes in lifestyle. The success of DM management is strongly influenced by the patient’s adherence to maintain his health, which includes adherence to a therapeutic regimen in the form of medication and diet (Kementerian Kesehatan RI, 2019). This dis- ease if not managed properly can cause chronic complications that can increase the blood sugar, reduce quality of life, increase morbidity and mor- tality, and bring economic losses (Abidin, 2018). The World Health Organization (WHO) pre- dicts an increase in the number of people with dia- betes in Indonesia from 8.4 million in 2000 to around 21.3 million in 2030. The prevalence of DM in In- donesia ranks fifth in the world in 2008 with a total of 8.4 million(Kementerian Kesehatan RI, 2020). Data from the Health Office of East Java Prov- ince (2011), DM is included in the 10 most diseases, namely 69,018 people from 37 million population. The city of Surabaya ranks first with the highest number of DM sufferers, which is 14,377 people every year (Izza, 2019). Non-compliance with DM sufferers from year to year tends to increase, which is 50% in developed countries and lower in devel- oping countries (Abidin, 2018). The average num- ber of patient visits DM in Adi Husada’s hospital 10-15 people every day. Information of nurses in there that most patients follow the therapy when were hospitalized. The Indonesian Endocrinology Association (PERKENI) (2015) explains that the diagnosis of DM can be made if the fasting plasma glucose ex- amination is over 126 mg/dl, plasma glucose ex- amination is over 200 mg/dl, and HbA1c is over 6.5%(Thomas et al, 2016). The main obstacle in managing DM is the saturation of the patient fol- lowing treatment and diet for a long time, causing failure of blood glucose control. DM sufferers say they are not too restrictive of their diet because they have taken medication, and consume food freely only at certain times, such as attending wed- dings or parties, and prefer to avoid the side effects of drugs by not taking them without reporting to the doctor. Patients with diabetes will adhere to the therapeutic regiment when they are hospitalized, but when they are at home and carry out their usual routines, the patient returns to his previous lifestyle, ignores diet, and visits the hospital so that the pain gets worse, blood glucose levels are high and are accompanied by complications (Abidin, 2018). Good glycemic control will minimize the oc- currence of long-term complications so that people with diabetes need several management strategies, including control of adherence to drug programs, diet, and physical activity. The American Diabetes Association (ADA) in 2017 recommends weight loss, increased activity physical, counseling, medi- cation, annual monitoring, and cardiovascular screening (American Diabetes Association, 2017). One of the interventions that can improve the com- pliance of DM patients is behavioral therapy. Be- havioral Therapy is a behavior therapy with coun- seling and psychotherapy approaches to change negative or maladaptive behavior into expected or adaptive behavior. Rahmah (2019) in her study ex- plains that in this therapy the counselor provides positive treatment and stimulus according to the client’s problem and directs it to problem solving. The stages of Behavioral Therapy include: 1) As- sessment, 2) Setting goals, 3) Applying techniques, 4)  Evaluation and Termination. One technique of behavioral therapy is Modeling (Rahmah, 2019). Modeling is giving examples based on knowl- edge and experience so that it can be observed di- rectly or indirectly by clients (Pambudi dkk, 2019). Modeling is formed through direct (imitation) and indirect (vicarious conditioning) observation (Munir, 2018). Behavior therapy with this modeling tech- nique has an impact not only on imitating, but also adding or subtracting, strengthening behaviors that have been formed and leaving old negative behav- iors so that new behaviors are formed, and main- tain the desired behavior through the observed model (Bisri dkk, 2018). The results of the Nengsih study (2019) showed that participant modeling therapy given to Schizo- phrenia patients could improve adherence to taking medication after 4 sessions were given. The pa- tient learns to behave in increasing adherence to taking medication after being directed and guided by the therapist with the model that has been ob- served. The modeling technique given in this study refers to changes in cognitive, affective, and indi- vidual behavior produced through observation of one or several models (Nengsih, 2019). Rahmah’s study (2019) also proves that be- havioral therapy with modeling techniques carried out for 7 meetings can handle negative thoughts 362 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 360–367 and behaviors due self-efficacy to lowin an em- ployee. The studyer uses a real model of the em- ployee leader who can be observed and has been able to trade well, according to the Islamic approach, and has successfully responded to various chal- lenges (Rahmah, 2019). Behavioral Therapy Interventions with Mod- eling Techniques have specific objectives: 1) Ob- taining new attitudes through models, 2) Reducing fear and anxiety after observing the model, 3) Tak- ing new responses or skills and showing them to new behaviors, and 4) Motivating to perform some- thing that may already be known or learned. The modeling implementation sessions include: 1) ses- sion 1 identifies behaviors that cause maladaptive behavior and provides role models for adaptive be- havior, 2) session 2 assists patients in carrying out adaptive behavior, 3) session 3 motivates patients to perform adaptive behavior, 4) session 4 discusses the benefits therapy and adaptive behavior (Nengsih, 2019)..  In this case, behavior therapy interventions with modeling techniques can produce new behavior changes that are obedient to the DM therapy regi- men (Nengsih, 2019). Based on the facts above, studyers are interested in conducting study that will prove the effect of Behavior Therapy with Model- ing Techniques on Changes in Compliance with DM Patients. METHODS This study was conducted on July 5rd – Sep- tember 3rd 2021. The study design used was a quasy- experimental with pretest posttest and control group. Samples were taken from DM patients undergoing treatment at Adi Husada’s Hospital Surabaya, as many as 40 people divided into 20 people in the intervention group and 20 people in the control group, with consecutive sampling technique. The inclusion criteria for this study sample were: 1) Type 2 DM patients, 2) Age 26-65 years, 3) physically, mentally, cognitively, able to read and write, and willing to be respondents. While the exclusions cri- teria of this study included: 1) not having a smartphone, 2) DM patients with complications, 3) not participating in the intervention twice. The instrument used a demographic data ques- tionnaire and also used an observation form for examination of Temporary Blood Sugar (GDS) with a normal value of < 200 mg/dl, a medication adher- ence questionnaire with the Morisky Medication Adherence Scale (MMAS) with Cronbach’s Alpha 0.608, and a diet compliance questionnaire. Per- ceived Dietary Adherence Questionnaire (PDAQ) with Cronbach’s Alpha 0.78. The adherence score is in the range 0-75, the smaller the score, the lower the compliance (Assad et al, 2015). The implementation of the study in the inter- vention group was given behavioral therapy inter- vention with modeling techniques as many as 4 sessions for 2 weeks, 30-45 minutes for each meet- ing and each client. This intervention consists of: 1) Session 1 for identifying behaviors that cause non- compliance, 2) Session 2 for providing a role model to comply, 3) Session 3 for accompaniing patients in carrying out therapy and helping to overcome boredom and side effects of treatment, 4) Sessions 4 for motivating the application of obedient behav- ior, intervention benefits. While the control group received hospital standard education. This study used univariate analysis to calcu- late the frequency of demographic data and each variable, as well as bivariate analysis used SPSS statistical test Paired sample t-test and Indepen- dent sample t-test. The hypothesis accepted if the p value <0.05. RESULTS General Data 1. A g e Table 1 shows that there was no difference between the control group and the intervention group, namely most of the respondents in this study were in the 46-55 year age group, namely 12 people (60%) in the control group and 11 people (55%) in the intervention group. 2. Gender Table 2 shows that there was no difference between the control group and the intervention group, ie most of the respondents in this study were women, namely 14 people (70%) in the controlgroup and 16 people (80%) in the intervention group. 3. Education Table 3 shows that there was no difference between the control group and the intervention group, i.e. most of the respondents in this study had the last education level of high school/equivalent, namely 13 people (65%) in the control group and 11 people (55%) in the intervention group. 363Sulistyana, Kristiani, The Effect of Behavioral Therapy with Modeling Techniques on ... Age (Years) Control Group Intervention Group Amount N % N % N % 26-35 years old 2 10 2 10 4 10 36-45 years old 4 20 3 15 7 17,5 46-55 years old 12 60 11 55 23 57,5 56-65 years old 2 10 4 20 6 15 Total 20 100 20 100 40 100 Source: Primary Data Table 1 Distribution of Respondents by Age Gender Control Group Intervention Group Amount N % N % N % Male 6 30 4 20 10 25 Female 14 70 16 80 30 75 Total 20 100 20 100 40 100 Source: Primary Data Table 2 Distribution of Respondents by Gender Education Control Group Intervention Group Amount N % N % N % Not in school 0 0 1 5 1 2,5 Elementary School/ Equivalent 1 5 2 10 3 7,5 Junior High School/ Equivalent 1 5 1 5 2 5 Senior High School/ Equivalent 13 65 11 55 24 60 Bachelor’s Degree/ Equivalent 5 25 5 25 10 25 Total 20 100 20 100 40 100 Source: Primary Data Table 3 Distribution of Respondents by Education Occupation Control Group Intervention Group Amount N % N % N % Not Working 4 20 3 15 7 17,5 Entrepreneur 5 25 5 25 10 25 Private 7 35 9 45 16 40 ASN/TNI/POLRI 4 20 3 15 7 17,5 Total 20 100 20 100 20 100 Source: Primary Data Table 4 Distribution of Respondents by Occupation 364 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 360–367 Control Group Intervention Group Amount N % N % N % < 1 years 3 15 4 20 7 17,5 1-5 years 6 30 5 25 11 27,5 5-10 years 7 35 8 40 15 37,5 > 10 years 4 20 3 15 7 17,5 Total 20 100 20 100 40 100 Source: Primary Data Table 5 Distribution of Respondents by Old Suffers DM Tipe 2 Old Suffers DM Tipe 2 Control Group Intervention Group Amount N % N % N % Not in school 0 0 1 5 1 2,5 Oral (PO) 14 70 16 80 30 75 Injektion 6 30 4 20 10 25 Total 20 100 20 100 40 100 Source: Primary Data Table 6 Distribution of Respondents by History of DM Treatment History of DM Treatment 4. Occupation Table 4 shows that there was no difference between the control group and the intervention group, ie most of the respondents in this study worked as private employees, namely 7 people (35%) in the control group and 9 people (45%) in the intervention group. 5. Old Suffers DM Tipe 2 Table 5 shows that there was no difference between the control group and the intervention group, most of the respondents in this study suf- fered from Type 2 DM for 5-10 years namely 7 people (35%) in the control group and 8 people (40%) in the control group. 6. History of DM Treatment Table 6 shows that there was no difference between the control group and the intervention group, that is, most of the respondents in this study received oral anti-DM treatment, namely 14 people (70%) in the control group and 16 people (80%) in the intervention group. Specific Data 1. Paired T-Test Analysis of Adherence Table 7 shows that based on the results of the Paired t-test statistical test, the control group and the intervention group both experienced changes in adherence, namely p = 0.03 (p < 0.05) in the con- trol group and p = 0.000 (p < 0, 05) in the interven- tion group, so it can be concluded that there is a significant change in respondent adherence before and after being given the intervention in both groups. This is also evidenced by the mean 95% CI in both groups that does not involve the number 0, then the results are declared significant. However, the in- tervention group experienced a greater increase in adherence than the control group, which was indi- cated by the t-count value of 12.16. 8. Independent T-Test Analisys of Adher- e nc e Table 8 shows that the difference in the aver- age change in adherence before and after being given Behavioral Therapy with Modeling Tech- niques in the control group and the intervention group 365Sulistyana, Kristiani, The Effect of Behavioral Therapy with Modeling Techniques on ... was 16.95 points. The results of the statistical inde- pendent sample t-test obtained a value of p = 0.00 (p <0.05) so it can be concluded that there is a sig- nificant difference in changes in adherence between the control group and the intervention group. DISCUSSION The Effect of Behavioral Therapy with Mod- eling Techniques on The Adherence of Diabates Mellitus (DM) The results of the measurement of the adher- ence variable in DM patients in the intervention group showed that all respondents experienced an increase in adherence after being given interven- tion of Behavioral Therapy with Modeling Tech- niques. Paired t-test results showed that the con- trol group and the intervention group had the same change with p=0.03 in the control group and p=0.00. The average there was an increase adherence, but in the control group there was only a slight increase in t count, which was 2.35. Meanwhile, in the inter- vention group, the t-count was greater, which was 12.16. The intervention group received Behavioral Therapy with Modeling Techniques for 2 weeks. as many as 4 sessions, which means that Behav- ioral Therapy with Modeling Techniques has an effect on increasing the compliance of DM patients The results of data analysis used independent sample t-test obtained p value = 0.00 (p <0.05), so it can be concluded that there is a significant differ- ence in changes in DM management adherence (diet and medication) between the control group and the intervention group. Most of the respondents before being given Behavioral Therapy with Modeling Techniques were found to be irregular in taking treatment be- cause they felt that their bodies had no complaints, were afraid to inject DM, or forgot, and neglected their diet because they experienced boredom, the disease did not go away and felt weak if they lim- ited their food. Most of the respondents were aged 46-55 years. A young person is at risk of disobedi- ence because when he is suffering from a chronic disease, he will experience internal conflicts when he is declared sick but his body has no complaints so that it causes him not to follow the advice of health workers. However, with increasing age, dis- ease control irregularities can also occur due to boredom undergoing treatment that does not cure, forgetting the control schedule, taking medication, or consuming allowed and prohibited foods. In ad- dition, with increasing age, a person needs and de- pends on his family to take control to the hospital so that it can often cause delays in control (Susanti dan Sulistyana, 2020). Increased adherence in the intervention group experienced a lot of female respondents. Women are more concerned and careful about their health. While men tend to be disobedient because they do more physical activity outside the home than women, so they consume more high-calorie foods to meet the energy expended. This is what can underlie men tend to not care or ignore the recommendations Respondent Group Adherence 95% CI T p* Pre (Mean ± SD) Post (Mean ± SD) Control Group 29,1±10,45 32,25±9,04 -6,72±-0,38 2,35 0,03 Intervention Group 23,55±11,79 49,6±12,57 -30,53±-21,57 12,16 0,000 Source: Primary Data Table 7 The Result of Paired T-Test Analysis of Adherence Adherence Control Group Intervention Group Mean 95% CI p* (Mean ± SD) Post (Mean ± SD) Difference Value Difference 32,65 ± 9,03 49,6 ± 12,57 16,95 -23,96 : -9,95 0,000 Source: Primary Data Table 8 The Result of Independent T-Test Analysis of Adherence 366 Jurnal Ners dan Kebidanan, Volume 8, Issue 3, December 2021, page 360–367 suggested by hea lth wor ker s (Susa nti da n Sulistyana, 2020). The results showed that the increase in adher- ence was experienced by many respondents with a high school education level/equivalent. Another fac- tor that supports a person’s success in complying with the therapeutic regimen is knowledge. Some- one who has a good level of knowledge is more likely to be more obedient (Susanti dan Sulistyana, 2020). Education shapes a person’s way of think- ing so that it is broader, including understanding the factors that cause illness and maintaining his health. In addition, the higher a person’s education level, the easier it is for that person to access information from various sources (Sulistyana, 2020). A mindset person’s will change for the better and wiser with age, in this case the mindset of his health condition. Another factor that can affect adherence to DM management is the length of time suffering from DM. The main obstacle in managing DM is patient saturation in following a diet and taking anti- DM drugs for a long time or for life. Someone who undergoes treatment for a long time will be bored and want to feel free to try various foods (Sulistyana, 2020). An action that is carried out continuously and monotonously will cause boredom or boredom so that it causes someone to try new things, in this case people who suffer from DM undergoing regu- lar treatment for years can cause the person to become bored because the impact cannot be seen directly. This modeling therapy can be given to patients who experience ineffectiveness of the therapeutic regimen due to non-adherence to a treatment pro- gram. In a study conducted by Nengsih (2019), modeling therapy conducted on 112 respondents for 4 sessions with a duration of 30-45 minutes/ses- sion/client was proven to be effective in increasing patient compliance in carrying out previously non- adherent treatment (Nengsih, 2019). While in this study, the modeling technique was carried out in 4 sessions for 2 weeks, containing material related to sharing experiences when sick, providing support, motivation, enthusiasm, and so- lutions from fellow DM sufferers who have suc- cessfully controlled their disease. This modeling technique is given by emphasizing on changing one’s way of thinking (mindset) and behavior because of a sense of compatriots’ fate when suffering from the same disease, so that it can increase the confi- dence and commitment of other DM sufferers to follow the diet program and DM treatment obedi- ently in order to reach the highest level. optimal health, reduce morbidity and disability, and death due to DM. This is in line with Smith’s study (2018), namely modeling or observational learning which empha- sizes changes in one’s cognitive and behavioral as- pects after observing other people who act accord- ing to what they experience. Empirically identified modeling can overcome one’s fears and phobias after observing other people who can overcome these fears (Smith, 2018). This is also in line with Sulistyana’s study (2020) that the experience of peers in similar illness conditions can lead to confi- dence and enthusiasm for DM sufferers to return to adherence with their health care management. Modeling has an impact not only on imitating but also sorting out, adding or subtracting the ob- served behavior, so that new positive behaviors can be obtained, leaving old negative behaviors, and maintaining the desired behavior. In this case, if someone sees other people of the same age suc- cessfully running a healthy lifestyle for DM, it will foster a sense of confidence and enthusiasm so that they can comply with the therapy regimen they are undergoing. Furthermore, if you have grown a sense of confidence and enthusiasm, you will get a new attitude and take a response to new behavior. The modeling technique has the effect of strengthening the behavior that has been formed and weakening inappropriate behavior so that new behavior can be formed according to the observed model CONCLUSION The above discussion can be concluded that there was a significant difference in changes in adherence of DM sufferers between the control group and the intervention group, and there was a significant effect behavioral therapy with modeling techniques on changes in adherence of Diabetes Mellitus patients. SUGGESTION The further studyers can involve other depen- dent variables in order to analyze the positive ef- fect of behavioral therapy with this modeling tech- nique for people with DM 367Sulistyana, Kristiani, The Effect of Behavioral Therapy with Modeling Techniques on ... REFERENCES Abidin, Z. (2018). Health Education dengan Pendekatan Social Media Reminder dan Audiovisual terhadap Kepatuhan dan Kadar Glukosa Darah Pasien DM Tipe 2 di Rumah Sakit Universitas Airlangga Surabaya. 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