Effectiveness of an educational intervention in the integral care of patients with diabetes mellitus

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Methods A pre-experimental study was carried out with 103 patients with diabetes mellitus treated at Essalud, La Libertad, during the second quarter of 2024. Pre and post educational intervention information was collected about knowledge of the disease, complications, physical activity and diet, adherence to treatment and family support, number of medical and nursing controls per quarter, glycemia values, HbA1c and compliance with treatment after informed consent. The educational intervention included theoretical aspects of diabetes mellitus, self-care, physical activity, nutrition and family support in 2-hour workshops, once a week, for 2 months. Results Predominantly female, mean age 63.22 years, higher education, marital status married/cohabiting and main occupation employed/independent. The 97.1% had type 2 diabetes mellitus, 38.8% reported disease duration < 5 years, 72.8% were treated with metformin and the main comorbidity was hypertension (58.3%). The educational intervention improved knowledge about diabetes mellitus (p < 0.001), achieved a significant change in eating habits (p = 0.022) and family support (p = 0.043), and homogenized the level of support among families (p = 0.025). 51.5% of the participants were noncompliant with the prescribed treatment. A significant difference (p < 0.01) was observed in the proportion of patients complying with treatment before and after the intervention. 76.8% of patients who initially complied with treatment continued to do so after the intervention. The efficacy of the educational program on glycemic control was not evidenced. Regarding integral control, 83.5 % of the patients received quarterly medical care and 44.7 % received nursing care. Conclusion The educational program was effective in improving knowledge about DM2, adherence to healthy eating and significantly improved the level of family support and compliance with treatment. 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F1000Research 2025, 14 :187 ( https://doi.org/10.12688/f1000research.159626.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Effectiveness of an educational intervention in the integral care of patients with diabetes mellitus [version 1; peer review: awaiting peer review] Evelyn Goicochea-Rios https://orcid.org/0000-0001-9994-9184 1 , Nélida Milly Otiniano https://orcid.org/0000-0001-9838-4847 2 Evelyn Goicochea-Rios https://orcid.org/0000-0001-9994-9184 1 , Nélida Milly Otiniano https://orcid.org/0000-0001-9838-4847 2 PUBLISHED 11 Feb 2025 Author details Author details 1 Essalud Red Asistencial La libertad, La Libertad, Trujillo, 13007, Peru 2 Universidad Cesar Vallejo, Trujillo, La Libertad, Peru Evelyn Goicochea-Rios Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Nélida Milly Otiniano Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Integrative Biology & Medicine collection. Abstract Background To evaluate the effectiveness of an educational intervention in the integral care of patients with diabetes mellitus. Methods A pre-experimental study was carried out with 103 patients with diabetes mellitus treated at Essalud, La Libertad, during the second quarter of 2024. Pre and post educational intervention information was collected about knowledge of the disease, complications, physical activity and diet, adherence to treatment and family support, number of medical and nursing controls per quarter, glycemia values, HbA1c and compliance with treatment after informed consent. The educational intervention included theoretical aspects of diabetes mellitus, self-care, physical activity, nutrition and family support in 2-hour workshops, once a week, for 2 months. Results Predominantly female, mean age 63.22 years, higher education, marital status married/cohabiting and main occupation employed/independent. The 97.1% had type 2 diabetes mellitus, 38.8% reported disease duration < 5 years, 72.8% were treated with metformin and the main comorbidity was hypertension (58.3%). The educational intervention improved knowledge about diabetes mellitus (p < 0.001), achieved a significant change in eating habits (p = 0.022) and family support (p = 0.043), and homogenized the level of support among families (p = 0.025). 51.5% of the participants were noncompliant with the prescribed treatment. A significant difference (p < 0.01) was observed in the proportion of patients complying with treatment before and after the intervention. 76.8% of patients who initially complied with treatment continued to do so after the intervention. The efficacy of the educational program on glycemic control was not evidenced. Regarding integral control, 83.5 % of the patients received quarterly medical care and 44.7 % received nursing care. Conclusion The educational program was effective in improving knowledge about DM2, adherence to healthy eating and significantly improved the level of family support and compliance with treatment. READ ALL READ LESS Keywords Diabetes mellitus Type 2, Health education, Comprehensive approach, self-management; self-care; glycaemic control. Corresponding Author(s) Evelyn Goicochea-Rios ( [email protected] ) Close Corresponding author: Evelyn Goicochea-Rios Competing interests: No competing interests were disclosed. Grant information: The research was financed by Essalud, within the framework of the Premio Kaelin 2024 Award - The project that gave rise to this article was awarded second position in the call for proposals (Resolution N° 89-IETSI-ESSALUD-2023), Annex 5: Kaelin project budget Funding of S/18,650.00 soles. The funders have not been involved at any stage in the development of this research . The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Goicochea-Rios E and Otiniano NM. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Goicochea-Rios E and Otiniano NM. Effectiveness of an educational intervention in the integral care of patients with diabetes mellitus [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :187 ( https://doi.org/10.12688/f1000research.159626.1 ) First published: 11 Feb 2025, 14 :187 ( https://doi.org/10.12688/f1000research.159626.1 ) Latest published: 31 Mar 2026, 14 :187 ( https://doi.org/10.12688/f1000research.159626.3 )  There is a newer version of this article available. Suppress this message for one day. Introduction Diabetes mellitus (DM) is a chronic metabolic disease with heterogeneous etiology and varied clinical presentation. Its microvascular and macrovascular complications affect various organs and systems and the patient’s quality of life due to the costs associated with it. 1 It has a high prevalence worldwide 2 and increasingly affects age groups under 40 years of age. It is related to overweight or obesity, sedentary lifestyle and consumption of processed foods. It is also reported that between 50 and 70% of DM cases are not controlled. DM was the sixth leading cause of death in Peru in 2018 3 and in the American continent, it occupied the same place as a cause of death in 2019. 2 Older adults with type 2 DM are at greater risk of presenting comorbidities and geriatric syndromes 4 , 5 and many live alone; factors that complicate the metabolic control of diabetes. 4 There is a worldwide consensus that a decrease in the frequency of complications is achieved when the patient takes responsibility for the care of his/her disease and the best strategy to achieve this is education of both the patient and the family. 6 – 8 For this reason, research is oriented towards the study of programs that through the approach of clinical, educational, behavioral and psychosocial aspects, help to develop positive health behaviors in patients, to meet the treatment objectives, decision making and the guidelines required for optimal self-care of DM. 7 , 9 Adherence to pharmacological treatment can be influenced by the patient’s beliefs, culture and level of education, but also by the way in which the physician communicates and informs, so it is important to analyze these factors to contribute to metabolic control 10 : fasting glycemia between 80-130 mg/dL; HbA1c < 7%; blood pressure <130/80 mm Hg; LDL cholesterol 50 mg/dL and triglycerides <150 mg/dL. 11 Health systems promote comprehensive care for people with chronic disease, which requires the participation of physicians, nurses, nutritionists, social workers, psychologists, as established in the family and community-based model of the Peruvian Ministry of Health. 12 Likewise, ESSALUD promotes the standardized and progressive health care model to guarantee the follow-up of people with chronic pathology. This model places the patients as co-responsible for their care, especially in their lifestyles, and as the center of a system for the delivery of comprehensive and interprofessional services over time. 13 The integral care of a diabetic patient includes health education with emphasis on behavioral aspects such as daily exercise, healthy eating, glycemic control and medical check-ups. Preventive behaviors include a physical activity plan or a healthy diet, i.e., patients and their families should be aware of carrying out these activities and know how to do them, incorporating the new knowledge into their daily activities. 14 We consider that the present study is important to understand the family and sociocultural context of patients with DM attending the I Albrecht Hospital and to identify the factors that favor or hinder compliance with treatment, namely: level of knowledge about DM and its complications, beliefs about diabetes, diet, physical activity, family support for food preparation, attendance to controls and level of therapeutic adherence. It is also of practical relevance to standardize educational interventions in workshops adapted to the existing reality in charge of the health team, so the general objective was to evaluate the efficacy of an educational intervention in the integral care of the patient with diabetes mellitus through the pre and post intervention analysis of knowledge about DM, dietary habits, type and frequency of physical activity, metabolic control, adherence to treatment and family support. Methods A quantitative, pre-experimental design study with pre-test and post-test was conducted. The population consisted of 580 outpatients with DM2 attended per month in family medicine at Hospital I Albrecht - Essalud during the second semester of 2024. Patients of both sexes, aged 40-79 years, with a diagnosis of DM2, with physical and mental autonomy, treated with oral hypoglycaemic agents alone or in combination with insulin, who agreed to participate in the study by signing the informed consent form and who attended at least 80% of the scheduled sessions were selected. Patients with limiting chronic complications (blindness, amputations, heart failure, G4 chronic kidney disease) and patients with DM2 referred to other facilities were excluded. The sample size was 150 participants and it was calculated with the formula for population proportions considering a confidence level of 95%, a test power of 80%. 15 Forty-seven patients dropped out: 15 did not attend all the scheduled workshops, 10 because they did not have someone to accompany them to the analysis, 4 because they traveled, 7 because they did not perform the post-intervention analyses, and 7 because they withdrew their informed consent; for this reason, the results of 103 patients who completed the entire program are presented. Consecutive non-random sampling was performed, 16 since participants were invited to participate in the study on the day they came to the appointment and the sampling frame consisted of the lists of patients with DM2 scheduled for outpatient family medicine consultations, in morning and afternoon shifts, six days a week and until the sample was complete. Pre and post educational intervention, the variables level of knowledge about diabetes, eating habits, glycemic control, adherence to treatment and family support were analyzed. Regarding comprehensive care, the following variables were analyzed pre and post intervention: fasting glycemia, glycosylated hemoglobin, medical and nursing control attendance, pharmacological treatment compliance report, healthy eating report, physical activity and family support. Procedures and techniques Permission was requested from the institution to carry out the present study, to have access to the clinical histories and to evaluate the patients who gave informed consent. The participants were informed of the objectives of the educational program, their sociodemographic data were collected, and the pre-intervention tests were applied. Before starting the educational program, tests were applied to identify the level of knowledge about DM2 (Diabetes Knowledge Questionnaire - DKQ 2417), 17 the eating style and physical activity questionnaire, 18 , 19 adherence to treatment using the Morisky-Green test 20 , 21 and to identify family/social support (Valadez test 22 ). Pre- and post-intervention fasting glycemia and post-intervention Hba1c were also analyzed. Likewise, the information recorded in the clinical history regarding compliance with treatment was recorded. DKQ2417 consists of 24 questions whose answers comprise the alternatives ‘Yes’, ‘No’ or ‘I don’t know’; one point is obtained for each correct answer and the final score is the sum of the points. Adequate knowledge: score of more than 13 or more than 55% of correct answers and inadequate knowledge: score of less than 13. 17 The eating style and physical activity questionnaire, was designed to identify dietary and nutritional risk factors in older adults with diabetes mellitus 2. It is interpreted according to whether eating habits are healthy or unhealthy: Healthy habits: Answer yes to questions 2,5,6, unhealthy habits: Answer yes to questions 1,3,4,7,8. 18 , 19 The Morisky Green test was used to assess adherence to pharmacological treatment. It consists of a series of 4 contrasting questions with a dichotomous yes/no response, which reflect the patient’s behaviour regarding compliance. The aim is to assess whether the patient adopts correct attitudes in relation to the treatment for their illness; it is assumed that if the attitudes are incorrect, the patient is non-compliant. The patient is considered to be compliant if he/she answers correctly to the 4 questions, i.e. No/Yes/No/No. 20 , 21 The Valadez-Figueroa questionnaire was used to assess family support for patients with DM2, the interpretation of which is: low family support: 51-119 points, medium support: 120-187 and high support: 188-265 points. 22 For sampling and analysis of fasting glucose and glycosylated haemoglobin, the services of an external clinical laboratory were contracted. The results were delivered personally to each participant. Educational workshops were carried out with the participation of the patients included in the study, with a total of 103 participants and some family members. For the workshops, the population was distributed in two groups. Each group attended four sessions to develop the contents of knowledge of diabetes mellitus, its manifestations, complications and treatment, as well as physical activity and nutrition. It was considered achieved if the patient had a minimum of 3 sessions and in the post-tests showed a favorable change in the evaluated aspects. As there were difficulties for the workshops to be 100% face-to-face, workshops were implemented on the zoom platform at the times proposed by the patients. For the variable integral care, it was ascertained whether the patient had periodic controls of at least one medical control per quarter and the result of glycemia and HbA1c (abnormal >120 mg/dl) and >7% 10 , 11 respectively) was interpreted. To motivate and maintain participation, participants were entered into a WhatsApp group through which they were sent reminders to attend the workshops, the laboratory and feedback messages about what was discussed in addition to the workshop recordings. The frequencies of the categorical variables were measured and the pre and post intervention results of each patient were evaluated. Likewise, for the quantitative variables, the Kolmogorov-Smirnov normality test was performed. 23 For data with normal distribution, the paired t-test was applied to evaluate the differences among the means of the scores obtained in the questionnaires on knowledge of DM, healthy diet, adherence to treatment and family support obtained before and after the educational intervention. The Wilcoxon test was applied for data that did not have normal behavior. In addition, the analysis was complemented with the presentation of absolute and percentage frequencies to compare the changes in the before and after behavior in each category by applying the Mc Nemar test. A p-value < 0.05 was considered statistically significant, with a confidence level of 95%. Ethical considerations The protocol entitled ‘Efficacy of an educational intervention in the integral care of patients with diabetes mellitus’ was submitted for consideration, comment, guidance and approval to the Research Ethics Committee prior to commencement of the research. This committee named Research and Ethics Committee of Health Care Network La Libertad - EsSALUD, approved the research project through Certificate N° 60 of 22 May 2023. The research was conducted by professionals with appropriate scientific and ethical education, training and qualifications, with supervision by a competent and qualified medical practitioner. The ethical principles of Helsinki were complied with.data protection of the personal identity, privacy and confidentiality of the participants was complied with. 24 , 25 This document is shown in extended data. Participants signed a written and informed consent form, after explanation of the purpose of the research, the possible risks and benefits as well as the possibility to withdraw at any time, if deemed appropriate and without reprisal. 24 , 25 Results Table 1 shows that 60.2% are women, the average age of the patients is 63.22 years, 68.0% are 60 years or older, 42.7% have higher education, 70.9% are married or cohabiting, 44.7% are employed or self-employed, 97.1% have type 2 diabetes mellitus and regarding the duration of the disease, 38.8% are less than 5 years. 72.8% were treated with metformin and the main comorbidity was arterial hypertension with 58.3%. Table 1. Characterization of patients with diabetes mellitus. Hospital I Albrecht. Essalud 2024. Characteristics n % Sex Male 41 39.8% Female 62 60.2% Age (Average ± S) (63.22 ± 7.96) 20-40 years 1 1.0% 41-59 years 32 31.1% 60-older 70 68.0% Level of education Illiterate 1 1.0% Primary School 17 16.5% Secondary School 29 28.2% Technician 11 10.7% Higher Education 44 42.7% Marital Status Single 9 8.7% Married/Cohabiting 73 70.9% Separated/Divorced 10 9.7% Widow (er) 11 10.7% Occupation Self-employed/employee 46 44.7% Housekeeper 37 35.9% Unemployed/retired 20 19.4% Duration of illness 15 years 18 17.5% Treatment Metformin 75 72.8% Insulin 4 3.9% Metformin + insulin 3 2.9% Metformin + glibenclamide 17 16.5% glibenclamide 2 1.9% Others 2 1.9% Comorbidity None 18 17.5% Hypothyroidism 6 5.8% Dyslipidemia 12 11.7% Obesity 6 5.8% Anemia 3 2.9% Arterial hypertension 60 58.3% Chronic kidney disease 1 1.0% Others 25 24.3% Table 2 shows a significant improvement in patients’ knowledge after the intervention. The mean knowledge improved with statistically significant difference (p < 0.001). With respect to family support there was a significant improvement in the level of support after the intervention. The difference between the means is statistically significant (p = 0.043), according to the Student’s t-test. The educational intervention not only increased average family support, but also homogenized the level of support among families, reducing the dispersion of scores. Regarding eating habits, it is evident that the educational intervention achieved a significant change as the percentage of patients with healthy eating habits increased from 3.9% to 12.6% (p = 0.022), indicating better adherence to a balanced diet (p = 0.022). Table 2. Summary of effectiveness of the educational intervention in improving knowledge about diabetes mellitus, family support and healthy eating. Indicator n Initial value Mean (DS) After the intervention Mean (DS) p Knowledge about DM 103 14.78 (2.65) 16.35 (2.21) <0.001 Family support 103 171.1 (18.6) 171.5 (18.0) 0.043 Indicator n % (n) % (n) p % Healthy eating habits 103 3.9% (4) 12.6% (13) 0.022 Table 3 shows that 51.5% of the participants stated that they did not comply with the prescribed treatment. Table 3. Adherence to treatment in patients with DM2 according to the Morisky Green test. Adherence to treatment N % Yes 50 48.5% No 53 51.5% Total 103 100.0% In Table 4 , McNemar’s test shows a significant difference (p < 0.01) in the proportion of patients complying with treatment before and after the intervention, suggesting that the intervention had a positive impact on improving treatment compliance. 76.8% of patients who were compliant with treatment maintained that behavior after the intervention. However, the proportion of patients who were initially noncompliant with treatment and failed to improve their compliance remained. Table 4. Effectiveness of educational intervention in improving adherence to treatment in patients with DM. Compliance with the initial treatment Compliance with treatment after the intervention Total Mc' Nemar test Yes No n % n % n % Sig. Yes 43 76.8% 13 23.2% 56 54.4% <0.01 No 0 0.0% 47 100.0% 47 45.6% Total 43 41.7% 60 58.3% 103 100% Table 5 shows that there was no improvement in glycemic control with the educational intervention. The mean glucose went from 132.5 to 143.1 according to the Wilcoxon test. The proportion of patients with adequate glycemic control dropped from 60.19% to 48.54% post intervention. Table 5. Glucose values and glycemic control in patients with DM2. Indicator Initial glycemia Final glycemia Wilcoxon Sig. Mean 132.5 143.1 3774 <0.001 95% C.I. for the mean Inferior 125.8 135.0 Superior 139.2 151.2 Median 122.9 131.3 Standard deviation 34.4 41.6 Minimum 70 80 Maximum 268.7 280.1 Range 198.7 200.1 Initial glycemic control Glycemic control after the intervention Total Mc' Nemar test Yes No n % n % n % Sig. Yes 46 74.19% 16 25.81% 62 60.19% 0.012 No 4 9.76% 37 90.24% 41 39.81% Total 50 48.54% 53 51.46% 103 100.00% In Table 6 , we can see that 83.5% of patients have at least a quarterly follow-up with their physician and 44.7% with nursing, which indicates a regular frequency of follow-up according to EsSalud standards. Regarding Hba1c levels, the mean Hba1c is 7.54% for patients ≤ 69 years and 6.96% for patients ≥ 70 years. Only 33% of 70, have good metabolic control. Table 6. Integral management of patients with diabetes mellitus. Integral control n % Quarterly control with Medical doctor Yes 86 83.5% No 17 16.5% Nurse Yes 46 44.7% No 57 55.3% Reported adherence to treatment Yes 50 48.5% No 53 51.5% Glycosylated hemoglobin control by age group Up to 69 years (average ± S) (7.54% ± 1.67%) Good diabetes control 34 33.0% Risk of poor control 24 23.3% Poor control 24 23.3% 70 years or older (average ± S) (6.96% ± 1.44%) Good diabetes control 18 17.5% Risk of poor control 0 0.0% Poor control 3 2.9% Discussion The population studied was predominantly female, with an average age of 63.22 years, higher education, married or cohabiting, and with a main occupation as an employee. Almost all patients had type 2 diabetes mellitus (DM2). As for the duration of the disease, the most frequent was less than 5 years. Two thirds of patients receive treatment with metformin and the main comorbidity was arterial hypertension. With respect to the characteristics of the population, in a Peruvian study on family support and glycemic control, the predominant population was female, with a mean age of 63.5 years ±12.10 years, occupation housewife followed by independent worker and the most common level of education was secondary education followed by primary education, 24 data very similar to those recorded in this study. Other studies also report a predominance of women, mean age of 53.14 years ±8.99, marital status married, 8 employed and with secondary education. 6 Other studies reported that the average age was 63 years. 26 , 27 with a predominance of women (55.9%) but the majority of patients had only primary education (58.9%), followed by those with secondary education (20.5%). 26 Regarding the time of illness, 70.30% of the patients had a time of illness less than or equal to 15 years (n = 111), and in 29.70%, it was more than 15 years. The average time of illness was 11 years, with a standard deviation of 9.51. 26 While in a study carried out in Colombia, the average time since the diagnosis of DM was 11.3 ± 8.5 years. 19 Regarding this variable, it is important to mention that it is referred by the patient and that many of them are not clear about the time of illness, they tend to deny the disease or say that it is of recent onset. In the present study, we found a significant improvement in patients’ knowledge about Diabetes Mellitus (DM) and its complications after the educational intervention (p < 0.001) and the level of adequate knowledge increased from 83.5% to 95% after the intervention (p < 0.001). About this variable, it has been described that those educational interventions are useful to change a certain behavior and to facilitate adequate self-care 28 and that structured educational programs for patients with DM2, especially aimed at older adults, have great potential; however, there is still room for improvement. 29 In the present study, the DKQ-24 17 was used to identify the knowledge that patients with DM2 have of the disease, with the cut-off point of correctly answering ≥ 55% of the questions. The DKQ-24 is one of the most widely used questionnaires and the results indicate that more than 75% have adequate knowledge about their disease. Thus, a study conducted in ESSALUD with a population with similar characteristics in terms of sex, marital status and educational level, established a cut-off point of 75% for the results of the DKQ-24, and found that 17% of patients with DM2 had adequate knowledge. 30 In the present study, the educational intervention achieved a significant change in the dietary habits of patients with DM, with better adherence to a healthy diet (p = 0.022). The Health Belief Theory explains that in order for patients to change behavior, they must perceive and understand the seriousness of the disease and the benefits of changing behavior 31 and adopting new habits. 32 They must also understand the effects of not changing. In this way, patient self-care is encouraged. 31 , 32 From the health services, relevant and timely education, according to the Integrated Theory of Health Behavior Change, promotes knowledge and attitude change in patients as the only way to modify the behavior of the community. Both theories are applied in the case of patients with diabetes mellitus. When analyzing treatment compliance, 51.5% of the participants reported noncompliance. This finding is consistent with the 35-50% non-compliance rate reported in patients with chronic diseases, which is even higher in developing countries. 33 A Peruvian study reported that 74.3% of patients were not adherent to DM treatment2 30 Patients are considered to be adherent to DM2 treatment when they have a compliance rate>=80% of pharmacotherapy and recommendations on diet, exercise and disease self-management, although in practice, less than 10% of patients with DM2 meet these criteria. 34 In this regard, a panel of 58 experts pointed out that lack of adherence to treatment in patients with DM2 leads to an increase in visits to emergency services, hospitalizations, failure to achieve therapeutic objectives, higher healthcare costs and a decrease in the patient’s quality of life. It also has negative consequences for the patient’s health and can mislead the treating physician as to the real effectiveness of the medication. 34 The educational intervention had a positive impact on improving family support, especially in families that initially had a high level of support. Research highlighted that family involvement is very important in the management of diabetes, as it resulted in a greater reduction in glycosylated hemoglobin HbA1c and a significant improvement in adherence to treatment. Intervention with family involvement is useful in diabetes management, especially when spouses or women are caregivers, 35 an effect that through multivariate analysis showed that family members who were spouses or women were strong predictors of better glycemic control. 36 The literature reviewed indicates that any educational intervention aimed at patients with DM2 should involve family, friends and organizations in the community in which the patient lives, ideally within the framework of a government policy that provides the patient with a social support network. 6 It has also been described that the involvement of family members and caregivers is very important as one of the most influential factors in diabetes self-care practices and in the maintenance of long-term improvements. 29 The educational intervention had a positive impact on improving compliance with treatment. Of the patients who adhered to their treatment, 76.8% maintained this behavior after the intervention, although the proportion of patients who initially did not adhere to their treatment and did not manage to improve their adherence was maintained. A patient with DM2 with good adherence to pharmacological treatment is more likely to also comply with adherence to the rest of the indications and change their eating, physical activity, and recreational habits. 34 Adherence to treatment has been shown to depend on several factors, including different individual and social levels, as most of them depend on the patient, the medication, the health care providers and the health care systems. Studies identified some of these factors for diabetes mellitus, such as depression, education level, gender, age, smoking status and employment status. Therefore, it is important to identify and pay attention to the effective factors involved in adherence to treatment in diabetic patients. 32 The educational intervention showed no improvement in glycemia values and the proportion of patients with adequate glycemic control dropped from 60.19% to 48.54% after the intervention. It is likely that the time of the educational intervention should have been longer to evaluate this variable, since in other studies it takes between 8 to 12 months to achieve favorable changes in metabolic control 8 and maintaining them over time is more difficult. Therefore, follow-up periods of more than three years are recommended with periodic reevaluation of the patients at the end of the educational intervention. 10 Regarding integral control, the majority of patients comply with the EsSalud standard by performing at least a quarterly control with a physician and less than 45% comply with nursing control. Regarding Hba1c levels, the mean Hba1c is 7.54% for patients ≤ 69 years and 6.96% for patients ≥ 70 years. Only 33% of 70, have good metabolic control. This is similar to that reported in a study in which patients with an average age of 63.9 years had HbA1c of 7.5%. 27 It has been described that it is important to adapt the general glycemic control goal (HbA1c < 7%) to each patient. Thus, in people without frailty and without risk of hypoglycemia, the HbA1c goal is < 6.5% and in the presence of frailty, comorbidities and risk of hypoglycemia, a less strict glycemic control goal may be appropriate (HbA1c 8-8.5%). 37 Other authors suggest that the HbA1c goal should also be adapted according to the patient’s age, years of disease and presence of complications. 24 It is important to consider that there are seven variables that are significantly associated with good diabetes mellitus control (P < 0.05): self-reported medication adherence, number of medications to which patients did not adhere, medication knowledge, diabetes knowledge, education level, total self-efficacy, and anxiety. 37 Scientific studies that have examined the topic of education in diabetes mellitus have systematically demonstrated that structured educational programs represent a fundamental pillar in disease management. The fact that a diabetic assumes a proactive role in the care of their condition not only favors its metabolic control but also increases patient adherence to their monitoring, contributing to improved nutritional status and clinical parameters related to their disease. 6 Among the limitations of the study is that the use of structured questionnaires with closed questions could contain biased responses and that the patients cannot express everything they think. It was not possible to implement physical activity workshops because most patients had medical restrictions for physical activity. The duration of the intervention did not allow us to see the change in glycemia and HbA1c values. Also, the generalizability of the results may be limited because the subjects were selected from a single diabetes care program. It is concluded that structured educational programs are effective in improving the level of knowledge and lifestyles of patients with DM2, and that it is therefore necessary to strengthen these programs to improve the comprehensive care of these patients. Authors’ contribution Evelyn Goicochea-Ríos: Conceptualization, formal analysis, methodology, data collection, investigation, visualisation, writing – original draft preparation, writing – review & editing, funding acquisition. Nélida Milly Otiniano: Methodology, data collection, formal analysis, writing – original draft preparation, writing. Data availability All data underlying the results are available as part of the article are available in the Zenodo repository, under the title “ DATA BASE Effectiveness of an educational intervention in the integral care of patients with diabetes mellitus ” available from https://doi.org/10.5281/zenodo.14563599 . 38 Supplementary material The supplementary material is available in the Zenodo repository, under the title. Effectiveness of an educational intervention in the integral care of patients with diabetes mellitus. 38 This project contains the following data: Database with results pre and post educational intervention, Diabetic family support assessment tool, Eating habits questionnaire, Educational Intervention workshops, Informed consent protocol, Morisky Green Test, Physical Activity Capability Questionnaire, Ethics committee certificate, 8-GATE-Knowledgequestionaire Spanish and format for collecting data. 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Publisher Full Text Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 11 Feb 2025 ADD YOUR COMMENT Comment Author details Author details 1 Essalud Red Asistencial La libertad, La Libertad, Trujillo, 13007, Peru 2 Universidad Cesar Vallejo, Trujillo, La Libertad, Peru Evelyn Goicochea-Rios Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Nélida Milly Otiniano Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The research was financed by Essalud, within the framework of the Premio Kaelin 2024 Award - The project that gave rise to this article was awarded second position in the call for proposals (Resolution N° 89-IETSI-ESSALUD-2023), Annex 5: Kaelin project budget Funding of S/18,650.00 soles. The funders have not been involved at any stage in the development of this research . The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (3) version 3 Revised Published: 31 Mar 2026, 14:187 https://doi.org/10.12688/f1000research.159626.3 version 2 Revised Published: 11 Feb 2026, 14:187 https://doi.org/10.12688/f1000research.159626.2 version 1 Published: 11 Feb 2025, 14:187 https://doi.org/10.12688/f1000research.159626.1 Copyright © 2025 Goicochea-Rios E and Otiniano NM. 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COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: AWAITING PEER REVIEW AWAITING PEER REVIEW ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 11 Feb 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 3 (revision) 31 Mar 26 read Version 2 (revision) 11 Feb 26 read read Version 1 11 Feb 25 Saldy Yusuf , Hasanuddin University, South Sulawesi, Indonesia MARIA SOFIA CUBA-FUENTES , Universidad Peruana Cayetano Heredia, San Martín de Porres, Peru Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 CUBA-FUENTES M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 16 Apr 2026 | for Version 3 MARIA SOFIA CUBA-FUENTES , Universidad Peruana Cayetano Heredia, San Martín de Porres, Peru 0 Views copyright © 2026 CUBA-FUENTES M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Based on the most recent version of the manuscript, I recommend acceptance with no further major revisions. The authors have adequately addressed the main concerns raised in previous rounds of review. In particular, they have: (1) clarified the definition of “integral care” and its relationship to the educational intervention; (2) provided a clearer description of the study population, inclusion and exclusion criteria, and sampling procedures; (3) specified the nature of the educational intervention and the variables assessed; and (4) added a participant flowchart that improves transparency and reproducibility of the methods. The introduction more clearly states the research aim, the methods section now contains sufficient detail for replication, and the discussion better situates the findings within the existing literature and reflects more explicitly on implications and limitations. Overall, the study is methodologically sound for its design, the results are presented in a coherent way, and the conclusions are supported by the data. The topic is relevant for diabetes care and health education in similar settings, and the manuscript now meets an acceptable scientific standard. I therefore support indexing of this version. Competing Interests No competing interests were disclosed. Reviewer Expertise Family Medicine, Primary Care reply Respond to this report Responses (0) CUBA-FUENTES MS. Peer Review Report For: Effectiveness of an educational intervention in the integral care of patients with diabetes mellitus [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :187 ( https://doi.org/10.5256/f1000research.197420.r472084) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-187/v3#referee-response-472084 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 CUBA-FUENTES M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 09 Mar 2026 | for Version 2 MARIA SOFIA CUBA-FUENTES , Universidad Peruana Cayetano Heredia, San Martín de Porres, Peru 0 Views copyright © 2026 CUBA-FUENTES M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The manuscript addresses an important topic and presents relevant findings for the field. However, the research objective could be stated more explicitly in the introduction. While the manuscript provides contextual background, the specific research question and its contribution to the existing literature should be more clearly articulated. Clarifying the conceptual framework and linking it more explicitly to current research would strengthen the overall narrative. Additional detail is needed to ensure transparency and reproducibility. In particular, the manuscript would benefit from a clearer description of: how participants or data sources were selected inclusion and exclusion criteria the procedures used for data collection the analytical framework applied. Providing this information would allow readers to better understand the methodological rigor of the study and facilitate replication. The results presented in the manuscript are informative; however, the interpretation of these findings could be expanded. In particular, the discussion would benefit from deeper engagement with recent literature addressing similar topics. Placing the results within the broader international context would help highlight the contribution of the study and clarify how it advances current knowledge. The discussion section could be further developed to explore the implications of the findings for policy, practice, or future research. Although some limitations are acknowledged, this section could be expanded. It would be helpful for the authors to discuss potential sources of bias, limitations related to data availability or methodological constraints, and how these factors may affect the interpretation of the results. This manuscript addresses a relevant topic and provides useful insights for the field. With improvements in methodological transparency, clearer articulation of the research objectives, and a more developed discussion of the implications of the findings, the manuscript would make a valuable contribution to the literature. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Not applicable Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Family Medicine, Primary Care reply Respond to this report Responses (1) Author Response 28 Mar 2026 Evelyn Goicochea Rios, Essalud Red Asistencial La libertad, La Libertad, 13007, Peru Dear Dr Sofia Cuba, We have received your comments and recommendations, and we would like to respond to them as follows: The manuscript addresses an important topic and presents relevant findings for the field. However, the research objective could be stated more explicitly in the introduction. While the manuscript provides contextual background, the specific research question and its contribution to the existing literature should be more clearly articulated. Clarifying the conceptual framework and linking it more explicitly to current research would strengthen the overall narrative. The wording of the introduction has been improved and the aim of the research has been explicitly stated. 2.Additional detail is needed to ensure transparency and reproducibility. In particular, the manuscript would benefit from a clearer description of: how participants or data sources were selected, inclusion and exclusion criteria, the procedures used for data collection, the analytical framework applied. This information can be found in the methodology section, and we have included Figure 1, which details information on the participants, the inclusion and exclusion criteria, and the population on which the study was conducted.Information on the procedure used for data collection is provided in the ‘Techniques and Procedures’ section and the data collection form has been outlined. 3. Providing this information would allow readers to better understand the methodological rigor of the study and facilitate replication. The results presented in the manuscript are informative; however, the interpretation of these findings could be expanded. In particular, the discussion would benefit from deeper engagement with recent literature addressing similar topics. Placing the results within the broader international context would help highlight the contribution of the study and clarify how it advances current knowledge. The results are discussed and compared with the findings of other studies in the discussion chapter, and the literature on education for patients with diabetes has been expanded. 4. The discussion section could be further developed to explore .the implications of the findings for policy, practice, or future research. This suggestion was taken on board 5. Although some limitations are acknowledged, this section could be expanded. It would be helpful for the authors to discuss potential sources of bias, limitations related to data availability or methodological constraints, and how these factors may affect the interpretation of the results. The report also mentions the potential biases arising from questionnaires containing closed-ended questions and has included the limitations regarding the capacity of the institutional auditorium We look forward to your comments View more View less Competing Interests No competing interests. reply Respond Report a concern CUBA-FUENTES MS. Peer Review Report For: Effectiveness of an educational intervention in the integral care of patients with diabetes mellitus [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :187 ( https://doi.org/10.5256/f1000research.196200.r458047) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-187/v2#referee-response-458047 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Yusuf S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 16 Feb 2026 | for Version 2 Saldy Yusuf , Hasanuddin University, South Sulawesi, Indonesia 0 Views copyright © 2026 Yusuf S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Interesting manuscript, but I note some points that need revision. Background: since the central topic is integral care of patients with DM, how did author define this term, and integrate educational intervention. The background will be clear if authors explain what is unknown regarding integral care which make current study different with similar previous studies. We also found no clear aim statement at the end of background. Method We suggest authors to present participants flow chart (from recruitment to analysis, including its drop out reason). Educational workshop: What is the participants of current study? patient, family, or both? why there is some family members included? its inconsistent with previous information. For the workshops, the population was distributed in two groups. Its unclear why authors allocated participants in two groups, while in method current study reported as pre and post intervention (without control), all of tables also indicate no control group (only single group). In unclear in method, delivery of educational workshop, does it face to face, zoom, or hybrid (combine) approach. For the variable integral care, its unclear for readership, whether integral care as research variable or as intervention modality? authors has used some instruments: 1. Diabetes Knowledge Questionnaire - DKQ 2417. 2. The eating style and physical activity questionnaire 3. The Morisky-Green test 4. Valadez test Do these instruments use independent variables? and also evaluate fasting glucose and glycosylated haemoglobin (does it research outcome?), please clarify. Then, how about the variable integral care (does it independent of dependent variable?) how did author measure, what is the scale or score? Please explain unit analysis, type of data, the reason for selecting statistical test. Table 5 unclear Fasting glucose or glycosylated haemoglobin? We found no conclusion statement. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? No Competing Interests No competing interests were disclosed. Reviewer Expertise diabetes mellitus, diabetic foot, foot care, wound care, wound management, clinical nursing reply Respond to this report Responses (1) Author Response 04 Mar 2026 NELIDA MILLY OTINIANO, Universidad Cesar Vallejo, Trujillo, Peru Dear reviewer, we appreciate your comments and suggestions and respond below. 1. Background: Since the central topic is integral care of patients with DM, how did author define this term, and integrate educational intervention. The background will be clear if authors explain what is unknown regarding integral care which make current study different with similar previous studies. We also found no clear aim statement at the end of background. Response : The definition of the variable ‘integral care’ was considered if the patient underwent periodic check-ups, with at least one medical examination per quarter, and underwent fasting blood glucose and HbA1c tests. Abnormal values were considered to be >120 mg/dl and >7% respectively. - The definition of the variable ‘integral care’ can be found in Procedures and techniques. - The educational intervention was considered part of the protocol for caring for patients with diabetes mellitus. It is described in the background section. - The general objective was to evaluate the efficacy of an educational intervention in the integral care of the patient with diabetes mellitus through the pre and post intervention analysis of knowledge about DM, dietary habits, type and frequency of physical activity, metabolic control, adherence to treatment and family support”… (in the last paragraph of the background section) 2. Method: We suggest authors to present participants flow chart (from recruitment to analysis, including its drop out reason). Response : The flowchart was placed in the manuscript. 3. Educational workshop: What is the participants of current study? patient, family, or both? why there is some family members included? its inconsistent with previous information. For the workshops, the population was distributed in two groups. Its unclear why authors allocated participants in two groups, while in method current study reported as pre and post intervention (without control), all of tables also indicate no control group (only single group). In unclear in method, delivery of educational workshop, does it face to face, zoom, or hybrid (combine) approach. Response : The unit of analysis was exclusively the patient with DM2. Family members participated solely as educational support. No data was collected or analyzed from family members. - The division was exclusively for logistical reasons (capacity and schedules), and both groups received the same intervention. There was no control group. - The article mentions that the workshops were predominantly in-person, supplemented by some virtual sessions via Zoom. - integral care is one of the variables under investigation and is also a component of the person-centred care model for people with diabetes mellitus in Peru. 4. Authors has used some instruments: - Diabetes Knowledge Questionnaire - DKQ 2417. - The eating style and physical activity questionnaire - The Morisky-Green test - Valadez test Do these instruments use independent variables? Response: Instruments used measure dependent variables: * Knowledge (DKQ-24) * Eating habits * Treatment adherence (Morisky-Green) * Family support (Valadez test) 4.1 and also evaluate fasting glucose and glycosylated haemoglobin (does it research outcome?), please clarify. Response : Fasting glucose (mg/dL) and glycated haemoglobin HbA1c (%) were considered clinical outcome variables, as they allow the impact of the educational intervention on the metabolic control of patients with type 2 diabetes mellitus to be assessed. - Both variables were measured using standardized laboratory analysis. Fasting glucose was assessed in the pre- and post-intervention periods, while HbA1c was assessed as a complementary indicator of glycaemic control after the intervention. 4.2 Then, how about the variable integral care (does it independent of dependent variable?) how did author measure, what is the scale or score? Response: In this study, ‘integral care’ was not considered a single variable with a specific scale or score. It was conceptualized as a multidimensional construct that integrates clinical, behavioural, and psychosocial components of type 2 diabetes mellitus management. - Operationally, comprehensive care was assessed using specific and measurable indicators: level of knowledge (DKQ-24), eating habits, treatment adherence (Morisky-Green), family support (Valadez), fasting glucose, HbA1c, and attendance at medical and nursing check-ups. Therefore, comprehensive care was analyzed through the joint behavior of these dependent variables. 5. Please explain unit analysis, type of data, the reason for selecting statistical test. The variables analyzed were classified according to their nature: Response : Continuous quantitative variables: fasting glucose (mg/dL), glycosylated haemoglobin HbA1c (%), DKQ-24 questionnaire score and family support test score (Valadez). - Discrete quantitative variables: number of quarterly check-ups. - Dichotomous categorical variables: adherence to treatment (yes/no), eating habits (healthy/unhealthy), attendance at medical and nursing check-ups (yes/no). - The normality of the quantitative variables was assessed using the Kolmogorov-Smirnov test and graphical analysis. For the comparison of pre- and post-intervention means: - - The Student's t-test for related samples was used when the variable was normally distributed. - The non-parametric Wilcoxon signed-rank test was used when the distribution was not normal. - For the analysis of paired categorical variables (pre- and post-), the McNemar test was used, which is appropriate for comparing proportions in dependent samples. A statistical significance level of p < 0.05 was established, and 95% confidence intervals were reported. 6. Table 5 unclear Response: Table 5 shows only fasting blood glucose values (mg/dL) compared before and after theintervention. 7. We found no conclusion statement. Response : The conclusion appears at the end of the discussion: ‘It is concluded that structured educational programs are effective in improving the knowledge and lifestyles of patients with T2D and that, therefore, these programs need to be reinforced in order to improve the comprehensive care of these patients’... View more View less Competing Interests There is no competing interest reply Respond Report a concern Yusuf S. Peer Review Report For: Effectiveness of an educational intervention in the integral care of patients with diabetes mellitus [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :187 ( https://doi.org/10.5256/f1000research.196200.r458053) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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