Effectiveness of a knowledge, attitude, and self-efficacy program for people having type 2 diabetes mellitus with uncontrolled blood sugar in a northeastern province of Thailand: A quasi-experimental study

Effectiveness of a knowledge, attitude, and self-efficacy program for people having type 2 diabetes mellitus with uncontrolled blood sugar in a northeastern province of Thailand: A quasi-experimental study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Effectiveness of a knowledge, attitude, and self-efficacy program for people having type 2 diabetes mellitus with uncontrolled blood sugar in a northeastern province of Thailand: A quasi-experimental study Nitikorn Phoosuwan, Amornrat Wongsrila, Pakorn Pusuwan, Warinmad Kedthongma, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6650347/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Diabetes Mellitus is one of the most common chronic non-communicable diseases worldwide. Managing individuals with type 2 diabetes requires a multifaceted approach that includes lifestyle modifications, medication adherence, regular monitoring, and patient education. This study is aimed at investigating the effectiveness of a knowledge, attitude, and self-efficacy program for people having type 2 diabetes mellitus with uncontrolled blood sugar in a northeastern province of Thailand. Methods The study employed a quasi-experimental design. An intervention program Knowledge, Attitude, and Self-efficacy for individuals with type 2 diabetes mellitus and uncontrolled blood sugar, based on Bandura’s self-efficacy concept within the Social Cognitive Theory, was developed and implemented. Integrating Traditional Thai Medicine practices, such as Ruesi Dutton and Maneevej exercises, and Thai foot massage, the program comprised six sessions delivered over 12 weeks. Participants aged 55 years and older receiving treatment at health promotion hospitals in a northeastern province of Thailand were divided into intervention and control groups comprising 43 and 44 individuals, respectively. Data collection utilized a five-part questionnaire covering demographic information, diabetes knowledge, attitude, self-efficacy, and self-care behaviors, as well as measured accumulated blood sugar levels (HbA1c) before and after the program. Data analysis employed descriptive statistics, independent t-tests, and paired sample t-tests. Results After completion of the intervention program, the average scores of the intervention group significantly differed from those of the control group in terms of diabetes knowledge, self-efficacy, self-care behaviors, and accumulated blood sugar levels (HbA1c) (p0.05). Conclusion The intervention program proved to be a valuable tool in promoting better healthcare outcomes for individuals with type 2 diabetes and improving blood sugar control. Healthcare professionals should encourage, facilitate, and support patients' self-care management while focusing on behavioral changes in newly diagnosed diabetes patients. Future research should involve a larger sample size and examine the sustainability of self-care behaviors over extended durations. Health sciences/Health care/Disease prevention/Lifestyle modification Health sciences/Health care/Patient education Intervention program knowledge attitude self-efficacy people with diabetes type 2 self-care behaviors Thailand Figures Figure 1 Introduction Diabetes Mellitus (DM), a chronic, non-communicable disease, is a major global health issue affecting over 422 million people worldwide, primarily in low- and middle-income countries. It is directly responsible for 1.5 million annual fatalities [ 1 ]. The prevalence of diabetes has steadily increased, and 642.7 million cases are estimated by 2030 and 783.2 million by 2045 [ 2 ]. Also Thailand faces a growing diabetes burden, with 300,000 new diagnoses annually and over 3.2 million registered cases [ 3 ]. This is attributed to socioeconomic, demographic, environmental, and genetic factors, with lifestyle and environmental influences being key drivers of type 2 diabetes mellitus (T2DM) [ 4 ]. Knowledge is fundamental for effective diabetes management, enabling improved self-care, treatment satisfaction and enhanced quality of life [ 5 ]. However, many individuals, particularly in developing countries, lack adequate diabetes-related knowledge and skills [ 6 ]. Failure to control blood sugar can lead to various complications, such as kidney disease, neuropathy, cardiovascular diseases, eye disorders, and chronic wounds [ 7 ]. Self-care for people with T2DM include dietary control, regular physical activity, blood glucose control, weight monitoring, foot care, and medication adherence [ 7 – 9 ]. Health education covering diet, exercise, blood glucose control, and medication adherence has proven effective in enhancing health literacy and behavior [ 9 – 11 ]. Managing T2DM requires a multifaceted approach, encompassing lifestyle modifications, medication adherence, monitoring, and patient education. Several studies have shown effective self-care management methods for persons with T2DM [ 9 , 11 , 12 , 13 ]. Bandura's Social Cognitive Theory (SCT) introduces self-efficacy (SE) as an individual's belief in his or her ability to perform tasks and manage challenges to achieve outcomes [ 14 , 15 ]. Higher SE correlates with better treatment adherence, improved self-care, and an enhanced quality of life [ 16 – 18 ]. If individuals believe they can accomplish something and expect positive results, they are more likely to exhibit behavior aligned with those beliefs [ 8 , 19 ]. Self-efficacy reflects overall self-confidence, behavior, thoughts, and emotional responses to environmental challenges or new situations [ 20 ]. Culturing self-management behavior and establishing a positive attitude toward treatment can enhance SE [ 21 ]. The SE concept of the SCT was used as conceptional framework to develop an intervention program for persons with uncontrolled T2DM. Exercises from Traditional Thai Medicine (TTM), such as Ruesi Dutton and Maneevej, along with Thai foot reflexology massage, were incorporated into innovative self-care practices. These exercises stem from the principle of Buddhist Dhamma Manamai, promoting integrated holistic self-care of the body, mind, spirit, and one's physical and social environment. The benefits of Ruesi Dutton include pain reduction, decreased blood pressure, improved joint angles, increased muscle strength, and enhanced quality of life (22–24]. Similarly, Maneevej reduces muscle aches and improves functional status [ 25 , 26 ]. Thai foot reflexology massage of TTM helps alleviate peripheral neuropathy symptoms in patients with T2DM [ 27 ]. This foot massage involves gentle pressure to improve blood flow 27, 28]. In 2022, there were 59,581 Thai individuals with diabetes in the Nakhon Phanom Province, with 3,373 newly diagnosed cases. Renu Nakhon District, with a population of approximately 35,590, had a total of 4,587 persons with diabetes, including 216 new cases [ 29 ]. An important goal in managing diabetes in Thailand is to encourage behavioral changes and regular medication to control blood sugar levels near normal values. This includes aiming for accumulated blood sugar levels (HbA1c) < 7% [ 3 ]. Only 13.13% of 2,289 persons with diabetes achieved controlled HbA1c levels, while a growing number have uncontrolled levels, a trend increasing yearly. According to Bandura's SE concept [ 14 , 15 ], behavior is influenced by perceived abilities. Individuals confident in their abilities are more likely to demonstrate them [ 19 ]. Healthcare professionals (HCPs), particularly nurses, play a significant role in educating, supporting, and empowering patients. Evidence suggests that nursing interventions improve self-management behaviors and glycemic control by facilitating patient involvement and knowledge acquisition [ 7 , 13 , 30 , 31 ]. Daily diabetes self-care poses challenges for many Thai individuals with T2DM, who struggle with blood sugar control [ 32 , 33 ]. Few studies focus on intervention programs integrating educational and holistic self-care approaches to improve blood sugar control and prevent complications. These programs provide diabetes knowledge, nutrition guidance, traditional Thai exercises, Thai foot massages, and role models sharing successful self-care management experiences. This study aimed to investigate the effectiveness of knowledge, attitude, and self-efficacy program for people having T2DM with uncontrolled blood sugar in a northeastern province of Thailand. Method Design This study adopted a quasi-experimental approach to investigate knowledge, attitude, self-efficacy, and self-care behaviors among people with T2DM [ 34 ]. An intervention program was developed and implemented, involving both an intervention group and a control group. Pre- and post-experiment tests assessed participants' knowledge, attitude, self-efficacy, and self-care behaviors. The study targeted individuals with uncontrolled T2DM in health promotion hospitals. Setting Renu Nakhon District, one of the three districts with the highest diabetes rates in Nakhon Phanom Province, northeastern Thailand [ 29 ], was selected for the study. The research was conducted in health promotion hospitals within the district. Intervention program The “Knowledge, Attitude, and Self-Efficacy for People with Type 2 Diabetes Mellitus (KAS-T2DM) program” was developed by the researchers based on Bandura’s SE concept within the SCT [ 14 , 15 ]. The program aimed to enhance participants' self-belief through mastery experiences, vicarious experiences, role models, verbal persuasion, and emotional arousal. The intervention comprised six sessions delivered over 12 weeks. Sessions 1–5 were conducted weekly, while Session 6 took place in Week 12. Each session lasted approximately 60–120 minutes. See Table 1 . Table 1 Knowledge, Attitude and Self-efficacy for people with type 2 diabetes mellitus program (KAS-T2DM program) in the intervention group Implementation Time duration (minutes) Information sources (Self-efficacy concept) Contents of KAS-T2DM program Session 1: “Preparation” (week 1) 120 Verbal persuasion Provide information about the study and the KAS-T2DM program, rights for participants, completion of a pre-test questionnaire and conducting a blood test (HbA1c) Session 2: Activity “Know it, Prevent it” (week 2) 120 Verbal persuasion Vicarious experiences Mastery experiences Provide diabetes knowledge and highlight role models in life activities by observing others’ experiences. Share insights from patients with complications caused by poor blood sugar control. Discuss experiences and exchange ideas. Session 3: Activity “How to eat when you have diabetes” (week 2) 120 Verbal persuasion Vicarious experiences Mastery experiences Provide nutritional guidance, such as suitable foods for patients with diabetes. Feature role models who have successfully managed their self-care behaviors. Facilitate experience-sharing and foster confidence in adopting behavioral changes. Session 4: Activity 1 “Good health with the principles of Dhamma Manamai” (week 4) 120 Verbal persuasion Vicarious experiences Mastery experiences Introduce holistic healthcare based on Buddhist Dhamma Manamai, incorporating physical and mental well-being from Traditional Thai Medicine. Practice “3 Ruesi Dutton poses” and “5 Maneevej poses” of traditional Thai exercises Session 4: Activity 2 “Thai foot reflexology massage” (week 4) 120 Vicarious experiences Mastery experiences Educate participants about Thai foot reflexology massage. Distribute foot massage equipment and practice pressing 13 reflex points on the soles of the feet. Session 5: “Evaluation of the outcomes of the four sessions” (week 5) 120 Verbal persuasion Vicarious experiences Mastery experiences Review the knowledge gained from all sessions. Conduct a post-test questionnaire. Facilitate discussions to exchange insights, address challenges, and provide feedback for program improvement. Session 6: “Evaluation for a blood test” (week 12) 120 Verbal persuasion Vicarious experiences Mastery experiences Measure accumulated blood sugar levels (HbA1c) for the second time. Facilitate discussions to exchange ideas and reflect on experiences from the program. Week 1 (Session 1): Objectives and program benefits were explained. Participants provided consent, completed a pre-test questionnaire, and had their accumulated blood sugar levels (HbA1c) measured for the first time. Week 2 (Session 2): Titled “Know it. Prevent it”, this session involved expert lectures using a booklet to share knowledge about diabetes and healthy behaviors. Participants reviewed blood sugar results, interacted with role models experiencing complications, and exchanged ideas and experiences. Week 3 (Session 3): Titled “How to Eat When You Have Diabetes”, the session provided nutrition guidance on suitable foods for diabetes management and foods to limit or avoid. Role models shared self-care success stories, fostering confidence in behavioral changes. Week 4 (Session 4): Delivered as two activities: (1) “Good Health with the Principles of Dhamma Manamai ” . Lecturers introduced Thai Traditional Medicine (TTM), focusing on holistic wellness. Participants practiced meditation, music therapy, and traditional Thai exercises, such as “3 Ruesi Dutton poses” for relaxation and “5 Maneevej poses” for physical fitness. And (2) “Thai Foot Reflexology Massage”: Participants learned and practiced reflexology massage techniques targeting 13 key reflex points, with equipment provided for self-massage. Week 5 (Session 5): In this session, participants’ progress was evaluated. Knowledge from previous sessions was reviewed, post-test questionnaires were completed, and participants discussed experiences and obstacles in self-care management. Feedback was collected for program improvement. Week 12 (Session 6): In this session, the participants’ accumulated blood sugar levels (HbA1c) were re-measured, and they shared self-care management experiences from the program. Participants Patients with type 2 diabetes receiving treatment at health promotion hospitals (primary health care units) in Renu Nakhon District were invited to participate. The participants were individuals diagnosed with T2DM by a physician, who were unable to control their blood sugar levels. Inclusion criteria included: (1) having a blood sugar level (HbA1c) > 7%, (2) being 55 years of age or older, (3) having been diagnosed with diabetes for at least 6 months, (4) having no severe complications, such as diabetic retinopathy, foot ulcers, or end-stage renal disease, (5) being able to read and write, and (6) being willing to participate. Exclusion criteria included: (1) participants terminating their involvement in the research study, and (2) participants migrating during the study period. Of the 130 patients with T2DM approached, 88 agreed to participate, while 42 were excluded for reasons such as refusal (n = 21), being unreachable (n = 16), and other reasons (n = 5). Participants were divided into intervention and control groups, with 44 individuals in each group. See Fig. 1 . Data collection A questionnaire designed by the researchers was utilized in this study. It was based on relevant documents and scientific literature and comprised five parts: sociodemographic information, diabetes knowledge, attitudes toward diabetes, self-efficacy, and self-care behaviors. The content validity of the questionnaire was evaluated by four experts, yielding an index of objective consistency (IOC) score of 0.96. Reliability testing was conducted among patients with type 2 diabetes who were unable to control their blood sugar levels. The questionnaire demonstrated an overall Cronbach's alpha coefficient of 0.77 (acceptable), and a Kuder-Richardson score of 0.50 (acceptable range: 0.2–0.8). Part 1: Sociodemographic Characteristics. This section included information on gender, age, marital status, educational level, duration of diabetes, and body mass index (BMI). This section captured information such as gender, age, marital status, educational level, duration of diabetes, and body mass index (BMI). Part 2: Diabetes Knowledge. This section consisted of 14 items in Thai language [ 32 ]. Participants were asked to select the correct answer (right or wrong) for each question, encompassing both positive and negative prompts. The Kuder-Richardson-20 score for this section was 0.50. Part 3: Attitudes Toward Diabetes. Eight questions developed by the researchers. A five-point Likert scale was used, ranging from “weakly agree” to “strongly agree,” with scores from 1 (least agree) to 5 (most agree) for each item. The total score ranged from 5 to 35, with higher scores indicating a more positive attitude. The Cronbach's alpha coefficient for this section was 0.71. Part 4: Self-Efficacy. This section featured eight questions from the Self-Efficacy Questionnaire for patients with diabetes, developed by the Stanford Patient Education Research Center and translated into Thai [ 35 ]. Each question used a 10-point scale, with 1 = not at all confident and 10 = extremely confident, yielding scores from 1 to 10. The Cronbach's alpha coefficient for this section was 0.85. Part 5: Self-Care Behaviors. Six categories were included: resuscitation (20 questions), and diet, medication, exercise, stress management, and ongoing care (5 questions each) [ 35 ]. Responses were rated on a three-point scale: “frequently practiced,” “sometimes practiced,” and “never practiced.” The total score was 60 points, and the Cronbach's alpha coefficient was 0.75. Procedure Permission to conduct the study and collect data was obtained from the directors of health promotion hospitals (primary health care units) in Renu Nakhon District. Nurses at the hospitals provided a list of patients with type 2 diabetes and uncontrolled blood sugar levels. Invitation letters were sent to the patients, detailing the study's purpose and their rights as participants in the KAS-T2DM program, including the option to withdraw at any time. Participants who consented to join signed a research consent form and returned it to the researchers. Those in the intervention group participated in the KAS-T2DM program, while the control group received standard treatment provided at government healthcare facilities. The KAS-T2DM program lasted for 12 weeks. After completing the KAS-T2DM program, participants from both the intervention and the control groups were asked to complete the post-study questionnaire again in week 5. Additionally, in week 12, participants underwent a second blood test to measure accumulated blood sugar levels (HbA1c). The study was conducted from October 1 to December 31, 2023. Data analysis The data were analyzed using the Instance software program. Descriptive statistical analysis was performed, including calculations of the mean and standard deviation (SD). Baseline sociodemographic characteristics were compared between the intervention group and the control group using the Pearson chi-square test and an independent sample t-test. To compare mean scores from the questionnaires on diabetes knowledge (Phuthai language version), attitudes towards diabetes, self-efficacy, self-care behaviors, and blood sugar levels (HbA1c), the analysis included normality tests to verify the data's normal distribution. Differences in mean scores between the intervention and control groups, pre and post-KAS-T2DM program, were analyzed using independent t-test statistics. The level of significance was set at 0.05, with a 95% confidence interval was used. Ethical considerations The study received approval from the Ethics Committee of the Nakhon Phanom Provincial Public Health Office (REC 041/66). Participants were fully informed of the study’s purpose, assured of anonymity and confidentiality, and informed of their right to withdraw at any time. Informed consent was obtained through signed forms prior to completing questionnaires and undergoing blood tests for HbA1c measurement. The study adhered to the ethical principles outlined in the Declaration of Helsinki [ 36 ]. Results The results of this study indicated no significant differences between the intervention and control groups in terms of sociodemographic characteristics such as gender, age, education, and duration of diabetes (p > 0.05). See Table 2 . Table 2 Sociodemographic characteristics of participants in the intervention group (n = 43) and the control groups (n = 44) Sociodemographic characteristics Intervention group n (%) Control Group n (%) Total n (%) \(\:{x}^{2}\) p-value Gender 0.838 0.360 Male 16 (36.4) 12 (27.3) 28 (31.8) Female 28 (63.6) 32 (72.7) 60 (68.2) Age (years) 0.182 0.669 ≤ 65 24 (52.2) 22 (47.8) 46 (52.3) ≥ 66 20 (47.6) 22 (50.0) 42 (47.7) ( \(\:\stackrel{-}{x}\) = 64.35, S.D. = 3.94, Min = 58, Max = 74) Marital status 0.503 0.478 Single 11 (25.0) 14 (31.8) 25 (28.4) Married 33 (75.0) 30 (68.2) 63 (71.6) Educational level 5.441 0.066 Primary school 30 (68.2) 39 (88.6) 69 (78.4) Secondary school 11 (25.0) 4 (9.1) 15 (17.0) Bachelor's degree or Higher 3 (6.8) 1 (2.3) 4 (4.5) Duration of diabetes (years) 2.176 0.337 1–5 9 (20.5) 6 (13.6) 15 (17.0) 6–10 10 (22.7) 16 (36.4) 26 (29.5) > 10 25 (56.8) 22 (50.0) 47 (53.4) ( \(\:\stackrel{-}{x}\) = 11.30, S.D. = 8.12, Min = 1, Max = 30) Body mass index (kg/m2) 0.752 0.386 ≤ 22.9 16 (36.4) 20 (45.5) 36 (40.9) ≥ 23.0 28 (63.6) 24 (54.5) 52 (59.1) ( \(\:\stackrel{-}{x}\) = 24.09, S.D. = 3.75, Min = 16.65, Max = 34.25) Note: S.D.=Standard Deviation Significant differences were observed in diabetes knowledge (Phuthai language version) between the intervention and control groups (p < 0.001). However, no significant difference was found between the two groups regarding attitudes toward diabetes (p = 0.553). Additionally, significant differences were noted in self-efficacy (p < 0.05) and self-care behaviors (p < 0.001). Participants in the intervention group achieved higher scores in diabetes knowledge, self-efficacy, and self-care behaviors compared to those in the control group after completing the KAS-T2DM program. See Table 3 . Table 3 Comparison of average diabetes knowledge (Phuthai language version), attitude towards diabetes, self-efficacy, and self-care behavior between the intervention group and the control group after participating in the KAS-T2DM program using independent t-test statistics. Variable \(\:\stackrel{-}{x}\) S.D. t p-value Diabetes knowledge (Phuthai language version) Intervention group Control group 8.93 6.87 1.58 1.78 5.588 < 0.001* Attitude towards diabetes Intervention group Control group 30.98 30.48 3.07 4.62 0.596 0.553 Self-efficacy Intervention group Control group 66.44 61.43 7.81 13.63 2.097 0.039* Self-care behaviors Intervention group Control group 57.02 52.68 1.50 3.67 7.247 < 0.001* *p-value < 0.05; S.D.=Standard Deviation; KAS-T2DM program = Knowledge, Attitude, and Self-efficacy for People with Type 2 Diabetes Mellitus program Regarding accumulated blood sugar levels (HbA1c), there was no significant difference between the intervention and control groups prior to participation in the KAS-T2DM program (p = 0.892). However, after completing the program, a significant difference was observed in HbA1c levels (p = 0.05), with participants in the intervention group exhibiting lower HbA1c levels compared to the control group. See Table 4 . Table 4 Comparison of mean accumulated blood sugar level (HbA1c) between the intervention group (n = 43) and the control group (n = 44) before and after the KAS-T2DM program Accumulated blood sugar level \(\:\stackrel{-}{x}\) S.D. t p-value Blood sugar level (HbA1c) before the KAS-T2DM program Intervention group Control group 8.99 8.94 1.68 1.91 0.136 0.892 Blood sugar level (HbA1c) after the KAS-T2DM program Intervention group Control group 8.80 9.68 1.50 2.23 -2.141 0.035* *p-value < 0.05; S.D.=Standard Deviation; KAS-T2DMprogram = Knowledge, Attitude, and Self-efficacy for People with Type 2 Diabetes Mellitus program Discussion The results of this study highlight the effectiveness of the KAS-T2DM program, which is rooted in Bandura’s SE concept within the SCT [ 14 , 15 ], for patients with T2DM and uncontrolled blood sugar levels. The program, a self-efficacy focused structured educational initiative, incorporated concepts such as verbal persuasion, vicarious experiences, mastery experiences, emotional arousal, and role modeling elements applied throughout all sessions. Its content addressed diabetes knowledge, nutritional guidance, traditional Thai exercises like Ruesi Dutton and Maneevej, and Thai foot reflexology massage. This reinforces the pivotal role of SE enhancement in improving and sustaining self-management behaviors among individuals with T2DM who participated in the program. These results align with findings from several studies [ 8 , 9 , 17 , 19 ]. As a result, participants in the intervention group displayed increased knowledge, improved self-efficacy, enhanced self-care behaviors, and lowered blood sugar levels (HbA1c) after completing the program. These findings are consistent with previous research [ 10 , 11 , 17 , 19 ], which has demonstrated the efficacy of diabetes health education in enhancing health literacy and behaviors. Additionally, traditional Thai exercises from Thai Traditional Medicine (TTM) and Thai foot reflexology massage provide supplementary benefits, including reduced blood sugar levels, improved blood circulation, enhanced joint flexibility, increased muscle strength, pain reduction, and overall quality of life improvements for individuals with T2DM. Diabetes education serves as a cornerstone in diabetes self-management and care, emphasizing the importance of integrating patient families, healthcare professionals (HCPs), communities, and decision-makers into the educational process [ 31 ]. Therefore, HCPs, particularly nurses, are encouraged to motivate and support individuals with diabetes in their self-care management and to extend this intervention program to broader groups to improve diabetes care and empower self-management behaviors. The intervention group participants exhibited significantly higher diabetes knowledge compared to the control group. Knowledge plays a fundamental role in diabetes management, as it fosters self-efficacy and self-care skills, leading to greater satisfaction with prescribed treatments and improved quality of life [ 5 ]. This finding corroborates prior research [ 13 , 30 , 37 ], which observed notable improvements in diabetes knowledge. When individuals believe in their capacity for self-care management and anticipate positive outcomes, they are more likely to adopt and sustain these behaviors [ 13 , 19 , 37 ]. High levels of knowledge can positively impact self-efficacy, increasing self-care capabilities, adherence to treatment regimens, and potentially lowering the risk of complications [ 19 , 37 ]. Regarding attitudes toward diabetes, no significant difference was observed between the intervention and control groups following the KAS-T2DM program. This finding aligns with a prior study [ 38 ], which reported notable improvements in knowledge, skills, and clinical practice but no clear change in attitude. Patients often require time to overcome challenges and adapt to behavioral changes [ 33 , 39 ]. HCPs, particularly nurses, play a vital role in helping patients shift their attitudes, address barriers, and support positive behavioral changes. After completing the KAS-T2DM program, the SE of the intervention group significantly improved. This result aligns with research suggesting that SE is a critical determinant of success in self-management behaviors [ 16 , 17 , 39 ]. Self-efficacy strongly influences self-care and disease management behaviors in diabetes control. Patients with higher SE are more likely to adhere to treatment recommendations for chronic illnesses and adopt behavioral modifications that enhance their self-care capacity [ 16 – 18 ]. Activities tailored to cultural contexts can foster self-motivation and SE, promoting positive behavioral changes [ 40 ]. In this study, participants’ self-care behaviors also improved significantly after completing the program. This finding is consistent with previous studies [ 12 , 41 ], which observed higher self-care behavior scores after implementing interventions designed to encourage behavioral change in newly diagnosed diabetes patients. Effective glycemic control is essential in reducing the risk of complications for individuals with diabetes [ 42 ]. Participants with uncontrolled blood sugar levels in this study demonstrated lower HbA1c levels after completing the KAS-T2DM program compared to the control group. Promoting SE in healthy eating across various situations has been shown to improve glycemic control in individuals with T2DM [43]. Diabetes self-management is crucial for achieving optimal glycemic control [ 31 ]. Thus, individuals with T2DM should receive counseling to support self-care behaviors, enabling effective diabetes management. This suggests that the KAS-T2DM program successfully empowered participants to enhance their SE, resulting in improved self-care behaviors and better diabetes management, ultimately reducing the risk of complications. Strengths and limitation The KAS-T2DM Program was developed to assist individuals with type 2 diabetes mellitus (T2DM) who struggle to control their blood sugar levels. The program was based on Bandura’s SE concept within the SCT, incorporating components designed to promote self-care management for people with uncontrolled T2DM. It is the first intervention program to include elements such as diabetes knowledge, nutritional guidance, and Thai Traditional Medicine (TTM) practices, such as traditional Thai exercises like Ruesi Dutton and Maneevej, Thai foot reflexology massage, and measurement of accumulated blood sugar levels (HbA1c). An innovative handbook aimed at improving health behaviors among patients with T2DM was developed as part of the program. The effectiveness of the training program was demonstrated using a quasi-experimental approach [ 34 ]. Additionally, the questionnaire used for data collection, comprising five parts, was rigorously tested for content validity and reliability prior to use. A limitation of the study was the relatively short implementation period of the KAS-T2DM Program, lasting only 12 weeks. To evaluate the long-term effects and sustainability of health behaviors and accumulated blood sugar levels (HbA1c), future research could extend the program’s duration to six months or one year. A longer timeframe would allow for a more comprehensive assessment of its effectiveness and the potential for lasting improvements in self-care management among individuals with T2DM. Another limitation lies in the participant selection method. Participants were chosen using a convenience sampling approach and divided into intervention and control groups, which may affect the generalizability of the study’s findings. Conclusions This quasi-experimental study developed and implemented the KAS-T2DM program, grounded in Bandura’s SE concept within the SCT, to support self-care management in patients with type 2 diabetes mellitus (T2DM) who struggle to control their blood sugar levels. The program encompassed diabetes knowledge, nutrition guidance, and Thai Traditional Medicine practices, including two traditional Thai exercises such as Ruesi Dutton and Maneevej, and Thai foot reflexology massage. The program demonstrated substantial effectiveness in improving outcomes related to self-care management by enhancing participants’ knowledge, awareness of their abilities, self-efficacy in adopting healthy behaviors, and blood sugar levels (HbA1c). It has proven to be a valuable tool in promoting better healthcare outcomes for individuals with T2DM, helping them achieve improved blood sugar control. Therefore, HCPs should encourage, facilitate, and support people with diabetes in their self-care management while promoting healthy lifestyle behaviors. Additionally, HCPs should focus on fostering behavioral changes in newly diagnosed diabetes patients. Future research should involve larger participant groups enrolled in the KAS-T2DM program and examine the sustainability of their self-care behaviors over extended durations. Abbreviations BMI Body Mass Index DM Diabetes Mellitus HbA1c Accumulated Blood Sugar HCP Healthcare Professionals KAS-T2DM Knowledge, Attitude, and Self-efficacy for People with Type 2 Diabetes Mellitus SE Self-efficacy SCT Social Cognitive Theory T2DM Type 2 Diabetes Mellitus TTM Traditional Thai Medicine Declarations Ethics approval and consent to participate The study received approval from the Ethics Committees in Thailand from Nakhon Phanom Provincial Public Health Office (REC 041/66). The participants were fully informed about the purpose of the study, assured of anonymity and confidentiality and told that anyone could drop out at any time. They provided their consent by signing an informed consent form before completing the questionnaires and blood tests to measure accumulated blood sugar levels. The study was conducted in accordance with the Declaration of Helsinki Clinical trial Not applicable. Consent for publication Not applicable. Availability of data and material Datasets are available on reasonable request to the corresponding author. Competing interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Authors' contributions NP, AW and PP contributed to the conception and design of the study. NP and AW collected the data from the questionnaire. NP, AW, PP, WK and PCL analyzed, interpreted, and presented the data. PCL and NP wrote the manuscript. All authors were involved in the revision of the manuscript, and each of them approved its final version. Funding This research received no specific grant from any funding agency. Acknowledgements The authors thank the participants in this study. 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Effect of educational guidelines on diabetic patients’ knowledge, attitude, and self-efficacy regarding use of artificial pancreas. Evidence-Based Nurs. Res. 6 (3), 1–9. https://doi.org/10.47104/ebnrojs3.v6i3.338 (2024). Heine, M. et al. Health education interventions to promote health literacy in adults with selected non-communicable diseases living in low- to-middle income countries: A systematic review and meta-analysis. J. Eval Clin. Pract. 27 (6), 1417–1428. https://doi.org/10.1111/jep.13554 (2021). McKeon, G. et al. Social media interventions targeting exercise and diet behaviours in people with Noncommunicable diseases (NCDs): A systematic review. Internet Interv . 27 , 100497. https://doi.org/10.1016/j.invent.2022.100497 (2022). Chinnabutr, N. Behavior modification programs for self-care of new diabetic patients who receive services in the diabetes clinic Phanom Phrai Hospital, Phanom Phrai District, Roi Et Province. J. Health Environ. Educ. 8 (4), 29–37 (2023). Nejhaddadgar, N., Darabi, F., Rohban, A., Solhi, M. & Kheire, M. The effectiveness of self-management program for people with type 2 diabetes mellitus based on PRECEDE-PROCEDE model. Diabetes Metab. Syndr. 13 (1), 440–443. https://doi.org/10.1016/j.dex.2018.08.016 (2019). Bandura, A. Self-efficacy: The exercise of control (W.H. Freeman and company, 1997). Waddington, J. Self-efficacy. ELY J. 77 (2), 237–240. https://doi.org/10.1093/elt/ccac046 (2023). Lin, K. et al. Effects of depression, diabetes distress, diabetes sel-fefficacy, and diabetes self-management on glycemic control among Chinese population with type 2 diabetes mellitus. Diabetes Res. Clin. Pract. 131 , 179–186. https://doi.org/10.1016/j.diaberes.2017.03.013 (2017). Qin, W., Blanchette, J. E. & Yoon, M. Self-Efficacy and Diabetes Self-Management in Middle-Aged and Older Adults in the United States: A Systematic Review. Diabetes Spectr. 33 (4), 315–323. https://doi.org/10.2337/ds19-0051 (2020). Zeng, B., Sun, W., Gary, R. A., Li, C. & Liu, T. Towards a conceptual model of diabetes self-management among Chinese Immigrants in the United States. Int. J. Environ. Res. Public. Health . 11 (7), 6727–6742. https://doi.org/10.3390/ijerph110706727 (2014). Rojruangnon, P. et al. Effects of self-efficacy enhancement program to food consumption behavior modification among diabetes mellitus risk groups at Khlongtonsai. Khlongsan Bangkok JDMS . 46 (3), 81–88 (2021). https://he02.tei-thaijo.org Yao, Y. et al. General self-efficacy modifies the effect of stress on burnout in nurses with different personality types. BMC Health Serv. Res. 18 (1), 667. https://doi.org/10.1186/s12913-018-3478-y (2018). Graham, L. et al. Measurement of adherence in a randomized controlled trial of a complex intervention: supported self-management for adults with learning disability and type 2 diabetes. BMC Med. Res. Methodol. 16 (1), 132. https://doi.org/10.118612874-016-0236-x (2016). Ngowsiri, K., Tanmahasamut, P. & Sukhonthasab, S. Rusie Dutton traditional Thai exercise promotes health related physical fitness and quality of life in menopausal women. Complement. Ther. Clin. Pract. 20 (3), 164–171. https://doi.org/10.1016/j.ctcp.2014.05.002 (2014). Khanthong, P. et al. Traditional Thai exercise (Ruesi Dadton) for improving motor and cognitive functions in mild cognitive impairment: a randomized controlled trial. J. Exerc. Rehabil . 17 (5), 331–338. https://doi.org/10.12965/jer.21425.271 (2021). Chaowpeerapon, T. et al. Three-dimensional kinematic analysis and muscle activation of the upper extremity in Ruesi Dutton Exercises. Siriraj Med. J. 74 (11), 721–730. http://dx.doi.org/10.33192/Smj.2022.85 (2022). Sungwan, P., Thathong, P. & Muenchan An effect of Maneevej exercise to office syndrome among office workers of university. Thai Red Cross Nurs. J. 14 (2), 251–263 (2021). Waichompu, N., Boontu, R., Yacob, M. & Maeng, D. The effect of Maneevej upper body exercise on upper muscular pain in the elderly Yupo Subdistrict, Mueang District, Yala Province. J. Health Res. Innov. ; 4 (2): (2022). ISSN 2651 – 1312. Wiratama, R. D., Muhith, A. & Zahro, C. Reflexology on blood sugar levels in patients with diabetes mellitus: Literature review. J. Appl. Nurs. Health . 5 (2), 276–286. https://doi.org/10.55018/janh.v5i2.157 (2023). Agustini, N. L. P. I. B., Wulansari, N. T., Yusniawati, Y. N. P. & Sintia, N. W. The effect of foot massage on decreasing peripheral neuropathy diabetic complaints in the patients with type 2 diabetes mellitus. Jurnal Ners . 14 (3), 305–309. http://dx.doi.org/10.20473/jn.v14i3(si).17152 (2019). Nakhon Phanom Provincial Public Health Office. Health Data Center. HDC. Access on 20 May 2024. Retrieved from https://npm.moph.go.th/ Ghannadi, S. et al.. Evaluating the effect of knowledge, attitude, and practice on self-management in type 2 diabetic patients on dialysis. J. Diabetes Res. 2016; July 10 : 20163730875. https://doi.org/10.1155/2016/3730875 Rashed, O. A., Sabbahb HAl, Younisc, M. Z., Kisac, A. & Parkashd, J. Diabetes education program for people with type 2 diabetes: An international perspective. Eval Program. Plann. 56 , 64–68. http://dx.doi.org/10.1016/j.evalprogplan.2016.02.002 (2016). Phoosuwan, N., Ongarj, P. & Hjelm, K. Knowledge on diabetes and its related factors among the people with type 2 diabetes in Thailand: a cross-sectional study. BMC Public. Health . 22 (1), 2365. https://doi.org/10.1186/s12889-022-14831-0 (2022). Lundberg, P. C. & Thrakul, S. Self-care management of Thai Buddhists and Muslims with type 2 diabetes after an empowerment education program. Nurs. Health Sci. 20 (3), 402–408. http://doi.org/10.1111/nhs.12423 (2018). Polit, D. F. & Beck, C. T. Nursing research: Generating and assessing evidence for nursing practice 11th edn (Wolters Kluwer Health, 2020). Beckerle, C. M. & Lavin, M. A. Association of self-efficacy and self-care with glycemic control in diabetes. Diabetes Spectr. 26 (3), 172–178 (2013). World Medical Association. Ethical principles for medical research involving human subjects. World Medical Association & the Declaration of Helsinki., (2013). Available at: https://www.wma.net/what-we-do/medical -ethics/declaration-of-helsinki/ (reviewed on 22nd November, 2017). Lim, S. C. et al. Impact of continuing medical education for primary health care providers in Malaysia on diabetes knowledge, attitudes, skills and clinical practices. Med. Educ. Online . 25 (1), 1710330. https://doi.org/10.1080/10872981.2019.1710330 (2020). Jiang, X., Jiang, H. & Li, M. The role of self-efficacy enhancement in improving self-management behaviors for type 2 diabetes mellitus patients. Diabetes Metab. Syndr. Obes. 17 , 3131–3138. https://doi.org/10.2147/DMSO.5460864 (2024). van Wageningen, A. P. Culturally tailored diabetes self-management educational (DSME) program and its impact on motivation and self-efficacy among Hispanic adults with T2DM: A pilot study. Doctoral Projects . 151. https://doi.org/10.31979/etd.gs9k-vv22 (2022). Sritin, P. Effects of discharge planning program in the uncontrolled type 2 diabetes patients at Charoensin Hospital, Sakon Nakhon Province. ECH J. 8 (2), 240–249 (2023). Fatehi, F. G., Malekzadeh, A., Akhavimirab, M. & Rashidi, Afkhami-Ardekani, M. The effect of short message service on knowledge of patients with diabetes in Yazd, Iran. Iran. J. Diabetes Obes. (IJDO) . 2 (1), 27–31 (2010). Jackson, I. L., Eshiet, U. I., Onung, S. I. & Egbe, E. S. Diabetes management self–efficacy and glycaemic control among people with type 2 diabetes in a resource–limited setting. Discover Public. Health . 22 , 35. https://doi.org/10.1186/s12982-025-00423-x (2025). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6650347","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":463487929,"identity":"4f12c345-9274-4cce-9289-8a375e7dde34","order_by":0,"name":"Nitikorn Phoosuwan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYDACZgaGgw1gFg9c6AABLcwYWtgSCFrDiKaFxwCvBnN2/oMHZ1Tcy2OQ7j344MOfw4n9s3u+SfMw1Mnh0mLZDHTYhjPFxQwy55INZ7YdTpxx5+w2oJbDxri0GBwGannYlpDYIJFjJs3bcDi34UYuSMuBxAaitPD8OZw7/0bOM5DD6vFq2QjXwnY4d8ONHDagFuYEPA4zODjjTEJim8wZY6Bf0us33kgztpxjcNgQpy3nDz7+2FORkNgv3WMIDDFrY7kbyQ9vvKmok8dlCxywSaAaRVADEEgQVjIKRsEoGAUjFAAARMBZC/vBl+MAAAAASUVORK5CYII=","orcid":"","institution":"Uppsala University","correspondingAuthor":true,"prefix":"","firstName":"Nitikorn","middleName":"","lastName":"Phoosuwan","suffix":""},{"id":463487930,"identity":"76c394a3-4e2b-4be3-acf7-a7773d9c7c20","order_by":1,"name":"Amornrat Wongsrila","email":"","orcid":"","institution":"Non Sa-at Subdistrict Health Promoting Hospital","correspondingAuthor":false,"prefix":"","firstName":"Amornrat","middleName":"","lastName":"Wongsrila","suffix":""},{"id":463487931,"identity":"f93b3c62-bc19-4c3f-a698-66036e305d86","order_by":2,"name":"Pakorn Pusuwan","email":"","orcid":"","institution":"University of Phayao","correspondingAuthor":false,"prefix":"","firstName":"Pakorn","middleName":"","lastName":"Pusuwan","suffix":""},{"id":463487932,"identity":"bb4b0f60-8682-40d3-9d6f-89d14f9cc1c3","order_by":3,"name":"Warinmad Kedthongma","email":"","orcid":"","institution":"Kasetsart University Chalermphrakiat Sakon Nakhon","correspondingAuthor":false,"prefix":"","firstName":"Warinmad","middleName":"","lastName":"Kedthongma","suffix":""},{"id":463487933,"identity":"e14c2961-7b66-4afc-b8bf-1391ba826133","order_by":4,"name":"Pranee C. Lundberg","email":"","orcid":"","institution":"Uppsala University","correspondingAuthor":false,"prefix":"","firstName":"Pranee","middleName":"C.","lastName":"Lundberg","suffix":""}],"badges":[],"createdAt":"2025-05-13 01:53:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6650347/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6650347/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83771057,"identity":"4dce36d2-8751-48fb-af67-0384ee2052fa","added_by":"auto","created_at":"2025-06-02 12:32:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":158857,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram for the quasi-experimental study\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6650347/v1/9d6c864c1c456415c838c76d.png"},{"id":83771880,"identity":"40843d01-9abe-414d-8c11-5b42ebea3632","added_by":"auto","created_at":"2025-06-02 12:40:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":934537,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6650347/v1/c174c146-7cdf-449a-9c43-b12abc51efab.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of a knowledge, attitude, and self-efficacy program for people having type 2 diabetes mellitus with uncontrolled blood sugar in a northeastern province of Thailand: A quasi-experimental study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetes Mellitus (DM), a chronic, non-communicable disease, is a major global health issue affecting over 422\u0026nbsp;million people worldwide, primarily in low- and middle-income countries. It is directly responsible for 1.5\u0026nbsp;million annual fatalities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The prevalence of diabetes has steadily increased, and 642.7\u0026nbsp;million cases are estimated by 2030 and 783.2\u0026nbsp;million by 2045 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Also Thailand faces a growing diabetes burden, with 300,000 new diagnoses annually and over 3.2\u0026nbsp;million registered cases [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This is attributed to socioeconomic, demographic, environmental, and genetic factors, with lifestyle and environmental influences being key drivers of type 2 diabetes mellitus (T2DM) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKnowledge is fundamental for effective diabetes management, enabling improved self-care, treatment satisfaction and enhanced quality of life [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, many individuals, particularly in developing countries, lack adequate diabetes-related knowledge and skills [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Failure to control blood sugar can lead to various complications, such as kidney disease, neuropathy, cardiovascular diseases, eye disorders, and chronic wounds [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Self-care for people with T2DM include dietary control, regular physical activity, blood glucose control, weight monitoring, foot care, and medication adherence [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Health education covering diet, exercise, blood glucose control, and medication adherence has proven effective in enhancing health literacy and behavior [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Managing T2DM requires a multifaceted approach, encompassing lifestyle modifications, medication adherence, monitoring, and patient education. Several studies have shown effective self-care management methods for persons with T2DM [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBandura's Social Cognitive Theory (SCT) introduces self-efficacy (SE) as an individual's belief in his or her ability to perform tasks and manage challenges to achieve outcomes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Higher SE correlates with better treatment adherence, improved self-care, and an enhanced quality of life [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. If individuals believe they can accomplish something and expect positive results, they are more likely to exhibit behavior aligned with those beliefs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Self-efficacy reflects overall self-confidence, behavior, thoughts, and emotional responses to environmental challenges or new situations [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Culturing self-management behavior and establishing a positive attitude toward treatment can enhance SE [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The SE concept of the SCT was used as conceptional framework to develop an intervention program for persons with uncontrolled T2DM.\u003c/p\u003e \u003cp\u003eExercises from Traditional Thai Medicine (TTM), such as Ruesi Dutton and Maneevej, along with Thai foot reflexology massage, were incorporated into innovative self-care practices. These exercises stem from the principle of Buddhist Dhamma Manamai, promoting integrated holistic self-care of the body, mind, spirit, and one's physical and social environment. The benefits of Ruesi Dutton include pain reduction, decreased blood pressure, improved joint angles, increased muscle strength, and enhanced quality of life (22\u0026ndash;24]. Similarly, Maneevej reduces muscle aches and improves functional status [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Thai foot reflexology massage of TTM helps alleviate peripheral neuropathy symptoms in patients with T2DM [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This foot massage involves gentle pressure to improve blood flow 27, 28].\u003c/p\u003e \u003cp\u003eIn 2022, there were 59,581 Thai individuals with diabetes in the Nakhon Phanom Province, with 3,373 newly diagnosed cases. Renu Nakhon District, with a population of approximately 35,590, had a total of 4,587 persons with diabetes, including 216 new cases [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. An important goal in managing diabetes in Thailand is to encourage behavioral changes and regular medication to control blood sugar levels near normal values. This includes aiming for accumulated blood sugar levels (HbA1c)\u0026thinsp;\u0026lt;\u0026thinsp;7% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Only 13.13% of 2,289 persons with diabetes achieved controlled HbA1c levels, while a growing number have uncontrolled levels, a trend increasing yearly. According to Bandura's SE concept [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], behavior is influenced by perceived abilities. Individuals confident in their abilities are more likely to demonstrate them [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Healthcare professionals (HCPs), particularly nurses, play a significant role in educating, supporting, and empowering patients. Evidence suggests that nursing interventions improve self-management behaviors and glycemic control by facilitating patient involvement and knowledge acquisition [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Daily diabetes self-care poses challenges for many Thai individuals with T2DM, who struggle with blood sugar control [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Few studies focus on intervention programs integrating educational and holistic self-care approaches to improve blood sugar control and prevent complications. These programs provide diabetes knowledge, nutrition guidance, traditional Thai exercises, Thai foot massages, and role models sharing successful self-care management experiences. This study aimed to investigate the effectiveness of knowledge, attitude, and self-efficacy program for people having T2DM with uncontrolled blood sugar in a northeastern province of Thailand.\u003c/p\u003e "},{"header":"Method","content":"\n\u003ch3\u003eDesign\u003c/h3\u003e\n\u003cp\u003eThis study adopted a quasi-experimental approach to investigate knowledge, attitude, self-efficacy, and self-care behaviors among people with T2DM [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. An intervention program was developed and implemented, involving both an intervention group and a control group. Pre- and post-experiment tests assessed participants' knowledge, attitude, self-efficacy, and self-care behaviors. The study targeted individuals with uncontrolled T2DM in health promotion hospitals.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eRenu Nakhon District, one of the three districts with the highest diabetes rates in Nakhon Phanom Province, northeastern Thailand [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], was selected for the study. The research was conducted in health promotion hospitals within the district.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIntervention program\u003c/h3\u003e\n\u003cp\u003eThe \u0026ldquo;Knowledge, Attitude, and Self-Efficacy for People with Type 2 Diabetes Mellitus (KAS-T2DM) program\u0026rdquo; was developed by the researchers based on Bandura\u0026rsquo;s SE concept within the SCT [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The program aimed to enhance participants' self-belief through mastery experiences, vicarious experiences, role models, verbal persuasion, and emotional arousal. The intervention comprised six sessions delivered over 12 weeks. Sessions 1\u0026ndash;5 were conducted weekly, while Session 6 took place in Week 12. Each session lasted approximately 60\u0026ndash;120 minutes. See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKnowledge, Attitude and Self-efficacy for people with type 2 diabetes mellitus program (KAS-T2DM program) in the intervention group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplementation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime duration\u003c/p\u003e \u003cp\u003e(minutes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInformation sources (Self-efficacy concept)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eContents of KAS-T2DM program\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession 1: \u0026ldquo;Preparation\u0026rdquo; (week 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVerbal persuasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProvide information about the study and the KAS-T2DM program, rights for participants, completion of a pre-test questionnaire and conducting a blood test (HbA1c)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession 2: Activity \u0026ldquo;Know it, Prevent it\u0026rdquo; (week 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVerbal persuasion\u003c/p\u003e \u003cp\u003eVicarious experiences\u003c/p\u003e \u003cp\u003eMastery experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProvide diabetes knowledge and highlight role models in life activities by observing others\u0026rsquo; experiences. Share insights from patients with complications caused by poor blood sugar control. Discuss experiences and exchange ideas.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession 3: Activity \u0026ldquo;How to eat when you have diabetes\u0026rdquo; (week 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVerbal persuasion\u003c/p\u003e \u003cp\u003eVicarious experiences\u003c/p\u003e \u003cp\u003eMastery experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProvide nutritional guidance, such as suitable foods for patients with diabetes. Feature role models who have successfully managed their self-care behaviors. Facilitate experience-sharing and foster confidence in adopting behavioral changes.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession 4:\u003c/p\u003e \u003cp\u003eActivity 1 \u0026ldquo;Good health with the principles of Dhamma Manamai\u0026rdquo; (week 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVerbal persuasion\u003c/p\u003e \u003cp\u003eVicarious experiences\u003c/p\u003e \u003cp\u003eMastery experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntroduce holistic healthcare based on Buddhist Dhamma Manamai, incorporating physical and mental well-being from Traditional Thai Medicine. Practice \u0026ldquo;3 Ruesi Dutton poses\u0026rdquo; and \u0026ldquo;5 Maneevej poses\u0026rdquo; of traditional Thai exercises\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession 4: Activity 2 \u0026ldquo;Thai foot reflexology massage\u0026rdquo;\u003c/p\u003e \u003cp\u003e(week 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVicarious experiences\u003c/p\u003e \u003cp\u003eMastery experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEducate participants about Thai foot reflexology massage. Distribute foot massage equipment and practice pressing 13 reflex points on the soles of the feet.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession 5: \u0026ldquo;Evaluation of the outcomes of the four sessions\u0026rdquo;\u003c/p\u003e \u003cp\u003e(week 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVerbal persuasion\u003c/p\u003e \u003cp\u003eVicarious experiences\u003c/p\u003e \u003cp\u003eMastery experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReview the knowledge gained from all sessions. Conduct a post-test questionnaire. Facilitate discussions to exchange insights, address challenges, and provide feedback for program improvement.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSession 6: \u0026ldquo;Evaluation for a blood test\u0026rdquo;\u003c/p\u003e \u003cp\u003e(week 12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVerbal persuasion\u003c/p\u003e \u003cp\u003eVicarious experiences\u003c/p\u003e \u003cp\u003eMastery experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMeasure accumulated blood sugar levels (HbA1c) for the second time. Facilitate discussions to exchange ideas and reflect on experiences from the program.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWeek 1 (Session 1): Objectives and program benefits were explained. Participants provided consent, completed a pre-test questionnaire, and had their accumulated blood sugar levels (HbA1c) measured for the first time.\u003c/p\u003e \u003cp\u003eWeek 2 (Session 2): Titled \u0026ldquo;Know it. Prevent it\u0026rdquo;, this session involved expert lectures using a booklet to share knowledge about diabetes and healthy behaviors. Participants reviewed blood sugar results, interacted with role models experiencing complications, and exchanged ideas and experiences.\u003c/p\u003e \u003cp\u003eWeek 3 (Session 3): Titled \u0026ldquo;How to Eat When You Have Diabetes\u0026rdquo;, the session provided nutrition guidance on suitable foods for diabetes management and foods to limit or avoid. Role models shared self-care success stories, fostering confidence in behavioral changes.\u003c/p\u003e \u003cp\u003eWeek 4 (Session 4): Delivered as two activities: (1) \u0026ldquo;Good Health with the Principles of Dhamma Manamai\u003cem\u003e\u0026rdquo;\u003c/em\u003e. Lecturers introduced Thai Traditional Medicine (TTM), focusing on holistic wellness. Participants practiced meditation, music therapy, and traditional Thai exercises, such as \u0026ldquo;3 Ruesi Dutton poses\u0026rdquo; for relaxation and \u0026ldquo;5 Maneevej poses\u0026rdquo; for physical fitness. And (2) \u0026ldquo;Thai Foot Reflexology Massage\u0026rdquo;: Participants learned and practiced reflexology massage techniques targeting 13 key reflex points, with equipment provided for self-massage.\u003c/p\u003e \u003cp\u003eWeek 5 (Session 5): In this session, participants\u0026rsquo; progress was evaluated. Knowledge from previous sessions was reviewed, post-test questionnaires were completed, and participants discussed experiences and obstacles in self-care management. Feedback was collected for program improvement.\u003c/p\u003e \u003cp\u003e Week 12 (Session 6): In this session, the participants\u0026rsquo; accumulated blood sugar levels (HbA1c) were re-measured, and they shared self-care management experiences from the program.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003ePatients with type 2 diabetes receiving treatment at health promotion hospitals (primary health care units) in Renu Nakhon District were invited to participate. The participants were individuals diagnosed with T2DM by a physician, who were unable to control their blood sugar levels. Inclusion criteria included: (1) having a blood sugar level (HbA1c)\u0026thinsp;\u0026gt;\u0026thinsp;7%, (2) being 55 years of age or older, (3) having been diagnosed with diabetes for at least 6 months, (4) having no severe complications, such as diabetic retinopathy, foot ulcers, or end-stage renal disease, (5) being able to read and write, and (6) being willing to participate. Exclusion criteria included: (1) participants terminating their involvement in the research study, and (2) participants migrating during the study period. Of the 130 patients with T2DM approached, 88 agreed to participate, while 42 were excluded for reasons such as refusal (n\u0026thinsp;=\u0026thinsp;21), being unreachable (n\u0026thinsp;=\u0026thinsp;16), and other reasons (n\u0026thinsp;=\u0026thinsp;5). Participants were divided into intervention and control groups, with 44 individuals in each group. See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003eA questionnaire designed by the researchers was utilized in this study. It was based on relevant documents and scientific literature and comprised five parts: sociodemographic information, diabetes knowledge, attitudes toward diabetes, self-efficacy, and self-care behaviors. The content validity of the questionnaire was evaluated by four experts, yielding an index of objective consistency (IOC) score of 0.96. Reliability testing was conducted among patients with type 2 diabetes who were unable to control their blood sugar levels. The questionnaire demonstrated an overall Cronbach's alpha coefficient of 0.77 (acceptable), and a Kuder-Richardson score of 0.50 (acceptable range: 0.2\u0026ndash;0.8).\u003c/p\u003e \u003cp\u003ePart 1: Sociodemographic Characteristics. This section included information on gender, age, marital status, educational level, duration of diabetes, and body mass index (BMI). This section captured information such as gender, age, marital status, educational level, duration of diabetes, and body mass index (BMI).\u003c/p\u003e \u003cp\u003ePart 2: Diabetes Knowledge. This section consisted of 14 items in Thai language [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Participants were asked to select the correct answer (right or wrong) for each question, encompassing both positive and negative prompts. The Kuder-Richardson-20 score for this section was 0.50.\u003c/p\u003e \u003cp\u003ePart 3: Attitudes Toward Diabetes. Eight questions developed by the researchers. A five-point Likert scale was used, ranging from \u0026ldquo;weakly agree\u0026rdquo; to \u0026ldquo;strongly agree,\u0026rdquo; with scores from 1 (least agree) to 5 (most agree) for each item. The total score ranged from 5 to 35, with higher scores indicating a more positive attitude. The Cronbach's alpha coefficient for this section was 0.71.\u003c/p\u003e \u003cp\u003ePart 4: Self-Efficacy. This section featured eight questions from the Self-Efficacy Questionnaire for patients with diabetes, developed by the Stanford Patient Education Research Center and translated into Thai [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Each question used a 10-point scale, with 1\u0026thinsp;=\u0026thinsp;not at all confident and 10\u0026thinsp;=\u0026thinsp;extremely confident, yielding scores from 1 to 10. The Cronbach's alpha coefficient for this section was 0.85.\u003c/p\u003e \u003cp\u003ePart 5: Self-Care Behaviors. Six categories were included: resuscitation (20 questions), and diet, medication, exercise, stress management, and ongoing care (5 questions each) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Responses were rated on a three-point scale: \u0026ldquo;frequently practiced,\u0026rdquo; \u0026ldquo;sometimes practiced,\u0026rdquo; and \u0026ldquo;never practiced.\u0026rdquo; The total score was 60 points, and the Cronbach's alpha coefficient was 0.75.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003ePermission to conduct the study and collect data was obtained from the directors of health promotion hospitals (primary health care units) in Renu Nakhon District. Nurses at the hospitals provided a list of patients with type 2 diabetes and uncontrolled blood sugar levels. Invitation letters were sent to the patients, detailing the study's purpose and their rights as participants in the KAS-T2DM program, including the option to withdraw at any time. Participants who consented to join signed a research consent form and returned it to the researchers. Those in the intervention group participated in the KAS-T2DM program, while the control group received standard treatment provided at government healthcare facilities. The KAS-T2DM program lasted for 12 weeks.\u003c/p\u003e \u003cp\u003eAfter completing the KAS-T2DM program, participants from both the intervention and the control groups were asked to complete the post-study questionnaire again in week 5. Additionally, in week 12, participants underwent a second blood test to measure accumulated blood sugar levels (HbA1c). The study was conducted from October 1 to December 31, 2023.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe data were analyzed using the Instance software program. Descriptive statistical analysis was performed, including calculations of the mean and standard deviation (SD). Baseline sociodemographic characteristics were compared between the intervention group and the control group using the Pearson chi-square test and an independent sample t-test.\u003c/p\u003e \u003cp\u003eTo compare mean scores from the questionnaires on diabetes knowledge (Phuthai language version), attitudes towards diabetes, self-efficacy, self-care behaviors, and blood sugar levels (HbA1c), the analysis included normality tests to verify the data's normal distribution. Differences in mean scores between the intervention and control groups, pre and post-KAS-T2DM program, were analyzed using independent t-test statistics. The level of significance was set at 0.05, with a 95% confidence interval was used.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e The study received approval from the Ethics Committee of the Nakhon Phanom Provincial Public Health Office (REC 041/66). Participants were fully informed of the study\u0026rsquo;s purpose, assured of anonymity and confidentiality, and informed of their right to withdraw at any time. Informed consent was obtained through signed forms prior to completing questionnaires and undergoing blood tests for HbA1c measurement. The study adhered to the ethical principles outlined in the Declaration of Helsinki [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe results of this study indicated no significant differences between the intervention and control groups in terms of sociodemographic characteristics such as gender, age, education, and duration of diabetes (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). See Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" style=\"width: 624px;\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSociodemographic characteristics of participants in the intervention group (n\u0026thinsp;=\u0026thinsp;43) and the control groups (n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003eSociodemographic characteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003eIntervention group\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{x}^{2}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.838\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.360\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e16 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e12 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e28 (31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e28 (63.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e32 (72.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e60 (68.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.182\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.669\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026le; 65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e24 (52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e22 (47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e46 (52.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026ge; 66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e20 (47.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e22 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e42 (47.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 607.6px;\" colspan=\"8\" align=\"left\"\u003e\n \u003cp\u003e(\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\)\u003c/span\u003e\u003c/span\u003e = 64.35, S.D. = 3.94, Min\u0026thinsp;=\u0026thinsp;58, Max\u0026thinsp;=\u0026thinsp;74)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003eMarital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.503\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.478\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e11 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e14 (31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e25 (28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e33 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e30 (68.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e63 (71.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003eEducational level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e5.441\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003ePrimary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e30 (68.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e39 (88.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e69 (78.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003eSecondary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e11 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e4 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e15 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003eBachelor\u0026apos;s degree or\u003c/p\u003e\n \u003cp\u003eHigher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e3 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e1 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e4 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 429px;\" colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003eDuration of diabetes (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e2.176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.337\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003e1\u0026ndash;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e9 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e6 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e15 (17.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003e6\u0026ndash;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e10 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e16 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e26 (29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026gt; 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e25 (56.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e22 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e47 (53.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 429px;\" colspan=\"4\" align=\"left\"\u003e\n \u003cp\u003e(\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\)\u003c/span\u003e\u003c/span\u003e = 11.30, S.D. = 8.12, Min\u0026thinsp;=\u0026thinsp;1, Max\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 439px;\" colspan=\"5\" align=\"left\"\u003e\n \u003cp\u003eBody mass index (kg/m2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\n \u003cp\u003e0.752\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65.845px;\" align=\"left\"\u003e\n \u003cp\u003e0.386\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026le; 22.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e16 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e20 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e36 (40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026ge; 23.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\" align=\"left\"\u003e\n \u003cp\u003e28 (63.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e24 (54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e52 (59.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 73.993px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 439px;\" colspan=\"5\" align=\"left\"\u003e\n \u003cp\u003e(\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\)\u003c/span\u003e\u003c/span\u003e = 24.09, S.D. = 3.75, Min\u0026thinsp;=\u0026thinsp;16.65, Max\u0026thinsp;=\u0026thinsp;34.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 102.755px;\" colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd style=\"width: 65.845px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 617.6px;\" colspan=\"8\"\u003eNote: S.D.=Standard Deviation\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eSignificant differences were observed in diabetes knowledge (Phuthai language version) between the intervention and control groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, no significant difference was found between the two groups regarding attitudes toward diabetes (p\u0026thinsp;=\u0026thinsp;0.553). Additionally, significant differences were noted in self-efficacy (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and self-care behaviors (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Participants in the intervention group achieved higher scores in diabetes knowledge, self-efficacy, and self-care behaviors compared to those in the control group after completing the KAS-T2DM program. See Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" style=\"width: 856px;\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of average diabetes knowledge (Phuthai language version), attitude towards diabetes, self-efficacy, and self-care behavior between the intervention group and the control group after participating in the KAS-T2DM program using independent t-test statistics.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth style=\"width: 421.313px;\" align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 221.687px;\" align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003eS.D.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 51px;\" align=\"left\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 80px;\" align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 421.313px;\" align=\"left\"\u003e\n \u003cp\u003eDiabetes knowledge (Phuthai language version)\u003c/p\u003e\n \u003cp\u003eIntervention group\u003c/p\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 221.687px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8.93\u003c/p\u003e\n \u003cp\u003e6.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.58\u003c/p\u003e\n \u003cp\u003e1.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5.588\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 421.313px;\" align=\"left\"\u003e\n \u003cp\u003eAttitude towards diabetes\u003c/p\u003e\n \u003cp\u003eIntervention group\u003c/p\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 221.687px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30.98\u003c/p\u003e\n \u003cp\u003e30.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.07\u003c/p\u003e\n \u003cp\u003e4.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.596\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.553\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 421.313px;\" align=\"left\"\u003e\n \u003cp\u003eSelf-efficacy\u003c/p\u003e\n \u003cp\u003eIntervention group\u003c/p\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 221.687px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e66.44\u003c/p\u003e\n \u003cp\u003e61.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.81\u003c/p\u003e\n \u003cp\u003e13.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.097\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.039*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 421.313px;\" align=\"left\"\u003e\n \u003cp\u003eSelf-care behaviors\u003c/p\u003e\n \u003cp\u003eIntervention group\u003c/p\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 221.687px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e57.02\u003c/p\u003e\n \u003cp\u003e52.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003cp\u003e3.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 51px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.247\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 80px;\" align=\"left\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 826px;\" colspan=\"5\"\u003e*p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05; S.D.=Standard Deviation; KAS-T2DM program\u0026thinsp;=\u0026thinsp;Knowledge, Attitude, and Self-efficacy for People with Type 2 Diabetes Mellitus program\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eRegarding accumulated blood sugar levels (HbA1c), there was no significant difference between the intervention and control groups prior to participation in the KAS-T2DM program (p\u0026thinsp;=\u0026thinsp;0.892). However, after completing the program, a significant difference was observed in HbA1c levels (p\u0026thinsp;=\u0026thinsp;0.05), with participants in the intervention group exhibiting lower HbA1c levels compared to the control group. See Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of mean accumulated blood sugar level (HbA1c) between the intervention group (n\u0026thinsp;=\u0026thinsp;43) and the control group (n\u0026thinsp;=\u0026thinsp;44) before and after the KAS-T2DM program\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAccumulated blood sugar level\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eS.D.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" align=\"left\"\u003e\n \u003cp\u003eBlood sugar level (HbA1c) before the KAS-T2DM program\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntervention group\u003c/p\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.99\u003c/p\u003e\n \u003cp\u003e8.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.68\u003c/p\u003e\n \u003cp\u003e1.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.892\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" align=\"left\"\u003e\n \u003cp\u003eBlood sugar level (HbA1c) after the KAS-T2DM program\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntervention group\u003c/p\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.80\u003c/p\u003e\n \u003cp\u003e9.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003cp\u003e2.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-2.141\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.035*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e*p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05; S.D.=Standard Deviation; KAS-T2DMprogram\u0026thinsp;=\u0026thinsp;Knowledge, Attitude, and Self-efficacy for People with Type 2 Diabetes Mellitus program\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study highlight the effectiveness of the KAS-T2DM program, which is rooted in Bandura\u0026rsquo;s SE concept within the SCT [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], for patients with T2DM and uncontrolled blood sugar levels. The program, a self-efficacy focused structured educational initiative, incorporated concepts such as verbal persuasion, vicarious experiences, mastery experiences, emotional arousal, and role modeling elements applied throughout all sessions. Its content addressed diabetes knowledge, nutritional guidance, traditional Thai exercises like Ruesi Dutton and Maneevej, and Thai foot reflexology massage. This reinforces the pivotal role of SE enhancement in improving and sustaining self-management behaviors among individuals with T2DM who participated in the program. These results align with findings from several studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs a result, participants in the intervention group displayed increased knowledge, improved self-efficacy, enhanced self-care behaviors, and lowered blood sugar levels (HbA1c) after completing the program. These findings are consistent with previous research [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], which has demonstrated the efficacy of diabetes health education in enhancing health literacy and behaviors. Additionally, traditional Thai exercises from Thai Traditional Medicine (TTM) and Thai foot reflexology massage provide supplementary benefits, including reduced blood sugar levels, improved blood circulation, enhanced joint flexibility, increased muscle strength, pain reduction, and overall quality of life improvements for individuals with T2DM. Diabetes education serves as a cornerstone in diabetes self-management and care, emphasizing the importance of integrating patient families, healthcare professionals (HCPs), communities, and decision-makers into the educational process [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Therefore, HCPs, particularly nurses, are encouraged to motivate and support individuals with diabetes in their self-care management and to extend this intervention program to broader groups to improve diabetes care and empower self-management behaviors.\u003c/p\u003e \u003cp\u003eThe intervention group participants exhibited significantly higher diabetes knowledge compared to the control group. Knowledge plays a fundamental role in diabetes management, as it fosters self-efficacy and self-care skills, leading to greater satisfaction with prescribed treatments and improved quality of life [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This finding corroborates prior research [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], which observed notable improvements in diabetes knowledge. When individuals believe in their capacity for self-care management and anticipate positive outcomes, they are more likely to adopt and sustain these behaviors [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. High levels of knowledge can positively impact self-efficacy, increasing self-care capabilities, adherence to treatment regimens, and potentially lowering the risk of complications [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding attitudes toward diabetes, no significant difference was observed between the intervention and control groups following the KAS-T2DM program. This finding aligns with a prior study [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], which reported notable improvements in knowledge, skills, and clinical practice but no clear change in attitude. Patients often require time to overcome challenges and adapt to behavioral changes [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. HCPs, particularly nurses, play a vital role in helping patients shift their attitudes, address barriers, and support positive behavioral changes.\u003c/p\u003e \u003cp\u003eAfter completing the KAS-T2DM program, the SE of the intervention group significantly improved. This result aligns with research suggesting that SE is a critical determinant of success in self-management behaviors [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Self-efficacy strongly influences self-care and disease management behaviors in diabetes control. Patients with higher SE are more likely to adhere to treatment recommendations for chronic illnesses and adopt behavioral modifications that enhance their self-care capacity [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Activities tailored to cultural contexts can foster self-motivation and SE, promoting positive behavioral changes [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In this study, participants\u0026rsquo; self-care behaviors also improved significantly after completing the program. This finding is consistent with previous studies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], which observed higher self-care behavior scores after implementing interventions designed to encourage behavioral change in newly diagnosed diabetes patients.\u003c/p\u003e \u003cp\u003eEffective glycemic control is essential in reducing the risk of complications for individuals with diabetes [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Participants with uncontrolled blood sugar levels in this study demonstrated lower HbA1c levels after completing the KAS-T2DM program compared to the control group. Promoting SE in healthy eating across various situations has been shown to improve glycemic control in individuals with T2DM [43]. Diabetes self-management is crucial for achieving optimal glycemic control [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Thus, individuals with T2DM should receive counseling to support self-care behaviors, enabling effective diabetes management. This suggests that the KAS-T2DM program successfully empowered participants to enhance their SE, resulting in improved self-care behaviors and better diabetes management, ultimately reducing the risk of complications.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitation\u003c/h2\u003e \u003cp\u003eThe KAS-T2DM Program was developed to assist individuals with type 2 diabetes mellitus (T2DM) who struggle to control their blood sugar levels. The program was based on Bandura\u0026rsquo;s SE concept within the SCT, incorporating components designed to promote self-care management for people with uncontrolled T2DM. It is the first intervention program to include elements such as diabetes knowledge, nutritional guidance, and Thai Traditional Medicine (TTM) practices, such as traditional Thai exercises like Ruesi Dutton and Maneevej, Thai foot reflexology massage, and measurement of accumulated blood sugar levels (HbA1c). An innovative handbook aimed at improving health behaviors among patients with T2DM was developed as part of the program. The effectiveness of the training program was demonstrated using a quasi-experimental approach [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Additionally, the questionnaire used for data collection, comprising five parts, was rigorously tested for content validity and reliability prior to use.\u003c/p\u003e \u003cp\u003eA limitation of the study was the relatively short implementation period of the KAS-T2DM Program, lasting only 12 weeks. To evaluate the long-term effects and sustainability of health behaviors and accumulated blood sugar levels (HbA1c), future research could extend the program\u0026rsquo;s duration to six months or one year. A longer timeframe would allow for a more comprehensive assessment of its effectiveness and the potential for lasting improvements in self-care management among individuals with T2DM. Another limitation lies in the participant selection method. Participants were chosen using a convenience sampling approach and divided into intervention and control groups, which may affect the generalizability of the study\u0026rsquo;s findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis quasi-experimental study developed and implemented the KAS-T2DM program, grounded in Bandura\u0026rsquo;s SE concept within the SCT, to support self-care management in patients with type 2 diabetes mellitus (T2DM) who struggle to control their blood sugar levels. The program encompassed diabetes knowledge, nutrition guidance, and Thai Traditional Medicine practices, including two traditional Thai exercises such as Ruesi Dutton and Maneevej, and Thai foot reflexology massage. The program demonstrated substantial effectiveness in improving outcomes related to self-care management by enhancing participants\u0026rsquo; knowledge, awareness of their abilities, self-efficacy in adopting healthy behaviors, and blood sugar levels (HbA1c). It has proven to be a valuable tool in promoting better healthcare outcomes for individuals with T2DM, helping them achieve improved blood sugar control. Therefore, HCPs should encourage, facilitate, and support people with diabetes in their self-care management while promoting healthy lifestyle behaviors. Additionally, HCPs should focus on fostering behavioral changes in newly diagnosed diabetes patients. Future research should involve larger participant groups enrolled in the KAS-T2DM program and examine the sustainability of their self-care behaviors over extended durations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI\u0026nbsp; \u0026nbsp; \u0026nbsp;Body Mass Index\u003c/p\u003e\n\u003cp\u003eDM\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Diabetes Mellitus\u003c/p\u003e\n\u003cp\u003eHbA1c\u0026nbsp;Accumulated Blood Sugar\u003c/p\u003e\n\u003cp\u003eHCP\u0026nbsp; \u0026nbsp;\u0026nbsp;Healthcare Professionals\u003c/p\u003e\n\u003cp\u003eKAS-T2DM\u0026nbsp;\u0026nbsp;Knowledge, Attitude, and Self-efficacy for People with Type 2 Diabetes Mellitus\u003c/p\u003e\n\u003cp\u003eSE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Self-efficacy\u003c/p\u003e\n\u003cp\u003eSCT\u0026nbsp; \u0026nbsp; \u0026nbsp;Social Cognitive Theory\u003c/p\u003e\n\u003cp\u003eT2DM\u0026nbsp;Type 2 Diabetes Mellitus\u003c/p\u003e\n\u003cp\u003eTTM \u0026nbsp; \u0026nbsp;Traditional Thai Medicine\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe study received approval from the Ethics Committees in Thailand from Nakhon Phanom Provincial Public Health Office (REC 041/66).\u0026nbsp;The participants were fully informed about the purpose of the study, assured of anonymity and confidentiality and told that anyone could drop out at any time. They provided their consent by signing an informed consent form before completing the questionnaires and blood tests to measure accumulated blood sugar levels. The study was conducted in accordance with the Declaration of Helsinki\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical trial\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and material\u003c/p\u003e\n\u003cp\u003eDatasets are available on reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003eAuthors' contributions\u003c/p\u003e\n\u003cp\u003eNP, AW and PP contributed to the conception and design of the study. NP and AW collected the data from the questionnaire. NP, AW, PP, WK and PCL analyzed, interpreted, and presented the data. PCL and NP wrote the manuscript. All authors were involved in the revision of the manuscript, and each of them approved its final version.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors thank the participants in this study. We also thank the staff at the health promotion hospitals at Renu Nakhon District, Nakhon Phanom Province for facilitating data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Diabetes. Access on 4th. March (2025). 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Effects of discharge planning program in the uncontrolled type 2 diabetes patients at Charoensin Hospital, Sakon Nakhon Province. \u003cem\u003eECH J.\u003c/em\u003e \u003cb\u003e8\u003c/b\u003e (2), 240\u0026ndash;249 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFatehi, F. G., Malekzadeh, A., Akhavimirab, M. \u0026amp; Rashidi, Afkhami-Ardekani, M. The effect of short message service on knowledge of patients with diabetes in Yazd, Iran. \u003cem\u003eIran. J. Diabetes Obes. (IJDO)\u003c/em\u003e. \u003cb\u003e2\u003c/b\u003e (1), 27\u0026ndash;31 (2010).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJackson, I. L., Eshiet, U. I., Onung, S. I. \u0026amp; Egbe, E. S. Diabetes management self\u0026ndash;efficacy and glycaemic control among people with type 2 diabetes in a resource\u0026ndash;limited setting. \u003cem\u003eDiscover Public. Health\u003c/em\u003e. \u003cb\u003e22\u003c/b\u003e, 35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12982-025-00423-x\u003c/span\u003e\u003cspan address=\"10.1186/s12982-025-00423-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2025).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intervention program, knowledge, attitude, self-efficacy, people with diabetes type 2, self-care behaviors, Thailand","lastPublishedDoi":"10.21203/rs.3.rs-6650347/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6650347/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e Diabetes Mellitus is one of the most common chronic non-communicable diseases worldwide. Managing individuals with type 2 diabetes requires a multifaceted approach that includes lifestyle modifications, medication adherence, regular monitoring, and patient education. This study is aimed at investigating the effectiveness of a knowledge, attitude, and self-efficacy program for people having type 2 diabetes mellitus with uncontrolled blood sugar in a northeastern province of Thailand.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e The study employed a quasi-experimental design. An intervention program Knowledge, Attitude, and Self-efficacy for individuals with type 2 diabetes mellitus and uncontrolled blood sugar, based on Bandura’s self-efficacy concept within the Social Cognitive Theory, was developed and implemented. Integrating Traditional Thai Medicine practices, such as Ruesi Dutton and Maneevej exercises, and Thai foot massage, the program comprised six sessions delivered over 12 weeks. Participants aged 55 years and older receiving treatment at health promotion hospitals in a northeastern province of Thailand were divided into intervention and control groups comprising 43 and 44 individuals, respectively. Data collection utilized a five-part questionnaire covering demographic information, diabetes knowledge, attitude, self-efficacy, and self-care behaviors, as well as measured accumulated blood sugar levels (HbA1c) before and after the program. Data analysis employed descriptive statistics, independent t-tests, and paired sample t-tests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e After completion of the intervention program, the average scores of the intervention group significantly differed from those of the control group in terms of diabetes knowledge, self-efficacy, self-care behaviors, and accumulated blood sugar levels (HbA1c) (p\u0026lt;0.05). However, no significant difference was observed between the two groups regarding attitude (p\u0026gt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e The intervention program proved to be a valuable tool in promoting better healthcare outcomes for individuals with type 2 diabetes and improving blood sugar control. Healthcare professionals should encourage, facilitate, and support patients' self-care management while focusing on behavioral changes in newly diagnosed diabetes patients. Future research should involve a larger sample size and examine the sustainability of self-care behaviors over extended durations.\u003c/p\u003e","manuscriptTitle":"Effectiveness of a knowledge, attitude, and self-efficacy program for people having type 2 diabetes mellitus with uncontrolled blood sugar in a northeastern province of Thailand: A quasi-experimental study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-02 12:31:56","doi":"10.21203/rs.3.rs-6650347/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-16T17:03:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-15T13:02:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152260313289718619176824151466875068321","date":"2025-06-09T00:35:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-01T12:30:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296868441257494647185050392969410440469","date":"2025-05-31T16:42:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-28T10:13:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-28T10:09:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-26T09:41:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-24T11:55:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-05-13T01:37:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"26cc7e1e-73bf-437f-81b7-c0109fcc2b83","owner":[],"postedDate":"June 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":49214903,"name":"Health sciences/Health care/Disease prevention/Lifestyle modification"},{"id":49214904,"name":"Health sciences/Health care/Patient education"}],"tags":[],"updatedAt":"2025-09-29T16:09:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-02 12:31:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6650347","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6650347","identity":"rs-6650347","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}