Lifestyle Behavior Modification of Mothers of Diabetic Children’s through Application of Trans-theoretical Model of Change

Background: Diabetes self-management is defined as a set of skilled behaviors one engages in to manage one’s own illness. The Transtheoretical Model (TTM, stage-based model) is one of the six most commonly cited behavior change models frequently assumed to be more effective than a control situation. Aim: This study was conducted in order to investigate the lifestyle behavior of mothers of diabetic children’s before and after implementation of intervention strategies incorporating the Transtheoretical Model of Change. Setting: The study was conducted in the Diabetic center in EL Mogamaa EL Teby AL Shamal at Shebin El-kom that serves Menoufyia Governorate. Design: The experimental pre-post-test design was used in carrying out the study. Sample: The study used simple random sample of 100 mothers of diabetic children’s who were enrolled in the computerized program for diabetic children registration. Instruments: a) Trans-theoretical model of change for child questionnaire, b). Transtheoretical model of change for mother questionnaire. The main results: The experimental group, reported that 18.0% not having complications as a result of diabetes at the pre intervention phase, increased to 64.0% at the post intervention phase. Also the results of the studied mothers revealed that there was statistically significant difference between experimental and control groups within the baseline, the first and the second intervention regarding stages of change for dietary management, blood glucose monitoring by using the home device and preparation and insulin administration behaviors. Conclusion: The implementation of the Trans-theoretical Model of changebased behavioral intervention brought a positive change in stages of mothers’ behaviors related to dietary management, blood glucose monitoring by using the home device and preparation and insulin administration. Recommendation: Encourage primary care nurse practitioner to use the Transtheoretical Model of change or other health promotion models to enhance patient care, and adoption of healthy behavior. Copies of stage-matched intervention materials should be distributed at diabetic clinics. *Corresponding author: Magda M Mohsen, Prof. of community health nursing, Community Health Nursing DepartmentFaculty of Nursing-Menoufiya University, Egypt, Tel +20-48-222-170; Fax: +20-48-226-454; E-mail: salmame20003@yahoo.com Received February 05, 2013; Accepted April 10, 2014; Published April 20, 2014 Citation: Mohsen MM, Saafan NA, Attia A, El-Abassy A (2014) Lifestyle Behavior Modification of Mothers of Diabetic Children’s through Application of Transtheoretical Model of Change. J Nurs Care 3: 153. doi:10.4172/2167-1168.1000153 Copyright: © 2014 Mohsen MM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
Today, more than 240 million people worldwide are living with diabetes mellitus. Within the next 20 years, this number is expected to grow to 380 million. Children are not spared from this global epidemic, with its debilitating and life-threatening complications. Type 1 diabetes is growing by 3% per year in children and adolescents, and at an alarming 5% per year among pre-school children. It is estimated that 70,000 children under 15 years old develop type 1 diabetes each year (almost 200 children a day). Of the estimated 440,000 cases of type "1" diabetes in children worldwide, more than a quarter live in South-East Asia and more than a fifth in Europe [1] Over half of the children with diabetes develop complications within 15 years old. Type "2" diabetes in children is becoming a global public health issue with potentially serious outcomes. Type 2 diabetes affects children in both developed and developing countries [2]. Also, the International Diabetes Federation (2010) added that, in 2010, number of children with type 1 diabetes (thousands) is 54.4 aged 0-14 years, and number of newly-diagnosed cases per year (thousands) is 9.1 in The Middle East and North African Region. Also, six countries in The Middle East and North African Region are among the world's 10 highest for diabetes prevalence. These countries are Bahrain, Egypt, Kuwait, Oman, Saudi Arabia and United Arab Emirates. By far, the largest contribution to the total number of children with type 1 diabetes aged 0-14 years comes from Egypt, whose estimate in thousands is 25.447 [3].
A cornerstone of diabetes management is attention to lifestyle. Lifestyle modification, although different, is an equally integral part of type 1 diabetes management. Patients with type 1 diabetes need insulin, so they must learn to count or at least closely estimate the amount of carbohydrate they consume to help regulate their blood glucose levels and adjust their insulin doses. Failure to do so can lead to dangerous hyperglycemia or hypoglycemia [4]. Intensive modifications to lifestyle means structured education designed to facilitate change in behavior. Such education programes are used in type 1 and type "2" diabetes and in prevention of diabetes in people with impaired glucose tolerance [5].
that explains the process of how people attempt to modify health-risk behaviors. It is based on 20 years of research and has been successfully applied to a variety of health behavior areas, including smoking cessation, weight control, sunscreen use, dietary change, exercise acquisition, and stress management. Within this model, there are sets of common principles that explain why people succeed and fail in changing their behavior. Research has provided strong support for the reliability and validity of the model's core constructs, including stages of change, processes of change, decisional balance, and self-efficacy. The TTM theorizes help individuals to move through a series of stages of readiness in the adoption of a healthy behavior or cessation of an unhealthy behavior [5].
The school nurse is the most appropriate person to coordinate care for students with diabetes. Each student with diabetes should have a written plan, developed by the school nurse, incorporating physician orders, parent requests, and tailored to the specific developmental, physical, cognitive, and skill ability of the child. The nurse will conduct a nursing assessment of the student and develop a nursing care plan, taking into consideration the child's cognitive, emotional, and physical status as well as the medical orders contained in the Diabetes Medical Management Plan.

Significance of the study
The number of children who were registered in the computerized program for diabetic children and visited the Diabetic center in EL Mogamaa EL Teby AL Shamal, for Follow up at the beginning of the present study (the first of July 2009) were about 600 children ( 1 day to 16 years old). Mothers of Diabetic children should have a more positive role in caring for their children if equipped with the needed stage matched educational intervention that can promote their children's health and wellbeing.

Aim of the study
The aim of this study was to investigate the lifestyle behavior of mothers of diabetic children's before and after the implementation of intervention strategies incorporating the Trans-theoretical Model of Change.

Research hypotheses
Mothers of diabetic children's will improve their lifestyle behaviors in knowledge and practices toward diabetes mellitus in posttest than pretest.
Diabetic children whose mothers receive intervention strategies will have better health status than diabetic children whose mothers did not receive intervention strategies. Diabetic children will have better health status after intervention strategies than before implementation of intervention strategies.

Subject and Method
Design: -A quasi experimental; pre-test and post-test design was used to test the study hypotheses.

Setting:-This study was conducted in the Diabetic center
Sample: A simple random sample of 100 diabetic children and their mothers (100) who were enrolled in the computerized program for diabetic children registration. Mothers were selected according to the following criteria: The mothers didn't attend any pediatric diabetic educational program before the study.

Instruments for Data Collection
The data collection instrument was developed by the researcher after reviewing literature related to the model.

Constructed interviewing questionnaire including the following
Part one: -including the following a-Demographic data of the mothers such as; age, education and occupation.
b-Diabetic child investigation results from his medical reports.
c-Diabetic complications that the child suffers from as; visual coma, skin, and ect. The five-item Stage of Change was designed to assess mother's readiness for change. The mother was asked to select the most applicable response and was assigned to one of the 5 stages of change [(pre-contemplation=1, contemplation=2, preparation=3, action=4, maintenance=5)].
B: -The Diabetes Management Self-efficacy Scale related to Diet, blood glucose monitoring and preparation and insulin administration: -The scale contained eight sentences. All items were scored according to three point Likert scale. The scores were: Items Score I have no confidence in myself 1 I have moderate confidence in myself 2 I have great confidence in myself 3 Total score 24 The results were categorized as the following: • From 1-<8 lower management self-efficacy • From 9 -<16 moderate management self-efficacy • From 17-<24 higher management self-efficacy

Diabetes Management Decisional Balance Scale related to Diet, blood glucose monitoring and preparation and insulin administration
Eight items decisional balance scale was used in this study. There were four «pros» and four «cons» items on the measure and each item was rated using a 3-point Likert scale ranging from 1 (not important) to 3 (very important).

Processes of Change Questionnaire related to Diet, blood glucose monitoring and preparation and insulin administration
It measured the two processes of change (experiential and behavioral). Total scores of ten items were used to assess the processes of change. The 3-point Likert scale ranked from 1=never happen, to 3=happen a lot. Ethical considerations: Before data collection, the children and their mothers were informed about the aim of the study. They were given an opportunity to refuse or to participate. Also they were assured that, their information would remain confidential and used for the research purpose only. Then their consent to participate was obtained.

The Trans-theoretical Model of Change-Based-Behavioral Intervention's Educational Materials
Reliability of the tools: It was applied for testing the internal consistency of the tool, by administration of the same tools to the same subjects under similar conditions on one or more occasions. Answers from repeated testing were compared (Test-re-test reliability).
Validity of the tools: They were tested for content validity by jury of four experts in the field of Community Health Nursing and Pediatric Specialty to ascertain relevance and completeness, it was done after the pilot study.
Pilot Study: It was carried out on 10 diabetic children and their mothers to test practicability of the tools. Based on the findings of the pilot study, the necessarily modifications were done accordingly. They were excluded from the study sample. Both groups experimental and control group were taken copies from General Information Package about diabetes. Whereas, experimental group were given an additional copies from stagematched intervention materials according their stages of change. The control group of mothers received usual care from the Diabetic Center and was asked to fill the first questionnaire. (*) statistically significant at p<0.05 p 1 group=Comparison between the baseline and the first intervention data within each group (experimental or control) p 2 group=Comparison between the first intervention and the second intervention data within each group (experimental or control) p 3 group=Comparison between the baseline and the second intervention data within each group (experimental or control) p value=Comparison between experimental and control groups within data within each group the first and the second intervention data related to the application of the Transtheoretical Model of behavior change served as baseline assessment of the diabetic child's mother.

Data Collection:
According to the results of the pre-test assessment, the researcher implemented the first Transtheoretical Model of change-based behavioral intervention and gave mother's stage-matched intervention materials with explanation for them. The same maneuver (first intervention's post-test) was obtained after two months from immediate post-test of the first questionnaire to evaluate the success rate of the first Transtheoretical Model of Change-based behavioral intervention on improvement of behaviors and lifestyle modification related diabetes management.
According to the first intervention's post-test's results, the researcher implemented the second Transtheoretical Model of Changebased behavioral intervention and gave mothers stage-matched intervention materials. The same maneuver (second intervention's post-test) was obtained after two months from first intervention's posttest to evaluate the success rate of the first Transtheoretical Model of Change-based behavioral intervention on progress of behavior change and lifestyle modification related diabetes management. The follow up was done through telephone counseling 10-30 minutes every two weeks. (*) statistically significant at p <0.05 p 1 group=Comparison between the baseline and the first intervention data within each group. p 2 group= Comparison between the first intervention and the second intervention data within each group p 3 group= Comparison between the baseline and the second intervention data within each group p value=Comparison between experimental and control groups within the baseline, the first and the second intervention data Table 2: Classification of stages of change for blood glucose monitoring by using the home device behavior among the studied groups of mothers over time. (*) statistically significant at p<0.05 p 1 group= Comparison between the baseline and first intervention data within each group p 2 group= Comparison between the first and second intervention data within each group p 3 group= Comparison between the baseline and second intervention within each group p value= Comparison between experimental and control groups within the baseline, the first and the second intervention data Table 3: Classification of stages of change for preparation and insulin administration behavior among the studied mothers groups over time.

Stage of change for Preparation and Give Insulin Injection
modification before and after TTMBI. This was done through reusing the same tools after three months from the first TTMBI. Another three months from the second TTMBI for intervention group. Also, the control group of mothers was asked to fill the second questionnaire. This was done through the pre-and post-analysis of data.

Statistical Analysis
Data was analyzed by using SPSS version 13. Graphics were done using Excel program. Quantitative data were presented by mean and standard deviation. It was analyzed using student t-test for comparison between two means, and ANOVA (F) test for comparison between more than two means. Qualitative data were presented in the form of frequency distribution tables, number and percentage. It was analyzed by chi-square (χ2) test. However, if an expected value of any cell in the Table was less than 5, Fisher Exact test was used. Level of significance was set as P value <0.05 for all significant tests. Table 1: As noticed the baseline; most of the experimental group was at the preparation stage (70.0%), at the first intervention 68.0% were at the action stage and at second intervention 68.0% were at the maintenance stage. While in the control group, at the baseline and the first intervention less than half (40.0%) were at the pre-contemplation and contemplation stages.

Results
Pre contemplation (PC), contemplation (C), Preparation (P), Action (A), Maintenance (M) (*) statistically significant at p <0.05 t 1 = Comparison between contemplation and preparation stages within each baseline data for mother's dietary management for her child t 2 =Comparison between preparation and action stages within each first intervention data for mother's dietary management for her child t 3 =Comparison between action and maintenance stages within each second intervention data for mother's dietary management for her child p 1 =p value of comparison between contemplation and preparation stages within each baseline data for mother's dietary management for her child p 2 =p value of comparison between preparation and action stages within each first intervention data for mother's dietary management for her child p 3 =p value of comparison between action and maintenance stages within each second intervention data for mother's dietary management for her child p 4 =p value of comparison between baseline and first intervention data within each stage of change for mother's dietary management for her child p 5 =p value of comparison between first and second intervention data within each stage of change for mother's dietary management for her child t 1 =Comparison between contemplation and preparation stages within each baseline data for mother's blood glucose monitoring t 2 =Comparison between preparation and action stages within each first intervention data for mother's blood glucose monitoring t 3 =Comparison between action and maintenance stages within each section intervention data for mother's blood glucose monitoring p 1 =p value of comparison between contemplation and preparation stages within each baseline data for mother's blood glucose monitoring p 2 =p value of comparison between preparation and action stages within each first intervention data for mother's blood glucose monitoring p 3 =p value of comparison between action and maintenance stages within each second intervention data for mother's blood glucose monitoring p 4 =p value of comparison between baseline and first intervention data within each stage of change for mother's blood glucose monitoring p 5 =p value of comparison between first and second intervention data within each stage of change for mother's blood glucose monitoring scores of mothers' self-efficacy regarding blood glucose monitoring by using the home device behavior throughout stages of change at all three time points as a result of the intervention where p 1 =0.000, p 2 =0.000.

Discussion
The Transtheoretical Model (TTM) is based on the premise that people are at different stages of readiness for engaging in health behaviors, and that intervention approaches are likely to be most helpful when they are matched to the individual's current stage of change. Many people need to bring about dramatic lifestyle changes to achieve ideal diabetes control after diagnosis [6,7].
The aim of the present study was to investigate the lifestyle behavior of diabetic children's mothers before and after the implementation of intervention strategies incorporating the Transtheoretical Model of Change.
Concerning classification of stages of change for dietary management behavior among the studied mother groups over time, the present study findings revealed that, in the experimental group, there was statistical significant forward stages progression at all three time points. While, in the control group, at the baseline, of the first and the second intervention, there was no statistical significant forward stages progression at all three time points. Additionally, there was statistical significant difference between experimental and control groups at all three time points regarding stages of change for dietary management behavior (Table 1). This finding comes in agreement with Bradbury et al. who reported that, the American intervention participants were significantly more likely to move into action or maintenance related to fruit and vegetables consumption than the control participants [8].
Meanwhile, the present results are in congruence with Johnson et al. who mentioned that, the African-American intervention participants were more likely than the control group participants to move into action or maintenance and remain there for the duration of the study, regardless of their stages at the baseline. This means that implementation of the Transtheoretical model of change-based behavioral intervention brings a positive change in stages of behavior related to dietary management [9].
Regarding comparison of the mean scores of self-efficacy, pros, cons, Pre contemplation (PC), contemplation (C), Preparation (P), Action (A), Maintenance (M) (*) statistically significant at p <0.05 t 1 =Comparison between contemplation and preparation stages within each baseline data for mother's blood glucose monitoring t 2 =Comparison between preparation and action stages within each first intervention data for mother's blood glucose monitoring t 3 =Comparison between action and maintenance stages within each section intervention data for mother's blood glucose monitoring p 1 =p value of comparison between contemplation and preparation stages within each baseline data for mother's blood glucose monitoring p 2 =p value of comparison between preparation and action stages within each first intervention data for mother's blood glucose monitoring p 3 =p value of comparison between action and maintenance stages within each second intervention data for mother's blood glucose monitoring p 4 =p value of comparison between baseline and first intervention data within each stage of change for mother's blood glucose monitoring p 5 =p value of comparison between first and second intervention data within each stage of change for mother's blood glucose monitoring cognitive and behavioral processes related to dietary management for the experimental group, the present study findings revealed that, there was statistical increased in mothers' self-efficacy scores throughout stages of change at all three time points. On the same line, there was statistical improvement of dietary management pros. Also, there was statistical improvement of mothers' use of cognitive and behavioral processes of change. While, there was statistical decreasing of dietary management cons (Table 4). This foregoing present study results is in congruence with Ma et al. who indicated that American female's self-efficacy of fruit and vegeTable intake increased in a linear pattern from precontemplation to maintenance. Also, fruit and vegeTable consumption pros increased while cons decreased across the five stages in a predicTable manner.
Also, the present study finding comes in agreement with Tassell & Flett who mentioned that self-efficacy for maintaining a healthy diet was significantly higher, across stages for fruit and vegeTable consumption [10]. Moreover, Riebe et al. found that, regular exercise and maintenance of a healthy diet were associated with greater use of processes of change. Exercise was also associated with higher confidence. In addition, a healthy diet was associated with lower temptation scores [11].
Likewise, the present study finding comes in agreement with Rakowski who reported that forward stages progression led to higher pros scores and lower cons scores [12]. Also, intention to have a future mammogram was more significant than previous mammography in relation pros and cons scores. Additionally, the present results are in congruence with Frenn & Malin who found that participants' use of the processes of change related to a low-fat diet increased across stages [13]. Also, participants' use of the processes related to exercise increased significantly across stages. These changes as a result of implementation of the Transtheoretical model of change-based behavioral intervention.
Classification of stages of change for blood glucose monitoring by using the home device behavior among the studied mother groups over time, the present study revealed that, in the experimental group, there was statistical significant forward stages progression at all three time points. While, in the control group, at the baseline, of the first and the second intervention, there was no statistical significant forward stages progression at all three time points. Additionally, there was statistical significant difference between experimental and control groups at all three time points regarding stages of change for blood glucose monitoring by using the home device behavior (Table 2). This present findings come in agreement with Norris et al. who showed that, there was significantly more stages progression in the intervention group compared with the control group [14]. Additionally, Shirazi et al. found that after the education program related to increase exercise to prevent osteoporosis, the training group of Iranian women had a larger percentage of participants in the preparation and action stages than the control group and a larger percentage of the control group participants in pre-contemplation and contemplation [15]. Also, there were high statistically significant differences between the training group and the Concerning comparison of the mean scores of self-efficacy, pros, cons, cognitive and behavioral processes related to blood glucose monitoring by using the home device behavior for the experimental group, the present study findings indicated that there was statistical increase in mothers' self-efficacy scores throughout stages of change at all three time points, blood glucose monitoring behavior pros and use of the cognitive and behavioral processes of change. While, there was statistical decreasing of blood glucose monitoring behavior cons (Table  5). This finding is supported by Patterson et al. who found that, the intervention participants were more likely to report increases in dietary self-efficacy [15]. These changes as a result of implementation of the Transtheoretical model of change-based behavioral intervention.
The present study is supported by Plotnikoff et al. who indicated a significant increase in self-efficacy in the intervention group compared to the control group [16].
Concerning classification of stages of change for preparation and insulin administration behavior among the studied mother groups over time, the present study findings revealed that, in the experimental group, there was statistical significant forward stages progression at all three time points. While, in the control group, at the baseline, of the first and the second intervention, there was no statistical significant forward stages progression at all three time points. Additionally, there was statistical significant difference between experimental and control groups at all three time points regarding stages of change for preparation and insulin administration behavior ( Table 3). The present study findings come in agreement with and Barthollomew et al. who mentioned that there was significant increase in stages for readiness to meet the 5-A-Day criteria for fruits and vegetables consumption for the (*) statistically significant at p<0.05 t 1 = Comparison between X & SD of pre intervention of experimental & control group p 1 =p value of comparison between X & SD of pre intervention of experimental and control group t 2 =Comparison between X & SD of post intervention data of experimental group and control group p 2 =p value of comparison between X & SD of post intervention of experimental and intervention. control group P paired= Comparison of paired t test between each group either before and after P group=Comparison (using x 2 test) between each group either (experimental or control) before and after intervention Also, there was a marked increase in the proportion of American patients in the behavioral intervention group in the action/maintenance stage after 4 months and 12 months related to stage of change for physical activity. While, there was less observed increase among mothers in the control group. This means that the implementation of Transtheoretical model of change-based behavioral intervention brings a positive change in stages of behavior related to preparation and insulin administration.
Concerning comparison of the mean scores of self-efficacy, pros, cons, cognitive and behavioral processes related to preparation and insulin administration behavior for the experimental group, the present study findings indicated that, there was statistical increase in mothers' self-efficacy scores throughout stages of change at all three time points, preparation and insulin administration behavior pros and mothers' use of the cognitive and behavioral processes of change. While, there was statistical decrease of preparation and insulin administration behavior cons (Table 6). This present study findings come in agreement with Henry et al. who mentioned that, self-efficacy for dietary behavior has been increased through improvements in knowledge, training, experience, and familiarity with a task. These changes as a result of implementation of the Transtheoretical model of change-based behavioral intervention. This present study comes in agreement with Plotnikoff et al. who reported that the intervention group reported increased participants' self-efficacy and higher intention for physical activity participation, whereas the control group reported decreased self-efficacy and lower intention. Moreover, the intervention group perceived more pros and fewer cons of physical activity participation, whereas the control group reported no changes in these variables. Additionally, the intervention group reported more use of the processes of change, while the control group reported no changes in these variables [17].
Regarding laboratory data (fasting blood sugar, post prandial blood sugar and Glucosylated HB) of the studied children, the present study revealed that the values of those laboratory data dropped down in the experimental group after the intervention with statistical significant difference (Table 7 and Figure 1). This result was in accordance with the studies carried out by Anderson et al. who stated that there was significant reduction in the mean serum HBAIC concentrations after the intervention period and also reduction in mean serum of fasting and P 1 =Comparison between experimental group and control group before intervention P 2 =Comparison between experimental group and control group after intervention P=Comparison between each group (either experimental or control) before and after intervention  post prandial blood sugar concentrations after the intervention period. This means that implementation of the educational intervention was effective and brought improvements in health outcomes [18].
Regarding children's health status "presence or absence of complications", the findings of the current study clarified that, the intervention was effective in reducing the complications where the highest percentage of the experimental group have no complications as a results of diabetes at the post intervention phase compared to the pre intervention phase where a statistical significant improvement was found. While the highest percentage of the control group have complications as a results of diabetes at the post intervention phase because they receive the routine diabetic care (Table 6). This finding comes in agreement with Crowley, in London and Majaliwa et al. in Tanzania, who mentioned that their intervention had significant improvement for patients with diabetes. In addition, the present study was also supported by Jones et al. concluded that health behavior change intervention had the potential of positively impacting the health status of broad populations of individuals with diabetes in Canada [19].
Regarding practicing of sports among the studied children before and after the intervention, Table 8 and Figure 2 presented that, there was statistically significant difference between pre and post intervention phases in the experimental group. In the same line with the present finding was the study carried out by Mehana & Kilani, in Omanand Chavez in USA, who reported that increasing knowledge of children about importance of physical activity improved their participation in sports [20].

Conclusion
The results provide important evidence that the implementation of the Transtheoretical Model of change-based behavioral intervention improved the self-management practices and well-being of children with type I diabetes. Also, the findings supported the importance of the Transtheoretical Model as a useful framework for promoting changes and evaluating participants' progress.

Recommendations
Encourage primary care nurse practitioner to use the Transtheoretical Model of change or other health promotion models to enhance patient care, and adoption of healthy behavior. Also distribute copies of stage-matched intervention materials at diabetic clinics.