Effects of a Comprehensive Self-Care Program for Slowing Progression of Diabetic Nephropathy on Self-Care Behavior, Quality of Life, and Clinical Outcomes in Persons with Diabetes and Early Chronic Kidney Disease

Abstract

Diabetes mellitus is a major and growing global health concern that significantly affects health, quality of life, and healthcare systems, particularly as a result of diabetes-related complications and the need for continuous care. Developing an integrated, high-quality care system that facilitates seamless continuity across hospitals and healthcare networks is therefore essential to improving health outcomes among people with diabetes. Individuals with diabetes who are unable to maintain optimal glycemic control are at increased risk of developing both macrovascular and microvascular complications, particularly microvascular complications affecting various organs, including the retinal microvasculature, peripheral microvasculature,and renal microvasculature. Previous studies have demonstrated that for every 1% increase in glycated hemoglobin (HbA1c) above the recommended target, the risk of developing microvascular complications increases by 25%. Diabetic kidney disease, a major microvascular complication, is also a leading cause of chronic kidney disease among people with diabetes of patients requiring kidney replacement therapy for end-stage kidney disease. Therefore, appropriate self-care among people with diabetes can delay the progression of kidney deterioration and improve their quality of life.

This research was a randomized controlled trial comparing outcomes between an intervention group and a control group. The intervention was delivered by an advanced practice nurse (APN). The study aimed to examine the effects of a comprehensive self-care program designed to slow the progression of diabetic kidney disease on patient outcomes. The intervention was developed based on Orem's Self-Care Deficit Nursing Theory, motivational interviewing techniques to facilitate behavioral change, comprehensive diabetes care standards to delay kidney disease progression, and current evidence-based practice. A total of 68 participants with diabetes and chronic kidney disease stages 1–3a were randomly assigned to either the intervention group (n = 34) or the control group (n = 34).

The intervention group participated in a 12-week comprehensive self-care program consisting of two phases. Phase I: the contemplation and decision-making phase focused on preparing participants for behavior change through therapeutic relationship building, comprehensive health assessment, assessment of stage for behavioral change, and evaluation of self-care agency.The researcher employed motivational interviewing strategies, including open-ended questioning,reflective listening, affirmations, and summarizing, to encourage participants to express change talk (self-statement messages). Participants also received supportive-educative nursing interventions, diabetes self-management education, and self-care skills training specifically designed for individuals with diabetic kidney disease. In addition, participants were invited to join a LINE application group that provided 24-hour consultation for health advice and continuous motivational support. During the first week of the program, educational video files entitled "Diabetes Knowledge Package for Patients with Diabetic Kidney Disease" were provided for self-directed learning. Phase II focused on action and maintenance of behavioral change.Participants were followed up every two weeks through the LINE application using video and voice calls. These follow-up sessions were conducted to monitor self-care practices at home,provide counseling, reinforce self-management skills, and maintain motivation for sustained behavioral change. The control group received routine standard care. The total intervention period was 12 weeks. Data were collected using the Self-Care Behavior Questionnaire and the Quality-of-Life Questionnaire. Clinical outcomes included glycated hemoglobin, blood pressure, urinary albumin excretion, and estimated glomerular filtration rate. Data were analyzed using descriptive statistics, the independent t-test, Wilcoxon signed-rank test, and Mann–Whitney U test.

After completion of the 12-week intervention, the intervention group demonstrated significantly higher self-care behavior scores than both baseline and the control group (t = 13.51,p < .001). Quality of life was also significantly higher than at baseline and significantly higher than that of the control group (z = –4.02, p < .001). Estimated glomerular filtration rate was significantly higher than baseline and the control group (t = 3.26, p = .002). Furthermore,glycated hemoglobin was significantly lower than baseline and the control group (t = –6.65,p < .001). Both systolic blood pressure (t = –4.04, p < .001) and diastolic blood pressure (t = –3.32, p < .001) were significantly reduced compared with baseline and the control group.Urinary albumin excretion was also significantly lower than baseline and the control group (t = –2.26, p = .020). The findings indicate that the advanced practice nurse (APN) and diabetes educators should implement this comprehensive self-care program for people with diabetes and early-stage chronic kidney disease to delay the progression of diabetic kidney disease.

Keywords: Clinical outcomes, Comprehensive care, Diabetes mellitus, Early-stage chronic kidney disease, Motivational interviewing

Authors Contributions:
WS: Conceptualization, Method and design, Tool development, Tool validation, Data collection,Data analysis, Writing and revising the manuscript
JT: Conceptualization, Method and design, Supervision, Tool validation, Analysis and interpretation of data, Editing and revising the manuscript
SC: Data analysis, Method and design, Supervision, Tool validation, Analysis and interpretation of data, Editing and revising the manuscript
OJ: Conceptualization, Method and design, Tool validation