Development of a Care Model for Diabetes Patients Using Community Network and Family Participation in Phetchaburi Province

Abstract

This research and development study aimed to (1) assess the current situation, (2) develop a participatory diabetes care model involving community networks and families, and (3) evaluate model outcomes in Phetchaburi Province. Participants included a network mentoring team and 370 network personnel, and 180 diabetic patients, selected using purposive sampling. The study was conducted from November 2024 to December 2025. Research instruments included: 1) a diabetes behavior modification program; 2) a diabetes knowledge test; 3) network involvement in care; and 4) a questionnaire on diabetic patient care outcomes. Quantitative data were analyzed using descriptive statistics, with the Wilcoxon Signed-Rank Test and the Mann–Whitney U Test performed due to non-normal data distribution The research results are presented below. The developed model comprised seven role-based network measures and five behavior modification programs. In the network personnel group ( n = 330), knowledge of diabetes control after the intervention was significantly higher than before ( Mdn 16-17, Z = −15.205, p < .001, r = .837, large effect size). The percentage of those with a good level of knowledge increased from 86.1 % to 93.3%. Network participation also increased significantly ( Z = −4.107, p < .001, r = .226) , with the proportion of those with a high level of knowledge increasing from 32.7 % to 93.0%. In the patient group ( n = 180) , diastolic blood pressure ( DP) was the only variable that differed significantly. The study group reduced their HbA1c, FBS, systolic BP, BMI, behavior modification ( p = .088, near significance ), family /community support, and quality of life. However, these parameters did not show statistically significant differences. In summary, an integrated HBM and CCM care model can significantly enhance knowledge and network involvement and dramatically reduce diastolic blood pressure in patients. Other clinical and behavioral outcomes require a follow-up period longer than 12 weeks; therefore, extending the follow-up period to 6–12 months, conducting ongoing empowerment activities every 1–3 months, and linking clinical information systems with community networks via electronic communication for sustainability is proposed.