Mabel Florence G

“ASSESS THE EFFECTIVENESS OF SELF INSTRUCTION
MODULE (SIM) ON DIABETIC DIET AMONG PATIENTS WITH
DIABETES MELLITUS IN SELECTED DIABETIC CLINIC AT
BANGALORE”.
By
MS.G. Mabel Florence
Dissertation Submitted to the Rajiv Gandhi University of Health Sciences
Bangalore, Karnataka
In partial fulfillment of the requirements for the degree of
MASTER OF SCIENCE
IN
MEDICAL SURGICAL NURSING
Under the guidance of
Mrs. D. VASANTHA CHITRA, M.SC [N]., PGDHM., PGDB.
PROFESSOR, HOD, Department of Medical Surgical Nursing
Diana College Of Nursing, Bangalore - 560 064

2010
I
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation entitled “Assess the Effectiveness of Self
Instructional Module (SIM) on diabetic diet among patients with diabetes
mellitus in selected diabetic clinic at Bangalore” is a bonafide and genuine research
carried out by me under the guidance of Mrs. D. Vasantha Chitra, M.Sc.(N).,
PGDHM., PGDB., Professor , HOD, Department of Medical Surgical Nursing, Diana
College of Nursing, Bangalore-560064.
Place: Bangalore Signature of the Candidate
Date: (Ms. G. Mabel Florence)
II
CERTIFICATION BY THE GUIDE
This is to certify that the dissertation entitled “Assess the Effectiveness of Self
mellitus in selected diabetic clinic at Bangalore.” is a bonafide research done by
Ms. G. Mabel Florence in partial fulfillment of requirement for the degree of
Masters of Science in Nursing in Medical Surgical Nursing.
Place: Bangalore Signature of the Guide
Date: Mrs. D. Vasantha Chitra, M.Sc (N)., PGDHM., PGDB.
III
ENDORSEMENT BY THE HOD, PRINCIPAL/ HEAD OF THE
INSTITUTION
This is to certify that the dissertation entitled “Assess the Effectiveness of Self
mellitus in selected diabetic clinic at Bangalore” is a bonafide research done by
Ms. G. Mabel Florence under the guidance of Mrs. D. Vasantha Chitra, M.Sc (N).,
PGDHM., PGDB., Professor, HOD, Department of Medical Surgical Nursing, Diana
College of Nursing, Bangalore - 64.
Seal & Signature of the HOD Seal & Signature of the Principal
Mrs. D. Vasantha Chitra, M.Sc (N) Prof. Veda Vivek, Ph.D
IV
COPY RIGHT
DECLARATION OF THE CANDIDATE
I hereby declare that Rajiv Gandhi University of Health Sciences, Karnataka, shall
have the rights to preserve, use and disseminate this dissertation/thesis in print or
electronic format for academic/research purpose.
Place: Bangalore Signature of the Candidate
Date: January 2009 (Ms. G.Mabel Florence)
© Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.
V
ACKNOWLEDGEMENT
“I know that you can do all things;
no plan of yours can
be thwarted”
Job:42:2
First of all, I thank Lord Almighty for His abundant blessings showered on me, which
helped me to complete the study successfully.
With immense joy and gratitude, I recall minding all those who helped me to shape
this dissertation.
I profoundly thank the Management Trustee of Diana College of Nursing
Mr.Mallinath.G.Gola for his encouragement and constant support during my
studies.
I express my deep gratitude and immense thanks for the main designer of the study
Mr. Veda Vivek, Ph.D, Principal, Diana College of Nursing, for his valuable advice,
guidance, suggestions and kind support during the study.
I am highly indebted to my guide, Mrs.Vasantha Chitra, M.Sc (N), Professor and
HOD of Medical Surgical Nursing for her constant encouragement, inspiring
guidance and valuable suggestions right from the conception of this research work till
its completion and also aided me for statistical analysis of data.
I am immensely grateful to Class Coordinator, Mrs.Kalaivani, M.Sc (N), Professor,
HOD, Department of Obstetrics and Gynecological Nursing, Diana College of
Nursing for her inspiring guidance and timely support.
VI
I extend my sincere thanks to, Ms.Elizabeth Dora, M.Sc (N), Professor and HOD of
Child Health Nursing for her encouragement in joining the course.
I extend my heartfelt gratitude to all the experts who spared their valuable time and
effort for content validity and refining of the tool.
It gives me great pleasure to express my thanks to beloved Rev.C.Paul and
Rev.Shine for their great encouragement and valuable suggestion to join this course.
I express my thanks to Mrs. Padmavathi Mallinath, Bhavani Laser Tech, who
helped a lot during my studies and shape the dissertation.
Heartfelt thanks to the Library Staff of Diana College of Nursing and Rajiv Gandhi
University of Health Sciences, Bangalore and my Classmates for helping me in one
way or the other in completion of this dissertation.
I extend my thanks to Ms. Divya Rashmi for her timely support and Kannada
translation.
I sincerely thank Mr. Srinivas who helped me in Kannada editing.
My whole hearted thanks to Ms. Poonam Sharma for her extreme help in completion
of my dissertation.
I am greatly indebted to my most lovable Father Pr. D. Gnanadhas and
Smt. T.Vasantha, my loving sister Miss. G.Jayagreet and my beloved brother
Mr.G.Jabastin for their patience, sacrifices, constant inspiration and moral support,
showering their love, prayers and support.
VII
A greatful acknowledgement to beloved sister Christina and dear Brother David
Spurgeon who helped me in one way or other in completion of this dissertation.
I cannot express in words how much I owe to The Director of Diabetic Clinic,
Kalyan Nagar, Bangalore, and the participants of my study for the understanding
and full co-operation during my study period, without them this study cannot be
completed.
I would like to thank all my friends who helped me directly as well as indirectly to
complete this dissertation.
Ms.G.Mabel Florence
VIII
LIST OF ABBREVIATIONS USED
DM : Diabetes Mellitus
df : degree of freedom
NS : Not- Significant
r : reliability
S : Significant
SD : Standard Deviation
SIM : Self Instruction Module
WHO : World Health Organization
IX
ABSTRACT
Background of the study:
Nutrition plays a major role in the prevention and management of many diseases. One
of the most important advances in modern medicine is the better understanding of
basic requirements of fluid and electrolytes. One such disease which could be
managed by diet is diabetes mellitus. Diabetes mellitus is a metabolic disorder which
occurs in all age Groups.
DM is an “iceberg” disease posing a serious threat to be met within the 21st century.
Prevalence of type 2 DM is increasing globally, more so in developing countries like
India. One of the primary objectives in the care of Diabetic patient is to educate the
patient regarding diabetic diet. Hence the investigator decided to assess the
knowledge of diabetic patients regarding diabetic diet.
The study was undertaken to evaluate the “Assess the Effectiveness of Self-
Instruction Module (SIM) on diabetic diet among patients with diabetes mellitus
in selected diabetic clinic at Bangalore”.
Objectives of the study
1. To assess the pre test knowledge on diabetic diet among Experimental and Control
Group.
2. To compare the pre test and posttest knowledge on diabetic diet among
Experimental Group and Control Group.
3. To assess the effectiveness of self-instruction module by comparing the post test
knowledge on diabetic diet between Experimental and Control Group.
X
4. To find the association between posttest knowledge of Experimental and Control
Group and their selected demographic variables.
Methodology:
True Experimental design with Pretest and Posttest Control Group design was used to
evaluate the effectiveness of Self Instruction Module on diabetic diet among 80 (40
Experimental and 40 control) patients with diabetes mellitus who were selected by
using simple random sampling technique (Lottery method). A self administered
structured knowledge questionnaire was used to collect the data from subjects. The
conceptual framework of the study is based on Ernestine Wiedenbach Clinical
Nursing Practice - A Helping Art.
Result:
The Posttest mean of Experimental Group is 33.78 with SD 4.666, whereas in Control
Group the Posttest mean is 25.60 with SD 4.567. The obtained unpaired ‘t’ value is
7.324. As the calculated value is greater than the table value, 3.55 at 39 df, the
research hypothesis H2 stating that there is significant difference in Posttest
knowledge on diabetic diet between the Experimental and Control Group is accepted
at p< 0.001. Hence the Self Instruction Module was considered to be effective in
enhancing the knowledge of diabetic patients.
On associating the post test knowledge with the demographic variables, significant
association was found only with education, marital status and family history of
diabetes mellitus in Experimental Group and significant association was found only
with age Group, education and place of residence in Control Group. In this study the
XI
research hypothesis is accepted, hence it is revealed that there is significant difference
in the post test knowledge on diabetic diet between Experimental and Control Group
Interpretation and conclusion:
The study findings revealed that self instructional module on diabetic diet was
effective in improving knowledge of diabetic patients. The study also showed that
there was significant association between the post test level of knowledge with
selected demographic variables. Self instruction module will help to improve the
knowledge of diabetic patients on diabetic diet.
As consumption of the healthy diet plays a major role in the prevention and
management of many diseases, a thorough knowledge is essential for economy and
health. Indians, who rank first in diabetes globally, need enhancement of knowledge
regarding DM especially on diabetic diet through SIM or other teaching methods.
Nurses through this, can contribute to minimize the global burden imposed on our
country.
XII
TABLE OF CONTENTS
Chapter PARTICULARS PAGE NO.
1. Introduction 1
I
2. Objectives 10
II 3. Review of Literature 16
III 4. Methodology 26
IV 5. Results 39
6. Discussion 86
7. Conclusion 91
V 8. Summary 92
9. Bibliography 103
10. Annexures 108
XIII
LIST OF TABLES
SI.NO TABLES PAGE. NO
1. Frequency and Percentage Distribution of subjects by their 41
Age, Gender and Educational Status.
occupation, monthly income, religion, marital status and
place of residence.
type of family, family history of diabetes mellitus and
methods to control diabetes mellitus.
level of activity and source of knowledge.
5. Aspectwise Frequency and Percentage Distribution of 59
pretest and posttest scores of Experimental Group.
6. Aspectwise Pretest and Posttest Mean Standard Deviation 62
and Mean Percentage of Experimental Group.
7. Aspect wise Frequency and Percentage Distribution of 63
pretest and posttest knowledge scores of Control Group.
8. Aspect wise Mean, Standard Deviation, and Mean 66
percentage of pretest and posttest knowledge scores of
Control Group.
9. Frequency and Percentage Distribution of overall 67
knowledge scores of Experimental and Control Group.
10 Mean, SD and Mean % of overall knowledge scores of 69
XIV
Experimental and Control Group.
11 Aspectwise comparison of Pretest and Posttest Mean, 70
Standard deviation, Mean difference and Paired ‘t’ value
among Experimental Group
12 Aspect wise comparisons of Pretest and Posttest 72
knowledge scores of Control Group.
13 Comparison of overall Pretest and Posttest Mean, Standard 74
deviation, Mean difference and Paired ‘t’ value among
14 Comparison of Posttest Mean, Standard deviation, Mean 75
difference and Unpaired ‘t’ value between Experimental
and Control Group
15 Association of posttest knowledge of Experimental group 76
with selected demographic variables.
16 Association of posttest knowledge of Control Group with 81
selected demographic variables.
XV
LIST OF FIGURES
SI.NO FIGURES PAGE. NO
1. Conceptual framework 15
2. Schematic Representation of Study design 28
Percentage distribution of Experimental and Control Group

3. 42
by their age.
Percentage distribution of Experimental Group by their

4. 43
gender.
5. Percentage distribution of Control Group by their gender. 44

6. 45
by their educational status.

7. 47
by their occupation.

8. 48
by their monthly income.

9. 49
by their religion.

10. 50
by their marital status.

11. 51
by their place of residence.

12. 53
by their type of family.
XVI
13. 54
by their family history of diabetes mellitus.

14. 55
by their methods used to Control diabetes mellitus.

15. 57
by their level of activity.

16. 58
by their source of knowledge.
Percentage Distribution of knowledge variables among

17. 60
Experimental Group.
Percentage Distribution of knowledge variables among

18. 64
Control Group.
Percentage Distribution of Experimental and

19. 68
Control Group by their level of knowledge
XVII
LIST OF ANNEXURES
ANNEXURE.
ANNEXURES PAGE.NO
NO
Letter seeking and granting permission to conduct

1 108
the main study
2 Content validity certificate. 109
Letter seeking experts opinion and suggestions for

3 110
the content validity of tool
4 List of experts. 118
5 Data collection tool 120
6 Blue print of the questionnaire. 165
Scoring key for the structured knowledge

7 167
questionnaire.
XVIII
1. INTRODUCTION
“Some food is medicine,
some food is poison,
some food is tension,
some food is fear,
some food is lovely,
some food is bland,
some food is sweaty,
some food is spicy,
some food is nothing,
food is not only food….
A good eatable medicine….
At only some food….. some food!”
Otteri Selvakumar
The knowledge of human nutrition no longer entails merely prevention of deficiency
diseases like pellagra, beriberi or scurvy. Nutrition now plays a major role in the
prevention and management of many diseases. Indeed, even more than the discovery of
antibiotics, one of the most important advances in modern medicine is the better
understanding of basic requirements of fluid and electrolytes. This helps in the
management of serious medical cases and is very vital in the successful outcome of
surgery.1
1
Human diseases occur mostly due to the result of heredity, environment or food. It is not
possible to change heredity, it is difficult to change environment, but it is relatively easy
to change food habits. The lower the income, the higher the proportion of money spent
on food. Knowledge of proper nutrition therefore, is essential for economy and health1.
The food which enters our body gets digested, absorbed and metabolized in our body
which is influenced by many hormones and enzymes. One such hormone which helps in
the glucose metabolism is Insulin.
Metabolic disorder is a global health problem, in this diabetes mellitus is an ‘iceberg’
disease posing a serious threat to be met within the 21st century. Diabetes mellitus is
epidemic in both developed and developing countries2.
The symptoms of diabetes were described on an Egyptian papyrus, the Ebers papyrus,
which dates to about 1500 BC. In the first century, the Greek physician Areatus wrote a
malady in which the body “ate its own flesh” and gave off large quantities of urine. He
named it diabetes, the Greek word meaning “siphon” or “to pass through”. In the
seventeenth century, the word mellitus, from the Latin word meaning “honey” was added
because of the sweet nature of the urine. Today, the simple term diabetes refers to
diabetes mellitus3.
Around 150 million people suffer from diabetes in the world. With the increasing
incidence of diabetes, India leads the world today with the largest number of diabetics in
any given country followed by China and USA. Every fifth diabetic patient in the world
is in India and every fifth adult in Indian urban area is a diabetic4
2
It is estimated that 20% of the current global diabetic population resides in the South-
East Asia region, which bear the maximum global burden of the disease in the initial
decades of the 21st century. Diabetes mellitus is now seen as a heterogeneous group of
diseases, characterized by a state of chronic hyperglycemia. The underlying cause of
diabetes is the defective production or action of insulin, a hormone that controls glucose,
fat and amino acid metabolism4.
Prevalence of type 2 diabetes is increasing globally, more so in developing countries like
India due to rapid urbanization. It is estimated that prevalence of diabetes will rise to
5.5% in 2025 as compared to 4% in year 1995. The total direct cost for diabetes
management has doubled from 1998 to 2005. Therefore, prevention is important both on
monetary and human matters. There is an increasing amount of evidence that the patient
education is the most effective way to lessen diabetes and its management5.
The primary goal for patients with type 2 diabetes is to achieve and maintain near normal
blood glucose level. Making healthy food choices, especially modifying calorie intake,
can be beneficial. A moderate calorie modification and increase in physical activity may
lead to improved weight control. Research has shown that even a weight loss of 5 to 10%
is sufficient for improving glycemic control. Weight loss appears to increase insulin
sensitivity and normalize hepatic glucose production5.
In a dozen studies that monitored tens of thousands of people for years, being overweight
increased the risk of developing diabetes in men and women more than tenfold.
Unfortunately, anyone trying to avoid weight gain and diabetes will find little help from
restaurant menus. Restaurants serve large portions of tasty calorie-rich foods6
3
‘Prevention is better than cure.’ The preventive measures comprise maintenance of
normal body weight through adoption of healthy nutritional habits and physical exercise6.
When diabetes is detected, it must be treated. The aims of the treatment are to maintain
blood glucose level and maintain ideal body weight. Treatment is based on; diet alone,
diet and oral antidiabetic drug, diet and insulin. Good control of blood glucose protects
against the development of complications7.
Balancing three basic elements is essential in good control of diabetes. First, the healthy
diet forms the foundation for good management, second physical exercise, third to ensure
adequate insulin activity7.
Most chronic diseases cannot be cured, they must be managed in the home, at school, at
work elsewhere on a 24 hr basis not by the physician but by the patient themselves;
Diabetes mellitus is one among them. One of the primary objectives in the care of
Diabetic patient is to educate the patient regarding diabetic diet5.
At present days there are so many treatment regimens are existing to control Diabetes
Mellitus. So it is important to enhance the knowledge of the Diabetes patients about the
disease and its management such as the diet, Exercise, medication intake which inturn
helps the patient to practice these effectively in their day to day life. To control the global
burden of DM, patients and family members need to be educated regarding the problem.
Hence the investigator decided to assess the knowledge of diabetic patients regarding
diabetic diet, develop a SIM regarding diabetic diet and evaluate the effectiveness of
SIM.
4
NEED FOR THE STUDY
“Health is wealth”
Diabetes mellitus is a group of metabolic diseases characterized by increased levels of
glucose in the blood, resulting from defects in insulin secretion, insulin action or both.
The major classifications of diabetes are type I diabetes, type II diabetes, gestational
diabetes and diabetes mellitus associated with other condition or syndromes. Diabetes is
the third leading cause of death from disease, primarily because of the high rate of
cardiovascular disease such as myocardial infarction, stroke, and peripheral vascular
disease. Clinical manifestations of all types of diabetes include the ‘three Ps’, polyuria,
polydipsia and polyphagia8.
The World Health Organization estimated that the global number of people with
diabetes is expected to be at least 220 million in 20105. WHO and the International
Diabetes Federation predict that the number of diabetics in Asia could increase to 160
million by the year 20255.
It was projected that by the year 2025, 250 million people world over will be affected, of
these 75% will be from developing countries. But in the year 2008, it is projected that
300 million people with diabetes is expected by the year 20258.
According to the IDF’s 2003 statistics, the top 5 countries with the largest number of
diabetics were: India - 35.5 million, China - 23.8 million, USA - 16.0 million, Russia -
9.7 million and Japan - 6.7 million9
5
Diabetes mellitus is a deadly disease in India. In 1995, 19.4 million individuals were
affected; it is likely to go up to 57.2 million by the year 203010. The committee of RSSDI
2009 spoke about the dismal statistics of diabetes in India. Apparently, India which has
the highest numbers of diabetics in the world will home to about 51 million diabetics by
2010 and slated to touch 80 million by 203010.
The Indian diabetes risk score vary based on the demographic variables. The risk score is
10 when the age of the person lies between 30-44 years and it is 18 if the age is between
45-59 years. The risk score lessens to 7 if the age is over 5911.
These statistics show that the disease not only affects the rich, also it is most likely to
affect those with a sedentary lifestyle and who consume diets that are mainly unhealthy.
Diabetes management has five components: nutritional therapy, exercise, monitoring,
pharmacologic therapy and education. Education of nutritional therapy includes; nutrition
need for diabetics, meal planning and weight control which are the foundation of diabetes
management12.
A study was conducted to assess the risk assessment, knowledge and practice of diabetes
patients. About 27% individuals were found obese and 11% were overweight and on risk
assessment score 44% were found at high risk, 38% at low risk of developing diabetes
mellitus. Male gender, education and urban residence showed significantly better
knowledge regarding diabetes but scored more on risk assessment scale due to poor
dietary habits and lack of physical activity. Knowledge regarding cause, sign and
6
symptoms and complications was found lacking. Practices regarding diet and life style
were also found unsatisfactory13.
In another study the knowledge, beliefs, and practices of diabetics receiving free medical
care and those paying for medical care in Tamilnadu, India was compared. A
questionnaire was administered to elicit diabetic patients' knowledge regarding diet,
exercise, adverse effects, habits, and other matters; their beliefs about diabetes; and their
practices regarding diet, medication and self-monitoring. The results showed a large gap
between knowledge and action in both groups and a need for increased efforts toward
patient education regarding diabetes14.
Lack of knowledge among diabetes patient may alter their practice. Hence the
investigator had an interest to assess the knowledge of diabetes patient. As the glycemic
level is much influenced by dietary practices, the knowledge regarding diet becomes a
important strategy to be assessed14.
A concept mapping study conducted to assess the nutritional knowledge in diabetic
patients and evaluated the therapeutic patient education. 5 diabetic patients and their
family members were selected as a sample. Before the education session, patients and
their family members are knowledgeable about food. After education, new knowledge
and new links between old and recent knowledge testify of learning. This research shows
that using the preexisting knowledge of network of parents and children could contribute
to improve their education on nutrition15.
7
In a study conducted among 45 Type 2 diabetes mellitus patients about dietary
requirements, food selection, eating patterns and attitude about self management practices
which stressed the importance of diabetes nutrition education programs. The program
comprised of awareness of eating history, spousal support and time management
practices16.
According to the IDF’s 2003 statistics, committee of RSSDI 2009 report, the World
Health Organization and the International Diabetes Federation predict that India has the
highest numbers of diabetics in the world17. Hence Knowledge about the disease plays a
vital role in future development of disease and its early prevention and detection.
Research studies have shown that wherever massive education regarding diabetes
mellitus is provided to general population, it resulted in significant increase in knowledge
about the disease18.
Through the research report, it is evident that lack of knowledge is a contributing factor
for the Indians to rank first globally in diabetes17. So enhancing knowledge of diabetes
especially about diabetic diet is very useful among patient with diabetes mellitus18.
‘The overall goal of care is to control or regulate the disease rather than cure’.
‘Knowledge is power.’ Hence the investigator felt the need to help patients to enhance
the knowledge on diabetic diet. Knowledge enhancement can be done in variety of ways.
Mass awareness program by means of teaching or a SIM would be of great help. The
investigator had chosen the Self Instruction Module as knowledge weapon, because it can
be used in future as a reference for all the patients with diabetes mellitus.
8
There forth the investigator decided to develop a self-instruction module regarding
diabetic diet and assess the extent of effectiveness of self-instruction module in
improving the knowledge of diabetic diet among patients with diabetes mellitus.
9
2. OBJECTIVES
STATEMENT OF THE PROBLEM
ASSESS THE EFFECTIVENESS OF SELF-INSTRUCTION MODULE (SIM) ON
DIABETIC DIET AMONG PATIENTS WITH DIABETES MELLITUS IN
SELECTED DIABETIC CLINIC AT BANGALORE.
OBJECTIVES OF THE STUDY
1. To assess the pretest knowledge on diabetic diet among Experimental and Control
Group.
2. To compare the pretest and posttest knowledge on diabetic diet among
3. To assess the effectiveness of Self Instruction Module by comparing the posttest
OPERATIONAL DEFINITION
1. Assess: It refers to the statistical analysis of pretest and posttest knowledge as elicited
by structured knowledge questionnaire on diabetic diet among patients with diabetes
mellitus
2. Effectiveness: It refers to significant gain in the knowledge as determined by the
statistical difference in the pretest and posttest scores on diabetic diet among patients
with diabetes mellitus.
10
3. Self Instruction Module: It refers to systematically organized series of self learning
content on diabetic diet for patient with diabetes mellitus. It includes: general
information of diabetes mellitus, diabetic diet and menu plan.
4. Diabetic diet: It refers to the specific therapeutic diet used to treat the patients
5. Patients: It refers to the individuals both male and female between 30-70 years of
age suffering from type 2 diabetes mellitus attending the selected diabetic clinic at
Bangalore.
6. Diabetes Mellitus: It refers to the metabolic disorder due to deficit of insulin
production or resistance of insulin in the body.
ASSUMPTIONS
a. Patients with diabetes mellitus may have some knowledge on diabetic diet.
b. Self Instruction Module may enhance the knowledge on diabetic diet among patients
RESEARCH HYPOTHESIS
H 1: There will be significant difference between pretest and posttest knowledge
among Experimental and Control Group.
H 2: There will be significant difference in the posttest knowledge on diabetic diet
between Experimental and Control Group.
11
H 3: There will be significant association between posttest knowledge of Experimental
and Control Group and their selected demographic variables.
DELIMITATIONS
Study will be delimited to the patients:

• with type 2 diabetes mellitus
• between 30-70 years of age.
• attending selected diabetic clinic, Bangalore.
CONCEPTUAL FRAMEWORK
Conceptual framework serves as a springboard for theory development. As this is made
up of concepts which are mental images of a phenomenon, it provides for thinking and
interpreting what is seen. A model is used to denote symbolic representation of
concepts19.
The present study is aimed at assessing the effectiveness of self instruction module on
diabetic diet among diabetes mellitus patient. The investigator has modified the
Wiedenbach’s Clinical Nursing Practice - A Helping Art model given by Ernestine
Wiedenbach as a basis of conceptual framework which was found suitable to evaluate the
effectiveness of SIM among patients with diabetes mellitus.
12
MODIFIED WIEDENBACH’S CLINICAL NURSING PRACTICE - A HELPING
ART
The patient is an individual under treatment or care who experiences needs. The Need for
help is defined as “Measures or actions required and desired which potentially restore or
extend ability to cope with situational demands”20.
The clinical nursing has four components- philosophy, purpose, practice and art. The
philosophy is the personal stance of the nurse that embodies attitudes towards reality,
purpose is the overall goal. Nursing practice includes three steps- identifying, ministering
and validating the need for help. The art of clinical nursing requires using individualized
interpretations of behaviour in meeting the needs for help.
According to Wiedenbach, nursing practice consists of 3 steps21.
1. Identifying the need for help.
2. Ministering the needed help
3. Validating that the need for help was met.
Step 1: Identifying the need for help
The first step involves three components, which helps in identifying the need for help.
a) General information – comprising the inclusive criteria for the selection of samples
which includes patients with diabetes mellitus, who are 30 to 70 years of age and who
are capable to read and understand Kannada
b) Central purpose – was to assess the effectiveness of self instruction module on diabetic
diet among patient with diabetes mellitus.
13
c) Prescription – was the pretest and distributing Self Instruction Module on diabetic diet
Step 2: Ministering the needed help
This steps includes a component reality, which further has 5 subcomponents. They are:
a) Agent : Nurse is the agent who assess the effectiveness of self instruction module
on diabetic diet among patient with diabetes mellitus.
b) Recipient : Patient with diabetes mellitus who fulfills the inclusive criteria.
c) Facilities : Bangalore diabetic clinic.
d) Means : Administration of Self Instruction Module on diabetic diet for Experimental
group and administering structured questionnaire for both Experimental and Control
Group.
e) Goal: To identify the effectiveness of Self Instruction Module.
Step 3: Validating the needed help:
This step involves the assessment of pretest knowledge for Experimental and Control
Group and posttest knowledge for both Experimental and Control Group and comparing
the pretest and posttest score by means of statistical analysis. This enables the
investigator to decide and recommend either continuing or dropping this intervention -
SelfInstructionModule.
14
GENERAL INFORMATION MINISTERING THE NEEDED HELP
• Patients with Diabetes Mellitus
REALITIES
• 30-70 years of age
• Read and understand Kannada
Agent – Nurse
Recipient - Patients with Type 2 Diabetes Mellitus.
CENTRAL PURPOSE Facilities – Bangalore Diabetic Clinic
Effectiveness of Self Instruction Module on Means – Distribution of Self Instruction Module to
diabetic diet among patients with diabetes the Experimental Group alone.
mellitus Assessing the knowledge on diabetic diet
PRESCRIPTION
Pre-test and distributing Self Instruction Experimental Group Control Group
Module on diabetic diet
NURSE Goal – Assess the effectiveness of S IM
VALIDATING THAT NEED FOR HELP WAS MET

Pretest (Experimental and Control Group) Posttest (Experimental and Control Group)
Analysis
Comparing the pre and posttest of diabetic diet
Significant Not Significant
Effectiveness of Self Instruction Module
FIGURE 1: MODIFIED WIEDENBACH’S15

CLINICAL NURSING PRACTICE – A HELPING ART
3. REVIEW OF LITERATURE
A review of literature is an essential aspect of scientific research. It provides a basis for
future investigations, justifies the need for replication, throws light on the feasibility of
the study, indicates constraints of data collection and helps to relate the findings from one
study to another with a view to establish a comprehensive body of scientific knowledge
in a professional discipline22. So the investigator reviewed the related research and non-
research literature which was organized under the following sub headings.
1. Literature related to diabetes mellitus.
2. Literature related to diabetic diet.
3. Literature related to effectiveness of teaching on diabetic diet.
1. LITERATURE RELATED TO DIABETES MELLITUS
Diabetes mellitus is a chronic systemic disease characterized by either a deficiency of
insulin or a decreased ability of the body to use insulin. Diabetes mellitus some time
referred to as “high sugars” by both client and health care providers. Diabetes was
classified as either Type 1 diabetes mellitus or Type 2 diabetes mellitus23.
Diabetes Mellitus is caused by genetic defects, disease of the pancreas,
endocarcinopathies, drugs or chemical and infections. Management of diabetes mellitus
includes; regulate blood glucose, promote proper nutrition, promote regular physical
exercise, and administer medications such as oral antidiabetic agents and insulin
therapy23.
16
A study was conducted to assess the knowledge and practice of diabetes mellitus patients.
The study revealed certain facts about the knowledge and practice of diabetes mellitus
patients with relation to prevention of selected diabetic complications such as
hyperglycemia, hypoglycemia and wound infections etc. The resulted revealed that 60%
had inadequate knowledge, 32.4% had moderately adequate knowledge and 21% had
adequate knowledge24.
A community based study was conducted to assess the knowledge of 57 elderly diabetes
mellitus patients. Data was collected by the interview and the result showed that 18% did
not know what action to take with hyperglycemia, 46% did not know any hyperglycemic
symptoms or signs, 35% did not know what to do when self monitored blood sugar tests
and urine sugar tests read high, 21% did not seek medical advice on insulin25.
A study was conducted to assess the knowledge of diabetes mellitus patients by using
computer - based questionnaire. A sample of 79 Type 1 diabetes mellitus and 72 Type 2
diabetes mellitus patients were taken for the study. Their result showed that ignorance in
key areas like causes of hyperglycemia, undesirable effect of sugar and sweet foods,
symptoms of hyperglycemia, diet, foot care and therapy were unacceptably high in both
type 1 diabetes mellitus and type 2 diabetes mellitus groups26.
A quantitative survey was conducted to identify diabetic patients and family member’s
knowledge and views about diabetes and its treatment regimen. A convenient sample of
32 diabetics and 32 family members were selected. Findings revealed that the diabetics
and family members lack in knowledge regarding diabetes and its treatment and Health
education is recommended for them27.
17
A comparative study was conducted to assess the knowledge of diabetes mellitus
possessed by patients with diabetes and healthy adult. They randomly selected 120
patients with diabetes mellitus and 120 healthy adults for the study. Their result showed
that patients with diabetes mellitus were significantly more knowledgeable than the
healthy volunteers about risk factors, symptoms, chronic complication, treatment, self-
management and monitoring parameters. Educational level was the best predictive factor
for diabetes mellitus and public awareness28.
In a study the level of knowledge of diabetic patients about the disease was described. It
was found that a majority of diabetic patients [90.0%] had poor knowledge about the
disease, 83.7% had poor knowledge about the complications associated with diabetes and
96.3% had poor awareness of how to control the disease29.
A study was done to see if obese children get enough magnesium in their diets and if a
lack of magnesium can cause insulin resistance and eventually type 2 diabetes. They
studied 24 obese and 24 lean children who were between 8 and 17 years old and took
blood samples from each child to get their magnesium, blood glucose, and cholesterol
levels. Then a survey about what kinds of foods they ate was carried out and identified
that the diet contains enough magnesium. Finally, researchers compared the children's
magnesium levels with their insulin levels. Researchers found that 55% of obese children
did not get enough magnesium from the foods they ate, compared with only 27% of lean
children. Obese children had much lower magnesium levels in their blood than lean
children. The study concluded that Children with lower magnesium levels had a higher
insulin resistance30.
18
A study was conducted to know, if weight loss has an effect on how beta cells work and
the effectiveness of beta cells in slowing the progression of diabetes in older patients as
improving insulin sensitivity does. 19 overweight and obese older men with normal
fasting blood glucose were studied for 3 months and the men were weighed three times
per week. The result showed that the men in the study lost an average of nine pounds. All
the men lost weight, with fat making up 84% of the weight loss. Fasting blood glucose
levels were lower after the weight loss. Insulin sensitivity improved, resulting in an
improvement in beta cell function31.
2. LITERATURE RELATED TO DIABETIC DIET
Diabetic diet consists essentially of carbohydrates. 50% to 60% of the total caloric intake
has to be taken in the form of carbohydrate. Slowly metabolized forms of carbohydrate
should be preferred. Fat and proteins should not exceed more than 20% of the respective
total caloric intake. Vegetable fats should be preferred compared to animal fats. Patients
with type 2 diabetes mellitus who should lose weight have to be extremely careful
regarding the fat intake. Type 1diabetes can correct mistakes in the carbohydrate intake
by injecting fast insulin provided that they have in-depth knowledge regarding the mode
of action of insulin and dietary experience32.
Changing to a vegetarian diet probably won't cure your diabetes. But it may offer some
benefits over a non - vegetarian diet such as helping to control your weight and reduce
your risk of diabetes-associated complications such as cardiovascular disease and kidney
disease. This depends on the type of vegetarian diet33.
19
A study was conducted to find out whether there is a relationship between following a
Mediterranean-style diet and diabetes in healthy individuals. The study included 13,380
Spanish university graduates who did not have diabetes at the outset. Researchers
assessed participants' dietary habits and followed them for more than 4 years to find out
how many developed diabetes and to re-assess those who had developed the disease.
Reserchers found those who most closely followed the diet had the lowest risk for
diabetes and those who followed the diet least had the highest risk for developing
diabetes33.
The researcher evaluated the diet, physical activity, nutrition knowledge, Hb A [1c] and
behavioral change among Type 2 Diabetes patients. 48 urban diabetic patients and 38
relatives were selected. After the intervention, nutritional knowledge and diet health
awareness increased [P=. 013 and .001 respectively]. Focus group analysis suggested that
lack of support from family and health services, low-income neighborhood insecurity and
misleading ‘popular knowledge’ and advice are key barriers to behavioral change34.
A study was done to assess the relationship between green tea and total caffeine intake
and risk for self-reported type 2 diabetes among Japanese adults. The study included
17,413 men and women in 25 communities across Japan. They were between 40 and 65
years old and about half of them had diabetes. Participants completed a detailed
questionnaire about their health, lifestyle habits, and how much coffee and tea they drank.
The questionnaire was repeated at the end of the 5-year follow-up period. Researchers
found that green tea and coffee may offer some protection against type 2 diabetes35.
20
The link between coffee drinking and other factors in developing diabetes was examined
among 10,118 men and 11,197 women in Finland who were 35 to 74 years old.
Participants completed a detailed survey about their consumption of coffee, tea, alcohol,
and other beverages; their physical activity; and other habits for an average of 13.4 years.
The researchers found generally that more the coffee a person drank each day, the less
likely he or she was to develop diabetes. People who drank three to six cups of coffee
were 23% less likely to develop diabetes. Those who had seven or more cups of coffee
per day were 34% less likely to develop diabetes36.
An investigator studied how caffeine affects and lowers the chance of getting diabetes.
The researchers studied 910 adults who were at least 50 years old. The adults who took
part did not have diabetes at the beginning of the study. The adults were first tested for
diabetes between 1984 and 1988 and had another check-up in 1992-1996. The survey
asked questions about their coffee drinking habits. The researchers found that current or
past coffee drinkers who did not have diabetes at the start of the study had a 60% lower
chance of getting type 2 diabetes when compared with those who never drank coffee37.
An investigator examined the people with poorly controlled type 2 diabetes who followed
a low-carbohydrate, high-fat diet. The study included 40 people with poorly controlled
type 2 diabetes. Participants had a physical exam and blood drawn for lab tests and
completed a survey about their eating habits. The investigator revels that many people
with poorly controlled diabetes follow a low-carbohydrate diet38.
A study was conducted to evaluate the modification of dietary fat in the diet of diabetic
patients. Comparisons were also made between diets enriched with monounsaturated
21
fatty acids and with polyunsaturated fatty acids. With respect to lipid concentrations,
different group observed different effects. While one group saw no differences in fasting
lipids, they measured higher cholesterol after enriched with monounsaturated fatty acids.
Another group found higher total and LDL cholesterol levels after a polyunsaturated fatty
acids rich diet. Studies did not find any influence in glucose concentrations. Hepatic
glucose production and peripheral insulin sensitivity remained constant39.
Effects of three weight maintenance diets with different macronutrient composition on
carbohydrate, lipid metabolism, insulin and incretin levels in insulin resistant subjects
were studied among eleven offspring of obese and type 2 diabetes patients. They were
randomly divided into three groups: a) a diet high in saturated fat, b) diet rich in
monosaturated fat and c) diet rich in carbohydrate. Results showed that fasting serum
glucose concentrations fell during monounsaturated fatty acid-rich and CHO rich diets
compared with high saturated fat diets. Monounsaturated fatty acid-rich diet improved
insulin sensitivity compared CHO rich and high saturated fat diets respectively40.
Evidence for the role of whole grain foods and legumes in the etiology and management
of diabetes was investigated in a study. The study strongly supports the suggestion that
high intakes of whole grain foods protect against the development of type 2 diabetes
mellitus. People who consume approximately three servings per day of whole grain foods
and legumes are less likely to develop type 2 diabetes mellitus than people with low
consumers [less than 3 servings per week] with a risk reduction in the order of 20-30%41.
Three prospective studies were conducted among 160000 men and woman to examine the
relationship of whole grain or cereal fiber intake with the risk of type II diabetes. The
22
result revealed that type 2 diabetes was 21-27% lower for those who consume the highest
quintile of whole grain and 30-36% lower among those who consume highest quintile of
cereal fiber42.
A Study was conducted about carbohydrate and fiber recommendations for individuals
with diabetes. Researchers looked at information on things including weight loss,
carbohydrates, fiber, protein, fat, cholesterol, and glycemic index43.
In a study conducted, the following recommendations for people with diabetes was
suggested such as people should eat as much fruit as they want. People should eat 25-50
grams of fiber every day; High-fiber foods include oats and barley; whole-grain breads,
cereals and pastas; brown rice, dry beans, peas, and lentils; nuts, fruits, and vegetables.
The amount of cholesterol a person eats should be less than 200 mg per day. People
should eat foods with a low-glycemic index (such as prunes, milk, yams and bananas)44.
A study was conducted to assess the link between dietary habits and type 2 diabetes
among 69, 554 women. The study concluded that women who followed the western-diet
had a greater risk of type 2 diabetes, particularly if they ate processed meats, bacon, and
hot dogs. Overall, the Western diet raised the risk of diabetes by nearly 50% among the
women in this study45.
A correlational study was done to assess the relationship between eating a large amount
of refined carbohydrates and insulin resistance among type 2 diabetes. The study
concluded that more foods which contain refined carbohydrates reduces the nutrients in
the foods and add calories. In addition, more people are getting type 2 diabetes. People
23
should eat fewer refined carbohydrates and eat more fiber and whole grains to reduce
their chance of getting type 2 diabetes46.
A study was conducted to know, if drinking more sugar-sweetened drinks increases
women's risk of getting type 2 diabetes. 51,603 women were studied. None of them had
diabetes when the study began. They were followed for 8 years. Participants reported 741
new cases of type 2 diabetes during the study. Drinking more sugar-sweetened soft drinks
was linked to higher risk of diabetes. The result of the study was people should cut down
sugar-sweetened beverages to prevent obesity and type 2 diabetes47.
3. LITERATURE RELATED TO EFFECTIVE TEACHING ON DIABETIC DIET
A computer assisted teaching was conducted for the modification of dietary fat in the diet
of diabetic patients. With respect to lipid concentrations, different group observed
different effects. The uneducated group saw no differences in fasting lipids, they
measured a higher cholesterol level after an enriched with monounsaturated fatty acids
and educated group found higher difference in fasting lipids and cholesterol level. The
study concludes that computer assisted learning was very effective for diabetic patients,
in improving their level of knowledge48.
A randomized controlled trial was done to evaluate lifestyle interventions in people with
impaired glucose tolerance. The study included 78 men and women with IGT who were
between 24 and 75 years of age. Half of the participants were enrolled in a program that
encouraged healthy lifestyle habits, while the other half was told to follow their usual
habits. People in the healthy lifestyle groups were counseled by a dietician and physical
24
therapist. After the two year follow-up period, researchers found that those who received
counseling on healthy habits consumed much less fat in their diet, lost more body weight,
and improved their ability to handle insulin and glucose49.
A study was done to assess the dietary knowledge, practices and control of type 2
diabetes mellitus. 33 type 2 diabetes mellitus patients were selected. All 33 subjects had
truneal obesity and needed to lose weight. This was moderately severe in 60% of
subjects. About 52% received dietary advice. The latter had significantly higher mean
dietary knowledge score than those without dietary advice, dietary practices improved
significantly following diagnosis and counseling. A significant proportion of subjects
increased their use of food with low glycemic index [legumes 48.5%, cereals 90.9%]
following diagnosis50.
The Effects of a diet featuring low–GI foods to those of a diet based on the American
Diabetes Association (ADA) nutrition guidelines was compared in a study. Forty people
with poorly controlled type 2 diabetes took part in the study. Participants were divided
into two groups to receive eight nutrition education sessions focusing on either choosing
low–GI foods or basing daily eating on ADA nutrition guidelines. Information was
collected by A1C. The two groups significantly lowered their A1C levels by similar
amounts and also had similar improvements in blood fats and weight. However, the low–
GI group was less likely to have added or increased doses of diabetes medicines to
achieve better blood glucose control51.
25
4. METHODOLOGY
This chapter deals with the methodology followed in the study to assess the effectiveness
of Self Instruction Module on diabetic diet among patient with diabetes mellitus in
selected diabetic clinic at Bangalore and is discussed under the following headings.
Research approach , research design, setting, population, sample and sampling technique,
development and description of tool, scoring key, content validity, reliability, pilot study,
procedure for data collection and plan for data analysis.
RESEARCH APPROACH AND RESEARCH DESIGN:
The selection of research approach is the basic procedure for conduct of research enquiry.
Research approach tells researcher about what data to be collected and how to analyze it.
It also suggests possible conclusion to be drawn from the data22. In view of the nature of
the problem selected and the objectives to be accomplished, evaluative approach was
considered appropriate for the present study.
The selection of the design depends upon the purpose, research approach and variables to
be studied. True Experimental design with Pretest and Posttest Control Group design was
used to assess the knowledge of diabetes mellitus patient regarding diabetic diet in
selected diabetic clinic at Bangalore.
26
Schematic Representation of Research Design
Pretest Intervention Posttest

Group of diabetic patients
Day-1 Day – 1 Day – 7
O2
Experimental Group G1 O1 X
O2
Control Group G2 O1
G1 – Diabetic patients in Experimental Group
G2 - Diabetic patients in Control Group
X – Self Instruction Module on diabetic diet for Experimental Group is distributed on
same day after conducting pretest.
O1 - Pretest for Experimental and Control Group on 1st day
O2 - Posttest for Experimental and Control Group on 7th day
VARIABLES:
The variable for the present study are:
Dependent variable:
Knowledge on diabetic diet among diabetic patients who are attending diabetic clinics.
Independent variable:
Self Instruction Module on diabetic diet.
27
TARGET POPULATION DIABETIC PATIENTS
ACCESSIBLE POPULATION DIABETIC PATIENTS IN

DIABETIC CLINIC
DIABETIC PATIENTS WHO

SAMPLE / SAMPLE SIZE FULFILLS THE INCLUSIVE
CRITERIA ARE SELECTED
Sample size is 80 in which
Experimentalgroup is 40 and
Control Group is 40.
SAMPLING TECHNIQUE PURPOSIVE SAMPLING
SECTION: A- General information

TOOL FOR DATA SECTION: B- Structured knowledge
COLLECTION questionnaire to assess
the level of knowledge
on diabetic diet.
ANALYSIS DESCRIPTIVE STATISTICS

INFERENTIAL STATISTICS
Fig 2: SCHEMATIC REPRESENTATION OF STUDY DESIGN
28
Extraneous variables:
Personal characteristics which include age, sex, education, occupation, monthly income,
religion, marital status, place of residence, type of family, family history of diabetes
mellitus, level of activity, methods used to control hyperglycemia and source of
knowledge of diabetes mellitus.
SETTING OF THE STUDY:
The study was conducted in Bangalore Diabetic clinic, Kalyan Nagar. The criteria for
selecting this setting were geographical proximity, feasibility of conducting study,
availability of samples and familiarity of the investigator with the setting.
POPULATION:
The population of the study was the diabetic patients.
SAMPLING:
Sampling refers to the process of selecting a portion of population to represent the entire
population22.
SAMPLE:
Sample consists of the subjects selected to participate in a research study. In the present
study, samples are the diabetic patients who are attending selected diabetic clinic
Bangalore.
29
SAMPLE SIZE:
Patients with diabetes mellitus who fulfills the inclusive criteria attending diabetic clinic
at Bangalore.
Sample size is 80 in which Experimental Group is 40 and Control Group is 40.
SAMPLING TECHNIQUE
In this study simple random sampling (lottery method) technique was used to select the
samples based on inclusive and exclusive criteria and the samples are allotted to the
experimental and control group by means of lottery method.
CRITERIA FOR SELECTION OF THE SAMPLE:
1. Inclusive criteria:
Patients with diabetes mellitus who:
• Will be available at the time of data collection
• are suffering from type 2 diabetes mellitus.
2. Exclusive criteria:
The study excludes Diabetes mellitus patient
• who are not willing to participate in the study
• who do not know to read, write and speak Kannada
• who are in medical profession
30
DEVELOPMENT AND DESCRIPTION OF THE TOOL
Data collection tools are the procedures or instruments used by the researcher to observe
or measure key variables in the research problem.
Method of developing instrument
The tool was developed based on
• Literature review
• Discussion with the experts
• Preparation of blue prints
Preparation of blue print
A blue print of the tool was prepared by the researcher, which includes sections, number
of questions and weightage in percentage for each section (Annexure - V)
The components of the instrument
The instruments consist of two sections.
Section A:
Structured questionnaire to elicit general information of the patient which includes 13
items such as age, sex, education, occupation, monthly income, religion, marital status,
place of residence, type of family, level of activity, family history of diabetes mellitus,
methods to control hyperglycemia and source of knowledge.
31
Section B:
Structured Knowledge Questionnaire to assess the knowledge on diabetic diet. This
consist of 42 multiple choice questions given under the following headings
Part I: General information regarding diabetes mellitus which consists of 10 questions
Part II: consists of 28 questions related to diabetic diet.
Part III: consists of 4 questions related to dietary alteration
Scoring key:
Forty two items were included in the structured knowledge questionnaire to assess the
knowledge, comprehension and applicability. Each question in the structured knowledge
questionnaire had three options, one being the right answer and carried one mark and no
marks was given for wrong answers or unanswered questions. The total score was 40. A
scoring key was prepared showing item numbers and correct responses.
Obtained score
Percentage = ………………………. X 100
Total score
The differences in levels of knowledge are categorized as follows:
Inadequate knowledge - If the score obtained was less than 50%
Moderate knowledge _ If the score obtained lies between 50 - 75%.
Adequate knowledge _ If the score obtained was more than 75%.
32
DEVELOPMENT OF SELF INSTRUCTION MODULE:
The development of the SIM was based on the review of related research. The following
steps were adopted to develop the same.
¾ Preparation of first draft
¾ Development of the criteria checklist
¾ Description of the SIM
¾ Content validity of SIM
¾ Preparation of final draft
¾ Translation of SIM into Kannada.
Preparation of the first draft:
Preparation of first draft of SIM was developed based on objectives, literature review and
opinion of the experts. The main factors kept in mind while preparing information were,
the understanding level of patient language and relevance of illustration and picture.
Development of criteria check list:
The criteria checklist was developed to evaluate the Effectiveness of Self Instruction
Module based on the criteria stated. The criteria checklist consisted of headings such as
objectives, content, organization of the content, presentation, language and practicability.
Three response column was developed such as strongly agree, agree, disagree and a
column for remarks / suggestions of the evaluator.
33
Description of the self instruction module:
After an extensive review of literature and discussion with the experts, the SIM was
divided into the following sub headings:
Chapter – 1:
This chapter deals with the general information of diabetes mellitus which includes
introduction, specific objectives, definition, brief review of anatomy and physiology,
types of diabetes mellitus, causes, pathophysiology, signs and symptoms, diagnostic
procedure, treatment and complication of diabetes mellitus.
Chapter - 2:
Chapter two explains about diabetic diet which includes introduction, specific objectives,
meaning, goals of diabetic diet, dietary management, principles of planning diabetic diet,
calories intake, vitamin and minerals, dietary fiber, use of fenugreek, alcohol
consumption, sweeteners, misleading food labels, exercise, dietary alterations, dietary
guidelines and food stuffs that decreases the blood sugar level.
Chapter – 3:
This chapter describes the menu for diabetes mellitus which includes menu plan for 1200,
1500 and 2000 calories intake.
34
Content validity of SIM:
The draft of the SIM along with the criteria checklist was given to eleven experts, 8 were
from the field of Medical Surgical Nursing, 1 from Biostatician, 1 from Diabetalogist and
1 from Dietician. There was 100% agreement by experts in the content area. Modification
were made as per suggestion after discussing with the guide.
Preparation of the final draft
The final draft of the Self Instruction Module plan was made by making necessary
correction and modifications suggested by the experts.
Translation of the SIM:
After content validating of all the tools, the tools were given to a language expert to
translate them to Kannada language.
CONTENT VALIDITY:
Content validity of the SIM and tool was established by 11 experts; 8 experts from
Medical and Surgical Nursing, 1 diabetologist, 1 dietician and 1 biostatistician. Minor
suggestions were given regarding rearranging questions and some difficult words were
converted into simple words. The final SIM and tool was prepared as per the suggestions
and advice given by the experts. This was then edited by English language expert.
35
Pretesting of the tool:
Pretesting is the process of measuring the effectiveness of an instrument. The purpose is
to reveal problems relating to answering, completing and returning the instrument and to
point out weakness in the administration, organization and distribution of the instrument.
After obtaining permission from the Bangalore Diabetic clinic, Kalyan Nagar, the tools
were pretested by administering questionnaire to the diabetic patients. The pretesting of
the tool was done to check the clarity of the items, ambiguity of the language and
feasibility of the tool.
Reliability of the tool:
The reliability of the tool is defined as the extent to which the instrument yields the result
on repeated measures. It is concerned with consistency, accuracy, stability, equivalence
and homogeneity.
The reliability of the tool was a major criteria for assessing its quality and adequacy. A
pretest was done to establish the reliability and to determine the language clarity.
Reliability of the tool is determined by split half method. 8 diabetic patients were selected
and questionnaire was given and after one week the respondents were given the same
questionnaire. By using Karl Pearson correlation coefficient method, the ‘r’ value
obtained is 0.9712. It shows that the tool is highly reliable.
36
PILOT STUDY:
Pilot study is the trial run for major study. It is a major preliminary investigation of the
same general character as the major study. The present study was conducted in Bangalore
diabetic clinic Kalyan Nagar, Bangalore
After obtaining written permission from the director of Bangalore diabetic clinic, Kalyan
Nagar, Bangalore, the data was collected from 8 diabetic patients. The purpose of the
study was explained to the samples and informed consent was obtained prior to the data
collection, to get their cooperation and prompt answers. Confidentiality was assured to all
the subjects.
Structured questionnaire was administered to get the general information and assess the
pretest knowledge on diabetic diet from Experimental and Control Group on the 1st day.
On the same day SIM was given to the Experimental Group, while the samples in the
Control Group were taken on with the normal routines. Same questionnaire was
administered on the 7th day for both Experimental and Control Group.
The tool and the structured questionnaire was found to be feasible and practicable after
the pilot study and no further changes were done after the pilot study in the tool. The
investigator then proceeded for the main study.
Data Collection Procedure:
After obtaining permission from the concerned authority and informed consent from the
samples, the investigator collected the data from diabetic patients.
37
The data was collected in the following phases.
Phase-I
Structured questionnaire was administered to get background information and assess the
pretest knowledge of diabetic diet from Experimental and Control Group on the1st day.
On the same day Self Instruction Module on diabetic diet was issued to the Experimental
Group.
Phase-II
Same questionnaire was administered on the 7th day for both Experimental and Control
Group.
Plan for Data Analysis
The data obtained were analyzed in terms of objectives of the study using descriptive and
inferential statistics. The plan of data analysis was as follows:
• Organization of data in master sheet/computer
• Background information in terms of frequency and percentage.
• The knowledge of diabetic diet in terms of frequency, percentage, mean and standard
deviation.
• Paired‘t’ test to test the significant difference in the knowledge within the group.
• Un Paired‘t’ test to test the significant difference in the knowledge between
• χ2 test is applied to measure the association between the posttest level of knowledge
and selected demographic variables.
38
5. RESULTS
In order to find a meaningful answer to the research questions, the collected data must be
processed, analyzed in some orderly coherent fashion, so that patterns and relationships
can be discussed.
Analysis is done by categorizing, ordering, manipulating and summarizing data to obtain
answers to the research questions. The interpretation of tabulated data can bring light to
the real meaning and effectiveness of the findings.
This chapter deals with the quantitative results of the study which attempt to assess the
effectiveness of SIM on diabetic diet among 80 diabetic patients attending the selected
diabetic clinic. The collected data were organized, tabulated, analyzed and interpreted by
means of tables and graphs based on the formulated objectives of the study.
OBJECTIVES OF THE STUDY
Group.
2. To compare the pretest and posttest knowledge on diabetic diet among Experimental
and Control Group.
3. To assess the effectiveness of self Instruction Module by comparing the posttest
39
HYPOTHESIS
H 1: There will be significant difference between pretest and posttest knowledge among
Experimental and control Group.
H2: There will be significant difference in the posttest knowledge on diabetic diet
between Experimental and Control Group.
H 3: There will be significant association between posttest knowledge of Experimental
ORGANIZATION OF THE ANALYZED DATA
The analyzed data is presented on 5 sections:
SECTION A: Analysis of general information of Diabetic patients.
SECTION B: Pretest and posttest knowledge scores of diabetic patients
regarding knowledge on diabetic diet
SECTION C: Comparison of Pre and Posttest knowledge scores among
SECTION D: Comparison of Posttest knowledge scores between Experimental
and Control Group.
SECTION E: Association of Posttest knowledge of Experimental and Control
Group with selected demographic variables.
40
PRESENTATION OF THE ANALYZED DATA
SECTION A: ANALYSIS OF GENERAL INFORMATION OF DIABETIC
PATIENTS.
TABLE – 1: Frequency and Percentage Distribution of subjects by their Age,
Gender and Educational Status.
n=80(40+40)
SUBJECTS GROUP
EXPERIMENTAL CONTROL
CHARACT
CATEGORY (N=40) (N=40)
ERISTICS
f % f %
30-40 13 32.5 8 20.0
Age group 40-50 16 40.0 10 25.5
in years 50-60 7 17.5 14 35.0
60-70 4 10.0 8 20.0
Male 19 47.5 17 42.5

Gender
Female 21 52.5 23 57.5
Middle school and below 2 5.0 1 2.5
Secondary 12 30.0 17 42.5

Educational
Higher Secondary 6 15.0 - -
status
Graduate 13 32.5 15 37.5
Post Graduate and above 7 17.5 7 17.5
41
40% 40%
30 - 40
35% 35%
32.50% 40 - 50
30% 50 - 60
25% 60 - 70 25%
20% 20% 20%

17.50%
15%
10% 10%
5%
0%
GROUP GROUP
AGE IN YEARS
FIGURE 3: PERCENTAGE DISTRIBUTION OF EXPERIMENTALAND
CONTROL GROUP BY THEIR AGE
The above figure shows the Percentage Distribution of Experimental and Control group
by their Age in years.
With regard to the Experimental Group, Majority 16 (40%) of diabetic patients belongs to
40-50years of age, 13(32.5%) belongs to 30-40 years, 7(17.5%) of them belongs to 50-60
years and 4(10%) belongs to 60-70 years of age group.
In Control Group majority 14 (35%) of the diabetic patients belong to 50-60 years of age,
10 (25.5%) belongs to 40-50 years of age, 8 (20%) of them belong to 30-40 years of age
and 8(20%) belongs to 60-70 years of age group.
42
GENDER
48%
MALE
52% FEMALE
FIGURE 4: PERCENTAGE DISTRIBUTION OF EXPERIMENTAL
GROUP BY THEIR GENDER
The above figure shows the Percentage Distribution of Experimental group by their
gender.
Females were more in number when compared with males in Experimental Group.
21 (52.5%) diabetic patients are female and 19 (47.5%) are male.
43
GENDER
MALE
FEMALE
43%
57%
FIGURE 5: PERCENTAGE DISTRIBUTION OF CONTROL GROUP
BY THEIR GENDER
The above figure shows the Percentage Distribution of Control group by their gender.
23(57.5%) diabetic patients are females and 17(42.5%) are males in Control Group.
44
45% BELOW MIDDLE SCHOOL
42.50%
40%
SECONDARY
HIGHER SECONDARY 37.50%
35%
GRADUATE
32.50%
30% POST GRADUATE
30%
25%
20%
17.50% 17.50%
15% 15%
10%
5% 5%
2.50%
0%
0%
EXPERIMENTAL GROUP CONTROL GROUP

EDUCATION
CONTROL GROUP BY THEIR EDUCATIONAL STATUS
The above figure shows the Percentage Distribution of Experimental and Control Group
by their Educational status.
In Experimental Group majority 13(32.5%) of diabetic patients studied graduate
education, 12(30.0%) of them had their secondary education, 7(17.5%) had their post
graduate education, 6(15.0%) of them studied higher secondary education and only 2
(5.0%) diabetic patients studied less than middle school education.
In Control Group majority 17(42.5%) of diabetic patients studied secondary education,
15(37.5%) of them studied graduate education and 7(17.5%) had their post graduate
education.
45
TABLE 2: Frequency and Percentage Distribution of subjects by their occupation,
monthly income, religion, marital status and place of residence.
n=80(40+40)
SUBJECTS GROUP
CHARACTERI- EXPERIMENTAL CONTROL
STICS CATEGORY (N=40) (N=40)
f % f %
Daily wages 18 45.0 - -
Private employee 11 27.5 28 70.0

Occupation
Government employee 10 25.0 - -
Self employee 1 2.5 12 30.0
5000-15000 23 57.5 18 45.0
Monthly income 15000-25000 14 35.0 16 40.0
>25000 3 7.5 6 15.0
Christian 12 30.0 9 22.5
Religion Hindu 16 40.0 17 42.5
Muslim 12 30.0 14 35.0
Married 38 95.0 37 92.5
Marital status Unmarried 2 5.0 2 5.0
Separated - - 1 2.5
Place of Urban 17 42.5 22 55.0
Residence
Rural 23 57.5 18 45.0
46
70%
70% DAILY WAGES
60% PRIVATE EMPLOYEE
50% GOVERNMENT
45%
EMPLOYEE
PERCENTAGE
40% SELF EMPLOYED

30%
30% 27.50%
25%
20%
10%
2.50%
0% 0%
0%
EXPERIMENTAL GROUP CONTROL GROUP
OCCUPATION
FIGURE 7: PERCENTAGE DISTRIBUTION OF EXPERIMENTAL AND
CONTROL GROUP BY THEIR OCCUPATION
by their Occupation.
In Experimental Group majority 18(45.0%) of diabetic patients have daily wages,
11(27.5%) of them are private employee, 10(25.0%) are government employee and
1(2.5%) diabetic patient is self employed.
In Control Group majority 28(70.0%) of diabetic patients are private employee and
12(30.0%) are self employed.
47
CONTROL GROUP BY THEIR MONTHLY INCOME
Figure 8 shows the Percentage Distribution of Experimental and Control Group by their
Monthly Income in rupees.
In Experimental Group majority 23(57.5%) of respondents had a salary ranging between
Rs.5000-15000, 14 (35.0%) of them had salary ranging between Rs.15000-25000 and 3
(7.5%) of respondents had a salary above Rs.25000.
In Control Group majority 18(45.0%) of respondents had a salary ranging between Rs
5000-15000 per month, 16(40.0%) of them had a salary ranging between Rs 15000-
25000 per month and 6(15.0%) of respondents had a salary of Rs. 25000 and above per
month.
48
AND CONTROL GROUP BY THEIR RELIGION
by their Religion.
In Experimental Group majority 16 (40.0%) of diabetic patients belongs to Hindu
religion and 12 (30.0%) belongs to Christian and Muslim religion whereas in Control
Group majority 17 (42.5%) of diabetic patients were Hindu, 14 (35.0%) belongs to
Muslim religion and 9 (22.5%) of them were Christian.
49
CONTROL GROUP BY THEIR MARITAL STATUS
by their Marital status.
With regard to the respondents in Experimental group majority of the respondents
38(95.0%) were married and 2(5%) were unmarried whereas in Control Group
37(92.5%) of the respondents were married, 2(5%) unmarried and 1(2.5%) were found
separated.
50
AND CONTROL GROUP BY THEIR PLACE OF RESIDENCE
Place of residence.
Majority 23(57.5%) of the respondents in Experimental Group are dwelling in rural area
and 17(42.5%) are dwelling in urban area.
In Control Group majority of the respondents 22 (55.0%) are dwelling in urban area and
18 (45.0%) are dwelling in rural area.
51
TABLE -3: Frequency and Percentage Distribution of subjects by their type of
family, family history of diabetes mellitus and methods to control diabetes mellitus.
n=80(40+40)
SUBJECTS GROUP
CHARACTERISTICS CATEGORY (N=40) (N=40)
f % F %
Nuclear 24 60.0 22 55.0
Type of family Joint 14 35.0 18 45.0
Extended 2 5.0 - -
Family History of No 14 35.0 19 47.5
Diabetes Mellitus Yes 26 65.0 21 52.5
Drugs 8 20.0 10 25.0
Diet, exercise 8 20.0 9 22.0
Methods to control Diet, drugs 17 42.5 18 45.5
Diabetes Mellitus Exercise, drugs 2 5.0 1 2.5
Diet, exercise,
5 12.5 2 5
drugs
52
CONTROL GROUP BY THEIR TYPE OF FAMILY
Type of family.
Majority of respondents in Experimental and Control Group belong to nuclear family. In
Experimental group 24 (60%) of them belong to nuclear family, 14 (35%) belongs to
joint family and 2 (5%) belongs to extended family. In Control Group 22 (55%) belongs
to nuclear family and 18 (45%) belongs to joint family.
53
CONTROL GROUP BY THEIR FAMILY HISTORY OF DM
Family History of DM.
Majority 36 (65%) in Experimental Group and 21(52.5%) in Control Group have a family
history of diabetes whereas 14 (35%) and 19(47.5%) of respondents in Experimental and
Control Group respectively does not have the family history of diabetes mellitus.
54
CONTROL GROUP BY THEIR METHODS TO CONTROL DM
by their methods to control DM.
Majority 17(42.5%) in the Experimental Group and 18 (45.5%) in the Control Group
were having diet and drugs whereas at the least only 2 (5%) in the Experimental Group
and 1 (2.5%) in the Control Group were in the group of exercise and drugs.
55
TABLE – 4: Frequency and Percentage Distribution of subjects by their level of
activity and source of knowledge.
n=80(40+40)
SUBJECTS GROUP
CHARACTERISTICS CATEGORY (N=40) (N=40)
f % f %
Sedentary 10 25.0 9 22.5
Moderate 28 70.0 29 72.5

Level of activity
Heavy 2 5.0 2 5.0
Nil 7 17.5 8 20.0
Friends 8 20.0 6 15.0
Source of knowledge Relatives 18 45.0 21 52.5
Mass media 7 17.5 3 7.5
Internet - - 2 5.0
56
AND CONTROL GROUP BY THEIR LEVEL OF ACTIVITY
Level of activity.
With regard to the Experimental Group, 28 (70%) have moderate level of activity,
10 (25%) have sedentary level of activity and the least 2 (5%) have heavy activity. In
Control Group, 29 (72.5%) have moderate level of activity, followed by 9 (22.5%) of
them having sedentary level of activity and the least 2 (5%) have heavy activity.
57
CONTROL GROUP BY THEIR SOURCE OF KNOWLEDGE
Source of knowledge.
Considering the Experimental Group, majority 18(45.0%) got information from relatives,
8 (20.0%) of them got information from friends, 7(17.5%) have got information from
mass media and 7(17.5%) of them have no source of knowledge.
In Control Group, majority 21 (52.5%) of diabetic patients got information from
relatives, 6 (15%) have got information from friends, 3(7.5%) of them got information
from mass media, 2(5.0%) have got information from internet and 8(20.0%) have no
source of knowledge.
58
SECTION B: PRETEST AND POSTTEST KNOWLEDGE SCORES OF
DIABETIC PATIENTS REGARDING KNOWLEDGE ON DIABETIC DIET
TABLE – 5: Aspectwise Frequency and Percentage Distribution of pretest and
posttest scores of Experimental Group.
n = 40
Pretest Posttest
S.no Inadequate Moderate Adequate Inadequate Moderate Adequate
Aspects
f % f % f % F % F % F %
General
1.
information 22 55.0 18 45.0 - - 3 7.5 27 67.5 10 25.0
2.
Diabetic diet
9 22.5 24 60.0 7 17.5 - - 13 32.5 27 67.5
3. Dietary
alteration 31 77.5 7 17.5 2 5.0 1 2.5 13 32.5 26 65.0
59
FIGURE 17: PERCENTAGE DISTRIBUTION OF KNOWLEDGE VARIABLES
AMONG EXPERIMENTAL GROUP.
The above graph reveals the Pre and Posttest knowledge scores of Experimental Group.
Regarding the general information on DM, 22 (55%) got inadequate knowledge, 18
(45%) got moderate knowledge and no one got adequate knowledge in Pretest. In Posttest
3 (7.5 %) had inadequate knowledge, 27 ( 67.5%) of them had moderate knowledge and
10 (25 %) had adequate knowledge.
With regard to diabetic diet, 9 (22.5%) had inadequate knowledge, 24 (60%) had
moderate knowledge and 7 (17.5%) of them had adequate knowledge in Pretest, whereas
in Posttest 13 (32.5 %) had moderate knowledge, 27 (67.5 %) got adequate knowledge
and none of them had inadequate knowledge.
60
Considering the dietary alterations, 31 (77.5 %) got inadequate knowledge, 7 (17.5%) had
moderate knowledge and 2 (5%) got adequate knowledge. In Posttest 1 (2.5%) got
inadequate knowledge, 13 (32.5 %) had moderate knowledge and 26 (65 %) got adequate
knowledge.
61
Table 6: Aspectwise Pretest and Posttest Mean Standard Deviation and Mean
Percentage of Experimental Group.
n = 40
Pretest Posttest Mean %

Aspects
S.no Mean S.D Mean S.D Pretest Posttest
General
1. 5.20 .992 6.90 1.128 52.0% 69.0%
information
2.
Diabetic diet 17.55 4.696 23.25 3.927 62.67% 83.03%
3. Dietary
2.05 .846 3.63 .540 51.25% 90.75%
alteration
The above table shows the aspect wise mean, standard deviation and mean percentage of
Experimental Group.
With regard to the general information, the Mean of Pre and Posttest are 5.20, 6.90 with
the SD 0.992, 1.128 and the Mean percentages are 52.0 and 69 respectively.
When considering the diabetic diet, the Pre and Posttest Mean are 17.55, 23.25 with SD
4.696, 3.927 and the Mean percentages are 62.67 and 83.03 respectively.
When considering the dietary alterations, the Pre and Posttest Mean are 2.05, 3.63 with
SD 0.846, 0.540 and the Mean percentages are 51.25and 90.75 respectively.
62
TABLE – 7: Aspect wise Frequency and Percentage Distribution of pretest and
posttest knowledge scores of Control Group.
n = 40
Pretest Posttest
S. Inadequate Moderate Adequate Inadequate Moderate Adequate
no Aspects
f % f % f % f % f % F %
General
1.
information 29 72.5 11 27.5 - - 26 65.0 14 35.0 - -
2. Diabetic
diet 9 22.5 30 75.0 1 2.5 8 20.0 28 70.0 4 10.0
3. Dietary
alteration 24 60.0 11 27.5 5 12.5 20 50.0 14 35.0 6 15.0
63
FIGURE 18: PERCENTAGE DISTRIBUTION OF KNOWLEDGE VARIABLES
AMONG CONTROL GROUP.
The above figure reveals the Pre and Posttest knowledge scores of Control Group.
Regarding the general information on DM, 29 (72.5%) got inadequate knowledge, 11
(27.5 %) got moderate knowledge and no one got adequate knowledge in Pretest. In
Posttest 26 (65 %) had inadequate knowledge, 14 (35%) of them had moderate
knowledge and none of them had adequate knowledge.
With regard to diabetic diet, 9 (22.5 %) had inadequate knowledge, 30 (75 %) had
moderate knowledge and 1 ( 2.5%) of them had adequate knowledge in Pretest, whereas
64
in Posttest 8 (20 %) had inadequate knowledge, 28 ( 70%) had moderate knowledge and
4 (10 %) got adequate knowledge.
Considering the dietary alterations, 24 (60 %) got inadequate knowledge, 11 (27.5%) had
moderate knowledge and 5 (12.5%) got adequate knowledge. In Posttest 20 (50%) got
inadequate knowledge, 14 (35 %) had moderate knowledge and 6 (15 %) got adequate
knowledge.
65
Table 8: Aspect wise Mean, Standard Deviation, and Mean percentage of pretest
and posttest knowledge scores of Control Group.
n=40
Pretest Posttest Mean %

S.No Aspects
Mean S.D Mean S.D Pretest Posttest
1. General 4.98 .832 5.03 .973 49.8% 50.3%
information
2. Diabetic diet 17.48 3.374 17.98 3.504 62.42% 64.21%
3. Dietary 2.45 .815 2.63 .774 61.25% 65.75%
alteration
The above table shows the aspect wise mean, standard deviation and mean percentage of
Control Group.
the SD 0.832, 0.973 and the Mean percentages are 49.8and 50.3 respectively.
3.374, 3.504 and the Mean percentages are 62.42 and 64.21 respectively.
SD 0.815, 0.774 and the Mean percentages are 61.25and 65.75 respectively.
66
TABLE 9: Frequency and Percentage Distribution of overall knowledge scores of
n = 80 (40 +40)
Experimental Group Control Group
Sl. NO Level of knowledge Pre- test Post- test Pre- test Post- test
f % f % f % f %
1 Inadequate (< 50%) 11 27.5 - - 9 22.5 7 17.5
2 Moderate (50%-75%) 25 62.5 14 35.0 30 75.5 29 72.5
3 Adequate (>75%) 4 10.0 26 65.0 1 2.5 4 10.0
67
CONTROL GROUP BY THEIR LEVEL OF KNOWLEDGE
The above figure shows the percentage distribution of Pretest and Posttest knowledge of
Experimental and Control Group. With regard to the Experimental Group majority 25
(62.5%) of them had moderate knowledge (50%-75%), 11(27.5%) of them had
inadequate knowledge (< 50%) and 4 (10%) had adequate knowledge in Pretest. In
Posttest 14 (35%) of them had moderate knowledge (50%-75%) and majority 26 (65%)
of the patients with DM had adequate knowledge (>75%) and none of them had
inadequate knowledge in Posttest.
In Control Group majority 30 (75.5%) of them had moderate knowledge (50%-75%),
9 (22.5%) of them had inadequate knowledge (<50%) and only 1 (2.5%) had adequate
knowledge in Pretest. In Posttest majority 29 (72.5%) of them had moderate knowledge,
7 (17.5%) of them had inadequate knowledge and only 4 (10%) had adequate knowledge.
68
TABLE 10: Mean, SD and Mean % of overall knowledge scores of Experimental
and Control Group.
n = 40
Mean Standard Deviation Mean %

Sl.
Group
no Pretest Posttest Pretest Posttest Pretest Posttest
1 Experimental 24.80 33.78 5.897 4.666 62.0% 84.45%
2 Control 24.90 25.60 4.413 4.567 62.25% 64.0%
The above table shows the Pretest and Posttest Mean, Standard Deviation, and Mean
Percentage of Experimental and Control Group.
With regard to the Experimental Group, the Pre and Posttest mean are 24.80, 33.78 with
SD are 5.897, 4.666 and the Mean Percentage are 62 and 84.45 respectively.
In Control Group the Pre and Posttest values of mean are 24.90, 25.60 with SD 4.413,
4.567 and the Mean Percentage are 62.25 and 64 respectively.
69
SECTION C: COMPARISON OF PRE AND POSTTEST KNOWLEDGE
SCORES AMONG EXPERIMENTAL AND CONTROL GROUP.
TABLE 11: Aspectwise comparison of Pretest and Posttest Mean, Standard
deviation, Mean difference and Paired ‘t’ value among Experimental Group
n =80(40+40)
Mean SD Mean
Aspects ‘t’ test
Pretest Posttest Pretest Posttest Difference
General 9.276***
5.20 6.90 .992 1.128 1.70
information df=39
16.316***
Diabetic diet 17.55 23.25 4.696 3.927 5.70
df=39
10.400***
Dietary alteration 2.05 3.63 .846 .540 1.58
df=39
S = Significant NS= Not Significant * = 0.05 ** = 0.01 *** = 0.001
The above table shows the aspect wise mean, standard deviation and mean difference of
Experimental Group.
the SD 0.992, 1.128 respectively and the Mean difference is 1.70.
4.696, 3.927 respectively and the Mean difference is 5.70.
70
SD 0.846, 0.540 respectively and the Mean difference is 1.58.
The calculated ‘t’ value for general information, diabetic diet and dietary alteration are
9.276, 16.316 and 10.400 respectively.
As the calculated value for all the aspects are greater than the table value 3.551 at 39 df,
the research hypothesis H1 is accepted at p < 0.001.
71
TABLE 12: Aspect wise comparisons of Pretest and Posttest knowledge scores of
Control Group. n= 40+40 =80
Mean SD Mean ‘t’ test
Aspects pretest posttest Pretest posttest Difference
General 4.98 5.03 .832 .973 0.05 .495
information df=39
NS
Diabetic diet 17.48 17.98 3.374 3.504 0.50 2.508
df=39
Dietary alteration 2.45 2.63 .815 .774 0.18 2.876
df=39
**
The above table shows the aspect wise mean, standard deviation and mean difference of
Control Group.
the SD 0.832, 0.973 respectively and the Mean difference is 0.05.
3.374, 3.504 respectively and the Mean difference is 0.50.
72
SD 0.815, 0.774 respectively and the Mean difference is 0.18.
0.495, 2.508 and 2.876 respectively.
The calculated value ( 0.815) for general information is lesser than the table value 2.02 at
39 df we reject the research hypothesis H1. On considering the diabetic diet, the obtained
value (2.508) is greater than the table value 2.02 at 39 df, the research hypothesis H1 is
accepted at 0.05 level. With regard to the dietary alterations, the obtained value (2.876) is
greater than the table value 2.70 at 39 df, the research hypothesis H1 is accepted at 0.01.
73
Table 13: Comparison of overall Pretest and Posttest Mean, Standard deviation,
Mean difference and Paired ‘t’ value among Experimental and Control Group.
n = 80 (40 +40)
Mean Standard Deviation Mean Paired ‘t'

Sl.no Group
Pretest Posttest Pretest Posttest difference test
18.762* * *
1 Experimental 24.80 33.78 5.897 4.666 8.975
df = 39
2.706**
2 Control 24.90 25.60 4.413 4.567 .700
df =39
The above table shows the comparison of Mean, Standard Deviation, and Paired‘t' test
SD are 5.897, 4.666 respectively and the Mean difference is 8.975. The obtained t value
is 18.762. As the calculated value is greater than the table value, 3.551 at 39 df, the
research hypothesis H1, which states that there is significant difference between Pre and
Posttest knowledge on diabetic diet among the Experimental Group is accepted at
p < 0.001.
4.567 respectively and the Mean difference is 0.707. The obtained t value is 2.706. As
the calculated value is greater than the table value, 2.70 at 39 df, the research hypothesis
H1, which states that there is significant difference in Pre and Posttest knowledge on
diabetic diet among the Control Group is accepted at 0.01.
74
SECTION D: COMPARISON OF POSTTEST KNOWLEDGE SCORES
BETWEEN EXPERIMENTAL AND CONTROL GROUP
TABLE 14: Comparison of Posttest Mean, Standard deviation, Mean difference
and Unpaired ‘t’ value between Experimental and Control Group
n = 40
Sl.no Group Mean Standard Mean UnPaired ‘t' test
Deviation difference
1 Experimental 33.78 4.666 8.175 7.324
df=39
2 Control 25.60 4.567 ***
The above table shows the Comparison of Posttest Mean, Standard deviation, Mean
difference and Unpaired ‘t’ value between Experimental and Control Group.
7.324. As the calculated value is greater than the table value, 3.55 at 39 df, the research
hypothesis H2 stating that there is significant difference in Posttest knowledge on diabetic
diet between the Experimental and Control Group is accepted at p< 0.001.
75
SECTION E: ASSOCIATION OF POSTTEST KNOWLEDGE OF
EXPERIMENTAL AND CONTROL GROUP WITH SELECTED
DEMOGRAPHIC VARIABLES.
TABLE 15: Association of posttest knowledge of Experimental group with selected
demographic variables.
n = 40
Level of knowledge
χ2value
Sl.no Variables Moderate Adequate
50-75 % >75 %
Age group (years)
a. 30-40 3 10 1.874
1 b. 40-50 7 9 df =3
c. 50-60 2 5 NS
d. 60-70 2 2
Gender .054
2 a. Male 7 12 df =1
b. Female 7 14 NS
Education
3
a. Primary 2 0 14.472
b. Secondary 8 4 df = 4
c. Higher secondary 1 5 **
e. Under graduate 3 10
76
f. Post graduate 0 7
Occupation
a. Daily wages 9 9
6.993
4 b. Private employee 1 10
df = 3
c. Government employee 3 7
NS
d. Self employed 1 0
Monthly income
a. 5000-15000 5 18 4.485
5
b. 15000-25000 7 7 df = 2
c. >25000 2 1 NS
Religion
a. Christian 4 8 .348
6
b. Hindu 5 11 df = 2
c. Muslim 5 7 NS
Marital status
3.910
a. Married 12 26
7. df=1
b. Unmarried 2 0 *
Place of residence
.406
a. Urban 5 12
8 df=1
b. Rural 9 14 NS
77
Type of family
a. Nuclear 5 19 5.332
9
b. Joint 8 6 df=2
c. Extended 1 1 NS
Family history of DM 8.120
10 a. No 9 5 df=1
b. Yes 5 21 **
Methods to control DM
a. Drugs 5 3
8.969
b. Diet, Exercise 2 6
11 df=8
c. Diet, Drugs 5 12
NS
d. Exercise, Drugs 1 1
e. Diet, Exercise, drugs. 1 4
Level of activity
3.925
a. Sedentary 3 7
12 df=2
b. Moderate 9 19
NS
c. Heavy 2 0
Source of knowledge
13
a. Nil 5 2
6.950
b. Friends 3 5
df=3
c. Relatives 3 15
NS
d. Massmedia 3 4
78
Table 15 reveals the association of posttest knowledge of Experimental group with
selected demographic variables.
With regards to Age, the obtained χ2 1.874 value is lesser than the table value (7.82) at
p= 0.05 level, so it not is significant.
In relation to gender, the obtained χ2.054 value is lesser than the table value (3.84) at
p= 0.05 level, so it is not significant.
With regard to education, the obtained χ2 14. 472 value is greater than the table value
(13.28) at p= 0.01 level, so it is significant.
In relation to occupation, the obtained χ2 6.993 value is lesser than the table value (7.82)
at p= 0.05 level, so it is not significant.
In relation to monthly income the obtained χ2 4.485 value is lesser than the table value
(5.99) at p= 0.05 level, so it is not significant.
In relation to religion the obtained χ2.348 value is lesser than the table value (5.99) at
With regards to marital status the obtained χ2 3.910 value is greater than the table value
In place of residence the obtained χ2.402 value is lesser than the table value (3.84) at
79
In relation to type of family the obtained χ2 5.332 value is lesser than the table value
In relation to family history of diabetes mellitus the obtained χ2 8.120 value is greater
than the table value (9.49) at p= 0.05 level, so it is significant.
In methods to control diabetes mellitus the obtained χ2 3.937 value is lesser than the table
value (9.49) at p= 0.05 level, so it is not significant.
With regards to level of activity the obtained χ2 3.925 value is lesser than the table value
In source of knowledge the obtained χ2 6.954 value is lesser than the table value (7.82) at
Hence the research hypothesis H3 stating that there will be significant association
between posttest knowledge of Experimental Group and their selected demographic
variables is accepted with few demographic variables.
80
TABLE 16: Association of posttest knowledge of Control Group with selected
n = 40
Level of knowledge
χ2 value
Sl.no Variables Inadequate Moderate Adequate
<50% 50-75 % >75 %
1 Age group in years
a. 30-40 1 7 0
b. 40-50 0 10 0 14.902
c. 50-60 5 8 1 df =6
d. 60-70 1 4 3 *
2 Gender 3.140
a. Male 5 11 1 df =2
b. Female 2 18 3 NS
3 Education
a. Primary 0 1 0 15.895
b. Secondary 6 11 0 df = 6
c. Higher secondary - - - **
e. Under graduate 1 13 1
f. Post graduate 0 4 3
4 Occupation
a. Daily wages - - - 4.251
b. Private employee 3 21 4 df = 2
81
c. Government employee - - - NS
d. Self employed 4 8 0
5 Monthly income
a. 5000-15000 5 13 0 8.001
b. 15000-25000 1 13 2 df = 4
c. >25000 1 3 2 NS
6 Religion
a. Christian 0 8 1 7.255
b. Hindu 6 9 2 df = 4
c. Muslim 1 12 1 NS
7. Marital status 1.230
a. Married 7 26 4 df=4
b. Unmarried 0 2 0 NS
c. Separated 0 1 0
8 Place of residence 7.557
a. Urban 6 16 0 df=2
b. Rural 1 13 4 **
9 Type of family 2.776
a. Nuclear 2 17 3 df=2
b. Joint 5 12 1 NS
10 Family history of DM .354
a. No 4 13 2 df=2
82
b. Yes 3 16 2 NS
11 Methods to control DM
a. Drugs 2 7 1 8.969
b. Diet, Exercise 1 8 0 df=3
c. Diet, Drugs 2 13 3 NS
d. Exercise, Drugs 1 0 0 *
e. Diet, Exercise, drugs. 1 1 0
12 Level of activity 1.236
a. Sedentary 1 7 1 df=4
b. Moderate 6 20 3 NS
c. Heavy 0 2 0
13 Source of knowledge
a. Nil 1 5 2
b. Friends 3 3 0 9.143
c. Relatives 2 17 2 df=8
d. Massmedia 1 2 0 NS
e. Internet 0 2 0
Table 16 reveals the Association of posttest knowledge of Control Group with selected
With regards to Age the obtained χ2 14.902 value is greater than the table value (12.59) at
p= 0.05 level, so it is significant.
83
In relation to gender the obtained χ2 3.140 value is lesser than the table value (5.99) at p=
0.05 level, so it is not significant.
With regards to education the obtained χ2 15.895 value is greater than the table value
In occupation the obtained χ2 4.251 value is lesser than the table value (5.99) at p= 0.05
level, so it is not significant.
In relation to monthly income the obtained χ2 8.001 value is lesser than the table value
In relation to religion the obtained χ2 7.255 value is lesser than the table value (9.49) at
With regards to marital status the obtained χ2 1.230 value is lesser than the table value
In place of residence the obtained χ2 7.557 value is greater than the table value (5.99) at
p= 0.05 level, so it is significant.
In relation to type of family the obtained χ2 2.776 value is lesser than the table value
In relation to family history of diabetes mellitus the obtained χ2.354 value is lesser than
the table value (5.99) at p= 0.05 level, so it is not significant.
84
In methods to control diabetes mellitus the obtained χ2 8.969 value is greater than the
table value (7.82) at p= 0.05 level, so it is significant.
With regards to level of activity the obtained χ2 1.236 value is lesser than the table value
In source of knowledge the obtained χ2 9.143 value is lesser than the table value (15.51)
at p= 0.05 level, so it is not significant.
between posttest knowledge of Control Group and their selected demographic variables is
accepted with few demographic variables.
85
6. DISCUSSION
This chapter deals with the discussion, based on the objectives of the study and
hypothesis. The present study was to assess the Effectiveness of Self Instruction Module
on diabetic diet among patients with diabetes mellitus in selected diabetic clinic at
Bangalore.
Experimental and 40 control) patients with diabetes mellitus. A self-administered
structured knowledge questionnaire was used to collect the data from subjects. Pretest
was done on first day for both Experimental and Control Group separately. Self
Instruction Module was given to Experimental group on first day after conducting pretest
examination whereas Control Group followed the normal routines. Posttest was
conducted on the seventh day for Experimental and Control Group separately to evaluate
the effectiveness of self instruction module on diabetic diet.
Objectives are:
Group.
2. To compare the pretest and posttest knowledge on diabetic diet among Experimental
and Control Group.
3. To assess the effectiveness of self-instruction module by comparing the posttest
86
The first objective is to assess the pretest and posttest knowledge on diabetic diet
With regard to the Experimental Group majority 25 (62.5%) of them had moderate
knowledge (50%-75%), 11 (27.5%) of them had inadequate knowledge (< 50%) and 4
(10%) had adequate knowledge in Pretest. In Posttest 14 (35%) of them had moderate
knowledge (50%-75%) and majority 26 (65%) of the patients with DM had adequate
knowledge (>75%) and none of them had inadequate knowledge in Posttest.
In Control Group majority 30 (75.5%) of them had moderate knowledge (50%-75%),
9 (22.5%) of them had inadequate knowledge (<50%) and only 1 (2.5%) had adequate
knowledge in Pretest. In Posttest majority 29 (72.5%) of them had moderate knowledge,
7 (17.5%) of them had inadequate knowledge and only 4 (10%) had adequate knowledge.
This study finding is supported by an Experimental study, where 72% of the
Experimental and Control Group had an inadequate knowledge on diabetic diet in pretest,
but after the distribution of information booklet, majority (75%) of the Experimental
group had adequate knowledge comparing to the Control Group. The study revealed that
the information booklet is important to increase the knowledge on diabetic diet52.
The second objective is to compare the pretest and posttest knowledge on diabetic
diet among Experimental and Control Group.
87
SD 5.897, 4.666 respectively and the Mean difference is 8.975. The obtained ‘t’ value is
hypothesis H1, which states that there is significant difference between Pre and Posttest
knowledge on diabetic diet among the Experimental Group is accepted at p < 0.001.
4.567 respectively and the Mean difference is 0.707. The obtained ‘t’ value is 2.706. As
the calculated value is greater than the table value, 2.70 at 39 df, the research hypothesis
H1, which states that there is significant difference in Pre and Posttest knowledge on
diabetic diet among the Control Group is accepted at 0.01.
This study finding is supported by the true Experimental study, in which the planned
teaching program was conducted among 60 samples. The teaching program was
significant (t=18.032) at p< 0.001 level. The study concluded that due to planned
teaching program 75% of the samples had adequate knowledge in posttest when
compared to pretest53.
The third objective is to assess the effectiveness of Self Instruction Module by
comparing the posttest knowledge on diabetic diet between Experimental and
Control Group.
88
This study finding is supported by an Experimental study conducted among 150 type 2
diabetic patients by using random sampling method to find out the effectiveness of
information booklet. In this study the research hypothesis is accepted because the
obtained t value (14.732) is greater than the table value (3.55) at p=0.001 level. The study
revealed that there is significant difference in the posttest knowledge on diabetic diet
between Experimental and Control Group54.
The fourth objective is to find the association between posttest knowledge of

Experimental and Control Group and their selected demographic variables.
The association of posttest knowledge of Experimental group with selected demographic
variables.
In experimental group there was no significant association between diabetic diet with
demographic variable such as age, gender, occupation, monthly income, religion, marital
status, place of residence, type of family, methods used to control DM and level of
activity.
Significant association was found between diabetic diet with demographic variables
such as education with χ2 = 14. 472 which is greater than the table value (13.28) at p=
0.01 level. With regard to the marital status, the obtained χ2 3.910 value is greater than
the table value (3.84) at p= 0.05 level and in relation to family history of diabetes
mellitus the obtained χ2 8.120 value is greater than the table value (9.49) at p= 0.05
level.
89
In control group there was no significant association found between the diabetic diet
with demographic variable such as gender, occupation, monthly income, religion,
marital status, type of family, family history of diabetes mellitus, level of activity, and
This study finding is supported by an another study conducted among 100 diabetic
patients by using simple Random sampling technique to find out the effectiveness of
planned teaching program on diabetic diet. In this study the variables such as age,
religion, socio economic status are significant in Experimental group at p=0.001 level but
it is not significant in Control Group55.
90
7. CONCLUSION
This chapter deals with the conclusion of the study which was done to evaluate the
“Effectiveness of self instruction module on diabetic diet among diabetic patients in
selected diabetic clinic at Bangalore”
diet between the Experimental and Control Group is accepted at p< 0.001. Hence the Self
Instruction Module was considered to be effective in enhancing the knowledge of
diabetic patients.
On the basis of findings the investigator concluded that SIM has improved the knowledge
of the diabetes mellitus patient.
“ Diabetic diet could control blood glycemic level and save your life”
As consumption of the healthy diet plays a major role in the prevention and management
of many diseases, a thorough knowledge is essential for economy and health. Indians,
who rank first in diabetes globally, need enhancement of knowledge regarding DM
especially on diabetic diet through SIM or other teaching methods. Nurses through this,
can contribute to minimize the global burden imposed on our country.
91
8. SUMMARY
Nutrition plays a major role in the prevention and management of many diseases. One of
the most important advances in modern medicine is the better understanding of basic
requirements of fluid and electrolytes. One such disease which could be managed by diet
is diabetes mellitus.
DM is an “iceberg” disease posing a serious threat to be met within the 21st century.
Prevalence of type 2 DM is increasing globally, more so in developing countries like
India. One of the primary objectives in the care of Diabetic patient is to educate the
patient regarding diabetic diet. Hence the investigator decided to assess the knowledge of
diabetic patients regarding diabetic diet, develop a SIM regarding diabetic diet and
evaluate the effectiveness of SIM.
The present study was done to “Assess the effectiveness of self instruction module on
diabetic diet among patient with diabetes mellitus in selected diabetic clinic at
Bangalore”.
Objectives of the study:
Group.
2. To compare the pretest and posttest knowledge on diabetic diet among
Experimental group and Control Group.
3. To assess the effectiveness of self-instruction module by comparing the posttest
knowledge score of diabetic diet between Experimental and Control Group.
92
Hypothesis:
H1: There will be significant difference between pretest and post test knowledge among
the Experimental group and Control Group.
H2: There will be significant difference in the posttest knowledge on diabetic diet
between Experimental and control group.
H3: There will be significant association between posttest knowledge of Experimental
Assumptions:
- Patients with diabetes mellitus may have some knowledge on diabetic diet
- Self-instruction module may enhance the knowledge on diabetic diet among patients
The literature review included a Medline search for published and unpublished research,
a manual search of recent literature, a citation review of relevant primary and secondary
articles. Review of literature related to the present study has been organized as follows:
Literature related to diabetes mellitus
Literature related to diabetic diet.
Literature related to teaching on diabetic diet.
93
The literature review helped the investigator to develop the conceptual frame work,
methodology for the study, data analysis and interpretation.
The conceptual framework of the study is based on Ernestine Wiedenbach Clinical
Nursing Practice - A Helping Art. It provided the comprehensive framework for
achieving the objectives of the study.
Experimental and 40 control) patients with diabetes mellitus who were selected by using
simple random sampling technique (Lottery method). A self administered structured
knowledge questionnaire was used to collect the data from subjects. Content validity of
the tool was validated by 11 experts including 9 Nursing Personnel, 1 Biostatistician, 1
diabetologist and 1 dietician. Reliability was obtained by split half method; the calculated
r-value was 0.9.
Pilot study was conducted on 8 (4+4) diabetic patients who are attending the Bangalore
diabetic clinic Kalyan Nagar. Pilot study showed the feasibility for main study. The main
study was conducted with 80 (40+40) samples. Pretest was done on first day for both
Experimental and Control Group separately. Self Instruction Module was given to the
Experimental group on first day after conducting pretest whereas Control Group followed
the normal routines. Posttest was conducted on the seventh day for Experimental and
Control Group separately to evaluate the effectiveness of Self Instruction Module. The
obtained data was analyzed in terms of objectives and hypothesis using descriptive and
inferential statistics.
94
Findings of the study:
With regard to the age of the Experimental Group, Majority 16 (40%) of diabetic patients
belongs to 40-50years of age and 4(10%) belongs to 60-70 years of age group. In Control
Group majority 14 (35%) of the diabetic patients belong to 50-60 years of age and
8(20%) belongs to 60-70 years of age group.
Females were more in number when compared with males in Experimental Group.
21 (52.5%) diabetic patients are female and 19 (47.5%) are male. 23(57.5%) diabetic
patients are females and 17(42.5%) are males in Control Group.
Considering the educational status, in Experimental Group majority 13(32.5%) of
diabetic patients studied graduate education and only 2 (5.0%) diabetic patients studied
less than middle school education. In Control Group majority 17(42.5%) of diabetic
patients studied secondary education and 7(17.5%) had their post graduate education.
Considering the occupation, in Experimental Group majority 18(45.0%) of diabetic
patients have daily wages and only 1(2.5%) diabetic patient is self employed. In Control
Group majority 28(70.0%) of diabetic patients are private employee and 12(30.0%) are
self employed.
With regard to the monthly income, majority 23(57.5%) of respondents in Experimental
Group had a income ranging between Rs.5000-15000 and 3 (7.5%) of respondents had a
salary above Rs.25000. In Control Group majority 18(45.0%) of respondents had a salary
ranging between Rs 5000-15000 per month and 6(15.0%) of respondents had a salary of
Rs. 25000 and above per month.
95
In Experimental Group, majority 16 (40.0%) of diabetic patients belongs to Hindu
religion and 12 (30.0%) belongs to Christian and Muslim religion whereas in Control
Group majority 17 (42.5%) of diabetic patients were Hindu, 14 (35.0%) belongs to
Muslim religion and 9 (22.5%) of them were Christian.
With regard to the respondents in Experimental group majority of the respondents
38(95.0%) were married and 2(5%) were unmarried whereas in Control Group 37(92.5%)
of the respondents were married, 2(5%) unmarried and 1(2.5%) were found separated.
Majority 23(57.5%) of the respondents in Experimental Group are dwelling in rural area
and 17(42.5%) are dwelling in urban area. In Control Group majority of the respondents
22 (55.0%) are dwelling in urban area and 18 (45.0%) are dwelling in rural area.
Majority of respondents in Experimental and Control Group belong to nuclear family. In
Experimentalgroup 24(60%) of them belong to nuclear family, 14 (35%) belongs to joint
family and 2(5%) belongs to extended family. In Control Group 22 (55%) belongs to
nuclear family and 18 (45%) belongs to joint family
Majority 36(65%) in Experimental Group and 21(52.5%) in Control Group have a family
history of diabetes whereas 14(35%) and 19(47.5%) of respondents in Experimental and
Control Group respectively does not have the family history of diabetes mellitus.
Majority 17(42.5%) in the Experimental Group and 18 (45.5%) in the Control Group
were having diet and drugs whereas at the least only 2 (5%) in the Experimental Group
and 1 (2.5%) in the Control Group were in the group of exercise and drugs.
96
With regard to the Experimental Group, 28 (70%) have moderate level of activity,
10 (25%) have sedentary level of activity and the least 2 (5%) have heavy activity. In
Control Group, 29 (72.5%) have moderate level of activity, followed by 9 (22.5%) of
them having sedentary level of activity and the least 2 (5%) have heavy activity.
Considering the Experimental Group, majority 18(45.0%) got information from relatives,
8 (20.0%) of them got information from friends, 7(17.5%) have got information from
mass media and 7(17.5%) of them have no source of knowledge. In Control Group,
majority 21 (52.5%) of diabetic patients got information from relatives, 6 (15%) have got
information from friends, 3(7.5%) of them got information from mass media, 2(5.0%)
have got information from internet and 8(20.0%) have no source of knowledge.
The knowledge score of the experimental group with regard to the general information on
DM, 22 (55%) got inadequate knowledge, 18 (45 %) got moderate knowledge and no one
got adequate knowledge in Pretest. In Posttest 3 (7.5 %) had inadequate knowledge, 27
(67.5%) of them had moderate knowledge and 10 (25 %) had adequate knowledge.
The knowledge score of the experimental group with regard to diabetic diet is 9 (22.5 %)
had inadequate knowledge, 24 (60 %) had moderate knowledge and 7 (17.5%) of them
had adequate knowledge in Pretest, whereas in Posttest 13 (32.5 %) had moderate
knowledge, 27 (67.5 %) got adequate knowledge and none of them had inadequate
knowledge.
Considering the dietary alterations in experimental group, 31 (77.5 %) got inadequate
knowledge, 7 (17.5%) had moderate knowledge and 2 (5%) got adequate knowledge. In
97
Posttest 1 (2.5%) got inadequate knowledge, 13 (32.5 %) had moderate knowledge and
26 (65 %) got adequate knowledge.
The overall Pretest and Posttest knowledge of Experimental Group majority 25 (62.5%)
of them had moderate knowledge (50%-75%), 11 (27.5%) of them had inadequate
knowledge (< 50%) and 4 (10%) had adequate knowledge in Pretest. In Posttest 14
(35%) of them had moderate knowledge (50%-75%) and majority 26 (65%) of the
patients with DM had adequate knowledge (>75%) and none of them had inadequate
knowledge in Posttest.
In Control Group majority 30 (75.5%) of them had moderate knowledge (50%-75%), 9
(22.5%) of them had inadequate knowledge (<50%) and only 1 (2.5%) had adequate
knowledge in Pretest. In Posttest majority 29 (72.5%) of them had moderate knowledge
(50%-75%), 7 (17.5%) of them had inadequate knowledge (<50%) and only 4 (10%) had
adequate knowledge.
9.276, 16.316 and 10.400 respectively. As the calculated value for all the aspects are
greater than the table value 3.551 at 39 df, the research hypothesis H1 is accepted at p <
0.001.
98
In experimental group there was no significant association between diabetic diet with
demographic variable such as age, gender, occupation, monthly income, religion, marital
status, place of residence, type of family, methods used to control DM and level of
activity.
Significant association was found between diabetic diet with demographic variables
such as education with χ2 = 14. 472 which is greater than the table value (13.28) at p=
0.01 level. With regard to the marital status, the obtained χ2 3.910 value is greater than
the table value (3.84) at p= 0.05 level and in relation to family history of diabetes
mellitus the obtained χ2 8.120 value is greater than the table value (9.49) at p= 0.05
level.
In control group there was no significant association found between the diabetic diet
with demographic variable such as gender, occupation, monthly income, religion,
marital status, type of family, family history of diabetes mellitus, level of activity, and
between posttest knowledge of Experimental and Control Group and their selected
demographic variables is accepted with few demographic variables.
99
Implications:
The implications drawn from the study are of vital concern to the field of nursing
including field of Nursing Service, Administration, Education and Research. Nurses face
many challenges in caring the holistic needs of the client.
Nursing Practice:
• Nurses working in hospitals should provide adequate information regarding
diabetic diet among patients with type 2 diabetic mellitus.
• Nurses working in the clinical area and at OPD can make use of the SIM for
delivering information regarding self administration of insulin.
• Nurses should teach the patient about the benefits diabetic diet, so that the patient
can practice in the home settings.
Nursing Education:
• Before nurses can utilize their practices, they need to have a strong foundation in
terms of education. Awareness needs to be created among type 2 Diabetes
Mellitus patients regarding diabetic diet and other control measures thereby
preventing complications.
• Teaching strategies such as demonstration, use of video film, procedure manuals
and computer assisted interventions can be used to train the patients.
100
Nursing Administration:
• Staff development programme in any organization is the prime responsibility of
the nursing administrator. Advancement of science and technology, development
of various sub specialties, increasing social demands and improved medical
technology puts a challenge for the nurses to demonstrate their professional and
personnel growth.
• To update and reinforce their knowledge a continuing nursing education
department in the hospital should be established to conduct regular in service
education programme to nurses who are working in diabetic clinic.
• Public awareness programs and camps can be arranged by the nurse administrator.
Nursing Research:
• More interventional studies can be conducted to make the nurse as well as the
public aware of controlling diabetes mellitus.
Limitations:
The investigator faced ample difficulty in collecting review of literature related to
knowledge domain on diabetic diet as most of the literatures are focusing on the practice
domain.
Recommendations:
1. Study can be replicated with larger samples for better generalization.
101
2. Similar study can be conducted using cross over design with other techniques.
3. Similar study can be conducted among other group of diabetes mellitus.
4. Similar study can be conducted in other setting.
102
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4. Park K. Textbook of Preventive and Social Medicine. 18th edition. Jabalpur.
Banasidas Bhanot Publishers. 2007; P 413-415.
5. Sheeba Jabakani. Statistics of Diabetes Mellitus. Health Herald. 2008; Sep: 4-5
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Archives of Disease in Childhood. 2008; 93: 512-517.
7. Jotkowitz AB, Rabinowitz G. Internal Medicine F, Soroka. J Manaj Care Pharm.
2003; Nov-Dec 9(6): 552-8.
8. Murtaugh MA, Jacobs DR JR. Epidemiological support for the protection of
whole grains against Diabetes. Proc Nutr Soc. 2003: Feb 62(1): 143-149.
9. Reeds DN. Human Nutrition. Geriatrics and Nutritional Sciences. www.
wustl.edu.
10. MA Martinez-Gonzalez. Prevalence and risk of developing Diabetes. British
Medical Journal. 2006.
11. Kappeler H, Diabetic Diet. 2000.
12. Daly JM, Hartz AJ. An assessment of knowledge of Diabetic Diet with type 2
Diabetes.
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13. Davis N, Forbes B. Nutritional strategies in type 2 Diabetes Mellitus. Mt Sinai J
Med. 2009; Jun 76(3): 257-68.
14. Barnard ND, Katcher HI. Knowledge of Diabetes Management. Nutr Rev. 2009.
May 67(5): 255-63.
15. Maria Collazo Clavell. Diabetic Diet can control Diabetes. 2007.
www.nlm.nih.gov/medlineplus/diabeticdiet.
16. Yunsheng Ma. Epidemiology of Diabetes and practice of Diabetic Diet.
Nutrition. 2008; 28: 45-56.
17. MA Martinez-Gonzalez. Prevalence and risk of developing Diabetes. British
Medical Journal Published online. 2006
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May 67(5): 255-63.
19. Jackueline Fawcett. Text Book of Nursing Theory. 4th edition. 1998;. P 132-136.
20. Chin and Jacobs. Text book of Nursing Theory, 3rd edition. 1983; P 415-435.
21. Wesley L. Ruby. Text book of Nursing Theory. 4th edition. 2000; P 124-125.
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23. Brunner and Suddarth. Text book of Medical Surgical Nursing. 11th edition.
Philadelphia. Lippincott company. 2008; P 1150-1170.
24. Abioye-Kutevi EA, Oiefeitimi EO. Assessment of dietary knowledge Practices
and control of Diabetes. Niger J Med. 2005; Jan-Mar14 (1): 58-64
25. G Hu. Jiot. Community based study to assess the knowledge and practice of
Diabetic Diet. Int J Obes. 2006; 30: 1742-1749.
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26. Tucholski K. Deja G, Skala-Zamorowska E, knowledge of Diabetes Mellitus.
Department of family and Medicine.
27. Carver C. Insulin treatment and the knowledge of management Type 2 Diabetes.
Diabetes Educ. 2006; Nov-Dec 32(6): 910-7.
28. Marchand C, Crozet C. comparative study was conducted to assess the knowledge
of Diabetes Mellitus possessed by patients with Diabetes and healthy adult. Rev
Med Suisse. 2007; Apr 43(105): 868-872.
29. Nield L, Moore HJ. Dietary advice for treatment of Diabetes Mellitus Cochrane
Database Syst Rev. 2007; Jul 18(3) CD004097.
30. M.Huerta. Magnesium deficiency is associated with insulin resistance in obese
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31. Utzschneider KM, Carr DB, Barsness SM. Diet induced weight loss is associated
with an improvement in b-cell function in older men. J Clin Endocrinal Metab.
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32. Joice M Black. Text book of Medical Surgical Nursing. 7th edition. New York.
Saunders Company. 2005; P 1243-1253.
33. Lewis Heitkemper. Textbook of Medical Surgical Nursing. 7th edition. Missouri.
Mosby Company. 2007; P 1035-1048.
34. Patient Educ Couns. 2001; Aug 44(2): 171-178.
35. H Iso. The relationship between green tea and total caffeine intake and risk for
self reported Type 2 Diabetes among Japanese adults. Ann intern Med. 2006; 144:
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36. B Smith. Does the coffee consumption reduces the risk of Type 2 Diabetes in
individuals with impaired glucose. Diabetes Care. 2006; 29: 2395-2395.
37. Tuomilehto J, Hu G, Bidel S. Coffee consumption and risk of Type 2 Diabetes
Mellitus among middle- aged men and women. JAMA 2004; 291: 1213-1219.
38. Y Ma. Low carbohydrate and high- fat intake among adult patients with poorly
controlled type 2 Diabetes Mellitus. Nutrition. 2006; 22: 1129-1136.
39. Kodama S, Saito K. Influence of fat and carbohydrate proportions on the Dietary
profile. Diabete care. 2009; Jun 76(3): 257-68.
40. C.S. Zipitis, A.K. Akobeng. Overweight is the risk of Diabetes Mellitus.
Archives of Disease in Childhood . 2008; 93: 512-517.
41. Venn BJ, Mann JI. Cereal grains legumes and Diabetes. Eur J Clin Nutr. Year
2004: Nov 58(11): 1443-1461.
42. Van de Laar FA, Akkermans RP. Evidence for effects of Diet for Diabetes from
43. Systematic review. J Clin Nutr; 2007; Aug 61(8): 929-937.
44. Segal- Isaccson CJ, CarelloE. Dietary fats, carbohydrates and Diabetes Mellitus.
Curr Diab Rep. 2001; Oct 1(2): 161-169.
45. Bears Myers. Adult Health Nursing. 3rd edition. London. Mosby Company. 1998;
P 1406-1410.
46. Gross LS, Li L, Ford ES. Increased consumption of refined carbohydrates and the
epidemic of Type 2 Diabetes. Am J Clin Nutr. 2004; 79: 774-779.
47. Schulze MB, Manson JE, Ludwig DS. Sugar sweetened beverages weight gain
and incidence of Type 2 Diabetes. JAMA. 2004; 292: 927-934.
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48. Segal- Isaccson CJ, CarelloE. A computer assisted teaching on Dietary fats and
Diabetes Mellitus. Curr Diab Rep.
49. J C Oldroyed. Randomized controlled trial evaluating lifestyle interventions in
people with impaired glucose tolerance. Diab Res clin Pract. 2006; 72: 117-127.
50. Albarran NB. Ballesteros Mn. Dietary behavior, practice and Diabetes care
patient. Education couns. 2006; May 61(2): 191-199.
51. Andel M, Brune rova L. Diabetic and reduction diet for Diabetes patient. Venitr
Lek. 2004; May 50(5): P 363-370.
52. Kamal NM, Badawy YA. Diabetics knowledge of disease and management. East
mediterr Health J. 1999; sep5 (5): P 974-983.
53. Savora M, Miller C. food selection and eating patterns among people with
Diabetes Mellitus. J Nutr Educ. 2001; Jul- Aug 33(4): 224-233.
54. Schalch A, Ybarra J. Psycho educational nutritional program in Diabetic patient.
2001; Oct 1(2): 161-169.
55. Shilubanc HN, Potgieter E. Patients and family member’s knowledge and views
56. Yun LS, Harsan Y. Comparison of knowledge of Diabetes Mellitus between
patients with family members. Patient Educ Couns. 2007; Dec 69 (1-3): 47-54.
107
ANNEXURE - 1
LETTER SEEKING AND GRANTING PERMISSION TO CONDUCT

MAIN STUDY
108
ANNEXURE - 2
CONTENT VALIDITY CERTIFICATE
I here by certify that I have validated the tool of Ms Mabel Florence.G, II year MSc
Nursing Student of Diana College of Nursing, Bangalore, who is undertaking a study to
“Assess the Effectiveness of Self Instruction Module on diabetic diet among patients
with diabetes mellitus in selected diabetic clinics at Bangalore.”
Date: Signature and Seal of the Expert
Place: Name and Designation
109
ANNEXURE - 3
LETTER SEEKING EXPERTS OPINION AND SUGGESTIONS FOR
THE CONTENT VALIDITY OF TOOL
From,
Ms. Mabel Florence. G.
II year M.Sc Nursing Student,
Diana College of Nursing,
Hegde Nagar, Bangalore-64.
To,
Forwarded Through,
The Principal,
Diana College of Nursing,
Hegde Nagar, Bangalore-64.
Respected Sir/ Madam,
Sub: Requesting for content validation of the research tool.
I Ms. Mabel Florence. G. II year M.Sc Nursing student of Diana College of Nursing
have undertaken a research on “ Effectiveness of Self Instruction Module on diabetic
diet among patients with diabetes mellitus in selected diabetic clinics at Bangalore.
110
I request you to kindly validate my tool (Knowledge Questionnaire) and Self Instruction
Module for its relevance, appropriateness and degree of agreement of the content.
Herewith I am enclosing a copy of
• Criteria checklist
• Tool
• Self instruction module
May I request you to kindly go through the content and give your valuable suggestions in
the given columns.
Thanking you in anticipation
Date: Yours truly,
Place:
G. Mabel Florence
111
EVALUATION CRITERIA FOR CONTENT VALIDITY ON SELF
INTRUCTION MODULE
INSTRUCTIONS
The expert is requested to go through the criteria listed below for the evaluation of self-
instruction module on diabetic diet. In the criteria checklist there are two main response
columns given below (agree or disagree). Kindly go through the content and place tick
mark against response column and remarks in the remarks column.
SI.NO CRITERIA A D REMARKS

1. Objectives
Formulation of objectives.
1.1. General objective is comprehensive in
terms of
• Knowledge
• Understanding
• Application
1.2.Specific objectives are comprehensive
in terms of
• Knowledge
• Understanding
• Application
2. Content
Selection of the content
Is the content on Diabetic diet
• Appropriate
• Adequate
• Accurate
112
3. Organization of the content
Is the content organized in a
logical sequence?
4. Presentation
Does the self instruction module have
• An introduction
• General objectives
• Content outline
• Summary
5. Language
5.1. The language used is easy to follow.
5.2. The terminologies used are defined
clearly.
5.3. The language used is grammatically
sound.
6. Practicability
Does the self instruction module
contain the answers to the questions asked.
7. Figures
Are the figures
• Easy to follow
• Appropriate
• Attractive
8. Reinforcement
Questions are
• Appropriate
• Formulated correctly
Any other suggestion.
A=Agree D=Disagree Signature of the Expert
113
Dear Madam/ Sir,
Kindly go through the content and place tick mark against items given in the following
columns ranging from relevant to not relevant. If any modification, kindly give your
opinion in the remarks column.
SECTION A – DEMOGRAPHIC DATA
SL.NO RELEVANT NEEDS NOT REMARKS

MODIFICATION RELEVANT
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
SECTION: B
STRUCTURED QUESTIONNAIRE ON KNOWLEDGE REGARDING
DIABETIC DIET AMONG DIABETES MELLITUS PATIENTS.
SI.NO RELEVANT NEEDS MODIFICATION NOT RELEVANT REMARKS

1.
2.
3.
4.
114
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
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23.
24.
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36.
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115
41.
42.
Suggestions if any:
Date: Signature and Seal of the Expert
Place: Name and Designation
116
CERTIFICATE OF EDITING
This is to certify that the dissertation done by Ms G. Mabel Florence, 2nd year M.sc.
Nursing student from Diana College of nursing, on “Effectiveness of Self Instruction
Module (SIM) on diabetic diet among patients with diabetes mellitus in selected
diabetic clinic at Bangalore” is edited for English language appropriateness by me.
Date: Signature
Place: Bangalore Name and Designation
117
ANNEXURE – 4
LIST OF EXPERTS
1. Mr. Bosco Sundar Raj M.Sc (N),
Principal,
Miranda College of Nursing,
Yelahanka New Town, Bangalore.
2. Mrs. Bamini Devi M.Sc (N),
HOD of Medical Surgical Nursing,
Ramachandra Research Institute,
Chennai.
3. Mr. Biju Ramachandran M.Sc (N),
Principal,
KTG College of Nursing,
Heganahalli, Bangalore.
4. Mrs. Ajitha Rathnam M.Sc (N),
Sri Mookambika College of Nursing,
Kanyakumari, TamilNadu.
5. Mrs. Lakshmi Prabha.
Annapoorna College of Nursing,
118
Salem, Tamil Nadu,
6. Ms. Swapna Mary M.sc (N),
Sarvodaya College of Nursing,
Dasarahalli, Bangalore.
7. Mrs. Binutha M. Sc (N),
Azeezia College of Nursing,
Diamond Hills,
Kollam, Kerala.
8.Mrs. Vinitha Boy,
Christian Medical Mission,
Neiyur, Kanyakumari, TamilNadu.
9. Dr. Paramesh S. M.B.B.S.,M.D.,
Consultant Diabetologist
Bangalore Diabetic Center, Bangalore.
10. Dr. Rangappa PhD.,
Biostatistician,
Diana college of Nursing, Bangalore.
11. Mrs. Sunitha MSC (F.N)
Dietician,
Republic Hospital, Bangalore.
119
ANNEXURE - 5
SELF INSTRUCTION MODULE
The self-instruction module was prepared on the basis of literature on diabetes mellitus
and diabetic diet.
The module consists of introduction, objectives and chapters related to diabetes mellitus.
Each chapter contains a list of specific objectives, subject matter and reinforcement in the
form of test with specific instruction to move on to the next chapter only after answering
all the questions correctly.
General objective:
After completion of reading the following chapters, the patient will be able to explain the
diabetes mellitus and diabetic diet, apply skill in calculating calories intake and planning
menu for their own body weight.
Specific objectives:
After reading this self-instruction module the diabetic patients will be able to:
explain general information of the diabetes mellitus
calculate the calories intake for their own body weight
differentiate the foods to be included and foods to be avoided
apply skill in planning menu for them.
The content is divided into three chapters
120
Chapter-I:
This chapter discusses about the definition, causes of diabetes mellitus, types, signs and
symptoms of diabetes mellitus, diagnosis, treatment and complication of diabetes
mellitus.
Chapter-II:
This chapter explains regarding diabetic diet in relation to patients with diabetes mellitus.
Chapter-III:
This chapter deals with the menu plan for patient with diabetes mellitus.
121
CHAPTER-I
DIABETES MELLITUS
Introduction:
In order to know about diabetic diet it is essential to understand about diabetes mellitus.
This chapter deals with meaning of diabetes, causes of diabetes mellitus, types, signs and
symptoms of diabetes mellitus, diagnosis, treatment and the complication of diabetes
mellitus.
On completion of this chapter the learner will be able to:
1. define diabetes mellitus
2. list the type of diabetes mellitus
3. enumerate the causes for diabetes mellitus
4. list the symptoms of diabetes mellitus.
5. list the diagnosis, treatment and complication of diabetes mellitus.
Meaning of diabetes mellitus:
Diabetes mellitus is a metabolic disorder in which carbohydrate utilization is reduced and
fat and protein utilization is increased due to deficiency of insulin.
Brief Review of Anatomy and Physiology:
Metabolism is the mechanism by which the body converts the food into
energy. Digestive juices break down most of the food into a simple sugar
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called glucose. Glucose is the body’s main source of energy. After
digestion, glucose passes into the blood stream, where it is available for
cells to take in and use or store for later use.
In order for the cells to take in glucose, insulin must be present in the
blood. This insulin secreted by the gland pancreas, which is situated
behind the stomach. The beta cells of pancreas secrete insulin.
Pathophysiology:
Types of diabetes mellitus:
1. Type 1 or Insulin Dependent Diabetes Mellitus [IDDM]
2. Type 2 or Non Insulin Dependent Diabetes Mellitus [NIDDM]
3. Gestational diabetes.
4. Diabetes mellitus associated with other condition or syndrome
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1. Type 1 or Insulin Dependent Diabetes Mellitus [IDDM]:
In this type of diabetes mellitus, an autoimmune process destroys the beta cells of
pancreas that normally produce insulin. As a result the insulin is needed to control
blood glucose level so the pancreas is not able to produce insulin. It is a less common
diabetes mellitus and onset is sudden. It is seen most often in children and young adult.
It can be managed carefully by diet, exercise and insulin therapy.
2. Type 2 or Non Insulin Dependent Diabetes Mellitus [NIDDM]:
This type of diabetes mellitus, results from a decreased sensitivity to insulin [called
insulin resistance] or from a decreased amount of insulin production. It is a more
common type of diabetes mellitus and is gradual in onset. Usually occurs in over weight
adults and elderly people. It can be managed carefully by diet and exercise alone.
3. Gestational diabetes:
Onset is during pregnancy usually the second or third trimester, due to hormone
secreted by placenta, which inhibits the action of insulin.
4. Diabetes mellitus associated with other condition or syndrome:
It is otherwise called secondary diabetes. This type of diabetes occurs due to other
disorders. Examples for such disorders are pancreatic disease and hormonal
abnormalities.
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Causes of diabetes mellitus:
Signs and symptoms diabetes mellitus:
Patients with Diabetes Mellitus has signs and symptoms include :
• Passage of large volumes of urine
• Excessive thirst (polydipsia)
• Extreme hunger/eating to much
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• Glycosuria
• Frequent urination
• Unexplained weight loss
• Tingling or numbness in the hands/feet
• Feeling very tired/weakness much of the time
• Sudden vision changes
• blurred vision
• cuts and bruises that are slow to heal
• More infections than usual
• Extremely elevated glucose levels can lead to
lethargy and coma.
Diagnosis:
¾ Diagnosis can be confirmed by testing glucose level in urine and blood
• The normal Random blood sugar level is 80- 120mg /dl.
• The normal Fasting blood sugar level is 60-110 mg/ dl.
• The normal postprandial blood sugar level is 65-140 mg/ dl.
Treatment:
The treatment depends on how long the patient had diabetes, how high the blood
glucose level is, what medicine he is taking and his general state of health.
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The treatment modalities include:
Complication of diabetes mellitus:
a. Hypoglycemia
Low blood sugar due to excessive administration of insulin
b. Diabetic ketoacidosis:
Immediate complication of diabetes mellitus.
c. Macrovascular and microvascular complication:
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Conclusion:
This chapter discuss about the meaning, causes, signs and symptoms, diagnosis,
treatment and complication.
Reinforcement:
Fill up the blanks:
1. Insulin is produced by a special cell called…………..
2. ……………… diabetes is commonly managed by diet and exercise.
3. Polydipsia means ……………………………
key:
1. beta cells
2. type 2 or non insulin dependent
3. excessive thirst
128
CHAPTER-II
DIABETIC DIET
Introduction:
This chapter deals with meaning of diabetic diet, dietary management and how to
calculate the diabetic diet.
Specific Objectives:
At the end of the chapter the learners will be able to:
• explain the dietary management of diabetes mellitus
• list down the foods that can be included and avoided
• prepare the menu for diabetes mellitus.
Meaning:
Diabetic diet is as close to the normal diet as possible so as to meet the nutritional
needs and treatment of the individual patient. This diet is slightly low in carbohydrates,
but adequate in other food principles.
The goals of diabetic diet:
1. To improve health through optimum nutrition.
2. To provide calories for reasonable body weight, normal growth and
development.
3. To maintain glycemic control.
4. To achieve optimal blood lipid levels.
5. To minimize nutrition related chronic degenerative complications
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Dietary management:
A therapeutic diet plays an important role in the treatment of diabetes. The diet may be
used alone or in combination with insulin injection or oral hypoglycemic drugs.
Basic principles for planning diabetic diet:
9 Details regarding the patient’s day- to-day activity including his/ her current
dietary histories are first collected before preparing the dietary prescription.
Based on the nature of physical activity, body weight and dietary history, the
total daily requirements of calories are calculated.
9 Age, sex, activity, height, body weight, cultural factors.
9 Type of diabetes, mode of treatment, control of diabetes.
9 Aggravating factors; Infections, gastrointestinal disorders, cardiovascular
disorders, pregnancy.
The following are the essential consideration:
ESSENTIAL CONSIDERATION
1. Determining energy requirements
2. Distribution of energy in terms of carbohydrate, fats and protein
3. Determining the type of carbohydrate, fiber and type of Preparation
4. Distribution of carbohydrates
5. Stages of diabetes with reference to absence or presence of any Complication
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Calories:
The calculated calorie requirements should allow the patients to lose or gain weight as
required and maintain body weight 10% lower than the ideal/ desirable body weight.
How to calculate the ideal body weight:
Ideal body weight (in kg) can be simply calculated for an individual by subtracting 100
from his/ her height (in cms). For example ideal body weight of a person with 160cm
height is 60kgs(160-100).It is always better for a diabetic to maintain the body weight
10% lower than the ideal body weight.
The ideal body weight will show whether the person is over weight (20% above his ideal
body weight) or under weight (20% below the ideal body weight). Based on these, the
daily calorie requirements of an individual per kg body weight can be worked out as
indicated below.
The recommended calorie intake for Diabetic based on body weight:
Over weight - 20 kcal/ kg.wt per day.
Ideal weight – 30 kcal/ kg.wt per day.
Under weight -40 kcal/ kg.wt per day
Distribution of nutrients in the total calories:
The total daily intake of calories from carbohydrates, proteins and fat in the diet for a
diabetic should be distributed in the following way.
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Carbohydrates:
In Indian diets, carbohydrates provide 60-70% of the total calories.
Diabetics need not restrict the carbohydrate intake, but they can alter the type of
carbohydrate in their diet.
Distribution of carbohydrate in the diet:
The blood sugar level depends mainly on the intake of carbohydrate,
The total amount of the carbohydrates can conveniently be divided into 4-5 equal parts.
One third [33%] of the diet is served during lunch, another one third [33%] during dinner,
remaining one third [25%] is served during breakfast and the rest [9%] during evening tea
or at bedtime.
It may be necessary to give additional carbohydrates before the patient goes to sleep to
prevent hypoglycemia if the patient is on slow acting insulin.
Proteins:
Proteins are essential for growth and development and tissue repair. When needed,
proteins also provide energy to the body. One gram of protein provides 4kcal of energy.
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The protein rich foods are:
The Recommended Dietary Allowance [RDA] for protein is 1.0g/kg body weight. It is
generally recommended that 15-20%of total calories be derived from proteins. In insulin
dependent diabetic children, 1-1.5g of protein/kg body weight is recommended.
In diabetics with associated renal problems, protein is restricted to 0.6g/kg body weight.
Fats:
Fats are concentrated sources of energy. One gram of fat yields 9kcal. Excess intake of
fat thus increases body fat and leads to obesity.
Types of fat.
Saturated fats Polyunsaturated fats Monosaturated fats
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Saturated fats:
Saturated faty diets
Ghee, butter, vanaspati and coconut oil contain a high proportion of saturated fats, which
are likely to increase the serum cholesterol. They should be taken in small quantities.
Poly unsaturated fatty acids [PUFA]:
Vegetable fats, such as sunflower oil and sunflower, contain polyunsaturated fatty acids,
which are considered good for health.
Poly unsaturated fatty foods
134
Monosaturated fatty acids:
Present in groundnut, palm oil and olive oil are not harmful to the body.
Fats from above mentioned dietary sources are descried as visible fats.
We also get fats from cereals, pulses, milk products, eggs, flesh foods
and nuts and they are considered as invisible fats.
Since serum lipids are generally raised in diabetes, diabetics have to be
careful with the amount and nature of fat they consume.
Non-vegetarian diabetics can consume fish or chicken with out the skin,
instead of egg, mutton, liver and brain, which are high in cholesterol.
Diabetics can take 20g visible fat/ day.
“Fats from vegetable sources are better than those from animal sources”.
Vitamin and minerals:
o These are protective which in small amounts are essential for the body.
135
o They are found in green leafy vegetables, fresh fruits, milk and dairy
products, cereals, nuts, fish and egg. Daily intake of these foods can
provide enough vitamins and minerals.
Dietary fiber:
Fiber present in vegetables, fruits, legumes and fenugreek seed is soluble in nature
and more effective in controlling blood sugar, serum lipids than the insoluble fiber
present in cereals and millets.
Long term consumption of insoluble fiber also improves glucose tolerance.
Use of fenugreek seeds in the management of diabetes:
The quantity of fenugreek seeds to be taken daily depends up on the severity of diabetes.
The doses vary from 25g to 50g. To begin with, 25g of fenugreek seeds may be taken in
two equal doses of 12.5g each [approximately two teaspoons] along with lunch and
dinner. The seeds can be taken as a drink in water or in powder form as a drink in water
or buttermilk, 15 minutes before the meal.
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Alcohol consumption:
A major danger of alcohol consumption by the patient with diabetes is hypoglycemia,
especially for patients who take insulin. Alcohol may decrease the normal physiologic
reactions in the body that produce glucose (gluconeogenesis).
Alcohol consumption may lead to excessive weight gain (from the high caloric content of
alcohol), hyperlipidemia, and elevated glucose levels (especially with mixed drinks and
liqueurs)
Sweeteners:
Use of sweeteners is acceptable for patients with diabetes, especially if it assists in

overall dietary adherence. Moderation in the amount of sweeteners used is encouraged, to
avoid potential adverse effects.
TYPES OF SWEETENERS
NON-
NUTRITIVE
NUTRITIVE
The nutritive sweeteners
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¾ Nutritive sweeteners include fructose , sorbital, and xylitol.
¾ They are not calorie free; they provide calories in amounts similar to those
in sucrose (table sugar). They cause less elevation in blood sugar levels than
sucrose does and are often used in “sugar-free” foods.
The non-nutritive sweeteners:
• The non-nutritive sweeteners have minimal or no calories.
• It includes baked foods, non-alcoholic beverages, chewing gum, coffee,
confections, frosting, and frozen diary products.
Diabetics are advised artificial sweeteners in place of sugar such as saccharin and
aspartame, which are also calorie free.
Artificial sweeteners
Misleading food labels:
Foods labeled “sugarless” or “sugar free” may still provide calories equal to those
of the equivalent sugar containing products.
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Foods labeled “dietetic” are not necessarily reduced calorie foods. They may be
lower in sodium or have other special dietary uses.
Labels of “healthy foods” especially snacks they often contain carbohydrates such
as honey, brown sugar, and corn syrup. In addition the healthy food contain coconut or
palm oil. So it is contraindicated for the patient with diabetes and elevated blood lipid
levels.
Exercise:
Patients who require insulin should be taught to eat a 15 g carbohydrate snack or a
snack of complex carbohydrates with a protein before engaging in moderate exercise, to
prevent unexpected hypoglycemia.
The exact amount of food needed varies from person to person and should be
determined by glucose monitoring.
Some patients find that they do not require pre exercise snack if they exercise with
in 1-2 hours after a meal.
Diabetic patient who are engaging in strenuous exercise may require extra
carbohydrates before, during and after exercise.
Dietary alterations:
9 Lean diabetics are prescribed body weight-maintenance diets containing
1800to 2000kcals.
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9 Obese diabetics are given body weight reducing diets providing 1200 to
1500 kcals
Dietary alterations with associated disorder:
• Dietary fat intake has to be limited in diabetics with high serum lipids
or with heart disease.
• The protein intake has to be limited with renal disease. The intake of
protein is 0.8g/kg/day with evidence of macro albuminemia.
• Magnesium replacement possibly needed with high risk-glycosuria,
and ketoacidosis.
• The salt intake is <2400 mg/day in mild to moderate hypertension. The
salt intake is <2000mg/day with nephropathy, hypertension and edema.
Dietary guidelines:
In general, all foods can be classified into the following categories for diabetics.
Vegetables (any 2/ day)
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Foods to be included Foods to be avoided Reasons to avoid
Brinjal Potato
Beans Carrot
Cluster beans Beetroot
Radish white Colocasia These are high
Ash gourd Pumpkin-yellow calorie foods when
Bottle gourd Radish-red compared to other
Cauliflower Plantain green vegetables
All green leaves Yam
Pumpkin Tapioca
Coconut It is rich in saturated

fat and forms hyper
glycemia through
gluconeogenesis.
Pulses, Nuts and oil seeds
All dhal Cashew nut They yield high

All beans Ground nut calorie, raises blood
Gingelly seeds sugar level, in
Almond addition alters lipid
profile.
Fruits (any one if blood sugar level is controlled)
Small size guava-1 Jack fruit Sugar content is
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Small size apple-1 Custard apple higher than other
Small size orange-1 Mango fruits.
Small size pears-1 Sapota
Watermelon- 1slice Dates, raisins and other dry They have much
Papaya –1 slice fruits, tinned fruits, elements in the form
processed fruits. of preservatives,
which damage vital
organs.
With out sugar Sherbat These are rich in

Soft drinks monosaccharide
Tea
Honey energy value is 3/9
Coffee
calories for 100gm.
Skimmed milk
Soda
Alcoholic drinks Provides empty
Tomato juice
Processed milk products calorie rich in sugar
and fatty substances.
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Non-veg (any one/ week)
Boiled only, not fried

Dry fish Rich in salt
Egg white-2 no
Mutton (muscle)-4 pieces Egg yolk Rich in lipid
(50gm) Liver, brain, blood, head component. Blood
Skinless chicken-4 pieces Beaf sugar level is raised
(75gm) from non-
Fish-100gm carbohydrate sources.
Miscellaneous

Butter milk Jaggery, payasam, cake, ice Are rich in sugar and
Curd prepared from cow cream, cream biscuit, saturated fatty acid.
milk vadagam, fast foods,
Soya beans fermented and packed foods,
Mushrooms chips, butter, ghee, dalda,
bajji, vada, bread, halwa,
salted foods.
Tobacco and smoking Allow free radical

generation
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Foods stuffs that decreases blood sugar:
Name of the food stuffs

Reasons
Red beans It contains insulin stimulants

Bitter gourd Rich in branched chain amino acid
Black beans It contains insulin stimulant
Fenugreek Soluble fiber
Italian millet It is rich in leucine
Agathi green Rich in valine
Soya bean Insoluble dietary fiber
Wheat bran Insoluble dietary fiber
Corn Soluble dietary fiber
Guava Soluble dietary fiber
Apple Insoluble dietary fiber
In brief the diabetics should:
• avoid sweets
• use fat in limited amount
• takes cereals and pulses in right amount
• include high fiber foods as much as possible
• take vegetables as desired
• take permitted fruits in limited amounts.
• using white rice once a day controls diabetes
• red beans and black beans being insulin stimulants may be taken liberally.
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When diabetic patients have to eat in parties or restaurants they should select food
items from the menu based on these dietary guidelines.
Conclusion:
This chapter discussed about the diabetic diet it includes meaning, goals, dietary
management and dietary guidelines.
Reinforcement:
Fill up the blanks:
1. Types of fatty acids…………….., …………………, ……………….
2. Types of fibers……………., ……………………….
Key:
1. Saturated fats, polyunsaturated fats, monosaturated fats.
2. Soluble and insoluble fibers
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CHAPTER –III
MENU PLAN
Introduction:
This chapter deals with the menu plan for patient with diabetes mellitus based on the
calories intake.
At the end of the chapter the learners will be able to:
• list down the food stuff and amount can be used for diabetes mellitus.
• Apply a skill in developing menu plan according to the body weight.
DIABETIC DIET
1200 CALORIES DIABETIC DIET
Food stuff Vegetarian (g) Non-

Vegetarian (g)
Cereals 150 185
Pulses 60 15
Green leafy Vegetables 200 200
Other Vegetables 200 200
Fruits 100 100
Milk 300 100
Oil 10 15
Flesh foods - 50
This diet provides gm % calories

Proteins 50 16
Fats 29 21
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Carbohydrates 190 63
SAMPLE MENU
Vegetarian Non-
Vegetarian
Bed tea
Tea/Coffee 1 cup 1 cup
Break fast
Toast one one
Milk 1 cup -
Tea/Coffee - 1 cup
Orange one one
Lunch
Rice 1k 1k
Sambar 1k 1k
Amaranth 1k 1k
Butter milk 1k ½k
Tomato one one
Cucumber one one
Evening
Upma ½k ½k
Dinner
Phulka Three Four
Lentil dhal ¾k -
Beans curry 1k 1k
Egg curry - 1k
Buttermilk 1k -
Tomato one one
Radish one one
Note: oil to cook 3 tsp 4tsp
With 12.5 g fenugreek seeds
147

Vegetarian (g)
Cereals 225 250
Pulses 60 20
Fruits 100 100
Milk 300 150
Oil 15 20
Flesh foods - 70
Proteins 60 15.5
Fats 37 21.5
Carbohydrates 244 63.0
148
SAMPLE MENU
Vegetarian Non-
Vegetarian
Bed tea
Break fast
Toast
Milk Two Two
Tea/Coffee 1 cup -
Orange - 1 cup
Egg (half boiled) one one
- one
Lunch
Rice
Sambar 2k 2k
Phulka 1k 1k
curd one one
Tomato/Cucumber ½k ¼k
Pickle one one
1 piece 1 piece
Evening
Tea/Coffee
Upma 1 cup 1 cup
¾k ¾k
Dinner
Phulka (chapati)
Green gram dhal Three Four
Cauli flower curry 1k -
Fish/ Chicken curry 1k 1k
Roasted papad - 2 pieces
Tomato/cucumber one one
one one
Note: oil to cook
4 tsp 5 tsp
149

Vegetarian (g)
Cereals 300 350
Pulses 70 25
Fruits 200 200
Milk 400 200
Oil 20 30
Flesh foods - 30
Proteins 64 13
Fats 48 22
Carbohydrates 328 65
150
SAMPLE MENU
Vegetarian Non-
Vegetarian
Bed tea
Break fast
Toast
Milk Three Four
Orange 1 cup 1 cup
Egg (half boiled) one one
- one
Lunch
Rice
Sambar 2k 2k
Phulka 1k 1k
Butter milk one one
Tomato 1k ½k
Cucumber one one
one one
Evening
Tea/Coffee
Upma 1 cup 1 cup
Two Two
Dinner
Phulka (chapati)
Rice Two Two
Moth ½k ½k
Dondakai curry 1k -
Fish/Chicken roasted 1k 1k
Curd - 1 piece
Onion medium 1k -
Cabbage salad one one
2 tsp 2 tsp
Note: oil to cook
5 tsp 6 tsp
151
Summary:
This module helps you to plan a daily diabetic diet according to your ideal body weight
and also it will be very helpful for you to gain knowledge about diabetes mellitus and
diabetic diet.
Conclusion:
This chapter deals with the menu plan for diabetes mellitus according to
the calorie intake of the body.
“Health is wealth” So be healthy in ever for!
Live in prosperous!
Reinforcement
Fill up the blanks:
1. The 1200 calories diabetic diet yield ………………….gm of protein.

2. 244 gm of carbohydrates yield…………………..% of calories.
Key:
1. 50
2. 63%
152
TOOL FOR THE ASSESSMENT OF KNOWLEDGE REGARDING
DIABETIC DIET
Instruction to the respondents
Dear participants,
1. Kindly mark the appropriate answer by placing tick (√) in the boxes provided
for each question
2. Do not leave any question unanswered.
3. Do not tick multiple answers.
Dear participant,
This part of the questionnaire is related to general information of the participants. Kindly
tick the answers which you find appropriate from the options given. This information
provided will be kept confidential.
PART- I
Sample number: ( )
GENERAL INFORMATION:
1.Age:
30-40yrs ( )
40-50 yrs ( )
50-60 yrs ( )
60-70 yrs ( )
153
2.Sex:
Male ( )
Female ( )
3.Education:
Below middle ( )
Secondary ( )
Higher secondary ( )
UG ( )
PG and above ( )
4. Occupation:
Daily wages ( )
Private employee ( )
Government employee ( )
Self employment ( )
Other (specify) …………….. ( )
5. Monthly income:
Rs …………………../ month
6. Religion
Christian ( )
Hindu ( )
Muslim ( )
Others (Specify)……………
7. Marital status:
154
Married ( )
Unmarried ( )
Widower/ divorce ( )
Separated ( )
8. Place of Residence:
Urban ( )
Rural ( )
Semi urban ( )
Semi rural ( )
9. Type of family:
Nuclear family ( )
Joint family ( )
10. Family history of diabetes mellitus
No ( )
Yes (specify who)……………..
11. Methods you used to control hyperglycemia:
Drugs ( )
Diet, Exercise ( )
Exercise, Drugs ( )
Diet, Drugs ( )
Diet, Exercise, Drugs ( )
12. Level of activity:
Sedentary activity ( )
155
Moderate activity ( )
Heavy activity ( )
13. Source of knowledge of diabetes mellitus
No ( )
Friends ( )
Relatives ( )
Mass media ( )
Internet ( )
PART-II
You are requested to write the appropriate answer in the ( ) from the choice given below
General information about diabetes mellitus
1. Diabetes mellitus means ( )
a. Increased blood glucose level
b. Decreased blood glucose level
c. Normal blood glucose level
2. Insulin produced by a special gland is called ( )
a. Adrenal gland
b. Pancreas
c. Thyroid gland
156
3. Common causative factor for diabetes mellitus is
a. Inadequate secretion of insulin ( )
b. Increased secretion of insulin
c. Normal secretion of insulin
4. The first noticeable symptom of diabetes mellitus is
a. Polyurea, polydipsia ( )
b. Decrased thirst, loss of appitite
c. Delayed wound healing, fever
5. Weight loss occurs due to ( )
a. Diarrhea
b. Vomiting
c. Loss of protein from tissues
6. Hypoglycemia means ( )
a. Increased blood sugar level
b. Decreased blood sugar level
c. Normal blood sugar level
7. Normal random blood glucose level is
a. 80-120mg/dl ( )
b. 60-150 mg/dl
c. 80-100 mg/dl
8. The calculation of ideal body weight helps to identify ( )
a. Overweight or underweight
b. Overweight and obesity
157
c. Underweight and malnutrition
9. Immediate complication of diabetes mellitus is ( )
a. Diabetic ketoacidosis
b. Infection
c. Pain
10. Management of diabetes mellitus includes
a. Diet, exercise and hypoglycemic agents ( )
b. Diet, exercise and hyperglycemic agents
c. Diet, exercise and glycemic agents
Diabetic diet:
11. Diabetic diet means ( )
a. Slightly low in carbohydrates and meet the nutritional needs
b. Slightly high in carbohydrates and meet the nutritional needs
c. No carbohydrates and meet the nutritional needs
Formula:
12. The formula of ideal body weight is ( )
a. Subtracting 100 from his or her body weight
b. Subtracting 50 from his or her body weight
c. Subtracting 120 from his or her body weight
13. Formula used to calculate the calories intake of diabetic patients who ( )
engaged in sedentary work is
a. Ideal body weight x 30
b. Ideal body weight x 20
158
c. Ideal body weight x 40
14. Ideal body weight x 20: this formula is used to calculate the calories intake of
a. Diabetic patient with obese ( )
b. Diabetic patient with under weight
c. Diabetic patient with normal weight
Foods to be avoided :
15. Foods to be avoided for a patient with diabetes mellitus is ( )
a. Green leafy vegetables, vegetables, rice
b. Sugar, honey, sweetened juices
c. Milk products, pulses, meat
Calories:
16. Recommended calorie intake for a diabetic patient with ideal body weight is ( )
a. 20 kcal/kg wt/day
b. 30 kcal/kg wt/day
c. 40 kcal/kg wt/day
17. 1800 to 2000 kilo calories is recommended for diabetics who are ( )
a. Under weight
b. Moderate weight
c. Obese
18.The kilo calories consumed by obese diabetic patient is ( )
a. 1800 to 2000
159
b. 1200 to 1500
c. 1500 to 2000.
Carbohydrate:
19. Percentage of calories which will be distributed from carbohydrate in a patient with
diabetes is ( )
a. 60-70%
b. 15-20%
c. 15-25%
Protein:
20. Recommended Dietary Allowances of protein for patient with
diabetes mellitus is ( )
a. 1 gm/kg body weight
b. 2 gm/kg body weight
c. 3 gm/kg body weight
21. The percentage of calories wich will be distributed from protein is ( )
a. 60-70
b. 15-20
c. 15-25
Fat:
22. The fatty food which is good for health in a diabetic patient is ( )
a. Saturated fatty foods
b. Poly unsaturated fatty foods
160
c. monosaturated fatty foods and saturated fatty foods
23. The diet which contains more poly unsaturated fatty acids are ( )
a. Vegetable oil and sun flower oil
b. Coconut oil, olive oil
c. cod liver oil, ground nut oil
24. Diabetes mellitus patients are advised to take visible fat/day is ( )
a. 20 gm
b. 10 gm
c. 30 gm
25. The percentage of calories which will be distributed from fat is ( )
a. 60-70
b. 15-20
c. 15-25
26. Coconut is rich in ( )
a. Saturated fat
b. Poly unsaturated fat
c. Monosaccrides
27. Fats and milk products should be used ( )
a. Liberally
b. Moderately
c. Heavily
Diet which control hyperglycemia:
28. The fenugreek is used as a ( )
161
a. Hypoglycemic
b. Hyperglycemic
c. Glycemic
29. Rice which control hyperglycemia is ( )
a. White rice
b. Red rice
c. Fried rice
30. The foods stuffs that are stimulating the insulin secretion is ( )
a. Red beans and black beans
b. Bitter gourd and fenugreek
c. Fenugreek and wheat bran
31. The fruits that can be consumed by a patient with glycemic control is ( )
a. Either apple or orange or guava
b. Banana, apple, orange and guava
c. Banana, apple and orange.
Salt allowance:
32. The recommended level of salt for preparing food for a patient with diabetes
mellitus is ( )
a. < 5 gm
b. 2gm
c. < 2gm
Life style:
162
33. Alcoholic drinks are avoided because it provides empty calorie and ( )
a. Low in fat
b. Rich in sugar
c. High in vitamin C
Dietary prescription:
34. Dietary prescription for a diabetic is based on the ( )
a. Physical activity, body weight, dietary history and insulin therapy
b. Diabetes mellitus, hypertension, hypotension and insulin therapy
c. Patient personality, diabetes mellitus, retinopathy and insulin therapy.
35. The diet prescribed for a patient who has hypoglycemia which occurred as a
complication of insulin administration is ( )
a. Sugar
b. Meat
c. Rice
Timings of meals
36. The diabetics should can be careful with timing of meals is the one who is on
( )
a. Oral hypoglycemic agents
b. Dieting
c. Insulin
37. The usual meal pattern of type II diabetic patient is ( )
a. Breakfast, two meals, evening tea with bed time snacks
b. Breakfast, one meals and bed time snacks
c. Breakfast, one meals and evening tea with bed time snacks
38. the diabetics who do strenous exercise should have their meal ( )
163
a. Before, during and after the exercise
b. After the exercise
c. Regularly
Dietary alterations:
39. The dietary alteration advised for a diabetic patients who are suffering with heart
disease is
a. limited dietary fat ( )
b. limited soluble fiber
c. limited protein intake
40. The intake of protein should be restricted in a diabetic patients with ( )
a. renal disease
b. nervous disease
c. skeletal disease
Complication:
41. The diabetics who are consuming alcohol leads them to ( )
a. peripheral neuropathy
b. retinopathy
c. nephoropathy
42. The diabetics who are higher intake of fatty foods lead them in to ( )
a. moderat weight
b. obesity
c. underweight
164
ANNEXURE - 6
BLUEPRINT OF THE KNOWLEDGE QUESTIONNAIRE ON

DIABETIC DIET
Sl. Content area knowled Comprehens Application No. of

No ge ion questions Percentage
1 General 1,2,6,7 3,4,5,9,8 10 10 23.80%
information on
diabetes
mellitus
2 Meaning of 11 1 2.38%
diabetic diet
3 Formula 12,13,14 3 7.14%
4 Foods to be 15 1 2.38%
avoided
5 Calories 16,17,18 3 7.14%
6 Carbohydrate 19 1 2.38%
7 Protein 20,21 2 4.76%
8 Fat 22,23,24,25, 6 14.28%
26,27
9 Diet which 28,29,30,31 4 9.52%
control
hyperglycemia
10 Salt allowance 32 1 2.38%
11 Life style 33 1 2.38%
12 Dietary 34,35 2 4.76%
prescription
13 Timings of 36,37,38 3 7.14%

meals
14 Dietary 39,40 2 4.76%
alteration
15 Complication 41,42 2 4.76%
Total 8 27 7 42
Percentage 19.0% 64.28% 16.66% 100%
165
ANNEXURE - 7
SCORING KEY FOR STRUCTURED KNOWLEDGE
QUESTIONNAIRE
Item No Correct response Score

1 A 1
2 B 1
3 A 1
4 A 1
5 C 1
6 B 1
7 A 1
8 A 1
9 a
1
10 A 1
11 A 1
12 A 1
13 A 1
14 A 1
15 B 1
16 B 1
17 A 1
18 B 1
19 A 1
20 A 1
21 B 1
22 B 1
23 A 1
24 A 1
166
25 C 1
26 A 1
27 C 1
28 A 1
29 A 1
30 A 1
31 A 1
32 A 1
33 B 1
34 A 1
35 A 1
36 C 1
37 A 1
38 A 1
39 A 1
40 A 1
41 A 1
42 B 1
Maximum score - 42
LEVEL OF KNOWLEDGE:
Inadequate knowledge - <50%
Moderate knowledge - 50-75%
Adequate knowledge - >75%
167
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“ASSESS THE EFFECTIVENESS OF SELF INSTRUCTION

MODULE (SIM) ON DIABETIC DIET AMONG PATIENTS WITH

DIABETES MELLITUS IN SELECTED DIABETIC CLINIC AT

MS.G. Mabel Florence

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences

In partial fulfillment of the requirements for the degree of

MEDICAL SURGICAL NURSING

Under the guidance of

Mrs. D. VASANTHA CHITRA, M.SC [N]., PGDHM., PGDB.

PROFESSOR, HOD, Department of Medical Surgical Nursing

Diana College Of Nursing, Bangalore - 560 064

DECLARATION BY THE CANDIDATE

Instructional Module (SIM) on diabetic diet among patients with diabetes

mellitus in selected diabetic clinic at Bangalore” is a bonafide and genuine research

carried out by me under the guidance of Mrs. D. Vasantha Chitra, M.Sc.(N).,

PGDHM., PGDB., Professor , HOD, Department of Medical Surgical Nursing, Diana

College of Nursing, Bangalore-560064.

Place: Bangalore Signature of the Candidate

Date: (Ms. G. Mabel Florence)

Instructional Module (SIM) on diabetic diet among patients with diabetes

mellitus in selected diabetic clinic at Bangalore.” is a bonafide research done by

Ms. G. Mabel Florence in partial fulfillment of requirement for the degree of

Masters of Science in Nursing in Medical Surgical Nursing.

Place: Bangalore Signature of the Guide

Date: Mrs. D. Vasantha Chitra, M.Sc (N)., PGDHM., PGDB.

Instructional Module (SIM) on diabetic diet among patients with diabetes

mellitus in selected diabetic clinic at Bangalore” is a bonafide research done by

PGDHM., PGDB., Professor, HOD, Department of Medical Surgical Nursing, Diana

College of Nursing, Bangalore - 64.

Mrs. D. Vasantha Chitra, M.Sc (N) Prof. Veda Vivek, Ph.D

DECLARATION OF THE CANDIDATE

electronic format for academic/research purpose.

Place: Bangalore Signature of the Candidate

Date: January 2009 (Ms. G.Mabel Florence)

© Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.

“I know that you can do all things;

no plan of yours can

helped me to complete the study successfully.

I profoundly thank the Management Trustee of Diana College of Nursing

Mr.Mallinath.G.Gola for his encouragement and constant support during my

guidance, suggestions and kind support during the study.

I am highly indebted to my guide, Mrs.Vasantha Chitra, M.Sc (N), Professor and

HOD of Medical Surgical Nursing for her constant encouragement, inspiring

its completion and also aided me for statistical analysis of data.

I am immensely grateful to Class Coordinator, Mrs.Kalaivani, M.Sc (N), Professor,

HOD, Department of Obstetrics and Gynecological Nursing, Diana College of

Nursing for her inspiring guidance and timely support.

Child Health Nursing for her encouragement in joining the course.

effort for content validity and refining of the tool.

It gives me great pleasure to express my thanks to beloved Rev.C.Paul and

I express my thanks to Mrs. Padmavathi Mallinath, Bhavani Laser Tech, who

helped a lot during my studies and shape the dissertation.

University of Health Sciences, Bangalore and my Classmates for helping me in one

way or the other in completion of this dissertation.

I sincerely thank Mr. Srinivas who helped me in Kannada editing.

I am greatly indebted to my most lovable Father Pr. D. Gnanadhas and

Smt. T.Vasantha, my loving sister Miss. G.Jayagreet and my beloved brother

showering their love, prayers and support.