ORIGINAL ARTICLE The Journal of Nursing Research h VOL. 25, NO.

2, APRIL 2017

Empowerment Program for People With

Prediabetes: A Randomized Controlled Trial
Mei-Fang Chen1 & Shu-Ling Hung2 & Shu-Lin Chen3*

1
PhD, RN, Associate Professor, Department of Nursing, National Tainan Junior College of Nursing &
2
PhD, RN, Assistant Professor, Department of Nursing, National Tainan Junior College of Nursing &
3
RN, MSN, HN, Department of Nursing, Kaohsiung Municipal United Hospital.

prediabetes but also for nursing educators and healthcare

ABSTRACT policymakers.
Background: Practicing a health-promoting lifestyle is believed
to be effective for delaying or preventing the onset of diabetes. KEY WORDS:
However, although empowerment interventions have proven empowerment, prediabetes, health-promoting lifestyle, blood
effective for encouraging the adoption of a health-promoting sugar, self-efficacy.
lifestyle in people with diabetes, these interventions are rarely
promoted to people with prediabetes.
Introduction
Purpose: The aims of this study were to develop an empow- According to the World Health Organization (2013), the
erment program for people with prediabetes and to examine prevalence, mortality and expenditures attributable to
its efficacy in terms of the adoption of a health-promoting
diabetes have consistently increased. Therefore, determin-
lifestyle and improvements in blood sugar, body mass index,
ing how to prevent diabetes is now a major global health
and self-efficacy.
concern. Researchers have found that the risk of diabetes
Methods: A randomized controlled trial was conducted be- is 14- to 15-fold higher in individuals with prediabetes
tween May and December 2013. A convenience sample of than in those whose blood sugar is in the normal range
people with a fasting blood sugar level of 100Y125 mg/dl during and that the global prevalence of prediabetes is increasing
the previous 3 months was recruited from the health examination (de Vegt et al., 2001). In the United States, an estimated
center of a hospital in Kaohsiung, Taiwan. Participants were 79 million adults were classified as prediabetic in 2010
assigned to either the experimental group or the control group
(Centers for Disease Control and Prevention, 2013). In
using block randomization with a block size of 8. The experimen-
tal group (n = 38) participated in a 4-month empowerment
Taiwan, the number of people with prediabetes in 2005
program (the ABC empowerment program), which encouraged was approximately two times the number of people with
participants to practice a health-promoting lifestyle in three diabetes that year (Tsai, 2005). These data indicate the
phases: awareness raising, behavior building, and results urgent need to develop diabetes prevention strategies that
checking. The control group (n = 40) received routine clinical target people with prediabetes.
care. Statistical analyses included descriptive statistics, indepen- Lifestyle is known to be a major factor in preventing
dent t test, paired t test, and generalized estimated equations. chronic illness. For example, Amundson et al. (2009) and
Vanderwood et al. (2010) evaluated the effectiveness of a
Results: After controlling for the differences at baseline and
considering the interaction between group and time from base- behavioral risk reduction program that was designed to
line to 1 week and 3 months after completing the intervention, improve nutrition, exercise, and weight loss in a population
the generalized estimating equation showed significantly larger
improvements in a health-promoting lifestyle, blood sugar, and
Accepted for publication: May 3, 2015
self-efficacy in the experimental group than in the control group
*Address correspondence to: Shu-Lin Chen, No. 976, Jhonghua 1st
(p G .01). Furthermore, the experimental group achieved a larger Rd., Gushan District, Kaohsiung City 80457, Taiwan, ROC.
reduction in body mass index than the control group at 3 months Tel: +886 (7) 5552565 ext. 2401;
after completing the intervention (p = .001). E-mail: [email protected]
The authors declare no conflicts of interest.
Conclusions/Implications for Practice: The empowerment
program was shown to have short-term, positive effects on Cite this article as:
behavioral, physical, and psychosocial outcomes in a Taiwan Chen, M. F., Hung, S. L., & Chen, S. L. (2017). Empowerment
population with prediabetes. The results of this study provide program for people with prediabetes: A randomized controlled trial.
The Journal of Nursing Research, 25(2), 99Y111. doi:10.1097/
a useful reference not only for healthcare personnel when
jnr.0000000000000193
implementing empowerment interventions in people with

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The Journal of Nursing Research Mei-Fang Chen et al.

of people with prediabetes. At the 4-year follow-up, the sub- strategy, healthcare professionals play the role of ‘‘facilita-
jects who had implemented the recommended lifestyle modi- tor.’’ That is, they facilitate the practice of a health-
fications (modest weight loss, exercise, and reduction of promoting lifestyle, namely, by addressing questions, by
dietary fat and caloric intake) had a 58% lower risk of Type 2 helping set goals, and by encouraging people with prediabe-
diabetes compared with baseline. Studies performed on popu- tes to make decisions about their own healthcare (Anderson
lations in Taiwan have similarly reported that fasting blood & Funnell, 2010; Chen, Wang, Chin, et al., 2011). Healthcare
sugar decreases with improvements in a health-promoting professionals should also provide information that is necessary
lifestyle, including nutrition, physical activity, health responsi- for people with prediabetes to integrate the new knowledge and
bility, spiritual growth (or self-actualization), interpersonal skills into daily life (Dorsey & Songer, 2011). Reflection is the
relations, and stress management. These results suggest that final phase of the empowerment process. Reflection includes
practicing a healthy lifestyle may delay or prevent diabetes performing a self-check to determine whether the goal has
(Chen & Huang, 2005). Therefore, an effective intervention been reached and helping the person with prediabetes to
is needed to encourage a healthy lifestyle that effectively modify actions and goals as needed (Falk-Rafael, 2001). The
delays or prevents the onset of diabetes in people with prediabetes. program developed in this study combines all three of these
Effective health education strategies are needed to en- phases, namely, awareness raising, behavioral building, and
courage healthy lifestyles. However, the conventional diabe- results steps (ABC) checking, to facilitate the implementa-
tes education strategy is ‘‘compliance,’’ that is, convincing tion of a healthy lifestyle in people with prediabetes.
patients of the need to comply with the recommendations of When analyzed in terms of outcomes, empowerment
healthcare professionals, which makes patients feel power- refers to results that contribute to empowerment (Tengland,
less in the management of their lifestyles (Anderson & 2007). An empowered person is expected to have good health
Funnell, 2010). The World Health Organization (2006) outcomes, including positive behavioral, physical, and psycho-
identified empowerment as an effective patient education social outcomes (Chen et al., 2013). In people with prediabe-
strategy because it gives individuals a sense of control over tes, a health-promoting lifestyle is necessary to control blood
their lives, which decreases feelings of powerlessness. sugar effectively. Health-promoting lifestyle modifications
Empowerment models that have been proposed in the have also proven effective in lowering the overall risk of
literature define empowerment in terms of both processes diabetes (Amundson et al., 2009; Sharma & Garber, 2009).
and outcomes (Anderson & Funnell, 2010). As a process, In addition, improvements in blood sugar and body mass
empowerment helps people with prediabetes recognize their index (BMI) reportedly reduce the incidence rate of diabetes
power to control their health and to make decisions that (Centers for Disease Control and Prevention, 2013). Blood
affect their health (Funnell & Weiss, 2008). Empowerment sugar and BMI are standard physical indicators of predia-
interventions are usually implemented in three phases: betes control (Bardenheier et al., 2013). Self-efficacy is
awareness, action, and reflection (Chen, Wang, Chin, Chen, defined as the perceived self-confidence to plan and take
& Chen, 2011). Awareness raising is the initial phase of actions (Bandura, 1997) and is considered a psychosocial
empowering patients (Falk-Rafael, 2001). In people with outcome of empowerment (Anderson & Funnell, 2005).
prediabetes who are not currently experiencing diabetes Furthermore, self-efficacy has been positively associated with
symptoms, interventions should focus on raising their having a health-promoting lifestyle (Bhandari & Kim, 2016;
awareness of the need to practice healthy daily lifestyle, even Chen, Wang, & Hung, 2015). Therefore, health-promoting
if they find it difficult to implement (Chen & Lin, 2010). lifestyle, blood sugar, BMI, and self-efficacy are considered
Building an equal partnership is an essential initial step in appropriate outcome measures for empowerment interven-
establishing the trust needed for people with prediabetes to tions that target people with prediabetes.
share their experiences and opinions freely with their health- Empowerment programs have been applied in popu-
care professionals (Anderson & Funnell, 2010). Another lations of patients with diabetes, end-stage renal disease,
important objective for healthcare professionals is motivating hemodialysis, and acquired immunodeficiency syndrome
people with prediabetes to practice a healthy lifestyle through (Chen, Wang, Lin, Hsu, & Chen, 2015; Mancoske & Smith,
measures such as helping these people to understand how 2004; Tsay & Hung, 2004). However, no empowerment
hyperglycemia affects their health and helping them under- programs have been proposed for people with prediabetes
stand that they have both the right and the ability to make (Yuen, Sugeng, Weiland, & Jelinek, 2010). An empowerment
their own health decisions (Anderson & Funnell, 2010; Falk- strategy is particularly important for people with prediabetes
Rafael, 2001). Patients who recognize that they are able to because of the complexity and difficulty of implementing
make decisions about their health are likely to take health-promoting lifestyle modifications (Anderson & Funnell,
responsibility for practicing a health-promoting lifestyle. The 2010; Vermunt et al., 2013). Furthermore, a systematic review
second phase of the empowerment process is the action of the literature on community-based lifestyle interventions
phase, which emphasizes the adoption of health-promoting for prediabetes found that these interventions have rarely
behaviors. The strategies applied in this phase include mutual been reported in the context of populations in Taiwan (Wu,
participation and providing necessary information (Chen, Chang, & Chou, 2011). To reduce the occurrence of diabetes
Wang, Chin, et al., 2011). To apply the mutual participation in Taiwan, an effective empowerment program for people with

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Empowerment Program for People With Prediabetes VOL. 25, NO. 2, APRIL 2017

prediabetes must be developed. Furthermore, the efficacy of health examination center of a hospital in Kaohsiung,
this program must be confirmed in the target population. The Taiwan. The inclusion criteria were (a) fasting blood sugar
purpose of this study was thus to examine the efficacy of the between 100 and 125 mg/dl during the previous 3 months
proposed ABC empowerment program on promoting a health- (after a minimum of 8 hours nil per os), (b) clear mental
promoting lifestyle and improving the blood sugar levels, status and ability to communicate, (c) age of over 20 years,
BMI, and self-efficacy of a population of people with pre- (d) literacy and ability to write in Chinese, and (e) being in-
diabetes in Taiwan. Figure 1 shows the framework of the dependent and ability to practice a health-promoting lifestyle.
proposed empowerment intervention. Patients with diagnoses of Type 1 or 2 diabetes or of mental
disease were excluded.
The required sample size was estimated using G*Power
Methods (version 3.1.1; Germany) software (Faul, Erdfelder, Lang,
& Buchner, 2007). An earlier empowerment study had
Design reported an effect size of 0.6Y0.9 for a lifestyle modifica-
A randomized controlled trial was performed between May tion program (Chen, Wang, Lin, et al., 2015; DeCoster &
and December 2013. Participants were randomly assigned to George, 2005). Given an effect size of 0.6, an " level of
either the experimental group or the control group. The .05, and a power of 0.8, it was calculated that at least 18
experimental group participated in the ABC empowerment participants were required in each of the two groups.
program. The control group received routine clinical care. Twenty participants were recruited for the two groups to
Outcome variables were measured at baseline (T0), at 1 week accommodate an assumed 10% attrition rate.
after completing the intervention (T1), and at 3 months after
completing the intervention (T2). Because lifestyle modifica-
tions are the cornerstone of a prediabetes intervention that Procedure
effectively prevents or delays the progression from predia- An experimental design was applied in this study. Before
betes to diabetes (Sharma & Garber, 2009), implementing administering the health examination, a nurse explained
a health-promoting lifestyle was considered the primary the purpose, methods, and processes of the study. During
outcome measure. Self-efficacy, blood sugar, and BMI were the following 3 months, a researcher reviewed the medical
considered as the secondary outcome measures. records of all the patients who had consented to partici-
pate in the study to identify the target population of
individuals with prediabetes using the criterion of a blood
Participants sugar level of 100Y125 mg/dl after 8 hours of fasting.
The participants were individuals with prediabetes who Individuals in the target population who met this criterion
had been recruited by convenience sampling from the were contacted by telephone and invited to participate.

Figure 1. Empowerment theoretical framework and prediabetes empowerment program framework.

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The Journal of Nursing Research Mei-Fang Chen et al.

The researcher fully explained the purpose of the research, journal entries with other participants. In the final session, the
the procedures, and the relevant risks and benefits of the interveners guided the participants in evaluating their success
intervention to all of the participants during their regular in adopting a health-promoting lifestyle. Table 1 summarizes
hospital visits. After the participants provided their informed the details of the program.
consent, a trained research assistant collected their basic
data. Next, the participants were assigned randomly to Control group
either the experimental group or the control group using The participants in the control group received routine clinical
block randomization with a block size of 8. The randomi- care during their monthly clinical visits. Participants in the
zation order was generated using a computerized random- control group received conventional diabetes education,
numbers generator. The statistician then placed the group which was composed of three 30-minute face-to-face sessions
assignment information in sealed, opaque envelopes in the with a diabetes educator. They were recommended to com-
random order that was generated by the computer. Neither ply with the exercise and dietary guidelines developed by
the researcher nor the participants knew their assignments the Taiwan Bureau of National Health Insurance. Further-
until the participants opened these envelopes. more, control group participants received an educational
pamphlet about diabetes that they could read at home.
Interventions

Experimental group Data Collection

After a comprehensive literature review (Anderson & Medical records and structured questionnaires were used
Funnell, 2010; Chen, Wang, Chin, et al., 2011; Falk-Rafael, to collect outcome data at T0, T1, and T2. All question-
2001), a program was developed for empowering patients naires were administered by a trained research assistant
to implement a health-promoting lifestyle in three phases: who was blinded to the group assignments and who did
awareness raising, behavior building, and results (ABC not provide any services to the participants. Blood sample,
empowerment program) checking. A systematic review body weight, and body height data were also collected im-
indicated that empowerment interventions are usually mediately after the participants had completed the question-
performed for 12Y16 hours over a period of 1Y2 weeks naires. Each participant took approximately 20 minutes to
(Chen, Wang, & Tang, 2011). The intervention that was complete the questionnaires. Personal characteristics were
used in this study included eight 2-hour sessions that were collected only at T0.
delivered biweekly over a 4-month period.
In Session 1, the ABC empowerment education inter- Health-promoting lifestyle
vention was introduced, and the patients were divided into Health-promoting lifestyle was assessed using the Chinese
fixed groups of seven to eight patients and given time to version of the 24-item Health-Promoting Lifestyle Profile
become acquainted. In Sessions 2Y7, the education team (HPLP-S; Wei & Lu, 2005). The HPLP-S assessed the
discussed the essential elements of a health-promoting life- lifestyle habits of the subjects during the past 3 months,
style, including nutrition, physical activity, health responsi- including self-actualization, health responsibility, physical
bility, self-actualization, interpersonal relations, and stress activity, nutrition, interpersonal support, and stress man-
management. Each session focused on one aspect of a health- agement. Questionnaire responses were recorded using a
promoting lifestyle, and each session was delivered in two Likert scale that ranged from 1 = never to 4 = always, with
parts. The first part of the intervention required 40 minutes. a higher HPLP-S score indicating a higher frequency of
In this part, a team of educators presented on one aspect of a health behaviors. In a previous study of the HPLP-S in a
health-promoting lifestyle and its implementation. This team Taiwan population of people with prediabetes, the
was composed of a diabetes educator, diabetologist, dieti- Cronbach’s alpha was .92 (Chen & Lin, 2010). The
cian, occupational therapist, and psychologist. In the second Cronbach’s alpha was .89 in this study.
part, which required 60Y80 minutes, the participants received
guidance in developing a plan by applying the knowledge Blood sugar
that was gained in the first part. This part consisted of group Blood sugar was analyzed by laboratory examiners who were
activities such as simulating the use of the ABC steps to blinded to both groups. All blood sugar measurements were
implement one aspect of a health-promoting lifestyle. More- performed by a single hospital laboratory, which was certified
over, this part was delivered by a researcher who had by the Taiwan Accreditation Foundation. One research assis-
received a 9-hour empowerment education course that was tant collected all of the blood sugar values from medical records.
provided by the Taiwanese Association of Diabetes Educators
and who had performed a study of empowerment in people BMI
with diabetes. After each session, the participants were asked Height was measured to the nearest 0.5 cm, and weight was
to make journal entries describing their daily activities related measured to within 0.1 kg, with participants wearing light,
to the topic discussed in the session. In the following session, indoor clothing and no shoes. BMI was calculated as weight
the participants spent approximately 20 minutes sharing their (in kilograms) divided by the square of height (in meters).

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Empowerment Program for People With Prediabetes VOL. 25, NO. 2, APRIL 2017

TABLE 1.
Course Schedule for the ABC Empowerment Program
Course Main Topic Objective and Content
1 Introduction: Prediabetes and ABC Objectives:
empowerment program 1. Facilitate partnership between participants and healthcare providers.
2. Motivate participants to implement health-promoting lifestyles.
Content:
1. Introduction to the program
2. Team warm-ups
3. Introduction to prediabetes
4. The impact and complications of diabetes
5. The correlations of prediabetes, diabetes, and a health-promoting lifestyle
6. Definition of a health-promoting lifestyle and its benefits
2Y7 Health-promoting lifestyle: Objectives:
1. Nutrition 1. Raise awareness of personal health conditions and increase motivation
to practice health-promoting lifestyle.
2. Physical activity 2. Develop individual health-promoting lifestyle plan.
3. Self-actualization 3. Learn how to identify and use available healthcare resources.
4. Health responsibility 4. Learn how to monitor and adjust the implementation of a health-promoting
lifestyle.
5. Interpersonal relations Content: one domain per course.
6. Stress management Part I:
Knowledge lecture:
In the context of the topic discussed in each session, one aspect of a
health-promoting lifestyle and its implementation was presented by an
education team composed of a diabetes educator, diabetologist,
dietician, occupational therapist, and psychologist.
Part II:
Introduce and practice three steps of the ABC empowerment program, i.e.,
awareness raising step, behavioral modifying step, and checking results step.
Awareness raising phase:
1. Facilitate a partnership between participants and healthcare providers.
2. Motivate participants to implement a health-promoting lifestyle.
Assign participants to small groups and encourage them to share their
experience in maintaining motivation to implement a health-promoting
lifestyle. Empowerees to remain respectful, caring, and nonjudgmental
when discussing each topic.
Behavior building phase:
1. Setting personal goals.
2. Learning to implement a health-promoting lifestyle.
The group members discuss their personal goals and plans for implementing
a health-promoting lifestyle, including how to overcome obstacles. The
healthcare providers guide the participants in applying knowledge, setting
goal(s), and developing plans for implementing a health-promoting lifestyle.
Checking results phase:
1. Individual evaluation
2. Reflect on whether their goals have been reached and adjust the
implementation of a health-promoting lifestyle.
Demonstrate how to monitor daily routine activities. After the lesson for each
topic is completed, participants make daily records of their experience in
implementing a health-promoting lifestyle. The participants then refer to the daily
records in subsequent discussions of their success in achieving their goals.

(continues)

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The Journal of Nursing Research Mei-Fang Chen et al.

TABLE 1.
Course Schedule for the ABC Empowerment Program, Continued
Course Main Topic Objective and Content
8 Evaluation and conclusion Objectives:
1. Review the objectives and progress made by each participant.
2. Promote self-efficacy in implementing a health-promoting lifestyle.
Content:
1. Summary of six topics regarding health-promoting lifestyle and prediabetes.
2. Review outcomes of individual lifestyle changes and share thoughts.
& Describe how the program helped to implement a health-promoting lifestyle.
& Describe the pros and cons of participating in the program. What lessons were
learned?
& Suggest improvements to the ABC empowerment program.
3. Individual evaluation and certification award.

Self-efficacy study to each participant before enrolment. Participants

Self-efficacy was assessed using the Chinese version of the were informed that the study was voluntary, that they
25-item Self-efficacy of Health Behavior Scale, which was could withdraw from the study at any time, and that doing
developed by Chung (2000) to measure individual beliefs so would not affect their treatment.
regarding nutrition, exercise, psychological comfort, and
health responsibility. Items were rated on a Likert scale Analysis
that ranged from 1 = no belief to 4 = complete belief. The Data were analyzed using SPSS Version 17 (SPSS, Inc.,
range of total possible scores was 25Y100, with higher Chicago, IL, USA). Student t test and chi-square test were
scores indicating better self-efficacy. Chen and Lin (2010) used to examine intergroup differences in personal char-
obtained a Cronbach’s alpha of .95 for the Chinese acteristics and outcome variables. Paired-sample t tests
version of this scale in a study of a prediabetic population
were used to compare intragroup differences in outcome
in Taiwan. The Cronbach’s alpha was .91 in this study.
variables between T0 and T1, between T0 and T2, and
between T1 and T2. The generalized estimating equation
Personal characteristics
(GEE) model was used to identify the independent effects
Data on gender, age, marital status, educational level, religion,
of the empowerment program, to consider within-person
employment status, tobacco use, alcohol use, metformin use,
variability, and to account for correlated data resulting
and chronic disease status were collected from the participants.
from repeated measurements across different time points
Validity and reliability and multiple observations of the same individual (Zeger &
The content validity of the questionnaires used in this Liang, 1986). The interacting effects of group and time on
study was examined by five experts, including a physician, outcome variables were examined using the GEE model.
a dietician, a diabetes educator, and two university
professors with expertise in endocrinology and patient Results
empowerment. The experts rated the appropriateness of
the items from ‘‘very appropriate’’ (4 points) to ‘‘inappro- Participant Characteristics and Outcome
priate’’ (1 point). For each scale, the content validity index Variables at T0 in the Experimental Group
was calculated by dividing the number of items that were
rated 3 or 4 by the total number of items. The content
and the Control Group
validity index for all of the scales ranged from 0.90 to Of the 100 eligible subjects, 80 consented to participate in
0.96, which indicated good content validity (Polit, Beck, the study. Two participants in the experimental group
& Owen, 2007). Furthermore, Cronbach’s alpha was used were lost to follow-up at T1 because of transfer to another
to assess the internal consistency of each of the scales. hospital. Finally, 38 participants in the experimental group
and 40 in the control group completed the study at T2.
The experimental group had 95% retention rates at both
T1 and T2. The control group had 100% retention rates at
Ethical Considerations both T1 and T2. Figure 2 shows the procedure that was used
This study was approved by the Human Experiment and to perform the study, including the recruitment of partici-
Ethics Committee of Antai Medical Care Cooperation, pants, the intervention, and the measurement. Table 2 shows
Antai Tian-Sheng Memorial Hospital (IRB-101011). The that personal characteristics did not significantly differ between
researchers explained the purpose and procedures of the the two groups at pretest, indicating intergroup homogeneity.

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Empowerment Program for People With Prediabetes VOL. 25, NO. 2, APRIL 2017

Thus, personal characteristics were not adjusted in the GEE sugar, BMI, and self-efficacy between T0 and T1 and
models. Table 3 shows that, at T0, health-promoting life- between T0 and T2. Between T1 and T2, the experimental
style, blood sugar, BMI, and self-efficacy did not differ group significantly improved their BMI but revealed no
significantly between the two groups. significant change in health-promoting lifestyle, blood
sugar, and self-efficacy. In the control group, health-
Differences in Outcome Variables promoting lifestyle and self-efficacy only significantly
Between the Experimental and Control improved between T0 and T1. Blood sugar and BMI did
not significantly differ between T0 and T1 or between T0
Groups at T1 and T2
and T2. Health-promoting lifestyle, blood sugar, BMI, and
Table 3 shows that, at T1 and T2, improvements in
self-efficacy did not significantly differ between T1 and T2.
health-promoting lifestyle, blood sugar, and self-efficacy
were significantly larger in the experimental group than in
the control group. However, BMI did not differ signifi- Difference in the Changes in Outcome
cantly between the two groups. Variables Between the Experimental and
Control Groups
Difference in Outcome Variables Between
The group and time interaction and adjusted correspond-
T0 and T1, T0 and T2, and T1 and T2 Within ing outcome variables at T0 were analyzed using GEE
the Experimental and Control Groups analysis. Table 4 shows that analyses of the group main
Table 3 shows that the experimental group achieved signi- effect revealed no group effects in any outcome variables.
ficant improvements in health-promoting lifestyle, blood Over the three time points, the experimental and control

Figure 2. Flowchart of procedures for recruiting study participants and for performing the intervention and measurement.
BMI = body mass index.

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The Journal of Nursing Research Mei-Fang Chen et al.

TABLE 2.
Personal Characteristics in the Experimental Group and Control Group (N = 78)
Experimental
Group Control Group
Personal Characteristic of Participant n % n % 2 2/t p

Gender
Male 14 36.8 15 37.5 0.01 .952
Female 24 63.2 25 62.5
Age (years; mean, SD) 51.47 8.46 50.78 8.93 0.35 .724
Marital status
Married 15 39.5 15 37.5 0.03 .858
Single or widowed 23 60.5 25 62.5
Education
Elementary or junior high school 3 7.9 1 2.5 1.17 .558
Senior high school 17 44.7 19 47.5
College or above 18 47.4 20 50.0
Religion
Buddhism 16 42.1 19 47.5 1.40 .706
Taoism 12 31.6 8 20.0
Christianity 3 7.9 4 10.0
None 7 18.4 9 22.5
Employment status
Employed 9 23.7 8 20.0 0.16 .694
Unemployed or retired 29 76.3 32 80.0
Tobacco use
Yes 7 18.4 5 12.5 0.53 .469
No 31 81.6 35 87.5
Alcohol use
Yes 6 15.8 3 7.5 1.31 .252
No 32 84.2 37 92.5
Metformin use
Yes 1 2.6 2 5.0 0.30 .587
No 37 97.4 38 95.0
Chronic disease
Yes 31 81.6 33 82.5 0.01 .916
No 7 18.4 7 17.5

groups differed significantly in terms of health-promoting sugar, BMI, and self-efficacy at 3 months after completing the
lifestyle and BMI. A significant interacting effect between intervention. These findings indicate the efficacy of the ABC
time and group was observed in health-promoting life- empowerment program in having a short-term positive effect
style, blood sugar, BMI, and self-efficacy. After adjusting on clinical and psychosocial outcomes in people with pre-
for health-promoting lifestyle, blood sugar, BMI, and self- diabetes in Taiwan. Furthermore, these findings support the
efficacy at T0, the improvements in health-promoting theoretical construct of the model of empowerment as a
lifestyle, blood sugar, and self-efficacy were significantly process that affects empowerment results (Anderson & Funnell,
larger in the experimental group than in the control group 2010; Tengland, 2007).
from T0 to T1 and from T0 to T2. The decrease in BMI The health-promoting lifestyle in the experimental
was significantly larger in the experimental group than in group improved significantly between T0 and T1 and
the control group from T0 to T2 (Table 4). between T0 and T2, indicating that the program was effec-
tive in encouraging participants to adopt a health-promoting
lifestyle. In the experimental group, health-promoting life-
Discussion style improved at T1 and remained stable at T2. This initial
The experimental group improved significantly more than improvement in health-promoting lifestyle is consistent with
the control group in terms of health-promoting lifestyle, blood a previous study, which reported that patients with diabetes

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Empowerment Program for People With Prediabetes VOL. 25, NO. 2, APRIL 2017

TABLE 3.
Distribution of Health-Promoting Lifestyles, Blood Sugar, BMI, and Self-Efficacy
and Comparisons Between and Within Groups at T0, T1, and T2
T0 T1 T2 T1YT0 T2YT0 T2YT1
Variable Mean SD Mean SD Mean SD t p t p t p

Health-promoting
lifestyles
Experimental 63.63 G0.001 77.21 6.68 76.32 10.93 5.83 G.001 5.38 G.001 j0.56 .579
group
Control group 62.10 11.20 64.08 13.17 63.08 11.46 3.21 .003 1.60 .118 j1.72 .102
t (p) 0.57 (.571) 5.60 (G.001) 5.22 (G.001)
Blood sugar
Experimental 110.26 6.75 106.47 4.24 106.29 4.15 j3.93 G.001 j4.05 G.001 j1.56 .128
group
Control group 110.20 6.59 109.45 5.94 109.63 5.83 j1.99 .053 j1.49 .144 1.07 .291
t (p) 0.04 (.967) j2.54 (.013) j2.90 (.005)
BMI
Experimental 25.21 5.26 24.75 4.38 23.94 3.43 j2.42 .021 j3.04 .004 j3.26 .002
group
Control group 25.24 5.13 25.06 4.91 25.45 4.72 j1.76 .086 1.21 .235 1.67 .073
t (p) j0.03 (.980) j0.29 (.772) j1.61 (.112)
Self-efficacy
Experimental 66.95 20.83 89.08 8.67 89.42 8.12 5.64 G.001 5.81 G.001 1.92 .062
group
Control group 68.10 21.04 70.00 16.66 70.00 15.89 2.24 .031 1.97 .056 0.00 1.00
t(p) j0.24 (.809) 6.39 (G.001) 6.54 (G.001)

Note. T0 = baseline; T1 = 1 week after completing the intervention; T2 = 3 months after completing the intervention.

made lifestyle improvements immediately after completing and T2. In addition, at T2, the improvements in blood
an empowerment intervention (Chen, Wang, Chin, et al., sugar and BMI were significantly larger in the experimental
2011; Chen, Wang, Lin, et al., 2015). In addition, the lifestyle group than the control group, which is consistent with a
improvements that were observed in the experimental previous study (Tang, Funnell, Brown, & Kurlander, 2010).
group were sustained for up to 3 months after completing Because improvements in blood sugar and BMI may reduce
the intervention. Because the program encouraged increased the incidence of diabetes (Centers for Disease Control and
awareness, improved behavior, and self-reflection regarding Prevention, 2013), the ABC empowerment program devel-
the implementation of a health-promoting lifestyle, we oped in this study has strong potential efficacy for reducing
hypothesize that the program gave participants the internal the incidence of diabetes. The improved blood sugar and
motivation to make self-selected behavioral changes in their BMI in this study may result from participants practicing a
daily life, which then helped sustain the improvements in this health-promoting lifestyle, which has been reported to have
group. In the control group, adoption of a health-promoting a direct and positive effect on blood sugar and BMI
lifestyle increased at T1 but decreased at T2. This finding is (Laatikainen et al., 2007).
consistent with Chen, Wang, Chin, et al. (2011), who found In terms of the psychosocial aspects, the experimental
that an educational program that included monthly visits to group had significantly improved self-efficacy at T1 and T2
clinics and educational pamphlets initially improved the in comparison with T0. In contrast, the control group
health-promoting lifestyle of participants but did not sus- achieved significantly improved self-efficacy only at T1.
tain the improvements at 3 months after completing the In addition, the increases in self-efficacy were significantly
intervention. A possible explanation is that the participants larger in the experimental group than in the control group.
in the control group were motivated to implement recom- Similar findings have been reported previously (Chen,
mendations that were provided by healthcare professionals. Wang, Lin, et al., 2015). According to the social learning
External motivation to control a disease inhibits the sus- theory (Bandura, 1997), observing others can effectively
tainability of changes to behaviors. Therefore, the lack of improve self-efficacy as well as other behaviors. In addition,
sustained improvement in this group was not unexpected. because self-efficacy is boosted by feelings of mastery over
In terms of the physical aspects, the experimental group an experience (Bandura, 1997), the larger increase in self-
showed significantly improved blood sugar and BMI at T1 efficacy that was observed in the experimental group may

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The Journal of Nursing Research Mei-Fang Chen et al.

TABLE 4.
GEE Analysis of Changes in Health-Promoting Lifestyles, Blood Sugar, BMI, and
Self-Efficacy Between the Experimental and Control Groups
Variable B SE p

Health-promoting lifestyles
Intercept 62.10 1.75 G.001
Group (EG vs. CG) 1.53 2.67 .566
Time overall .003
T1 vs. T0 1.98 0.61 .001
T2 vs. T0 0.98 0.60 .106
Time  Group overall G.001
EG*( T1 vs. T0) vs CG*( T1 vs. T0) 11.60 2.38 G.001
EG*( T2 vs. T0) vs. CG*( T2 vs. T0) 11.71 2.40 G.001
Blood sugar
Intercept 110.20 1.03 G.001
Group (EG vs. CG) 0.06 1.49 .966
Time overall .095
T1 vs. T0 j0.75 0.37 .043
T2 vs. T0 j0.56 0.38 .131
Time  Group overall .002
EG*( T1 vs. T0) vs. CG*( T1 vs. T0) j3.40 1.04 .003
EG*( T2 vs. T0) vs. CG*( T2 vs. T0) j3.04 1.02 .001
BMI
Intercept 25.24 0.80 G.001
Group (EG vs. CG) j0.03 1.16 .979
Time overall .002
T1 vs. T0 j0.18 0.10 .075
T2 vs. T0 0.21 0.17 .222
Time  Group overall G.001
EG* (T1 vs. T0) vs. CG* (T1 vs. T0) j0.28 0.21 .194
EG* (T2 vs. T0) vs. CG* (T2 vs. T0) j1.48 0.45 .001
Self-efficacy
Intercept 68.10 3.28 G.001
Group (EG vs. CG) j1.15 4.68 .805
Time overall .068
T1 vs. T0 1.90 0.84 .023
T2 vs. T0 1.90 0.95 .046
Time  Group overall G.001
EG* (T1 vs. T0) vs. CG* (T1 vs. T0) 20.23 3.96 G.001
EG* (T2 vs. T0) vs. CG* (T2 vs. T0) 20.57 3.93 G.001

Note. GEE = generalized estimating equation; T0 = baseline; T1 = 1 week after completing the intervention; T2 = 3 months after completing the intervention;
EG = experimental group; CG = control group.
*Interacting effects.

have resulted from their increased confidence after repeated experimental group, BMI improved from a baseline of
success in problem-solving processes. In contrast, partici- 25.21 to 23.94 at 3 months after completing the interven-
pants in the control group had no opportunities to observe tion. A BMI over 24 is interpreted as overweight, whereas
others, which may explain their relatively smaller improve- a BMI of 18.5Y24 is considered normal (Ministry of
ments in self-efficacy. Health and Welfare, Health Promotion Administration,
Notably, the scores for health-promoting lifestyle and 2014). Therefore, participants in the experimental group
self-efficacy had improved to mediumYhigh levels by T1. changed from overweight at baseline to normal weight at
This large initial improvement may have limited further 3 months after completing the intervention. This change in
improvement from T1 to T2. However, because BMI may weight was slightly but clinically meaningful. In the exper-
be affected by both health-promoting lifestyle and self- imental group, blood sugar also changed from 110.26 to
efficacy, the improved adoption of a health-promoting 106.29. Although the change in blood sugar was statistically
lifestyle and the improved self-efficacy observed at T1 may significant, it was not clinically meaningful. The three main
have contributed to the improved BMI at T2. In the factors in blood sugar control are treatment, physical

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Empowerment Program for People With Prediabetes VOL. 25, NO. 2, APRIL 2017

condition, and self-management. No treatments (i.e., medi- to adopt the health-promoting lifestyle changes that are nec-
cations) were changed in the two groups during the essary to prevent the disease from progressing to diabetes.
intervention (data not shown). However, further studies Moreover, the successful implementation of a health-promoting
are needed to determine how physical condition (e.g., lifestyle requires a plan that is practical and realistic. The
presence of a chronic disease) or health habits (e.g., tobacco empowerment intervention in this study was designed to
or alcohol use) affect blood sugar in people with diabetes. facilitate healthcare professionals in guiding the participants
Some limitations of this study are noted. First, all of the to implement behavior changes in daily life. People with pre-
participants were recruited from a hospital in southern diabetes are likely to implement a health-promoting lifestyle if
Taiwan, which may limit the generalizability of the findings. they believe that the required lifestyle changes are realistic and
Thus, further evaluation of the empowerment program reasonably easy to implement. Generally, an intervention
using different samples is needed. Second, the control group that is designed to change behavior in people with asymp-
received conventional education, which required approxi- tomatic prediabetes must apply strategies that raise aware-
mately 30 minutes per month. The intervention group ness and promote mutual participation. This study thus
received eight 2-hour sessions that were delivered biweekly provides a reference for healthcare providers and researchers
over a 4-month period. Although the intensive nature of the who are responsible for designing empowerment programs
empowerment program might have contributed to the for people with prediabetes.
positive outcomes observed in the participants, it may limit
its practical application in clinical settings. Thus, the pro-
gram requires further modification to ensure that a consis- Acknowledgments
tently high completion rate is achieved in clinical settings. The authors thank the Taiwan Nurses Association for its
Third, because the efficacy of the empowerment program financial support of this study (Grant number TWNA-
was assessed at only 3 months after completing the inter- 1022001).
vention, a longer follow-up period is needed to confirm long-
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糖尿病前期個案之賦權計畫 The Journal of Nursing Research VOL. 25, NO. 2, APRIL 2017

糖尿病前期個案之賦權計畫—隨機對照試驗
陳美芳1　洪淑玲2　陳淑玲3*

1
國立臺南護理專科學校護理科副教授　2國立臺南護理專科學校護理科助理教授　
3
高雄市立聯合醫院護理科護理長

背　景 賦權介入可提升執行健康促進生活型態之結果 ，進而延緩或預防糖尿病的發生。然

而 ，少有研究測試賦權介入對於糖尿病前期個案的成效。

目　的 發展賦權介入方案 ，並評價對於糖尿病前期個案健康促進生活型態 、血糖 、身體質量

指數與自我效能之效果。

方　法 2013 年 5 月至 12 月 ，進行實驗性研究。在高雄市某醫院健檢門診 ，以方便取樣 ，選取

糖尿病前期個案 ，以隨機區塊方式 ，8 人為一區塊 ，分成實驗組與對照組。38 位實驗
組接受為期 4 個月「ABC 賦權介入方案」 ，依覺醒 、行動與省思階段 ，協助個案能執行
健康促進生活型態。40 位對照組接受原本之醫院照護。統計方法包括描述性統計 、獨
立樣本 t 檢定 、配對 t 檢定與廣義估計方程式。

結　果 從介入前至介入完成後 1 星期與 3 個月 ，實驗組比對照組在健康促進生活型態 、血糖與

自我效能有更大的改善（p < .01）。從介入前至介入完成後 3 個月 ，實驗組比對照組在身
體質量指數有顯著的降低（p = .001）。

結　論 賦權介入方案對台灣的糖尿病前期個案在行為 、生理 、心理與社會有短期正向結果 ，

此可作為教育 、實務及研究的參考。

關鍵詞：充能、糖尿病前期、健康促進生活型態、血糖、自我效能。

接受刊載：104年5月3日
*通訊作者地址：陳淑玲　　80457高雄市鼓山區中華一路976號
電話：（07）5552565－2401　　E-mail: [email protected]

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