A R T I C L E   I N F O		A B S T R A C T
ORIGINAL ARTICLE		Background: Diabetes is a chronic progressive disorder that imposes negative effects on various aspects of an individual's life. This study was conducted to compare the effect of video instructions in comparison with traditional training on glucose control in type 2 diabetic patients in Hamadan. Methods: In this experimental study, 120 patients with type 2 diabetes who referred to Diabetes Center of Hamadan were divided into two groups: intervention and control. Data collection tool was a questionnaire based on Health Belief Model completed by interviewing before, immediately after, and three months after the intervention. In addition, the serum levels of HbA1c were measured before and three months after the study. Intervention was conducted on three groups of 20 participants using video playback as well as question and answer sessions. Data were analyzed by SPSS21 using Friedman, Wilcoxon and Mann-Whitney tests. Results: This study revealed a significant difference in the median of knowledge, perceived threat, perceived benefits, and barriers in the intervention group immediately and three months after the intervention. HbA1c levels decreased after the intervention but this change was not significant. Three months after the intervention, in the intervention group educations provided by both physicians and videos were the most effective cues to action. Conclusion: Instructional videos for diabetes education can have a positive impact on healthy lifestyle in Patients with type 2 diabetes. It was concluded that decrease in HbA1c level needs longer intervention period; more than three months.   Keywords: Health Belief Model, Instructional Video, Type 2 Diabetes, Self-Efficacy
Article History: Received:4Apr 2017 Revised: 22 Apr 2017 Accepted: 15 May 2017
*Corresponding Author: Fereshteh Besharati Email: fereshteh.besharati@yahoo.com Tel: +98 9113470649
Citation: Hazavehei SMM, Rostami Moez M, Besharati F, Emdadi Sh, Khezeli M, Farhadian M. Comparison between the Impact of Video Instructions and Traditional Training on FBS Control in Type 2 Diabetics, Hamadan: A model based intervention. Social Behavior Research & Health (SBRH). 2017; 1(1): 9-17.

Diabetes as the most common metabolic disorder is associated with a range of serious complications which has a strong negative impact on various aspects of life and results in reduced quality of life and premature mortality.1-3 Type 2 diabetes is associated with obesity, overweight, inactivity, and is very common in individuals aged over 40 years.4, 5 It has been predicted that the prevalence of type 2 diabetes in later decades will have a significant growth and will be the main issue of public health with the prevalence of 439 million people in 2030.4 Third national surveillance of risk factors for
non-communicable diseases has reported the prevalence of diabetes in Iran as 7.7%, however due to increasing life expectancy in Iran, there is no doubt that the prevalence of diabetes will increase in the coming years.6 Various studies have proven that early detection and proper care of diabetes based on patient education and self-care can prevent acute
and chronic complications.7
Various methods are used for health education including lecture, discussions in small groups (focus groups), role playing, drama, video, and printed materials.8 Face to face method has previously been considered as the main approach for diabetes education, but other methods of education such as videos and Web-based training can be applied, because these kinds of education in particular can play an important role in delivering contents that are not possible through face-to-face method.9 A wide range of instructional media for interactive health communication are considered such as the Internet and video that can be useful in providing health information, reminder information, and establish the ability to behavior change.10 Instructional video, which is a form of persuasive communication, can be a useful tool in promoting public health.11 Several studies in various fields of health care have emphasized the greater effectiveness of video tape than other educational methods including lecture, instruction booklet, and a slide show.12-14 Since many health problems are closely related to human behavior, behavioral theories and models can be used in identifying and understanding the factors influencing behaviors and determining how these factors work.15 Health Belief Model (HBM) which has been chosen as the theoretical framework of this study is one of the most popular models in health education which mainly focuses on preventive measures and adopts behaviors to avoid illnesses and diseases. It is also used to determine the relationship between health beliefs and behavior.16 In various studies, the efficiency of HBM in describing and predicting the behavior proves preventive health.16 According to this model, a person must believe that he/she is vulnerable to the risk of a problem (perceived susceptibility), understand the depth, seriousness, and various complications of this risk (perceived severity). He/she also needs to realize benefits and barriers of adopting positive health behaviors, such as self-care behavior (perceived benefits and perceived barriers.10
In the present study, the HBM was used in writing the scenario and contents of the produced training videotapes. So, this study was conducted to compare the instructional video with traditional training on fasting blood sugar (FBS) control in type 2 diabetic patients in Hamadan.
Methods
This study was an educational intervention carried out with experimental methods. The sample included 120 patients with type 2 diabetes who were referred to Diabetes Center of Hamadan and were divided randomly into two groups: intervention and control. Patients' inclusion criteria in this study were as follows: the patient volunteered to participate in the study, type 2 diabetes diagnosed during the last two years, and the ability to participate in the various stages of program. Patients were excluded if they were not willing to continue the test, or could not participate in video demonstration sessions due to any problems.
A questionnaire developed based on the HBM was applied for data collection, including the following sections: demographic characteristics (age, gender, education, occupation, marital status, duration of diabetes, etc.), knowledge (6 questions), perceived susceptibility (5 items), perceived severity (5 items), perceived benefits
(7 items), perceived barriers (5 items), self-efficacy (3 items) and cues to action (1 item). Content validity method was used to assess the validity, so that a questionnaire was developed based on HBM and scientific resources. Then, in order to determine the validity, the questionnaire was offered to 10 experts of health education, they were asked to express their views on the content of questionnaire considering the research purpose. Finally, errors and ambiguities of the questionnaire were modified according to their comments and its validity was confirmed. To determine the reliability of the questionnaire, it was completed by 30 patients with type 2 diabetes (other than groups participating in the study), the result showed that the questionnaire had acceptable internal consistency (Cronbach's alpha 0.83).
The main method of education in the experimental group was based on an instructional video entitled as "healthy lifestyle in people with type 2 diabetes". For production of the video, the initial scenario was written by researchers based on HBM as well as the guidelines of the Ministry of Health and Medical Education related to the type 2 diabetes care. Then, other stages for execution of the video were conducted by director and other executives at the Media Lab of Health School in Hamadan University of Medical Sciences. Diabetic patients and staffs of Diabetes Center of Hamadan cooperated in this study. Validity of video post-production was approved by health education specialists, nutritionists, and endocrinologists.
Initially the list of diabetic patients referred to Diabetes Center of Hamadan was obtained from the head of the center. Next, patients who met the inclusion criteria were coded and randomly divided into two intervention and control groups. Participants in both intervention and control groups completed a questionnaire based on the HBM about diabetic patients' lifestyle. Further, HbA1c index of all participants were measured at the baseline free of charge in an accredited laboratory and approved by University of Medical Sciences. Then, the intervention group was divided into three equal groups each containing 20 members, for each
group an instructional video entitled as "healthy lifestyle in people with type 2 diabetes" was displayed approximately for half an hour at the amphitheater of Diabetes Research Center of Hamadan in the presence of researchers. For each group, after showing every part of the video, a Question-Answer-Relationship method was conducted and patients expressed their doubts and questions which were consequently answered by researchers. At the end of the session one CD of the video was delivered to the intervention group and they were asked to watch it again at home. The diabetic patients in intervention group completed the questionnaire immediately and 3 months after the video playback session. The control group also completed a questionnaire about the same time in two steps with intervention group. It is worth noting that HbA1c level was measured only twice for the intervention and control groups; before and 3 months after the intervention. During this period, the control group received the traditional training in the Diabetes Center.
In the present study, the ethical issues such as individual freedom and informed choice to participate in the study, explaining ambiguous points of study for participants, and confidentiality of personal information by researchers were observed. Written informed consent forms were obtained from participants. Research Council and Ethics Committee of Hamadan University of Medical Sciences approved the study.
Data were analyzed through SPSS21 software, descriptive statistics measures, Friedman, Wilcoxon and Mann-Whitney tests were applied for further investigation. Assumption of data normality was also examined by Kolmogorov-smirnov test.
Results
The average age of patients in the intervention group was 52.04 )10.25( and in the control group was 53.23 )9.66( years. The results showed that
69.8% of diabetic patients in the intervention group and 57.8% in the control group were under diploma. The majority of participants in both intervention
and control groups were married. The mean duration of diabetes in the intervention group and control group were 15.07 )8.38( and 12.78 )9.15( months, respectively. The results indicated that
there were no significant differences between the two groups in terms of age, gender, education level, economic status, and duration of diabetes.
Mann-Whitney test results represented that there were no significant differences between median of knowledge, perceived susceptibility, perceived benefits and barriers of intervention, as well as control groups before education. However, immediately after and three months after the intervention, significant differences in median scores of these variables between the two groups were observed (P-value < 0.05).
According to results of Friedman test, the changes in median of knowledge, perceived susceptibility, perceived severity, perceived benefits, and barriers during the time of the study were significant exclusively in the intervention group (P-value < 0.001). But the changes of self-efficacy score over the time of the study were not significant (P-value < 0.091). Moreover, changes in scores of all the aforementioned variables over the time of study in the control group were not statistically significant (Table 1).
In the intervention group, paired comparisons



of severity and perceived benefits before and immediately after the intervention, before and 3 months after intervention, as well as immediately and 3 months after intervention were statistically significant. Additionally, comparison of knowledge and perceived barriers immediately
and 3 months after intervention, as well as comparison of perceived susceptibility before and three months after intervention were not
significant (Table 2).
The physician was introduced as the most impressive cue to action before education within the intervention group (88.4%), but immediately and three months after the intervention the most impressive cues were the physician and instructional videos. Also, in the control group the most effective guide to action in all three periods was the physician.
According to paired T-test in the intervention group the average of HbA1c decreased from
7.82 to 7.75, but this change was not statistically significant (P-value > 0.05). There was no statistically significant difference in the control group in this regard (P-value > 0.05).Furthermore, according to the independent T-test, the average of HbA1c between the intervention and control groups before and after educational program did not have any significant difference.

Table 1. Comparison of knowledge and HBM structures before, immediately after, and 3 months after intervention in the intervention and control groups
Variables	Measuring time to intervention	Intervention group Median (IQR*)	Control group Median (IQR*)	Mann-Whitney test results
Knowledge	Before	4 (2)	4 (2)	P-value = 0.359
	Immediately after	5 (1)	4 (2)	P-value < 0.001
	Three months after	5 (2)	4 (2)	P-value < 0.001
	Friedman test	P-value < 0.001	P-value = 0.785
Perceived susceptibility	Before	20 (1)	20 (4)	P-value = 0.301
	Immediately after	22 (5)	20 (3)	P-value < 0.001
	Three months after	20 (3)	19.50 (0.6)	P-value = 0.005
	Friedman test	P-value < 0.001	P-value = 0.295
Perceived severity	Before	20 (3)	19 (5.75)	P-value = 0.012
	Immediately after	24 (5)	20 (3.75)	P-value < 0.001
	Three months after	20 (2.50)	20 (4.75)	P-value < 0.001
	Friedman test	P-value < 0.001	P-value = 0.106
Perceived benefits	Before	28 (1)	28 (6)	P-value = 0.075
	Immediately after	31.5 (7)	28 (3.88)	P-value < 0.001
	Three months after	28 (4.75)	27.5 (4)	P-value < 0.001
	Friedman test	28 (1)	P-value = 0.382
Perceived barriers	Before	16 (6)	15 (5.88)	P-value = 0.628
	Immediately after	20 (9)	15.5 (3)	P-value = 0.004
	Three months after	20 (3.75)	15 (4)	P-value < 0.001
	Friedman test	P-value = 0.003	P-value = 0.330
Perceived self-efficacy	Before	12 (2.75)	10 (3.75)	P-value = 0.027
	Immediately after	12 (5)	11 (3)	P-value = 0.002
	Three months after	12 (2.75)	11 (3)	P-value = 0.056
	Friedman test	P-value = 0.155	P-value = 0.091

Table 2. Comparison of knowledge and HBM structures at different measuring times in the intervention group
Variables	Before vs. Immediately after intervention	Before vs. 3 months after intervention	Immediately vs. 3 months after  intervention
Knowledge	P-value < 0.001	P-value = 0.005	P-value = 0.306
perceived susceptibility	P-value < 0.001	P-value = 0.084	P-value = 0.002
Perceived severity	P-value < 0.001	P-value < 0.001	P-value = 0.009
Perceivedbenefits	P-value < 0.001	P-value < 0.001	P-value = 0.002
Perceived barriers	P-value = 0.007	P-value = 0.004	P-value = 0.850

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