Introduction
The global prevalence of diabetes has been steadily increasing for over 50 years and has now reached epidemic proportions [1]. In 2021, the International Diabetes Federation (IDF) has projected that 536.6 million adults (10.5%) across the globe are currently affected by diabetes, whether diagnosed or undiagnosed. An estimated 44.7% of individuals with diabetes, totaling 240 million, are unaware of their condition. The majority of undiagnosed diabetes cases, more than 75%, are found in low and middle-income countries (LMICs). Projections indicate that this global prevalence will increase to 643 million (11.3%) by the year 2030 and further to 783 million (12.2%) by 2045 [2]. Diabetes management is complex and requires multiple interventions to be successful [3]. For both type 1 and type 2 diabetes, the cornerstone of treatment is diet and exercise. A diet that is low in refined carbohydrates, high in fiber, and high in monounsaturated fats should be encouraged [4]. Aerobic exercise for 90 to 150 min per week is also beneficial [3].
Diabetes education and patient engagement in management are paramount for achieving better outcomes, as evidenced by improved results associated with effective dietary management [5]. To effectively manage diabetes and prevent complications, patients must undertake crucial self-care activities including adopting a suitable diet, engaging in regular exercise, practicing proper foot care, monitoring blood glucose levels, utilizing antidiabetic medications, adhering to medication regimens, abstaining from alcohol and smoking, and undergoing regular health checkups [6]. A diabetes diagnosis presents patients with a multitude of challenges that significantly impact their treatment and well-being [7]. These challenges encompass feelings of dependency, loneliness due to social stigma and self-management demands, fear of potential complications, anxieties concerning the future, and the psychological burden leading to depression and anxiety [8, 9]. The ultimate goal in this regard is lifestyle modification, an art known as health promotion [1]. Health-promoting behaviors are a key determinant of health and are recognized as a fundamental factor in preventing many diseases. They are also acknowledged as an important strategy for maintaining and improving the independence, health, and quality of life of individuals with chronic conditions [10]. By identifying the weaknesses in the lifestyles of these patients, appropriate empowering interventions can be implemented [11]. Individuals who engage in health-promoting lifestyles are demonstrably healthier, exhibit improved overall functioning, and experience a reduced burden of disease, disability, and economic costs associated with illness [12]. Health-promoting lifestyles encompass various domains, including spiritual growth, self-actualization, health responsibility, healthy nutrition, physical activity, stress management, and interpersonal relationships [12]. Furthermore, one of the variables that influences patients’ acceptance of self-care responsibility is life satisfaction [13]. Life satisfaction is a cognitive evaluation based on individuals’ overall judgment of their life according to various criteria. It is influenced by personality traits, coping methods, and individuals’ perception of health and illness [14]. Moreover, life satisfaction in diabetic patients is contingent upon their expectations and evaluations of the quality of healthcare services, achievement of disease management goals, and nutritional health [15]. Evidence suggests that patients with chronic diseases have poorer health behaviors than healthy individuals [16]. Li et al. reported that the level of health-promoting behaviors in patients with chronic diseases was moderate [17]. Life satisfaction in people with type 2 diabetes is significantly associated with perceived changes in their own health status [18]. Controlling the amount of glycosylated hemoglobin has a significant impact on their mood and quality of life [19].
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Studies have reported that the level of life satisfaction in diabetic patients is lower compared to the general population [20]. Educational interventions can be effective in improving health-promoting lifestyle behaviors and their dimensions [21]. Patients are more likely to participate in their treatment and care goals if they perceive them as aligned with their own personal goals and priorities. Additionally, utilizing theories such as individual theories [e.g., the Health Belief Model, Theory of Planned Behavior], interpersonal theories [e.g., Social Cognitive Theory, Social Network and Support], and social theories [e.g., Social Mobility Theory, Communication Theory] [22], and increasing nursing research based on conceptual frameworks, contributes to the advancement of nursing knowledge [23].
On the other hand, educating patients is one of the most important tasks of nurses to, improve self-care, and promote the quality of life of in patient with chronic illness [2]. In a proper care relationship, the goal for the patient, family and caregivers is to restore and preserve the patient’s health [9]. By establishing a relationship between the nurse and the client, between the theoretical knowledge of the nurse and the patient’s expectations of how to perform care and treatment, the relationship is created [10]. The most important factor in maintaining high-quality nursing care is the relationship between the effectors [11]. Doctors and nurses should give priority to establishing effective communication with patients for the purpose of their participation in rational decision-making to preserve their health. Also, allow clients to express their opinions. Only in this way can they help each other and create a favorable environment for decision-making [12]. If patients understand the goals of their treatment and care in line with their goals and priorities, they will have more participation in them. One such interactive theory of behavior change is King’s Goal Attainment Model, which identifies problems through communication between nurses and care recipients and sets goals that are to be mutually achieved, facilitating action, reaction, and interaction between the nurse and the care recipient [8]. This theory is comprised of three main systems: personal, interpersonal, and social [23]. In the personal system, each individual is a unique being and a whole who is always interacting with the environment [24]. Understanding plays a significant role in the nurse-patient relationship, as accurate understanding facilitates everyday life and helps the individual to better interact with the surrounding environment [24]. The interpersonal system is formed through the interaction between two or more individuals within groups. The nurse-client relationship is an example of this. To understand this system, it is necessary to grasp the concepts of interaction, communication, transaction, role, stress, and stressors [24]. The social system, on the other hand, encompasses the dimensions of organization, authority, power, and decision-making. It is tasked with providing a framework for social interactions and interpersonal communications within society, such as in the workplace and organizations [25]. In the Goal Attainment Theory, great emphasis is placed on patient participation in decisions such as setting and agreeing on self-care goals, prioritizing goals, agreeing on methods of achieving goals, and understanding the patient’s perspective to determine the extent to which goals have been achieved [26]. The chronic nature of diabetes requires increased care over a longer period of time. This theory is important for long-term nurse-patient communication to assess satisfaction and achieve goals and nursing care [25, 26]. Studies have demonstrated the effectiveness of nursing intervention programs based on King’s Goal Attainment Theory in various diseases [27]. The application of this theory has been fruitful in improving diabetes treatment adherence and quality of life [28, 29]. In other diseases, such as acute coronary syndrome, it can modify daily activities based on prioritized goals [30]. A review of past evidence has shown that a greater emphasis has been placed on improving behavior in patients, while patient satisfaction has been neglected. On the other hand, it is essential to note that nursing is a scientific discipline based on professional knowledge, and the development of new approaches in clinical nursing requires sufficient knowledge of nursing theories. The use of nursing theories in clinical practice is an indicator of nursing knowledge and competence [24]. While King’s theory provides an excellent humanistic framework for creating a reciprocal and therapeutic relationship between nurses and patients, many nurses are unfamiliar with this theory, which has consequently reduced its application in clinical practice [24]. A holistic approach to nursing interventions based on nursing models can shift nursing care from a service-oriented spectrum to client-centered activities, leading to improved care standards, reduced costs, and ultimately improved quality of life for clients [31].Therefore, considering the lack of sufficient evidence based on King’s Goal Attainment Model in patients with type 2 diabetes, the present study was conducted to investigate the effect of an educational program based on King’s Goal Attainment Model on health-promoting behaviors and life satisfaction in patients with type 2 diabetes.
Methods
This study is a randomized controlled clinical trial with no blinding in November 2022 to April 2023 on patients with type 2 diabetes in Fars Province, south of Iran. In the present study, CONSORT (Consolidated Standards of Reporting Trials) checklist was used for determining the quality of randomized controlled trials [32]. The sampling method was convenience sampling. The inclusion criteria for the study were as follows: Suffering from type 2 diabetes for more than one year, fasting blood sugar (FBS) ≥ 126 mg/dL, no history of amputation due to the disease, no participation in an educational class in the past three months, ability and willingness to participate in the research, having basic literacy (have the ability to read the questions and answer the questionnaire), and ability to complete the questionnaire and informed consent form. The exclusion criteria were: having a chronic disease such as end-stage cancer, liver cirrhosis, mental health problems, a history of hospitalization for mental health problems, and death.
Based on the study of Ahmadi et al. [18] and considering (d = 9) and the standard deviation (s1 = 13.2, s2 = 9.4) with 95% accuracy and 90% power (α = 0.05, β = 0.1) a sample size of 33 subjects.
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was estimated for each group. The sample size was increased to 70 (in each group 35 subjects) by considering the probability of loss.
$$\:n=\frac{\left({s}_{1}^{2}+{s}_{2}^{2}\right)}{{d}^{2}}({Z}_{1-\alpha\:/2}+{Z}_{1-\beta\:}{)}^{2}$$
Randomization
Initially, the researchers selected 85 patients with type 2 diabetes using convenience sampling. 15 patients who lacked the inclusion criteria were excluded from the study; therefore,70 patients were randomly allocated to the intervention (N = 35) and control groups (N = 35). For random allocation, we placed 70 cards inside a box; 35 cards had the letter A on them, and 35 had letter B on them. The patients who had the inclusion criteria were asked to pick a card each. Those who picked an A card were allocated to the intervention group, and those who picked a B card were assigned to the control group. The patients could not see what was on the cards until they had taken them out of the box. Figure 1 displays consort flow diagram throughout the study (Fig. 1).
Fig. 1
Displays consort flow diagram throughout the study
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Intervention
An educational intervention based on King’s conceptual system [27] was performed for the patients in the intervention group. The topics of the educational intervention in the individual system review included the patient’s basic information, current status, understanding of the disease, and the patient’s participation in the learning process. In the interpersonal system review, the topics of interaction, communication, and transaction were taught. In the social system review, the topics of the educational system and social support were taught.
After coordinating with the head of the institution, we obtained the phone numbers of the patients to obtain written consent forms for participation in the study. Patients who met the inclusion criteria were selected. The informed consent form was provided to the patients in writing, and the objectives of the study were fully explained to them. Patients were assured that not participating in the study or withdrawing from the study would not disrupt their treatment process.
The educational intervention was delivered over seven one-hour sessions by the researcher, employing a multifaceted approach encompassing group discussions, informational pamphlets, lectures, and educational PowerPoint presentations. The educational content includes the education of types of diabetes, the difference in the causes and complications and symptoms specific to each type of diabetes, as well as the time required to visit an eye doctor, laboratory and blood sugar test, the amount of calories in food, the amount of useful walking, the amount and difference in the dosage of drugs in Different diabetic people, blood sugar control, increasing the skills of diabetic patients, strategies to reduce the intake of fat, sugary substances and bread and carbohydrates, increasing physical activity and strategies to avoid and reduce smoking, how to cut nails, foot care, how to measure and work It was with a blood sugar machine. With the feedback they gave in the training sessions and the questions they asked during the training sessions, it confirmed their understanding of our training materials.
Additionally, participants within the intervention group were afforded the opportunity to receive telephone consultations with the researcher, lasting 10–15 min, during weekdays (excluding holidays) from 8:00 AM to 8:00 PM, should such a need arise. In total, 70 to 105 min were considered for each person. The researcher ensured weekly receipt of educational materials by all patients through verbal confirmation of comprehension. Subsequently, two variables, health-promoting behaviors and life satisfaction, were assessed using standardized questionnaires, both immediately before and three months following the intervention. Patient completion of the questionnaires was facilitated by the researcher. The instruments used in this study were the demographic characteristics questionnaire, the Walker’s standard health-promoting lifestyle questionnaire, and the patient satisfaction questionnaire. At the end of the sessions and three months after the educational intervention, the Walker’s lifestyle and satisfaction questionnaires were completed again by the patient with the help of the researcher for both the intervention and control groups. The control group did not receive special training and received the usual care of health centers (education about medication and its known side effects, ways to improve one’s lifestyle and health behaviors concerning nutrition, physical activities, sleep and rest).
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Outcome
In this study, two issues were investigated. the secondary outcomes were health -promoting behaviors and life satisfaction in patients with Type 2 Diabetes.
The data collection tool consisted of three questionnaires
1.
Demographic information questionnaire: This questionnaire included questions about age, gender, education level, occupation, marital status, duration of illness, number of hospitalizations, family history of the disease, and the presence of another concurrent disease.
2.
The Walker Health-Promoting Lifestyle Profile: The primary research instrument was the Walker Health-Promoting Lifestyle Profile (HPLP) developed by Walker and colleagues in 1987 [33]. The English version of the HPLP consists of 52 items that are answered using a 4-point Likert scale (1 = never, 2 = sometimes, 3 = often, and 4 = always). The instrument measures health-promoting behaviors in six dimensions: Nutrition (9 items), Exercise (8 items), Health responsibility (9 items), Stress management (identification of stress sources and stress management strategies) (8 items), Interpersonal support (maintaining relationships with a sense of closeness) (9 items), Self-actualization (having a sense of purpose, striving for personal growth, and experiencing self-awareness and satisfaction) (9 items), In this questionnaire, higher scores indicate a higher health-promoting lifestyle, and lower scores indicate a lower health-promoting lifestyle. The Cronbach’s alpha of this questionnaire in Iran was reported by Mohammadizeidi, et al., and Amini, et al., to be 0.87 [34, 35].
3.
The Satisfaction with Life Scale (SWLS): The Satisfaction with Life Scale (SWLS) is a short 5 -item instrument designed to measure global cognitive judgments of satisfaction with one’s life. Each item scored on a 7 -point Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree). Scale scores range from 5 to 35, with higher scores indicating greater life satisfaction. Scores are categorized as extremely satisfied (31–35), satisfied (26–30), slightly satisfied (21–25), neutral (20), slightly dissatisfied (15–19), dissatisfied (10–14), and extremely dissatisfied (5–9). A higher score indicates a higher level of life satisfaction. Diener et al. (1989) reported the internal consistency reliability of the SWLS to be 0.83 using Cronbach’s alpha and 0.69 using the test-retest method. The construct validity of the SWLS was estimated using convergent validity with the Oxford Happiness Inventory (OHI) and the Beck Depression Inventory (BDI). The SWLS showed a positive correlation with the OHI and a negative correlation with the BDI [36]. The SWLS is a useful scale in Iranian psychological research [37].
Data analysis
Descriptive statistics, including means and standard deviations for quantitative variables and frequencies and percentages for qualitative variables, were used to summarize the data. The Kolmogorov-Smirnov test was used to assess the normality of the quantitative variables. The independent t-test and chi-square test revealed no statistically significant differences between both groups. To analyze the results, paired and independent t-tests, two-way ANOVA, and multivariate repeated measures ANCOVA were used. P-values < 0.05 were considered as the level of significance.
Results
In line with the overall aim of “Investigating the effect of an educational program based on King’s goal attainment model on health-promoting behaviors and life satisfaction in type 2 diabetes patients,” a total of 70 participants (35 in the intervention group and 35 in the control group) were enrolled in the study. The mean scores of health-promoting behaviors were compared before, immediately after, and three months after the intervention in both the intervention and control groups. The response rate was 100%. The majority of the participants were male (62.9%, n = 44), married (77.1%, n = 54), and had a primary school education (48.6%, n = 34). The results of the chi-square test showed that the two groups were not statistically significantly different in terms of demographic variables (age, gender, education, marital status, history of hospitalization, and history of hospitalization due to diabetes) (p > 0.05). (Table 1).
Table 1
Demographic information of the participants in both the intervention and control groups
Variables | Intervention group | Control group | Total | P value | |
|---|---|---|---|---|---|
Age | - | 59.34 ± 10.12 | 53.82 ± 11.57 | 0. 17* | |
Duration of diabetes (months) | - | 128.06 ± 92.29 | 83.26 ± 75.71 | 0. 21* | |
Gender | Female | 10(28.6%) | 16(45.7%) | 26(37.1%) | 0.14** |
Male | 25(71.4%) | 19(54.3%) | 44(62.9%) | ||
Education | Elementary | 20(57.1%) | 14(40%) | 34(48.6%) | 0.13** |
Less than Diploma | 7(20%) | 6(17.1%) | 13(18.6%) | ||
Diploma | 7(20%) | 8(22.9%) | 15(21.4%) | ||
University Student | 1(2.9%) | 7(20%) | 8(11.4%) | ||
Marital Status | Single | 7(20%) | 9(25.7%) | 16(22.9%) | 0.43** |
married | 28(80%) | 26(74.3%) | 54(77.1%) | ||
History of another disease due to diabetes | No | 7(20%) | 15(42.9%) | 22(31.4%) | 0.04** |
Yes | 28(80%) | 20(57.1%) | 48(68.6%) | ||
History of hospitalization | 0 | 11(31.4%) | 14(40%) | 25(35.7%) | 0.52** |
1 | 6(17.1%) | 9(25.7%) | 15(21.4%) | ||
2 | 10(28.6%) | 6(17.1%) | 16(22.9%) | ||
3 | 8(22.9%) | 6(17.1%) | 14(20%) | ||
History of hospitalization due to diabetes | 0 | 27(77.4%) | 33(94.3%) | 60(85.7%) | 0.12** |
1 | 5(14.3%) | 1(2.9%) | 6(8.6%) | ||
2 | 3(8.6%) | 1(2.9%) | 4(5.7%) | ||
Family history of diabetes | No | 7(20%) | 16(45.7%) | 23(32.9%) | 0.02** |
Yes | 28(80%) | 19(54.3%) | 47(67.1%) | ||
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According to the mean scores of health-promoting behaviors in the two groups before the intervention, there was no statistically significant difference between the two groups (p = 0.77).
However, the results of the between-group comparison using the independent t-test showed that there was a statistically significant difference in the mean scores of health-promoting behaviors between the control and intervention groups immediately after the intervention and 3 months after the intervention (p < 0.05). The results of the within-group comparison using the repeated measures ANOVA with adjustment for the effects of gender and duration of diabetes showed that the mean scores of health-promoting behaviors in the intervention group were significantly different between the three time points (before, immediately after, and one month after the intervention) (p = 0.012), but not in the control group (p = 0.29) (Table 2).
Table 2
Mean scores of health-promoting behaviors and life satisfaction before, immediately after, and three months after the intervention in the intervention and control groups
Variable | Groups | Before intervention | Immediately after intervention | Three months after intervention | p-value |
|---|---|---|---|---|---|
Health-promoting behaviors | Intervention Group | 109.1 ± 16.92 | 133.2 ± 22.94 | 139 ± 12.40 | 0.012 |
Control Group | 109.4 ± 9.81 | 123.31 ± 13.75 | 124.77 ± 12.69 | 0.29 | |
p-value | 0.77 | 0.008 | < 0.001 | ||
Life satisfaction | Intervention Group | 16.43 ± 5.48 | 23.60 ± 3.28 | 25.29 ± 2.88 | < 0.001 |
Control Group | 15.57 ± 3.61 | 22.06 ± 2 | 22.8 ± 2.17 | 0.23 | |
p-value | 0.29 | 0.011 | < 0.001 |
According to the mean scores of life satisfaction in the two groups before the intervention, there was no statistically significant difference between the two groups (p = 0.29). However, the results of the between-group comparison showed that there was a statistically significant difference in the mean scores of life satisfaction between the control and intervention groups immediately after the intervention (p = 0.011) and 3 months after the intervention (p = 0.001). The results of the within-group comparison using the repeated measures ANOVA with adjustment for the effects of gender and duration of diabetes showed that the mean scores of life satisfaction in the intervention group were significantly different between the three time points (before, immediately after, and one month after the intervention) (p = 0.001); however, there was no statistically significant difference in the control group (p = 0.23) (Table 2).
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To investigate the relationship between the mean scores of health-promoting behaviors and the mean scores of life satisfaction before, immediately after, and three months after the educational intervention in and between the control and intervention groups, the multivariate repeated measure analysis of covariance (ANCOVA) was used. With the adjustment of the effects of gender, duration of diabetes, family history of diabetes, and history of other diseases, the two variables of health-promoting behaviors and life satisfaction were simultaneously entered into the model. The simultaneous comparison showed that there was a statistically significant difference between the control and intervention groups in terms of the health-promoting behaviors variable (p = 0.001). However, there was no statistically significant difference between the control and intervention groups in terms of life satisfaction (p = 0.21). This result showed that the effect of the educational program based on King’s goal attainment model was only able to affect health-promoting behaviors over the course of the intervention, and had no effect on life satisfaction. The simultaneous comparison also showed that in the intervention group, time had an effect on health-promoting behaviors (p = 0.012) and life satisfaction (p = 0.012), but it did not have an effect in the control group (Table 3; Fig. 2).
Table 3
Correlation between the mean score of health-promoting behaviors and the mean score of life satisfaction before, immediately after, and three months after the educational intervention in and between the control and intervention groups
Health-promoting behaviors | Life satisfaction | |||||
|---|---|---|---|---|---|---|
Groups | Before intervention | Immediately after intervention | Three months after intervention | Before intervention | Immediately after intervention | Three months after intervention |
Intervention | 109.1 ± 16.92 | 133.2 ± 22.94 | 139 ± 12.40 | 16.43 ± 5.48 | 23.60 ± 3.28 | 25.29 ± 2.88 |
Control | 109.4 ± 9.81 | 123.31 ± 13.75 | 124.77 ± 12.69 | 15.57 ± 3.61 | 22.06 ± 2 | 22.8 ± 2.17 |
Effect of time in the intervention group | P = 0.012 | P = 0.001 | ||||
Effect of time in the control group | P = 0.31 | P = 0.14 | ||||
Effect of group over time | P = 0.001 | P = 0.21 | ||||
Fig. 2
Correlation between the mean score of health-promoting behaviors and the mean score of life satisfaction before, immediately after, and three months after the educational intervention in the control and intervention group
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Discussion
This study was conducted to investigate the effect of an educational program based on King’s goal attainment model [8] on health-promoting behaviors and life satisfaction in patients with type 2 diabetes. The findings of the study showed that there was a significant difference in the mean score of health-promoting behaviors between the control and intervention groups immediately and 3 months after the intervention, and in the mean score of life satisfaction immediately and 3 months after the intervention.
In the intervention group, the mean score of health-promoting behaviors improved immediately after the intervention compared to before the intervention, three months after the intervention compared to before the intervention, and three months after the intervention compared to immediately after the intervention. In the control group, the mean score of health-promoting behaviors also changed and improved immediately after the intervention compared to before the intervention, and three months after the intervention compared to before the intervention. However, there was no change between three months after the intervention and immediately after the intervention. The control group also received routine diabetic patient interventions based on the Iran Ministry of Health and Medical Education (MOHME) guidelines during the intervention.
A review of the literature showed that there have been studies on the effect of educational programs based on King’s goal attainment model on health-promoting behaviors scores, which are consistent with the results of the present study. In the study by Carotta et al. (2020), the use of King’s theory to improve self-care behaviors in diabetic patients was investigated. They showed in this study that nurse-patient interactions based on King’s theory can be appropriate for improving the self-care perception and behaviors of diabetic patients aged 21–59 in the primary care setting [29]. While the present study emphasizes the importance of King’s goal attainment theory, it was conducted as a descriptive cross-sectional study, and patients’ self-care perception and behavior were assessed using the Diabetes Self-Care Activities Summary and an assessment tool based on King’s goal attainment theory. In contrast, the present study was an interventional study based on King’s goal attainment theory, and in addition to health-promoting behaviors, patient satisfaction was also assessed, Peyamani et al. et al. (2023) examined the effect of using the nursing process based on the goal attainment theory on the daily living activities and quality of life of people with multiple sclerosis during the COVID-19 pandemic. They showed in their study that the goal attainment theory can effectively promote the achievement of mutual goals, quality of life, and daily living activities of MS patients during the COVID-19 pandemic [38]. The study by Khalili et al. (2023) examined multiple sclerosis as a chronic disease with similarities to diabetes and the need for long-term care to manage complications. Similar to the present study, their study used an intervention based on the goal attainment theory, but the duration of the intervention and the timing of data collection were different. They conducted the intervention for one month and collected data before and two months after the intervention. In a study by Karimy et al. (2015), the design and implementation of an educational program based on the empowerment model had a positive effect on health-promoting behaviors and their dimensions [39]. Their study was based on the individual empowerment model and was conducted during menopause using a researcher-made instrument. In contrast, the educational program based on King’s goal attainment model was more comprehensive and, in addition to individual empowerment, led to improved interpersonal relationships, self-perception, and interactive performance of patients. Their study was conducted on 90 menopausal women (45 in each group) and differed in terms of demographics, duration of intervention, and timing of data collection. Their intervention consisted of 5 educational sessions in the form of group discussion, and a post-test was conducted three months after the education. In contrast, the present study was conducted through 7 one-hour sessions in the form of group discussion, educational pamphlets, lectures, and educational PowerPoint presentations.
The results of the present study are not in line with the results of the study by Peyamani et al. (2023). In the study by Peyamani et al. (2023), the use of the nursing process based on the goal attainment theory on activities of daily living and quality of life in people with multiple sclerosis during the COVID-19 pandemic was investigated. They showed that the implementation of the nursing process based on the goal attainment theory did not have a statistically significant difference on the patient’s activities of daily living such as bathing, self-care, eating, toileting, in multiple sclerosis. However, it was effective on the activities of using the telephone, carrying medication, preparing food, housekeeping, shopping, using transportation, and managing income and expenses. Their study was conducted on 70 MS patients (35 in each group), but differed in terms of the data collection tool. These results may be due to the level of ability of the patients. The patients in their study were able to perform activities such as bathing, self-care, eating, toileting, and self-restraint [38]. Becker et al. (2009) [40] in their study entitled “Using Goal Attainment Scaling to Facilitate and Evaluate Individual Change in a Health Intervention for Women with Fibromyalgia Syndrome” showed that the Goal Attainment Scaling, an individually set criterion for change, can effectively capture behavioral changes associated with a health promotion intervention. Their study was different from the present study in terms of sample size (92 participants) and data collection at more time points (immediately after the 8-week classes, at the midpoint and end of the telephone support period, and 3 months later). The majority of women had reached their health promotion goals at 5 months (at the end of the telephone follow-up and 3 months after the end of the classes), with the exception of physical activity, which is consistent with the results of the present study. The lack of success in the area of physical activity was related to changes in their environment over the course of the study. Women who had initially chosen walking as their physical activity switched to swimming when the weather became too hot. It seems that these factors should be considered when setting the time frame for measurement.
The present study showed that the educational program based on King’s goal attainment model had a significant effect on the health-promoting behavior score in the intervention group. The health-promoting behavior score in the control group also improved immediately and three months after the intervention compared to before the intervention. Although the patients in the control group did not participate in the educational intervention sessions and did not receive the necessary education about the disease, it seems that the reason for the effectiveness in the control group can be attributed to the impact of routine education and guidance provided to patients with type 2 diabetes [41, 42]. It is also possible that during the study period, patients received diabetes education from various sources such as the media, health centers, and relatives, which was beyond the control of the researcher. Therefore, it can be said that the continuity and follow-up of education plays a significant role in promoting health-promoting behaviors in the intervention group. It is worth noting that in the present study, most of the participants had a primary level of education and were elderly, which could have made it difficult for them to understand the care required to control the disease and prevent complications.
The findings of the study showed that the effect of the educational program based on King’s goal attainment model on the life satisfaction score was significant immediately and three months after the educational intervention between the control and intervention groups. The effect of the educational program based on King’s goal attainment model on the life satisfaction score was also significant immediately and three months after the educational intervention in the intervention group, but not in the control group. A review of previous studies showed that few studies have been conducted on the effect of an educational program based on King’s goal attainment model on life satisfaction. Consistent with the results of the present study, the study by Didarloo et al. (2016) [43] showed that the goal attainment theory can effectively improve the quality of life of patients. It can be said that life satisfaction is defined as an overall assessment of an individual’s quality of life [44], and that a change in quality of life can in turn lead to an improvement in life satisfaction. The results of the present study showed that the effect of the educational program based on King’s goal attainment model was only significant on health-promoting behaviors over the course of the intervention, and was not significant on life satisfaction. This result suggests that the educational program based on King’s goal attainment model, while improving health-promoting behaviors, was not able to improve the life satisfaction of patients.
No similar studies were found that simultaneously examined health-promoting behaviors and life satisfaction. However, Tuncay et al. (2020) in their study entitled “The Relationship between Self-Care Management and Life Satisfaction in Diabetic Patients” showed that diabetes self-care management was significantly associated with life satisfaction levels [45]. This study was different from the present study in terms of the type and method of study. Their study was conducted as a cross-sectional correlation study. On the other hand, in the present study, the effect of time simultaneously affected health-promoting behaviors and life satisfaction in the intervention group, but not in the control group. It seems that one of the reasons for this is the intervention based on the educational program based on King’s goal attainment model, which improved health-promoting behaviors and improved patients’ self-care. However, no intervention was performed in the control group.
Chloubová et al. (2019) in their study examined the use of Imogene King’s nursing model in the care of patients with cardiac arrhythmias. They showed that the model had an effect on the respondents’ state of subjective perception, mental state, and emotions. They also showed that assessing the perceived quality of life of patients with arrhythmias using King’s interaction model enables nurses to view and plan the patient from a holistic perspective and provide individualized care [46]. One of the reasons for the difference can be attributed to the effective nurse-patient relationship in patients with cardiac arrhythmia. According to King’s model, an effective nurse-patient relationship helps nurses to understand the patients’ conditions, increase the quality of care, and improve the patients’ quality of life [24].
The educational program based on King’s goal attainment model appears to be a powerful tool in the nursing process, primarily because it provides effective communication with the patient and has been shown to improve health-promoting behaviors. The study contributes to the scientific knowledge of the application of King’s goal attainment theory in the context of nursing diagnoses. On the other hand, an important point of this theory is the participation of the patient in the determination of common goals and the care plan. By establishing patient-nurse interaction and active patient participation in nursing care, patients were able to share their questions, concerns, and worries with the researcher and their misunderstandings about the disease and its complications were addressed [24]. Through telephone follow-ups, the patient and their family were able to ask the researcher any questions they had for up to three months after the intervention. Additionally, by employing this theory as an effective nursing intervention, the costs of repeated visits to healthcare centers and readmissions can be reduced, and treatment side effects can be mitigated [38]. Consequently, patients’ trust in self-care during the treatment process can be increased. Considering the shortcomings of traditional education and the provision of routine education based on clinical guidelines, it is expected that patients’ active role in understanding and managing their disease will be considered, and the effectiveness of the goal attainment theory in active patient participation in disease management will be clarified, leading to increased patient independence [38]. In the case of individuals with chronic and long-term diseases, including diabetes, empowering and activating them to take a more active role in maintaining health and healthcare is of great importance. This person-centered approach to healthcare is recognized as a key framework in the management of long-term diseases. To effectively manage a long-term condition, individuals need to be able to actively participate in treatment decision-making, prevent complications, and manage risk factors. Identifying an individual’s level of activation can help guide and tailor care, and interventions aimed at increasing patient activation can improve patient engagement and health outcomes [47].
However, this study faced some limitations. First, the extent to which patients achieved their goals was not calculated due to the increased number of questionnaire items and participant fatigue. Therefore, it was unclear to what extent patients were able to achieve most of their prioritized goals, and using the King’s questionnaire would have addressed this limitation. Second, another limitation of this study was the time constraint. Health-promoting behaviors and life satisfaction are variables that require more time to be examined over time.
It appears that the implementation of the educational program based on King’s goal attainment model has led to the development of interpersonal relationships, improved self-perception, and interactive performance of patients. This theory can lead to an improvement in the patient’s health status and hospital quality indicators. Therefore, nurses can increase the effectiveness of nursing care by using patient-centered care protocols based on King’s theory [48]. It seems that a nurse-led educational program with an individual goal-oriented approach can be easily integrated into the current medical treatment system to achieve more effective lifestyle modification [49].
The present study investigated two variables, health-promoting behaviors and life satisfaction in patients, which is considered an innovation in its own right. Therefore, given the simplicity and comprehensibility of King’s goal attainment theory, it can be applied to type 2 diabetes. On the other hand, the participation and presence of patients in diabetes follow-up and registry programs, participation in diabetes association programs, or the presence of individuals with health specialties in the family or health literacy of individuals may affect the results of the study. The researcher was unable to control them due to the large population and limited time. It is suggested that special attention be paid to them in future studies.
Conclusion
The results suggest that the implementation of an educational program based on King’s goal attainment model has an effect on health-promoting behaviors and life satisfaction in patients with type 2 diabetes. Therefore, it is recommended that further studies be conducted on other patients with type 2 diabetes in different locations and with a longer follow-up period. It is also suggested that future studies investigate the effect of an educational program based on King’s goal attainment model on health-promoting behaviors and life satisfaction in other chronic diseases such as hypertension, chronic obstructive pulmonary disease, chronic kidney disease, etc., and with multimedia education.
Acknowledgements
The authors appreciate Fasa University of Medical Sciences for financially supporting this research. Also, authors would like to appreciate Fasa University of Medical Sciences & Clinical Research Development Unit of Fasa Valiasr hospital for financially supporting this research.
Declarations
Ethics approval and consent to participate
This study adhered throughout to the principles outlined in the revised Declaration of Helsinki. This internationally recognized statement provides ethical guidance for physicians and researchers conducting human subject research. Written informed consent was obtained from all participants. This ensured their comprehension of the study’s nature and their right to withdraw at any point. Confidentiality of participants’ personal information was guaranteed. Furthermore, participants were explicitly informed about the measures taken to ensure anonymity and confidentiality of their data. For added ethical oversight, approval for the study was granted by the Research Ethics Committees of Fasa University of Medical Sciences, Fars, Iran (code :IR.FUMS.REC.1401.124).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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