THE EFFECT OF COGNITIVE BEHAVIORAL THERAPY ON THE SELF- MANAGEMENT AND SELF-CARE BEHAVIOR OF TYPE 2 DIABETES MELLITUS PATIENTS

Diabetes mellitus (DM) is a metabolic condition characterized by chronic hyperglycemia (the increase of glucose levels in the blood) caused by an insulin secretion defect. One of the non-pharmacological therapies used to decrease the symptoms of type 2 DM is cognitive-behavioral therapy. The research objective was to identify the effect of cognitive behavior therapy (CBT) on the selfmanagement and self-care behavior of type 2 DM patients. The research used a quasi-experimental method with a two-group pretest-posttest design. The samples were 70 respondents, 35 of them being in the intervention group and the other 35 being in the control group, taken using a consecutive sampling technique. The data were gathered using the Diabetes Self-Management Questionnaires (DSMQ) and the Summary of Diabetes Self-Care Activities (SDSCA) questionnaires. The gathered data were analyzed by using the paired t-test and independent t-test. The study results showed significant differences in the mean scores of selfmanagement and self-care behavior between the intervention group (t=13.24; p=0.00) and the control group (t=14.63, p=0.00), respectively. It is recommended that cognitive behavior therapy be used as one of the non-pharmacological therapies to change self-care behavior in type 2 DM patients. Received: 11 October 2020 Revised: 10 February 2021 Accepted: 4 March 2021


INTRODUCTION
Diabetes mellitus (DM) is a metabolic condition characterized by the occurrence of chronic hyperglycemia (the increase of blood sugar levels) caused by defective insulin secretion. Hyperglycemia is followed by acute symptoms, such as extreme dehydration, fatigue, and frequent urination. The data from (Atlas, 2015) estimates that the incidence of type 2 DM is higher than the incidence of type 1 DM. During 2015-2018, the incidence of type 2 DM reached 415 million patients from several countries, including the United States of America with a prevalence of around 10-15%, Caucasia 4-6%, and Africa 2-4%. It is estimated that, by 2040, the incidence of type 2 DM will increase to 642 million people in the world.
According to (Dany et al., 2020), the prevalence of diabetes mellitus in Indonesia is around 3.4% of the total population, or around 265 million people. In Southeast Asia, Indonesia is ranked second with the incidence rate of diabetes mellitus at 8.4 million people, and it is projected to increase 2.5 times or to around 21.2 million people annually.
A survey by Basic Health Research showed that the number of type 2 DM patients in North Sumatra was at 1.4% of the population (Milita, Handayani, & Setiaji, 2021). The highest incidences were in Deli Serdang Regency (1.9%), Medan City (1.7%), Langkat Regency (1.8%), Simalungun Regency (1.6%), and Asahan Regency (1.5%) (Wijaya, 2019). Meanwhile, in Medan, the total number of type 2 DM patients is ranked third after hypertension and coronary heart disease (CHD), with the highest prevalence from each area existing in North Sumatra. The data originating from the Health Agency of Medan in 2017 showed that from 39 community health centers in Medan, the total number of type 2 DM patients that underwent treatment was 20,103 people (Rini, Afriadi, & Purnomo, 2019).
The increased prevalence of type 2 DM is caused by the failure of someone to perform self-care in daily life, such as poor self-management and self-control, no regularities, and no self-discipline to prevent type 2 DM (Zai et al., 2019). Cognitive-behavioral therapy is a psychotherapy that changes the process of an individual's maladaptive mindset (cognitive distortion) and overreactions (Elliott, 2012). The goal of CBT intervention is to help an individual to change irrational cognition into rational cognition. CBT consists of 8-12 sessions or more, where the patient is led to learn how to identify and change thoughts that are having a bad impact on behavior. Therefore, CBT can improve patients' self-care behavior with type 2 DM (Daniels, 2015).
Self-management is a psychiatric therapy that can change the process of an individual's thought patterns (cognitive), which are maladaptive and improve an individual's behavior (Daniels, 2015). Self-management aims to increase the patient's participation, involvement, and activation in positive health behaviors by facilitating knowledge, skills, and abilities to increase self-care competence (Davies et al., 2018). The existence of self-management combined with CBT intervention will lead to a patient's self-care behavior. Good self-care behavior in type 2 DM patients includes a healthy diet, physical activity, blood sugar level control, drug management, foot treatment, and not smoking (Eid et al., 2018a).
The purpose of this study was to examine the effect of CBT on the self-management and self-care behavior of Type 2 Diabetes Mellitus patients at Padang Bulan Health Center and Puskesmas Teladan, Medan City.

Study Design
This study was a quantitative study using a quasiexperimental design.

Participant
This study's population was all type 2 DM patients in Padang Bulan Community Health Center and Teladan Community Health Center, Medan, with 70 types 2 DM respondents conducted between October and November 2020. This study's respondents were 35 respondents; each group was calculated using power analysis and consecutive non-probability sampling (Delİce, 2001). The sample size was calculated based on a previous study (Adib Hajbaghery, Nabizadeh-Gharghozar, & Bolandianbafghi, 2019). They reported that the mean and the standard deviation of pre and post-intervention were 2.96 ± 1.01 and 2.18 ± 1.10. Despite this, the subjects in the intervention group still followed the DM protocol therapy as well.

Instruments
The study instruments were the Diabetes Self-Management Questionnaire (DSMQ) and the Summary of Diabetes Self-Care Activities (SDSCA). It was validated by three experts from the Faculty of Psychology and Universitas Sumatera Utara Hospital. The DSMQ consisted of 14 items, and the SDSCA was composed of 14 items. The instruments of the DSMQ and SDSCA had a good content validity index (0.94 and 0.97, respectively). Meanwhile, the reliability of the DSMQ was 0.86 and for the SDSCA was 0.74.

Intervention
The CBT intervention consisted of 5 sessions where each session was 30 minutes to 1 hour in duration. The intervention was conducted for four weeks. The researchers used several methods to perform the intervention: education, exercise, discussion, and role-play.

Data Collection
Data were collected in Padang Bulan Community Health Center and Teladan Community Health Center, Medan, conducted between October and November 2020.

Data Analysis
Data were analyzed using a computer software. Descriptive statistics (e.g., mean, median, frequencies, and standard deviation) were used to describe the study variables. The paired sample t-test and independent sample t test were employed to asses differences of self management and selfcare behavior between intervention and control group. The level of statistical significance for statistical analysis was at 0.05.

Ethical Consideration
This study gained ethical approval from the Health Research Ethics Committee of the Faculty of Nursing, University of Sumatera Utara (No. 1891/VIII/SP/2019). the intervention and control groups. Based on the education level, the majority of the respondents in the intervention group (37.1%) were high school graduates (13 people), and the total in the control group was 17 people (48.6%). By occupation, the majority were categorized as housewives, both in the intervention group and the control group were 23 people (65.7%). The respondents' income in the intervention group and the control group was more than IDR 1,500,000, and the total was 70 people (100%). The responses from 35 people (100%) in the intervention group suffered from type 2 DM for more than three years. Similarly, the control group respondents or 35 respondents (100%) also suffered from type 2 DM for more than three years.  Table 2, the mean score of self-management in the intervention group was 20.54 and 4.13 for SD, while in the control group, it was 21.11 for the mean score and 3.19 for SD. Also, the mean score for self-care behaviors in the intervention group was 42.86 and 7.50 for SD, while the control group had 42.77 for the mean score and 7.50 for SD.

RESULT
Therefore, it could be concluded that there was no difference in the mean score of self-management (t=-0.65; p=0.52) and self-care behaviors (t=0.05; p=0.96) between the intervention group and the control group before applying the self-management-based CBT.  Table 3 shows that the mean score of self-management (mean=47.37; SD=3.68) and self-care behavior (mean=78.20; SD=11.17) in the intervention group was higher after participating in the self-management-based CBT program than in the control groups. This result indicated that there was a difference between the mean score of self-management and self-care behaviors in the intervention group before and after the treatment (t=-193.09; p=0.00 and t=-55.42; p=0.00).  Table 4 depicts that the mean score of self-management (mean=47.37; SD=3.67) and self-care behaviors (mean=78.20; SD=11.17) in the intervention groups were higher than those in the control group. There were significant differences in the mean score of selfmanagement (t=13.24; p=0.00) and self-care behavior (t=14.63; p=0.00) between the two groups.

DISCUSSION
After participating in the self-management-based CBT intervention, self-care behaviors in intervention group and control group can be seen from the statistical result. It shows that the intervention group's score was higher after participating in the program (mean=74.57; SD=13.32) than the score before (mean=42.86; SD=7.61).
Meanwhile, the control group's self-care behavior score was higher after participating in the self-management-based program (mean=45.37; SD=8.229) than the score before (mean=42.77; SD=7.50). This result shows a difference in the mean score of self-care behavior in the intervention group before and after the treatment (t=-20.590; p=0.00).
The mean scores of self-management and self-care behavior in intervention group were higher than those in the control group. This is because they received a structured form of CBT intervention. The respondents played active roles in participating in each session during the intervention. CBT can change people's attitudes and behaviors by focusing on the thoughts and beliefs (cognitive process) and how they are connected to how they behave. A study conducted by (Munshi, 2017) also supported the fact that the cognitive-behavioral model can significantly increase self-care behavior in patients from chronic diseases.
The study results show that CBT's implementation provided a significant influence on increasing self-care behavior in patients with hypertension. This is in line with a study conducted by (Eid et al., 2018b), which showed that CBT effectively decreases the severity of the diagnosis and changes the self-care behavior of type 2 DM patients. (Uchendu & Blake, 2017) claimed that cognitive-behavioral therapy significantly improved the self-care of maintaining blood glucose in the short term for patients with diabetes. There is a difference in self-care behaviors between the intervention and control groups before and after the selfmanagement-based CBT. The analysis results show that the score for self-care behaviors in the intervention group was higher (mean=78.20; SD=11.17) than the score before (mean = 47.71; SD = 5.19). The results found a difference in the mean score of self-care behaviors in the intervention and control groups after the treatment (t=14.63; p=0.00).
A study conducted by (Chernyak et al. 2010) showed that the CBT approach effectively decreased irrational belief and stress. The result is also in line with the health belief model theory in (Daniels, 2015), which stated that someone who has obtained information and skills related to their disease would have a good perception towards their disease, and will form and strengthen their self-care behavior, and this is especially true for type 2 DM patients. It can be concluded that cognitive-behavioral therapy effectively increases the awareness of type 2 diabetes patients of the importance of performing optimal self-care behavior in daily life.
According to Gratzer and Khalid-Khan (2016), CBT can be an effective therapy for various problems, such as anxieties, chronic pains, depression, sleep disorders, dietary problems, and other. (Yang, Li, & Sun, 2020) claimed that CBT effectively reduces the severity of the symptoms and improves both the psychological and physiological symptoms of diabetes mellitus. The method of CBT also plays an important role. Providing information about diabetes, monitoring blood sugar regularly, and making a list of healthy menus, specifically diabetes, can also improve the expected outcome results (Pan et al., 2020).
Chronic diseases, such as type 2 DM, need a patientcentered approach (patient empowerment), emphasizing a collaborative approach that facilitates better behavioral changes. It is relevant that CBT is an educational tool aimed at educating patients to be therapists for themselves and emphasizing preventive actions (Gonzalez et al., 2010). With a combination of education and counseling that involves active patient participation, CBT will help patients change behavior and think adaptively and improve skills to make decisions related to diabetes (Harvey, 2015).

Limitations of the Study
This study has some limitations. This study setting limited in two community health centers in Medan City. The study had relatively a small sample size. This study intersects with the Ministry of Health's for elderly program.

CONCLUSION AND RECOMMENDATION
Cognitive behavior therapy (CBT) positively impacts the self-management and self-care behaviors of type 2 DM patients. CBT improves people's attitudes and behaviors with type 2 DM by focusing on the thoughts and beliefs they hold (their cognitive processing) and how they are connected with the way they behave.
The health services should consider using accurate interventions, such as cognitive-behavioral therapy intervention, to maximize recovery and medical treatment programs. It can be done by providing training on CBT to the healthcare staff, especially nurses, and then collaborating with psychologists to support the recovery of type 2 DM patients optimally. For future studies, it is suggested to conduct a study with different respondents and to use different locations. It is also suggested that it be better to use measurement scales as instruments, such as observation sheets. The research assistant is required to support the success of interventions provided to patients in future studies. The use of a long time is required to get good intervention results given to respondents before and after the interventions.