Effects of Nursing Intervention Based on Transtheoretical Model of Behavioral Change on Disposal of Home Medical Waste in Diabetic Patients

Ziwen XIE, Yan ZHAN, Hao ZHANG, Shuzhen ZHU

1. Hubei University of Medicine, Shiyan 442000, China; 2. Affiliated Taihe Hospital of Hubei University of Medicine, Shiyan 442000, China; 3. First People’s Hospital of Xiantao City, Xiantao 433000, China

Abstract [Objectives] To explore the effects of nursing intervention on the disposal of home medical waste for diabetic patients. [Methods] A total of 118 diabetic patients with insulin injection at home who visited a community service center in Shiyan City during November 2020 and September 2021 were selected as the research objects to implement the intervention, and the medical waste knowledge, attitude scores and standardized medical waste disposal were compared before and after the intervention. [Results] After the intervention, the patient’s medical waste knowledge score was significantly higher than that before the intervention, and the medical waste disposal attitude score was significantly higher than that before the intervention. [Conclusions] If the nursing intervention based on Transtheoretical Model (TTM) of Behavioral Change penetrates deep into patients’ families and communities, it is helpful to improve the knowledge and attitude of diabetic patients on home medical waste disposal, and regulate their home medical waste disposal behavior.

Key words Diabetic patients, medical waste, Disposal, Intervention research

1 Introduction

In China, the vast majority of diabetic patients have not received education on medical waste disposal and do not know the correct way to dispose of medical waste; more than 90% of patients directly mix medical sharps into home waste, while improper disposal of home medical waste will pose a potential threat to public health and environmental safety, and may also cause the spread of blood-borne diseases[1-6]. The 2016 edition of theChinaDiabetesDrugInjectionTechnicalGuidelinesclearly pointed out that medical staff should teach patients how to properly dispose of discarded injection equipment; medical institutions at all levels in China pay more attention to the health education of diabetic patients, but ignore the education related to the disposal of home medical waste[7]. In view of this, based on the Transtheoretical Model (TTM) of Behavioral Change, in conjunction with family doctors in the community, we implemented structured health interventions on the research subjects to explore the impact of nursing interventions on the diabetic patients’ home medical waste disposal behavior, so as to provide a certain reference for formulating home medical waste management and disposal strategies.

2 Data and methods

2.1 General dataWe selected 118 diabetic patients with insulin injection at home who were outpatients or established family doctor files in a community service center in Shiyan City during November 2020 and September 2021, including 47 males and 71 females; aged 32-82 years old, with an average (63.29±10.63) years old. There were 48 cases with educational level of primary school and below, 24 cases of junior high school, and 46 cases of senior high school and above. Insulin injection time: 10 cases were <1 year, 61 cases were 1-5 years, and 47 cases were >5 years. The course of diabetes was 0.5-30 years, with an average of (9.53±6.28) years. Only 8 patients received education on medical waste disposal. This research was reviewed and approved by the Medical Ethics Committee of the Affiliated Taihe Hospital of Hubei University of Medicine (approval number: 2022KS005).

Inclusion criteria: (i) Diagnosed diabetes patients who need to inject insulin at home and/or monitor blood glucose at home for more than one month. (ii) Diagnosed diabetic patients who need home insulin injection and/or home blood glucose monitoring care (investigate their caregivers when patients cannot complete insulin injections by themselves). (iii) Diabetic patients who have normal understanding and communication skills. (iv) Voluntary participants. Exclusion criteria: (i) Those with other serious diseases such as heart disease and kidney disease, or those with acute complications of diabetes requiring hospitalization; (ii) those with mental and psychological diseases; (iii) those with gestational diabetes who gave birth recently (less than 6 months); (iv) Those who do not cooperate with the study and drop out.

2.2 Research tool

2.2.1Intervention strategies. (i) Establishing the research team: establish a health education expert team for the standardized disposal of home medical waste for diabetic patients (one principal investigator, one diabetes doctor and one nurse, one family doctor and one nurse, and one doctor of infection department). The members of the expert team reviewed the literature and based on theRegulationsontheAdministrationofMedicalWastes(2003 version), theChinaDiabetesDrugInjectionTechnicalGuidelinespublished by the Chinese Diabetes Society of the Chinese Medical Association (CMA) in 2016, and the guidelines on home medical waste disposal published by the US CDC and EPA,etc., to formulate home medical waste disposal health education courses, atlases, and home medical waste disposal record sheets to ensure the scientificity and effectiveness of the courses.

(ii) We formulated the intervention program based on the Transtheoretical Model (TTM) of Behavioral Change. The Transtheoretical Model (TTM) of Behavioral Change was originally developed by American psychologist James Prochaska and his colleagues, based on social psychology, and focused on the behavioral change process and psychological needs of the subjects[8]. The TTM operates on the assumption that people do not change behaviors quickly and decisively. Rather, change in behavior, especially habitual behavior, occurs continuously through a cyclical process. According to the TTM, individuals move through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination[9]. This theory has been confirmed in a number of studies, and it can effectively improve the self-management level of patients, and is conducive to promoting the change of patients’ knowledge-belief-behavior[10-11].

2.2.2Evaluation indicators. (i) Scores on knowledge and attitudes of home medical waste disposal for diabetic patients: we seelcted the questionnaire for home medical sharps disposal of diabetic patients revised by Professor Ajit. Among them, there are a total of 13 items in the knowledge of patients’ home medical sharps disposal. In the positive items, if choosing a complete error, 1 point will be scored, and if making a mistake, 0 point will be scored; negative items are on the contrary, with a total score of 0-13 points, a score of ≤6 points indicates a low level of patient knowledge, 7-9 points are a medium level, and a score of 10 and above indicates that the patient’s knowledge of home medical waste disposal is good. The attitudes of home medical waste disposal were surveyed using the Likert 5-point scoring method: 1 stands for "strong disagree" and 7 means "strongly agree". Among them, the positive items are respectively 1-5 points, the negative items are the opposite, the total score is 12-60 points. Patients with a score of ≤34 points had low knowledge, patients with a score of 35-43 points were at medium level, and patients with a score of 44 points and above had high level of attitudes of home medical waste disposal. The Cronbach’s α coefficient of this scale was 0.74, and it has been proved to be a simple and effective tool for the evaluation of knowledge-attitude-practice (KAP) of home medical sharps disposal of diabetic patients.

(ii) The recovery of discarded needles of patients and the proportion of them brought back to the hospital for disposal. Expert team members jointly designed a home medical waste disposal record card and issued it to the participants. When patients bring the discarded needles back to the hospital for disposal, and when the family doctor visits the home for recycling or the researcher visits the home for recycling, it is necessary to check whether the patient’s home medical waste disposal record card matches the actual number of discarded needles.

3 Results and analysis

3.1 Comparison of knowledge scores on home medical waste disposal of patients at different time points before and after interventionWe used the repeated measures analysis of variance to analyze the differences in the knowledge of home medical waste disposal before the intervention, 4, 12, and 24 weeks after the intervention. The data did not meet the hypothesis of the Mauchly’s test of sphericity and were corrected using the Gernehuose-Geisser method. The results of this study showed that the knowledge scores of the patients at four repeated measurement time points (F=708.848,P=0.000), indicating that the knowledge scores before the intervention, 4, 12, and 24 weeks after the intervention were significantly different (P<0.05). We measured the patient knowledge scores at different time points, and showed a pairwise comparison of time points: At 4, 12, and 24 weeks after the intervention, the patient’s knowledge score was significantly improved compared with before the intervention, and the difference was statistically significant. Especially at the 4 weeks after the intervention, compared with that before the intervention, the knowledge score of the patients improved most significantly. At 12 weeks after the intervention, compared with the data at 4 weeks after the intervention, patients’ knowledge scores were improved, and the difference was statistically significant. With the passage of the intervention time point, the knowledge scores of the patients at 24 weeks after the intervention and 12 weeks after the intervention were in a stable state, and the difference was not statistically significant (P>0.05), as shown in Table 1.

Table 1 Repeated measures analysis of variance for medical waste disposal knowledge scores of patients

We used the repeated measures analysis of variance to analyze the differences in the knowledge of home medical waste disposal before the intervention, 4, 12, and 24 weeks after the intervention. The data did not meet the hypothesis of the Mauchly’s test of sphericity and were corrected using the Gernehuose-Geisser method. The results of this study showed that the attitude scores of the patients at the four repeated measurement time points were (F=1142.367,P=0.000), indicating that there were statistically significant differences in the attitude scores before the intervention, 4, 12, and 24 weeks after the intervention (P<0.05), as shown in Table 2.

Table 2 Repeated measures analysis of variance for medical waste disposal attitude scores of patients

3.2 Comparison of patients’ home medical waste disposal practicesBefore the intervention, only one patient put the discarded insulin needle in the alcohol bottle and discarded it in the domestic waste. At 1, 3, and 6 months after the intervention, 75 (63.5%), 82 (69.4%), and 66 (55.9%) patients discarded discarded needles in sharps storage boxes or other hard storage containers (such as mineral water bottles, alcohol bottle, milk bottle). These indicated that after the intervention, the proportion of patients who put sharps in the storage box gradually increased, and the difference with that before the intervention was statistically significant, as shown in Table 3. Before the intervention, no patient brought the discarded insulin needles back to the hospital for standardized terminal disposal. At 1, 3, and 6 months after the intervention, through outpatient follow-up of patients in community health service centers, collection of family doctors’ home visits, and home visits by researchers, 72 (61.0%), 76 (64.4%) and 61 (51.6%), respectively of the patients’ discarded needles could be brought back to community for disposal. These indicated that after the intervention, the proportion of patients who brought medical sharps back to hospitals for disposal gradually increased, and the difference with that before the intervention was statistically significant, as shown in Table 4.

Table 3 Comparison of patients’ waste needles placed in storage boxes at different time points

Table 4 Comparison of patients’ disposal of discarded needles brought back to community outpatient clinics at different time points

4 Discussion

4.1 Intervention of home medical waste disposal of diabetic patients can improve their scores of knowledge and attitude of home medical wasteThe results in Tables 1 and 2 show that at 4, 12, and 24 weeks after intervention, the scores of patients’ knowledge and attitude of home medical waste disposal were significantly improved. Compared with that before the intervention, the results were statistically different (P<0.05). These are similar to the research results of Tong Guanyingetal.[6], Wang Cuilingetal.[11], proving that the home medical waste disposal intervention can improve the patient’s knowledge score and attitude score of home medical waste disposal. In this study, we found that the effect of the intervention was better in one and three months after the intervention, and tended to be stable in six months after the intervention. The longer the intervention time, the more patients’ acceptance of knowledge and the formation of medical waste disposal habits were in a stable state. During the intervention, relevant education was provided through health education lectures, distribution of brochures, online WeChat popularization and family doctor home visits, which improved patients’ knowledge and attitude scores. However, in the survey, we found that only a small number of patients had received education related to home medical waste disposal. In the education of diabetic patients, more attention was paid to the education of insulin and blood glucose monitoring methods, but the education on how to dispose of home medical waste was ignored[12]. This suggests that healthcare workers should play an important role in the education of diabetes patients.

4.2 Practice analysis on home medical waste disposal of diabetic patientsIn this study, we found that 72 (61.0%), 76 (64.4%) and 61 (51.6%) of the 118 patients were able to bring the sharps storage box back to the hospital for standardized disposal at one, three, and six months after the intervention. Compared with that before the intervention, the recovery rate of sharps boxes was greatly improved, but the recovery rate did not reach the ideal state. First, in China, the management of home medical waste is temporarily in a blank area. For the time being, there is no independent collection of home medical waste, nor is there a normative disposal of home medical waste. Patients have formed long-term wrong cognitions and habits. Second, some patients feel that it is not convenient to collect them in storage boxes and bring them back to the hospital for disposal, and they also worry about personal privacy. In addition, the roles and main responsibilities of personnel at all levels of society should be clarified, and the synergistic role of the main bodies at all levels should be brought into full play.

Based on the community, we adopted a phased home health education model to intervene in diabetic patients and achieved good effects. Besides, family doctors also included health education on disposal of home medical waste during home visits, and observed whether the patient’s medical waste was disposed of correctly in the home environment. This is the innovation of our study. It is hoped that the relevant departments will pay attention to the problem of the disposal of home medical waste for diabetic patients, strengthen publicity efforts, and provide patients with a convenient, economical and environment-friendly medical waste recycling and disposal model. In the free distribution of diabetic patients’ storage boxes and needle exchange rewards, there will be fund issue, which should be further discussed. Furthermore, this study was only carried out in the urban community health service center, and the research should be expanded in future.