Impact of Short Message Service (SMS) Education Based on a Health Promotion Model on the Physical Activity of Patients with Type II Diabetes

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1 Originl Article Impct of Short Messge Service (SMS) Eduction Bsed on Helth Promotion Model on the Physicl Activity of Ptients with Type II Dibetes Hmideh Lri 1, Azit Noroozi 1,2, Rhim Thmsebi 2,3 Submitted: 30 Jn 2018 Accepted: 10 Apr 2018 Online: 28 Jun Deprtment of Helth, Bushehr University of Medicl Sciences, Bushehr, Irn 2 The Persin Gulf Mrine Biotechnology Reserch Center, Bushehr University of Medicl Sciences, Bushehr, Irn 3 Deprtment of Biosttistics, Bushehr University of Medicl Sciences, Bushehr, Irn To cite this rticle: Lri H, Noroozi A, Thmsebi R. Impct of short messge service (SMS) eduction bsed on helth promotion model on the physicl ctivity of ptients with type II dibetes. Mlys J Med Sci. 2018;25(3): To link to this rticle: Abstrct Introduction: Physicl ctivity is the most importnt self-mngement behviour in dibetes. The im of this study ws to evlute the impct of short messge service (SMS) bsed on helth promotion model (HPM) on the physicl ctivity of dibetic ptients. Methods: This qusi-experimentl study consisted of 37 type II dibetes ptients in n SMS group nd 36 type II dibetes ptients in control group. The ptients in both groups completed written consent forms nd questionnires t the beginning of the study. The ptients in the SMS group received trining messges within two weeks (two or three messges dily) in the field of physicl ctivity bsed on HPM constructs. Both groups completed questionnires in three stges (t the beginning of the study, four weeks fter the first visit, nd three months lter) comprising demogrphic fctors, questions regrding the constructs, nd 7-dy physicl ctivity recll. After dt collection, sttisticl nlysis ws conducted using n independent t-test, Chi-squre test, nd repeted mesures nlysis of vrince (ANOVA). Results: As compred with the control group, chnges in men scores of perceived self-efficcy (P = 0.001) nd fmily support (P = 0.046) of physicl ctivity in the trining group were significntly greter nd perceived brriers (P < 0.001) were significntly lower over time. The physicl ctivity performnce of the SMS group ws better three months fter trining s compred with tht of the control group (P < 0.001). Conclusion: The results demonstrted the efficcy of trining messges in chnging the beliefs nd physicl ctivity behviours of dibetic ptients. Keywords: helth promotion model, physicl ctivity, dibetes type II, short messge service, mhelth Introduction Dibetes is incresing worldwide. Due to ging, urbnistion, n incresed prevlence of obesity, nd physicl inctivity, the globl burden of dibetes type II is incresing (1). Dibetes ffects over 180 million people (2). According to estimtes, the numbers of ptients with dibetes will double by 2030, with bout hlf the dibetes popultion being in Oceni nd Asi (2). By 2025, there will be predicted 122% increse in the number of dults with type II dibetes (3). In ddition to the high prevlence of this disorder, the cost of dibetes is significnt. In mny countries, t lest 10% of the totl cost of helth cre is spent on dibetes (4). Dibetes Mlys J Med Sci. My Jun 2018; 25(3): Penerbit Universiti Sins Mlysi, 2018 This work is licensed under the terms of the Cretive Commons Attribution (CC BY) ( 67

2 Mlys J Med Sci. My Jun 2018; 25(3): control depends on self-mngement behviours, including nutrition control, sufficient physicl ctivity, dherence to mediction, nd blood sugr monitoring to void serious complictions nd mortlity (5). Despite the importnce of physicl ctivity in dibetes control, in the U.K., 68% of type II dibetic ptients nd 61% of ptients with type I dibetes hve been clssified s inctive nd sedentry (6). The Americn Dibetes Assocition recommends tht ptients with type II dibetes should hve t lest 150 min of erobic ctivity of moderte intensity ech week or 90 min of intensive erobic exercise ech week (7). Monitoring of physicl ctivity is importnt in dibetic ptients, nd this ctivity cn be monitored vi trining intervention (8). However, the impct of ny trining depends on pproprite ppliction of behviourl theories nd pproprite trining methods (8). The bsis of dibetes control is self-mngement. The min emphsis of helth promotion models (HPMs) is self-regultion (i.e., using internl stndrds nd self-ssessment s mens of motivtion, djustment of behviour, nd djustment of the externl environment). Thus, HPMs seem to be effective for inducing behviourl chnge in dibetic ptients. The revised model includes the following concepts of helth-promoting behviour: i) individul chrcteristics nd experiences, ii) behviour-specific cognition nd ffects, nd iii) behviourl outcomes. The concept of individul chrcteristics nd experiences includes personl fctors nd prior relted behviours. The concept of behviour-specific cognition nd ffects includes constructs, such s perceived benefits nd brriers, perceived self-efficcy, ctivity-relted ffect, interpersonl influences, nd situtionl influences. Pender et l. tested their HPM in multiple studies nd identified constructs, such s personl fctors (perceived helth sttus), perceived benefits nd brriers, perceived selfefficcy, nd interpersonl influences (socil support) s the best predictors of helthpromoting lifestyle (9). Reserchers hve used vriety of technologies to provide interventions in helth promotion, with the cell phone proving to be n effective technology in ll spects of humn life (10). Cell phone penetrtion in Irn tody hs reched 90% (10). Cell phones nd short messge services (SMS) re modern mens of communiction nd interction. They hve wide rnge of functionlities nd fetures, such s high-speed, permnent ccess, cost effectiveness, reltive security, storge cpbility, flexibility, nd content ttrctiveness (11, 12). As most people tody hve busy lives, nd trveling nd ttending trining clsses re not esy, SMS my be suitble method to deliver trining interventions. Previous studies demonstrted tht sending SMS ws n effective wy to promote self-mngement behviours in dibetic ptients (12, 13). However, in these studies, the trining messges were not bsed on HPM. Considering the importnce of physicl ctivity in dibetics nd the pervsiveness of the cell phone s communiction tool, this study ws designed to determine the impct of distnt trining progrm delivered through SMS nd bsed on HPM on the physicl ctivity of ptients with type II dibetes. The results cn be used to design trining progrm for dibetic ptients t the community level. Mteril nd Methods Study Design This clinicl tril study ws crried out from October 2016 to Februry 2017 to ssess the impct of trining using SMS on the physicl ctivity of ptients with type II dibetes who were referred to two dibetes clinics in the city of Bushehr, southwestern province in Irn. The inclusion criteri were the bility to red nd write, hving no dibetic foot ulcers, willingness to prticipte in the study, nd hving dibetes for one or more yers. The exclusion criteri included functionl inbility to wlk without cne, inbility to wlk one mile without rest, inbility to continue prticiption for t lest three months, nd hving crdiovsculr disese. Bsed on similr study (14), the smple size ws estimted s 36 subjects for ech group, considering ttrition rtes (10%) in 3-month follow up. Thus, bout 40 subjects were required for ech group (n SMS group nd control group). Two dibetes clinics were selected for smpling. Bsed on review of 1,775 records of ptients in Hftom-e-Tir Dibetes Clinic nd 514 records in dibetes clinic of the Socil Security Hospitl, tking into ccount the inclusion criteri, 145 ptients in Hftom-e- Tir Clinic nd 89 ptients in the Socil Security Hospitl were deemed eligible. Eighty of the 234 ptients were selected by ssigning code to ech eligible person nd rndom selection 68

3 Originl Article Impct of short messge service (SMS) on physicl ctivity using Excel softwre. Potentil prticipnts were contcted by telephone. After identifiction of subjects willing to prticipte, the individuls were rndomly divided into two groups (trining with SMS or control) by lottery. Of the 40 prticipnts in ech group, three ptients in the SMS group nd four ptients in the control group were unble to continue the study nd were excluded. Ultimtely, 37 ptients in the SMS group nd 36 ptients in the control group continued the study. Method nd Dt Collection At the beginning of the study, the ptients in both groups ttended the clinic on prticulr dy determined by themselves nd completed written consent form nd then questionnires. These included demogrphic questionnire, HPM constructs, nd 7-dy physicl ctivity recll questionnire. The ppointment intervl ws one hour per dy to llow the reserchers sufficient time to dminister the physicl ctivity questionnire through interviews nd to monitor the questionnires completion. The ptients in the SMS group received trining messges bsed on HPM. The trining consisted of two or three messges per dy for two weeks from Sturdy to Thursdy for 12 dys. The composition of the messges ws s follows: Dy 1: Trining bout the pproprite mount of physicl ctivity to control blood sugr nd the impct of physicl ctivity on dibetes (incresed perceived benefits). Dy 2: Physicl nd mentl benefits of physicl ctivity in ptients with dibetes (incresed perceived benefits). Dys 3 nd 4: Sports rules nd some tips bout hiking to chnge physicl ctivity step by step nd grdully increse this ctivity over 3-month period (incresed perceived selfefficcy). Dys 5 nd 6: Observing specific rules before physicl ctivity in the field of blood sugr control nd not consuming sncks before undertking physicl ctivity (reduced perceived brriers). Dys 7 nd 8: Undertking pproprite physicl ctivity bsed on blood sugr nd symptoms of low blood sugr nd tking pproprite mesures to eliminte it (reduced perceived brriers). Dy 9: Complictions of dibetes nd pproprite physicl ctivity (incresed perceived benefits). Dy 10: Incresing the bility to perform physicl ctivity or enhncing self-efficcy by, for exmple, emphsising grdul increse in physicl ctivity in ccordnce with the person s bility nd modifying the person s views on the usefulness of n increse in hert rte ssocited with physicl ctivity (incresed perceived selfefficcy). Dy 11: Identifying brriers to physicl ctivity, including problems relted to physicl ctivity during periods of high blood sugr, nd pproprite mesures to eliminte brriers, such s trining to reduce muscle crmps fter n initil increse in physicl ctivity (reduced perceived brriers). Dy 12: Asking support from friends nd fmily in cre nd ccompniment (perceived support). In ddition, to enhnce perceived support, contct number of n ctive member of the person s fmily or the number of n ctive friend ws tken to send messge. In ddition to the benefits, brriers, nd self-efficcy, recommendtions on cre, cceptnce, trust, nd ccompnying the ptient were sent to these contcts, nd they were sked to support the dibetic ptients in terms of physicl ctivity. On Fridy, the prticipnts in the SMS group put questions to the resercher nd received the nswers. In ddition, fter two weeks of dily trining messges, the prticipnts in the SMS group received two messges weekly (repetition of the initil messges bsed on the HPM constructs) for up to three months. When the messge ws red by the individul in the SMS group, confirmtion messge ws sent to the resercher from the ptient. In the first stge, four weeks fter questionnire completion, the prticipnts in both groups completed the questionnires bsed on the HPM constructs. In ddition, three months fter dt collection in the second stge, both groups completed questionnire relted to these constructs nd 7-dy physicl ctivity recll questionnire. At the beginning of the study, fter giving written consent, the prticipnts in the control group completed the questionnires on demogrphics, HPM constructs, nd 7-dy physicl ctivity recll. Four weeks lter, they 69

4 Mlys J Med Sci. My Jun 2018; 25(3): completed questionnires bsed on the HPM constructs. Three months lter, they completed the questionnires bsed on the HPM constructs nd 7-dy physicl ctivity recll gin. At the end of the study, they did not receive trining mterils. Instruments nd Mesures The dt collection tool in this study ws three-prt questionnire. The first prt contined informtion bout the prticipnt s chrcteristics (e.g., ge, sex, eduction, household income, body mss index [BMI], type of mediction, prior relted behviours, nd perceived helth sttus) nd experiences. Perceived helth sttus ws determined by 12-item short form helth survey exmining physicl nd mentl helth. Montzeri et l. reported Cronbch s lph of 0.73 (physicl helth spect) nd 0.72 (mentl helth spect) for this instrument (15). In this study, Cronbch s lph coefficient ws 0.79 for ll the tools. The second prt of the questionnire contined questions relted to the HPM constructs. Perceived benefits: Agreement or disgreement with the benefits of physicl ctivity were exmined by 28 questions, using 4-point Likert scle designed by Sechrist et l. (16). Cronbch s lph coefficient of the scle ws reported to be 0.89 (16). In this study, Cronbch s lph coefficient ws Perceived brriers: Sechrist et l. s (16) 14-point Likert scle ws used to ssess prticipnts perceptions of brriers to physicl ctivity. Cronbch s lph coefficient of the scle ws reported to be 0.77 (16). In this study, it ws Perceived socil support: The prticipnts perceptions of support from fmily nd friends in the field of physicl ctivity ws mesured by 15 nd 5 questions, respectively ( totl of 20 questions), with 5-point Likert scle. Cronbch s lph coefficients were reported to be 0.9 nd 0.86 for support from fmily nd friends, respectively (17). In this study, it ws 0.94 for ll the tools. Self-efficcy: The questionnire developed by Noroozi et l. (18) ws used to exmine the confidence of the prticipnts in undertking regulr physicl ctivity under different conditions. This questionnire hs 18 questions, which re scored on percentge scle (0 to 100%). Cronbch s lph coefficient of the scle ws 0.92 (18). In this study, it ws The third prt of the questionnire mesured physicl ctivity bsed on 7-dy physicl ctivity recll. The questionnire ws completed during semi-structured interview. In the interview, the subjects were sked to list the ctivities they hd undertken in the lst seven dys, strting with the dy before nd then going bckwrds. They were sked to determine the durtion (in minutes), intensity (bsed on chnges in hert rte s compred with wlking nd running), nd type of ech ctivity (dily ctivities or leisure ctivities). Using the instructions given in these tools, the metbolic equivlent (MET) ws clculted for the lst week. Previous reserch demonstrted the relibility of this questionnire, reporting n intrclss coefficient rnge between 0.34 nd Reserch lso showed tht this questionnire ws useful tool to ssess the mount of physicl ctivity (19). The heights nd weights of the prticipnts were mesured to determine the METs nd BMIs. The dt were nlysed by the Sttisticl Pckge for Socil Sciences Softwre (SPSS), version Descriptive sttistics, Chi-squre test, n independent t-test, nd repeted mesures nlysis of vrince (ANOVA) were used for dt nlysis. A CONSORT flow digrm of the study is displyed in Figure 1. Results In totl, 73 dibetic ptients (SMS group, n = 37; control group, n = 36) completed the study. There were no significnt differences between the SMS nd control groups in individul chrcteristics nd experience (demogrphic fctors). For instnce, the verge ge of the prticipnts in the SMS group ws (9.14) yers, nd the verge ge in the control group ws (9.07) yers (P = 0.160). The men (SD) BMI in the SMS group nd control group ws (5.19) nd (3.93), respectively (P = 0.897), nd the durtion of dibetes in the SMS group nd control group ws 7.73 (7.18) nd 8.78 (5.74), respectively (P = 0.493). Other demogrphic chrcteristics re shown in Tble 1. The prticipnts in the SMS nd control groups were lso similr s regrds their helth beliefs relted to physicl ctivity before 70

5 Originl Article Impct of short messge service (SMS) on physicl ctivity Initil pproch for selecting eligible ptients with type 2 dibetes by reviewing records (N = 2,289) 234 ptients were eligible Rndom selection (n = 80) Reserchers obtined initil consent by telephone cll (n = 80) Rndom lloction into two groups by lottery SMS group (n = 40) Control group (n = 40) Two prticipnts lost to follow up: (work nd illness resons) Received SMS for 12 dys One prticipnt lost to follow up (illness) Received two messges ech week by SMS First visit with intention to complete written consent nd questionnires (demogrphic, HPM constructs, nd 7-dy recll) (n = 40) First follow up: four weeks lter with intention to complete constructs questionnire (tret nlysis) (n = 38) Second follow up: three months lter with intention to complete questionnires (demogrphic, HPM constructs, nd 7-dy recll) (n = 37) First visit with intention to complete written consent nd questionnires (demogrphic, HPM constructs, nd 7-dy recll) (n = 40) First follow up: four weeks with intention to complete constructs questionnire (n = 37) Second follow up: three months lter with intention to complete questionnires (demogrphic, HPM constructs, nd 7-dy recll) (n = 36) Three prticipnts lost to follow up: (no nswer to phone clls, n = 1; illness, n = 2) One prticipnt lost to follow up (illness) Figure 1. CONSORT flow chrt of the prticipnts Tble 1. Demogrphic chrcteristics in two groups prior to trining Gender Eduction level Mrried sttus Job Drug type Demogrphic vribles Femle Mle Diplom Acdemic eduction Mrried single Housekeeper Employee pensionry Metformin Insulin Combine SMS group Control group Chi-squre n % n % sttistics P-vlue eduction, but the difference between the two groups ws sttisticlly significnt fter trining in severl constructs (Tble 2). Comprison of the pre- nd post-test results (immedite nd three months lter) of the SMS group by repeted mesures ANOVA reveled chnges in perceived helth sttus, perceived self-efficcy, perceived brriers, nd fmily support, with n increse in perceived helth sttus, self-efficcy, nd fmily support 71

6 Mlys J Med Sci. My Jun 2018; 25(3): (P < 0.001), s well s decrese in perceived brriers (P < 0.001). There were no sttisticlly significnt chnges in the constructs on perceived benefits nd support from friends (P > 0.05). In contrst, in the control group, there were no significnt chnges between the pre- nd post-test scores for ny of the constructs. Comprison of the two groups over time reveled no between-group difference in scores for perceived helth sttus, perceived benefits, nd support from friends (P > 0.05). However, self-efficcy nd fmily support were perceived to be higher nd brriers were perceived to be lower in the SMS group s compred with the control group (Tble 2). A comprison of chnges in the Tble 2. Constructs scores of helth promotion model during intervention Constructs Time SMS group Control group Men (SD) Men (SD) F (df 1, df 2 ) b P-vlue Perceived helth sttus Before eduction (6.62) (5.95) 1.98 (2, 142) After eduction (5.87) (5.87) 3 months lter (5.60) (6.20) F(df 1, df 2 ) 9.01 (2, 72) 1.23 (2, 70) P-vlue Perceived Self-efficcy Before eduction (21.35) (22.54) 7.03 (2, 142) After eduction (20.16) (20.10) 3 months lter (13.57) (21.33) F(df 1, df 2 ) 9.25 (2, 72) 2.24 (2, 70) P-vlue P < Perceived brrier Before eduction 2.20 (0.40) 1.96 (0.49) (2, 142) < After eduction 1.82 (0.43) 1.94 (0.38) 3 months lter 1.64 (0.31) 1.85 (0.36) F(df 1, df 2 ) (2, 72) 1.39 (2, 70) P-vlue P < Perceived benefit Before eduction 3.59 (0.32) 3.57 (0.35) 2.08 (2, 142) After eduction 3.63 (0.34) 3.45 (0.39) 3 months lter 3.63 (0.28) 3.54 (0.31) F(df 1, df 2 ) 0.39 (2, 72) 0.14 (2, 70) P-vlue Friend support Before eduction 2.75 (1.23) 2.78 (1.05) 0.07 (2, 142) After eduction 2.78 (0.98) 2.80 (0.97) 3 months lter 2.88 (1.16) 2.82 (1.02) F(df 1, df 2 ) 0.34 (2, 72) 0.03 (2, 70) P-vlue Fmily support Before eduction 3.03 (0.73) 3.30 (0.82) 3.14 (2, 142) After eduction 3.13 (0.72) 3.24 (0.69) 3 months lter 3.36 (0.76) 3.28 (0.76) F(df 1, df 2 ) 1.05 (2, 72) 0.04 (2, 70) P-vlue Comprison of men score chnges over time in ech group b Comprison of chnges in men scores over time between groups 72

7 Originl Article Impct of short messge service (SMS) on physicl ctivity constructs scores between the SMS nd control groups is presented in Figure 2. Pre- nd post-test men differences in the MET between the two groups were sttisticlly significnt (P < 0.001). The men (SD) of the MET in the SMS nd control groups over time is shown in Tble 3. Discussion This study showed tht SMS trining messges improved perceptions of self-efficcy nd fmily support nd reduced brriers to physicl ctivity mong dibetic ptients, subsequently incresing their level of physicl ctivity. However, short messges were not effective in improving perceived benefits of physicl ctivity or support of friends for physicl ctivity. Severl studies reported tht self-efficcy ws determinnt of physicl ctivity behviour (20 22). Thus, its promotion is importnt in encourging physicl ctivity. Vrious studies tht used different trining methods, including individul trining (23, 24), group trining (25), nd trining by SMS (26), indicted incresed self-efficcy in physicl ctivity, confirming the findings of recent study. Accordingly, providing positive feedbck nd recording dily progress were effective in strengthening self-efficcy in physicl ctivity. However, one study found tht SMS filed to increse self-efficcy in selfmngement behviours in dibetic ptients (13). This study ttributed the filure to multiple selfmngement behviours, with physicl ctivity being only one component of these behviours. Therefore, SMS my be ineffective in promoting components of self-mngement behviours Figure 2. Comprison of constructs scores chnge in over time between groups Tble 3. Men metbolic equivlent of tsk (MET) in two groups during intervention Group Before eduction Men (SD) Three months lter Men (SD) Men differences 95% CI of Diff. T-vlue P-vlue Control (479.48) (423.08) ( 93.03, 0.17) SMS (495.34) (502.01) (46.22, ) 4.78 <

8 Mlys J Med Sci. My Jun 2018; 25(3): other thn physicl ctivity, indicting the need for more reserch on the efficcy of SMS on ech component of self-mngement behviour. In the present study, SMS reduced the prticipnts perceptions of brriers to undertking physicl ctivity. Severl studies tht provided individul or group trining confirmed this finding (13, 23, 25). However, trining provided through printing mterils did not chnge people s perception of brriers to undertking physicl ctivity (27). This finding indictes tht people my need to be trined interctively to chnge their perceptions of brriers to behviours. Due to its simplicity nd effectiveness, SMS-bsed trining my be good wy of reducing perceived brriers. In ptients with specific conditions nd diseses, fmily support is very importnt in chnging helth behviours to promote helth (28). In this study, sending trining messges through SMS to the fmilies of dibetic ptients improved the level of fmilil support nd the prticipnts perceptions of socil support by fmily members in the field of physicl ctivity. Studies where trining ws conducted in the presence of fmily members of ptients chieved similr results (23, 29). Reserchers believe tht if person hs positive ttitude to behviour, nd people who re importnt to them confirm this behviour, the person performs the behviour (30). As sending short messges to friends filed to increse the prticipnts perceptions of friends support in the field of physicl ctivity, it seems tht fmily members re more importnt for dibetics. Thus, sending short messges to fmily members seems to be more effective thn sending them to friends. In this study, sending trining messges filed to chnge the prticipnts perceptions of the benefits of physicl ctivity, contrdicting the findings of severl studies (2, 23, 25). The discord could be due to the high level of perception of the benefits of physicl ctivity t the beginning of the study. Therefore, the trining messges filed to chnge their perceptions. As severl fctors, including ge, socil clss, eduction level, nd economic sttus (31), influence people s perceptions of helth, it should be expected tht trining interventions imed t chnging behviour do not hve much impct on helth sttus. In this study, sending trining messges did not chnge the prticiptions perceptions of their helth sttus. This study showed tht chnging helth beliefs bout self-efficcy, fmily support, nd brriers to physicl ctivity significntly incresed the men MET, in other words, the durtion of physicl ctivity in the SMS group. Severl studies tht incorported helth promotion progrm demonstrted the impct of the progrm on physicl ctivity promotion (23, 25, 32). In ddition, in some studies, sending SMS without tking into ccount the theoreticl frmework ws effective in incresing physicl ctivity (11, 14, 33). All these studies confirmed the recent findings. In the present study, the theoreticl frmework pplied ws effective in chnging dibetic ptients beliefs. In this study, more persistence nd continuity re expected from this behviour, confirming the need for more studies in this field. Therefore, the delivery of SMS messges bsed on HPM my be useful pproch for improving dibetic ptients beliefs bout physicl ctivity nd promoting physicl ctivity in these ptients. Conclusion According to the results, it seems tht the design nd implementtion of trining progrm using HPM hd positive impcts s regrds chnges in helth beliefs nd subsequently, promotion of physicl ctivity. Therefore, we recommend the use of cell phones nd SMS s redily vilble, ffordble tools to chnge the helth beliefs of dibetic ptients nd to induce helth-promoting behviours, such s physicl ctivity. Authors Contributions Conception nd design: AN Anlysis nd interprettion of the dt: RT Drfting of the rticle: HL Criticl revision of the rticle for importnt intellectul content: RT Finl pprovl of the rticle: AN Provision of study mterils or ptients: HL Sttisticl expertise: RT Obtining of funding: AN Administrtive, technicl, or logistic support: AN Collection nd ssembly of dt: HL 74

9 Originl Article Impct of short messge service (SMS) on physicl ctivity Acknowledgements We grtefully cknowledge ll persons who helped in this reserch. This study ws supported by the reserch deputy of Bushehr University of Medicl Sciences. Ethicl pprovl The study ws pproved by the Bushehr University of Medicl Sciences Ethics Committee (Ethic No: IR.BPUMS.REC ). Conflict of Interest Authors hve no conflicts of interest. Correspondence Dr Azit Noroozi Bchelor of Midwifery (Isfhn University, Isfhn, Irn), MSc Midwifery (Isfhn University, Isfhn, Irn), PhD of Helth Eduction & Promotion (Trbit Modres University, Tehrn, Irn) Associte Professor in Helth Eduction Deprtment of Helth, Bushehr University of Medicl Science, Bushehr, Irn. Tel: E-mil: References 1. Ayele K, Tesf B, Abebe L, Tilhun T, Girm E. Self cre behviour mong ptients with dibetes in Hrri, Estern Ethiopi: the helth belief model perspective. PloS One. 2012;7(4):e Byt F, Shojeezdeh D, Bikpour M, Heshmt R, Bikpour M, Hosseini M. The effects of eduction bsed on extended helth belief model in type 2 dibetic ptients: rndomized controlled tril. J Dibetes Metb Disord. 2013;12(1): Esteghmti A, Ashrf H, Khlilzdeh O, Rshidi A, Mohmmd K, Asgri F, et l. Trends of dibetes ccording to body mss index levels in Irn: results of the ntionl surveys of risk fctors of non-communicble diseses ( ). Dibetic Med. 2010;27(11): Shrifird G, Hzvehie S, Mohebi S, Rhimi M, Hsnzdeh A. The effect of eductionl progrmme bsed on Helth Belief Model (HBM) on the foot cre by type II dibetic ptients. Irn J Endocrinol Metb. 2006;8(3): Mohebi S, Prhm M, Pour EM, Kmrn A. Selfcre ssessment in ptients with dibetes in Qom city in Arch Hyg Sci. 2014;3(4): Heydri H, Bhrvnd F, Mohebi S, Pourni Y, Tbrie Y, Kmrn A. Predictive power of the trns-theoreticl model of physicl ctivity in ptients with type-2 dibetes. Bull Env Phrmcol Life Sci. 2014;3(3): Sigl RJ, Kenny GP, Wssermn DH, Cstned- Scepp C, White RD. Physicl ctivity/ exercise nd type 2 dibetes. Dibetes Cre. 2006;29(6): dicre Bghinimoghdm M, Hdvndkhni M, Mohmmdi M, Fllhzde H, Bghinimoghdm B. Current eduction versus peer-eduction on wlking in type 2 dibetic ptients bsed on Helth Belief Model: rndomized control tril study. Rom J Intern Med. 2012;50(2): Pender NJ, Murdugh CL, Prsons MA. Helth promotion in nursing prctice. 5th ed. Upper Sddle River, NJ: Person & Prentice Hll; Hghni F, Shhidi S, Mnoochehri F, Klntri B, Ghsemi G. The effect of distnce lerning vi sms on knowledge & stisfction of pregnnt women. Irn J Med Educ. 2016;16: Fonsec-Guedes CHF, Poss SS, Righetti RF, Jucá MF, Benseñor IJM, Crvlho CRF, et l. Efficcy of telephone support s tool for promoting dily physicl ctivity in type 2 dibetic ptients. J Dibetes Res Clin Metb. 2014;3(1): Zolfghri M, Mousvifr SA, Pedrm S. Mobile phone text messging nd telephone follow-up in Irnin type 2 dibetic ptients for 3 months: comprtive study. Irn J Dibetes Obes. 2009;1(1): Bghini Moghdm M, Theri G, Fllh Zdeh H, Prs M. The effect of instructionl designed SMS bsed on helth belief model (HBM) on doption of self-cre behviour of ptients with type II dibetes. Mod Cre J. 2014;11(1):

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