The Science of Diabetes Self-Management and Care 2025, Vol. 51(5) 505 –516 © The Author(s) 2025 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/26350106251371083 journals.sagepub.com/home/tde
Abstract
Purpose: The purpose of the study was to evaluate the effectiveness of a nurse-led intervention via the LINE Official Account (OA) application on knowledge, self-care, and clinical outcomes in patients with type 2 diabetes and comorbidities in Thailand.
Methods: A cluster 2-arm randomized controlled trial with assessments at baseline, 6 weeks, and 12 weeks was conducted in 2 noncommunicable disease clinics between October 2023 and March 2024. A total of 108 participants were recruited and randomly assigned to either the intervention group (n = 55) or control group (n = 53). Using Orem’s Self-Care Deficit Nursing Theory as a conceptual framework, the 12-week intervention included knowledge and behavioral assessment, health education support, and practicing reminder via the LINE OA application. The control group received usual care. Outcomes included knowledge, self-care agency, selfcare behaviors, A1C, blood pressure, and microalbuminuria (MAU). Data were analyzed using t-tests, repeated measures analysis of variance, and Cohen’s d.
Results: Compared to the control group, at 6 and 12 weeks, participants in the intervention group demonstrated significant improvements in knowledge, self-care agency, and self-care. Clinically significant changes in A1C, blood pressure, and MAU were observed at 12 weeks in the intervention group.
Conclusion: The study findings highlight the effectiveness of the nurse-led intervention via LINE OA application in knowledge, self-care, MAU, and A1C improvement. Extended study duration is recommended to assess sustainability for the future study.
The global prevalence of diabetes and hypertension (HT) has risen markedly in recent decades, leading to increased morbidity, mortality, and health care costs.1-3 Similarly, in Thailand, the incidence rates of both diabetes and hypertension have shown a steady increase over the past 5 years.4 The Health Data Center records reported that the prevalence of diabetes among Thai adults ages 15 years and older increased by approximately 18.51% from 2018 to 2022. Similarly, the prevalence of hypertension rose by around 16.57% during the same time frame.4 Currently, approximately 10% of the Thai population, over 6.5 million individuals, are affected by diabetes. HT affects about 1 in 4 adults, further contributing to the burden of noncommunicable diseases (NCDs).5 The coexistence of diabetes and HT increases the risk of cardiovascular events, chronic kidney disease (CKD), and other serious health complications.6 Evidence indicated that CKD adds complexity to the management of these interrelated conditions.4,5 This growing burden underscores the need for integrated strategies to manage chronic disease comorbidities within the Thai health care system.
To optimize the health of adults with diabetes with comorbidities, controlling blood sugar level, lowering blood pressure, and monitoring microalbuminuria (MAU) is necessary. Individuals are required comprehensive and sustained self-care, including healthy dietary practices, regular physical activity, and medication adherence.7,8 Furthermore, the 2022 National Standards for Diabetes Self-Management Education and Support (DSMES) framework addressed an important role of an inclusive health care team in providing health information, reinforcing self-management skills, assisting behavior change and self-management, and providing emotional support, which can lower A1C at least 0.6%.9,10 Specifically, diabetes care and education specialists (DCESs) play a critical role in delivering health education, facilitating behavior change, and monitoring health outcomes.11
In Thai community settings, where the number of DCESs is limited, nurses play critical roles in providing care to patients based on their self-care needs and capabilities. Self-care refers to an individuals’ ability to maintain, restore, and promote their well-being; perform appropriate behaviors; and manage symptoms.12 Individuals who experience self-care deficit but can perform activities independently require supportive and educational nursing systems to facilitate learning and maintain health.12 Adults with type 2 diabetes (T2DM) are required to modify their lifestyle and consistently manage their symptoms. Evidence indicated that integrating DSMES principles into nurse-led self-care programs can enhance the consistency and quality of support delivered through mobile health platforms.13,14 Due to their daily workload and limited resources, nurses often face challenges in engaging fully with DSMES programs. These constraints may result in inadequate follow-up on patients’ self-care practices and insufficient development of tailored strategies to manage diabetes and comorbid conditions.13,15 Also, it was recommended that focusing on person-centered care, DCESs should implement technology-enabled services to provide education and enhance self-care, including telehealth, mobile applications, and other digital health technologies.9,11
The LINE Official Account (OA) application is a communication platform on smartphones that is widely used in Thailand.16 Furthermore, it allows health care providers to share health education materials through multimedia, send reminders, and interact with patients in a user-friendly environment, which encourages patients to stay engaged in their health care.16,17 Using Orem’s12 self-care deficit nursing theory as a conceptual framework, the study intervention integrated LINE OA application to assess patients’ self-care needs, promote self-care behaviors, provide knowledge support, and monitor health and behavior was developed for community nurses in supporting self-care needs among adults with diabetes and comorbidities such as HT and CKD stage 3.
Therefore, the present study aims to evaluate the effectiveness of a 12-week nurse-led mobile health intervention delivered via the LINE OA in enhancing self-care behaviors and improving clinical outcomes for patients with diabetes and comorbidities. The hypothesis was that adults with diabetes with comorbidities who received a nurseled self-care program delivered through mobile health technology would be more likely to improve patients’ knowledge, self-care, and clinical indicators than those who received the usual care.
The study employed a cluster randomized controlled trial design because each general hospital has only 1 NCD clinic. This design is widely used if there is a risk of contamination in which nurses who were trained for delivering the intervention to participants may influence other participants within the group.18 This design allowed for a pragmatic evaluation of a nurse-led self-care program using mobile health technology in real-world clinical conditions.19,20 Therefore, 2 of 4 general hospitals were randomly selected and randomly assigned to the intervention group and the other to the control group.
This study was conducted at 2 NCD clinics in 2 general hospitals located in Ratchaburi province, Thailand. Eligible participants were recruited by the researcher based on the following inclusion criteria: adults ages 20 years or older with A1C ≥7.5%, blood pressure ≥140/90 mmHg, estimated glomerular filtration rate between 30 ml/min/1.73 m² and 59 ml/min/1.73 m², MAU with values ≥30 mg/L, treating with oral medications, access to a smartphone with internet and the LINE OA application, and the ability to communicate in Thai. The exclusion criteria were undergoing dialysis, diagnosed with terminal illness unrelated to CKD, and participating in another intervention program.
The minimum sample size was calculated using the G*Power software,21 focusing on A1C as the primary outcome variable. To achieve a statistical power of 0.80 and an alpha level of 0.05, the effect size was set at 0.56, as indicated by prior research.22 Consequently, the sample requires 51 patients per group. Considering an anticipated attrition rate of 20%, each group included 60 participants to ensure sufficient statistical power.
The study intervention integrated the LINE OA, which was developed using the ADDIE (analysis, design, development, implementation, and evaluation) model framework,23 a 5-phase instructional design framework, to ensure alignment with the Orem’s Self-Care Deficit Nursing Theory, which addresses patients’ self-care needs and health care provider requirements.
Analysis. Interview sessions were conducted to explore the patients’ problems in lifestyle changes and their selfcare needs. Nurses were also invited to participate in interview sessions to identify the challenges they encountered in supporting patient self-care and to elicit suggestions for enhancing nursing interventions. The information collected provided a comprehensive understanding from both patient and provider perspectives, ensuring that the intervention design addressed the practical needs of both groups.
Design and development. The LINE OA was structured by the researchers in 3 parts: providing health education, encouraging self-care activities, and monitoring health and behaviors. Education videos and infographics were developed and set to deliver each week. The study content focused on dietary consumption, medical adherence, exercise, and management of abnormal symptoms. Next, the application underwent review by 3 nurses and 5 patients regarding usability, content clarity, and functionality.
Implementation and evaluation. A 4-week pilot test was conducted with 2 nurses and 10 patients to ensure an effective system. During this period, patients accessed educational materials, received self-care reminders, and engaged in real-time communication with nurses. Both patients and nurses reported the application as user-friendly and beneficial for reinforcing self-care practices and patients’ engagement. These findings informed final adjustments, ensuring the application was optimized for the study.
Three nurses from the NCD clinic were recruited and assigned to the experimental group. To ensure the fidelity of the study, they were asked to participate in a structured 12-hour training session focused on program implementation and use of the LINE OA application. The training consisted of 2 main sessions (Table 1).
Session 1 focused on disease information and management strategies, including an overview of diabetes mellitus (DM), HT, and CKD, with emphasis on symptom management and expected self-care behaviors, such as dietary changes, physical activity, and medication adherence.
Session 2 prepared nurses for program implementation, including an introduction to the nurse-led self-care program, hands-on practice with self-care assessment tools, and training on using the LINE OA application to deliver health education, send reminders, monitor patient responses, and facilitate real-time communication with patients.
Using Orem’s12 Self-Care Deficit Nursing Theory as a framework, the 12-week nurse-led intervention program using LINE OA was developed. According to Orem,12 a nursing system should be based on patients’ therapeutic self-care demand, and nurses were required to fulfill patients’ abilities to perform self-care.
Week 1. After signed informed consent and baseline assessment, participants were given an overview of the program. The nurse engaged with patients and their families to provide basic knowledge of DM, HT, and CKD stage 3. Then, a discussion was held about participants’ self-care deficits based on the assessment findings, goals were set to meet their needs, and strategies and an activity plan for effective self-care were developed. Finally, patients were introduced and trained to use the LINE OA for accessing the program content and practicing the mechanism of the application.
Weeks 2 through 5. Participants received 5-minute health education videos and infographics via LINE OA 3 times per week, covering 4 topics, such as dietary consumption, medical adherence, exercise, and management of abnormal symptoms. At the end of each video, participants were required to answer 2 short quizzes to assess their knowledge. The trained nurses would manually send the right answer if the participants gave any wrong response.
Week 6. An assessment was performed to evaluate participants’ knowledge, self-care agency, and self-care. Then, a session was conducted to discuss their barriers of self-care and support their self-care needs.
Weeks 7 through 11. Videos and infographics were distributed to participants via LINE OA along with quizzes at the end of each topic to reinforce learning.
Week 12. Final assessments were performed, evaluating A1C, blood pressure, MAU, knowledge, self-care agency, and self-care practices.
After action review. An after action review (AAR) was conducted through semistructured exit interviews at the end of the study. The purpose was to evaluate participants’ experiences with the study program. Participants were adults with T2DM who had completed the 12-week program and nurses who were involved in the intervention. All participants provided informed consent prior to the interviews.
Participants in the control group received usual care at the NCD clinic, which included regular health assessments, treatment, and health education based on their illness conditions. After signed informed consent, the following were assessed at baseline and week 12: A1C, blood pressure, MAU, self-care knowledge, self-care agency, and self-care practices. At week 12, after completion of the study, the researcher provided these patients with the same health education and manual that the experimental group received, ensuring all patients had access to comprehensive educational resources.
Data were collected from October 2023 to March 2024. The quantitative data were collected at baseline, 6 weeks, and 12 weeks. Qualitative data were conducted after intervention with the semistructured interviews. After all participants signed the consent, they were asked to give baseline blood samples for A1C and MAU in their routine clinics.
The participants’ sociodemographic measure, developed by the research team, is a10-item questionnaire that collected participants’ age; gender; marital status; education level; occupation; history and duration of T2DM, HT, and CKD; complications; and treatment. These data were obtained through patient interviews and verified through medical charts.
The Knowledge Assessment Scale, developed by the researcher, consists of 10 dichotomous items assessing participants’ remembering and understanding of self-care practices across 4 domains: dietary consumption, medication adherence, exercise, and symptom management. Each correct response was scored as 1, yielding a total score ranging from 0 to 10. Higher scores indicate greater knowledge of self-care. The scale demonstrated acceptable internal consistency, with a Kuder-Richardson 20 coefficient of 0.70.
The Self-Care Agency Scale was developed by researchers. This 10-item scale assessed participants’ perception in their abilities to perform daily self-care tasks, including diet, exercise, medication, and symptoms management, and was scored on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree), with total scores ranging from 10 to 50. Higher scores indicated greater self-care agency. The scale demonstrated acceptable internal consistency, with a Cronbach’s alpha of 0.68.
The Self-Care Behavior Scale was developed by researchers to measure the frequency of engagement in recommended health behaviors. The 15 items span 4 domains, dietary control, medication adherence, physical activity, and symptom monitoring, and are rated on a 5-point Likert scale (1 = never, 5 = always). Total scores range from 15 to 75, with higher scores reflecting greater adherence to self-care practices. The scale demonstrated acceptable internal consistency, with a Cronbach’s alpha of 0.70.
The Client Satisfaction Scale was developed by researchers. It includes 10 items to evaluate participants’ satisfaction with the nurse-led mobile health intervention program delivered via the LINE OA. The scale focuses on design elements, multimedia content, usability, and overall user experience. Items are rated on a 5-point Likert scale (1 = very dissatisfied, 5 = very satisfied), resulting in scores ranging from 10 to 50. Higher scores indicate greater satisfaction. The scale demonstrated good internal consistency, with a Cronbach’s alpha of 0.78.
For clinical outcomes, A1C was assessed from venous blood samples by trained nurses and analyzed in the hospital laboratory. Blood pressure was assessed by the trained nurses at each clinic visit using a calibrated sphygmomanometer. MAU levels were assessed from first-morning urine samples collected by patients and analyzed at the hospital laboratory.
Semistructured interviews were developed to explore the experience of the study program and the use of LINE OA application. Participants were asked about their expectations, changes in self-care behaviors, perceived health outcomes, challenges, satisfaction, and suggestions for improvement; the interview for nurses was focused on the benefits and challenges of the program, experience of using the LINE OA application, and recommendations for the program refinement. Interviews were conducted privately at the clinic, lasted approximately 20 to 30 minutes, were audio-recorded with participant consent, and were transcribed verbatim.
Statistical analyses were performed using SPSS for Windows, version 18.0. Descriptive statistics, including percentage, mean, and standard deviation, were used to summarize participant characteristics and study outcomes. Within-group changes in outcome variables from baseline to week 6 and week 12 were analyzed using paired samples t-tests. Between-group comparisons of change scores were conducted using independent samples t-tests. Results were presented as mean differences with 95% CIs. Cohen’s d was calculated for the differences in outcomes between groups.24 Small, medium, and large effect sizes for Cohen’s d have been defined as 0.2, 0.5, and 0.8, respectively.24,25 All statistical analyses were set at 0.05.
For the exit interview, the interview transcripts were independently reviewed and coded by 3 researchers (PM, PP, WT). A thematic analysis approach was employed, involving iterative readings to ensure familiarity with the data. Coding results were compared, and discrepancies were resolved through discussion to achieve consensus on the emerging themes.
A total of 457 potential patients from 2 hospitals were screened for eligibility. One hundred and twenty patients with T2DM, HT, and CKD stage 3 from 2 NCD clinics were enrolled in the study, with 60 participants randomly selected and assigned to each group. Five patients in the intervention group and 7 in the control group were lost follow-up due to moving to another area or being unable to continue, leaving 55 participants in the experimental group and 53 in the control group for the final analysis (Figure 1).
As shown in Table 2, there were no differences in participants’ sociodemographic characteristics between the intervention group (n = 55) and the control group (n = 53) at baseline (P > .05). The mean age of participants in the intervention group was 57.7 years (SD = 9.7); for those in the control group, mean age was 59.2 years (SD = 9.5). Most of them were married female and had finished primary school education. Clinical characteristics were also similar between the groups, including the mean duration of T2DM, HT, and CKD. Systolic blood pressure (SBP), diastolic blood pressure (DBP), MAU, and A1C also showed no significant differences between the groups. No significant differences between groups in the mean scores of knowledge, self-care agency, and self-care were observed between the groups.
From baseline to 6 weeks and baseline to 12 weeks, participants in the intervention group reported significant improvement of knowledge (mean6-0 Δ = 1.71, P < .001; mean12-0 Δ = 2.89, P < .001) and high scores of self-care agency (mean6-0 Δ = 7.89, P < .001; mean12-0 Δ = 8.31, P < .001) and self-care (mean6-0 Δ = 7.54, P < .001; mean12-0 Δ = 10.63, P < .001). All study variable changes in the intervention group were more than the control group across time, and Cohen’s d ranged from 0.87 to 2.29, a large effect size (Table 3).
From baseline to 6 weeks and baseline to 12 weeks, the mean SBP and DBP were statistically significantly reduced in the intervention by −13.31 (P < .001), −9.19, −20.85, and −11.04 (P = .029), respectively, but not significantly changed in the control group, except DBP at week 12, which was increased by 2.02 (P = .010). Cohen’s d ranged from 1.41 to 2.19, a large effect size. The difference between group differences of change in SBP and DBP were observed across time in the intervention group (P < .001), and Cohen’s d ranged from 1.37 to 2.02, a large effect size.
The mean MAU did not change in the control group but significantly decreased by −36.12 in the intervention group (P < .001). Also, the mean A1C did not change in the control group but significantly decreased by −0.61 in the intervention group (P < .001). The Cohen’s ds for MAU and A1C change in the intervention group were 0.19 and 0.37, respectively, a small effect size. The between-group differences in MAU (−34.12) and A1C (−0.65) were observed in the intervention group (respectively, 95% CI, 0.61-0.65, P = .005; 95% CI, 1.36-1.52, P < .001). The Cohen’s ds for the changes between groups in MAU and A1C were 0.19 and 0.35, respectively, a small effect size.
Over 12 weeks, the intervention group demonstrated significant improvements in A1C and MAU compared to the control group (Table 4). Specifically, 52.8% (n = 29) of the participants in the intervention group showed a clinically reduced 0.5% or greater in A1C, whereas 5.7% (n = 3) of those in the control group showed a reduced 0.5% or greater of A1C. No one in the intervention group had MAU increased or exacerbation, whereas 18.9% (n = 10) of those in the control group reported increased or exacerbation.
Twenty patients were invited to participate in an interview session, which included 14 females and 6 males with a mean age of 51.25 years (SD = 9.25). The average duration of T2DM and HT was 6.95 years (SD = 5.33 and 5.90, respectively), and CKD stage 3 had been diagnosed for an average of 1.60 years (SD = 0.88). Three nurses participated in the review, all of whom were female with a mean age of 35 years (SD = 11.53). Two were single, and one was married. Their outpatient clinical experience ranged from 3 to 20 years, with a mean of 9.33 years (SD = 9.29). All held a bachelor’s degree in nursing, and 1 had completed specialized training in diabetes and HT care and served as a case manager for patients with these conditions.
Most patients reported enhanced confidence in managing their chronic conditions, increased self-care adherence, and appreciation for the app’s user-friendly interface and multimedia content. An example is, “I used to forget my medicine, but the videos and reminders from the app made me more aware. Now I take better care of myself” (female, 46 years). The patient handbook was also cited as a useful supplement. However, challenges in using the application were found in older persons, and they required support from family members.
Nurses reported more patient engagement in their self-care, and they found the application a benefit in providing education and monitoring patients’ health and behavior. One nurse reflected, “Patients asked more questions and showed interest in their health metrics. I think the app helped them connect their daily habits with their health outcomes.” Notably, they suggested digital literacy orientation at the beginning of the program.
Overall, both patients and nurses viewed the program was feasible, acceptable, and beneficial in supporting patients’ self-care in community settings.
The study findings reported that the nurse-led self-care program utilizing the LINE OA application was more effective than routine care in improving knowledge, self-care agency, self-care, and blood pressure at both 6 and 12 weeks. Additionally, it showed significant improvements in MAU and A1C at 12 weeks. These findings are consistent with previous studies that have demonstrated the benefits of mobile applications in enhancing self-care and reducing A1C levels among adults with T2DM, HT, and CKD.26-28 Furthermore, these findings provide important support for the feasibility of maintaining participants’ self-care efforts over a 12-week period in community settings.
In the study, the LINE OA application offered real-time, tailored health education based on patients’ knowledge levels and included interactive tools for health monitoring and management. Furthermore, nurses provided participants with individualized weekly reminders and educational materials, fostering sustained engagement and empowering participants to take charge of their self-care. Notably, participants in the intervention group reported a decrease in MAU and A1C, although the effect size was small. This suggests a need for further validation in a larger trial with a longer follow-up period.
These findings support Orem’s12 Self-Care Deficit Nursing Theory, which emphasizes the nurses’ roles in helping patients to bridge self-care deficits and achieve optimal health outcomes. In the study, before providing patients with education and ongoing support to engage in self-care actively, their knowledge and self-care practices were assessed for deficits. In comparison to the study of Changsieng et al,29 which implemented a nurse-led educational program for adults with T2DM using the Orem’s Self-Care Deficit Nursing Theory as a conceptual framework, the present study showed a reduction in A1C levels but with a small effect size. In their study,29 educational sessions were conducted and a booklet was used to monitor behavior, yielding an A1C reduction with a large effect size. Notably, the mean age of participants in Changsieng et al’s29 intervention was 50.3 years (SD = 7.8), whereas the mean age of participants in the present study was 57.7 years (SD = 9.7). These findings suggest that although traditional education holds promise, technology may help address the nursing shortage in community settings. Therefore, a nurse-led program using the LINE OA application may be more effective for improving A1C levels in younger participants. Specifically, using technology as an intervention may be a challenge among older adults.
The strength of this study included the nursing theory-driven intervention and the study design of a 2-group experimental trial. Despite the promising findings, the study has some limitations. First, most participants were elderly with low educational levels. Second, the study was conducted as a small trial, which might affect the sustainability of the intervention. Future study with larger sample sizes and extended follow-up periods is required to validate and build on these findings.
Nurses and patients involved in the study reported satisfaction with the use of the LINE OA, and they would recommend including this technology to communicate and monitor health. Despite the encouraging results, it is noteworthy to observe that patients with poor levels of digital literacy need time to learn how to use the technology in the intervention. Additionally, to encourage participation for the upcoming extended trial, a team developer should design appealing features. Furthermore, the free version of the LINE OA in the study had functional restrictions that may have reduced participants’ involvement.
This study found that a 12-week nurse-led self-care program using the LINE OA effectively improved self-care and clinical outcomes in patients with diabetes and comorbidities. The findings demonstrated the satisfaction of the program among patients and nurses, suggesting it be implemented in practice. Recommendation for future study was the large trial with a follow-up period to evaluate and build on these findings.
PM, PP, SL, WT, and OS collaboratively conceptualized and designed the study. PM and PP were responsible for delivering the intervention and collecting and analyzing the data. All authors (PM, PP, SL, WT, and OS) contributed to the interpretation and reporting of the study findings. PM and PP drafted the manuscript, which was critically reviewed by all authors. Each author approved the final version for submission.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was partially supported for publication by Faculty of Public Health, Mahidol University, Bangkok, Thailand.
Ethical approval for this study was obtained from the Human Research Ethics Committee, Faculty of Public Health, Mahidol University (MUPH 2022-083). All procedures adhered to the principles outlined in the Declaration of Helsinki. Participants were informed of their right to voluntarily participate, with the freedom to decline or withdraw from the study at any time without any impact on the standard care provided by health care professionals or the hospital.
Phenchan Meekaew https://orcid.org/0009-0009-2974-0508
Panan Pichayapinyo https://orcid.org/0000-0002-5320-5291
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From Department of Public Health Nursing, Faculty of Public Health, Mahidol University, Bangkok, Thailand (Miss Meekaew, Dr Pichayapinyo, Dr Thiangtham, Dr Lagampan); and Division of Nephrology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand (Dr Supasyndh).
Corresponding Author: Panan Pichayapinyo, Department of Public Health Nursing, Faculty of Public Health, Mahidol University, 420/1, Rajvithi Rd., Rajthavi, Bangkok, 10400, Thailand. Email: panan.pic@mahidol.ac.th
