Maternal Exposures to Hazardous Waste Sites and Industrial Facilities and Risk of Neural Tube Defects in Offspring

ALVIN SANCHEZ, Ptrp, mabs, mart juaresa cabantog, noel araneta, ma. Kristine dalay, rowel gandollas, anna karina lopez, and arnie primero PURPOSE: The factors influencing the effective role performances among the clinical instructors in Bulacan State University was examined in aid of developing a human resource development program. Methods: A descriptive co-relational approach was utilized in surveying a total of 40 Clinical Instructors in the hospital and community areas of exposure in the college of nursing at Bulacan State University. A self-evaluation questionnaire was adopted to measure the clinical instructors role performances as an educator, supervisor, evaluator and a nurse by profession. Results: The clinical instructors outstandingly perform the tasks and responsibilities of being a Supervisor, very satisfactory as an Educator, a Nurse and an Evaluator. Careful analysis of data revealed a non-significant relationship between the respondents age, gender, civil status, highest educational attainment, monthly income, rating in licensure exam, number of hours of training and seminar and length of experience as clinical instructor and their role performances. Meanwhile, type of nursing school graduated and length of experience as staff nurse were found to be predictive of their role performances. Conclusions: Being a product of a private institution and the length of experience as a nurse in the clinical area are factors having to affect the performance of an effective clinical instructor in Bulacan State University. Further investigation is recommended using larger sample to validate the findings of this study.
Key words: Role Performance, Clinical Instructor, Performance Evaluation, Nursing Education

Introduction This modern society has developed wide ranges of disease. A greater number of diseases have drastically arise in which by nature ranges from mild to some extent but can be life threatening on the other. In the latter years of the 20th century, diabetes mellitus (DM) emerged as one of the most important diseases in Western societies both in terms of its adverse effect on the health and lifestyles of a vast number of people, as well as its economic impact (Centers for Disease Control and Prevention, 2007). Statistics have shown increase in the incidence of diabetes mellitus over time. An estimated 246 million people worldwide suffer from DM in the year 2007. Apparently, this number could reach 380 million people by the year 2025 according to the World Health Organization largely due to population aging, unhealthy diets, a sedentary lifestyle and obesity. 144 million or almost 60 percent among the above stated figure are Asians. Wide range of factors from genetic and cultural differences to smoking and urbanization rate influences the diabetes trend in Asia. In the Philippines, six million Filipinos were projected to have the disease, yet half of them will remain undiagnosed. According to the Department of Health, statistics shoots to a rate of 19.8 from 8.9 percent in 1995 making diabetes mellitus the 9th leading cause of mortality in the Philippines (DOH, 2005). In Region III, diabetes mellitus ranked as the 6th leading cause of

mortality in 2001. in the provinces of Bataan, Bulacan, Nueva Ecija, Pampanga, Tarlac, Zambales. Diabetes Mellitus affectedg 1,466 individuals at a rate of 18.74 percent. Three years after, the numbers increased affecting 2,362 individuals (26.2%). In Bulacan alone, there is a steady increase in patients who were confined due to complicated type II diabetes mellitus from February 2008 to February 2009. Diabetes is one of the leading causes of disability and even of mortality, the leading cause of kidney failure, non-traumatic limb amputations, blindness; and the foremost contributor to cardiovascular diseases (CVD) (Shahady,2006). Despite better understanding of the pathophysiology and management of diabetes, patient outcomes have not shown parallel improvement. Our current system of patient education and clinical care has not effectively addressed this issue. The only defense against this disease is prevention and control. A major shift in the way we care for the patient is crucial to reduce the burden of suffering associated with diabetes and to forestall the development of CVD. This study was conducted to determine the extent of knowledge and attitude regarding diabetes and the compliance of type II diabetic patients at the Bulacan Medical Center. This preliminary study will provide insights for the development of a functional health education program for diabetic patients which may be useful for the patients in order to better manage their condition. The results of the study may help the hospital administrators to improve

their current program to prevent the occurrence of complication. Materials and methods The study made use of the descriptive method of research using a structured questionnaire supplemented by interview as the tools for data gathering. A four part questionnaire made by the researcher was used to determine the respondents profile, extent of knowledge, attitude and compliance in the treatment regimen. The respondents of the study composed of a total of 185 patients consulting at Bulacan Medical Center from September 2009 to November 2009. The data gathered were tabulated, organized and analyzed using the following statistical methods: frequency and percentage distribution, weighted mean, and standard deviation. The extent of knowledge, attitude and compliance was quantified using a four point scale: (4) Very Knowledgeable, Very Positive Attitu de, Full compliance; (3) Moderately Knowledgeable, Positive Attitude, Moderate Compliance; (2) Limited Knowledge, Negative Attitude, Limited Compliance; (1) No Knowledge at All, Very Negative Attitude, Non-compliance. A hypothesis of non-significant relationship between the extent of knowledge, attitude and compliance of patients regarding diabetes and their age, gender, average family income, educational attainment and family history was tested using Chisquare. rESULTS The profile of the respondents was determined in order to provide the necessary background information about the respondents. These were grouped in terms of age, gender, average monthly income, educational attainment and a family history of diabetes mellitus. Age. Result shows that the bigger part of the respondents belonged to the age group 35-44 years old with a 27.57 percentage. The mean age of the respondents was 51.77 with a standard deviation of 16.22, indicating that the majority of the respondents were between thirty-five to sixty-eight years of age. Gender. A little greater than half of the respondents were female with a 58.38 percent. The male respondents numbering 77 accounted for 41.62 percent. Average Monthly Family Income. Analysis of the monthly income data of the respondents revealed that the highest percentage of salary bracket was from one thousand to four thousand pesos. A total of 43.24 percent belonged to this category. Mean family income recorded was 9,567.56 pesos. Educational Attainment. Results also revealed that among the 185 respondents, majority of them reached the primary level of education with a 38.38 percent. In addition, 33.51 percent finished high school. Only about a quarter (24.32%) reached the college level and a very small number (3.78%) had post graduate education.

Family History of Diabetes Mellitus. 66.49 percent of the respondents had a positive family history of diabetes mellitus, while 33.51 percent of them did not have a history of diabetes mellitus in their family. 2. To live with diabetes, knowledge about the condition is highly imperative. In establishing the knowledge of the respondents regarding diabetes mellitus, the researcher listed six categories namely; the cause, disease process, signs and symptoms, complications, diabetic diet and effects of regular exercise. The summary of the mean responses on the knowledge of the respondents regarding diabetes mellitus reveals that the respondents knowledge about the cause of DM obtained an average weighted mean of 3.17, followed by a mean of 2.96 for their knowledge about the diabetic diet, 2.92 for the effects of regular exercise; a mean score of 2.88 on the signs and symptoms of diabetes mellitus; and 2.57 on the complications of the disease. But it is also shown on the table that their knowledge on the disease process had a weighted mean of 2.45 revealing that the respondents had limited knowledge on this aspect. This means that, collectively, despite the lack of knowledge on the pathophysiological response on the body of a diabetic, the respondents were moderately knowledgeable regarding diabetes mellitus having an average weighted mean of 2.82. Therefore, proper education must be given to the patients regarding pathology of diabetes mellitus for better understanding of the condition leading to better patient outcomes. 3. A positive attitude and acceptance of the condition is necessary for the patient to be able to fully submit themselves to the plan indicated for them for better patient outcomes. To be able to determine the extent of attitude of the respondents regarding diabetes mellitus, five factors were identified by the researcher namely: diet modification, regular exercise, weight monitoring, lifestyle modification, and self care. Attitude on diet modification obtained a mean of 2.61 showing a positive attitude on diet modification. This is highly desirable and in congruence with the statement made by Lesse in 2009 that a positive attitude towards diet modification can delay and possibly prevent the occurrence of hyperglycemic attacks. The respondents possess a positive attitude regarding their willingness to perform exercise as shown by the mean of 2.79. Exercise helps to keep cardiovascular system in good condition. In terms of weight monitoring, a mean value of 2.61 was obtained. This reflects a positive attitude that the respondents agreed that they could maintain a suitable body weight. This attitude was highly desirable according to Willet (1999) when he mentioned that diet modification together with weight monitoring could address strategies for better patient outcomes. Behavior of patient regarding lifestyle modification was also examined. The respondents believed that they could enjoy life while at the same time still keep good blood

sugar control showing a positive attitude with a weighted mean of 2.86. Furthermore, alcoholic beverage restriction was also agreed upon by the respondents again showing a positive attitude with a mean score of 2.83. This statement was evident of the result of the study of Pigman (2002) that patients who were using alcohol were 2.10 times more likely to have poor diabetic control than patients who were not using alcohol. In addition, cigarette smoking restriction also obtained a positive behavior among the respondents with a mean of 2.79. Oldroyd and his colleagues (2006) also added, as revealed in their study, that after adjustment for age, diet, and various diabetic medications, patients who smoke were 2.71 times more likely to have poor diabetic control than patients who dont smoke. In general, attitudes of patients showed a sought-after result, obtaining an average weighted mean of 2.76 which means that not only the respondents were moderately knowledgeable of the facts regarding diabetes, they also posses positive attitude regarding the condition. This was similar to the result of the study of Ambigapathy (2003) saying that an increase in knowledge would lead to an increase in attitude. 4. Compliance with the prescribed treatment regimen is also a key to achieving desired outcomes. The following indicators were set to institute baseline data on the extent of compliance of the respondents with their treatment regimen. These indicators were: prevention of complication, exercise, diet modification, weight monitoring, glucose monitoring, and medication. Results show that the data on the extent of compliance with the measures on the prevention of complication obtained full compliance with a mean score of 3.52. Personal hygiene and refraining from walking barefooted both obtained remarkable weighted mean of 3.61 and 3.56, respectively. This means that the respondents were doing full compliance in this area of the treatment regimen. Skin and foot care and carefully cutting the nails are also ways of preventing complications. These two obtained mean scores of 3.48 and 3.43 respectively. This shows that the respondents were moderately compliant on the part. Hygienic measures should be implemented so as to prevent recurrent infection, considering the fact that diabetic patients are very prone to skin infection says Alterman (2006). Refraining from walking barefooted minimize the A positive attitude and acceptance of the condition is necessary for the patient to be chances of having wounds at the periphery that go unnoticed (Smeltzer, 2000), thus limiting the chances of having limb amputations due to poor wound healing. Performing the prescribed exercise obtained a mean of 2.73. This means that the respondents were moderately complying with program intended for their exercise. This is to support what Dr. Allen Spiegel said in the study of Lesse (2009), not only did changes in physical activity prevent or delay the development of diabetes; they actually restored normal glucose levels in many people

who had impaired glucose tolerance. Exercise also helps in avoiding altogether or minimizing the long-term complications of diabetes. Methods regarding diet modification showed moderate compliance among the respondents having an average weighted mean of 2.88. Following the prescribed diet obtained a mean of 3.00. Avoiding foods that increase blood sugar showed a mean response of 2.97 while a mean of 2.65 was obtained by the indicator observing the caloric content of the food eaten. Effectiveness of diet modification is supported by the findings of Lesse in 2009 that diet modification which achieved a 5 to 7 percent weight loss reduced diabetes incidence by 58 percent among participants randomized to the study's lifestyle intervention group. It is also highly recommended that hospitals and diabetic clinics should maintain a diet record of patients and such diet must be composed of food groups and food exchanges that the client can choose from. Weight monitoring is another component of the treatment regimen. As shown in Table 4, this component received moderate compliance with an average weighted mean of 2.51. This means that the respondents followed general guidelines for weight monitoring. More than 80 percent of people with diabetes are overweight said Mutt (2008). Type II diabetes mellitus is strongly associated with obesity. Therefore, patients must be vigilant in obtaining the desired body weight so as to prevent the complications of the condition. Next among the factors in the treatment regimen is maintaining tract of the glucose level. Table 4 reveals a weighted mean of 2.91 for this factor. This means that the respondents were moderately compliant to monitoring their blood glucose level. Glucose monitoring helps people with diabetes manage the disease and avoid its associated problems said Beck (2003). A person can use the results of glucose monitoring to make decisions about food, physical activity, and medications. Compliance with the medications obtained a mean score of 2.63. This implies that the respondents were moderately compliant with their medications. Over time, high levels of blood glucose, also called blood sugar, can cause health problems. These problems include heart disease, heart attacks, strokes, kidney disease, nerve damage, digestive problems, eye disease, and tooth and gum problems. Diabetes medicines help keep the patients blood glucose in target range. Many choices are available. The American Diabetes Association recommends that most people start with metformin, a kind of diabetes pill. In general, patients extent of compliance shared an average weighted mean of 2.56 showing that they were moderately compliant in all aspect of the treatment regimen. It was further emphasized by Mutt (2008) that if one follows the guidelines of exercise, together with strict compliance with the diabetic diet and proper medication recommended by doctor, one can achieve a good blood sugar control, cardiovascular conditioning, and strengthening of the muscles and skeletal system.

5. In determining the relationship of knowledge, attitude and compliance with the respondents profile, five factors were used. Patients age, gender, average monthly income, educational attainment and family history of diabetes mellitus were the five factors. The researcher intended to determine if these factors affect the respondents knowledge, attitude and compliance. Age and gender were found to be significantly related to the patients level of knowledge, attitude and compliance. In general, a closer look at the data would show that as the patients mature in age, their knowledge and attitude regarding diabetes increase, consequently, their compliance with their treatment regimen improves. More so, it may be concluded that the female patients were more knowledgeable and had a positive attitude regarding diabetes mellitus and were more compliant with the treatment regimen compared with the males. Average monthly income, educational attainment and family history of diabetes mellitus were found to be not related to the patients level of knowledge, attitude and compliance. 6. The developed functional health education program for diabetic patients.
Please refer to page __ for the details of the Health Education Program for Diabetic Patients

1. The management of diabetes mellitus needs cooperation with the client. Regular follow check up and consultation should be made by the respondents to plan treatment regimen suited to their needs. 2. A regular on-going health education program must be done in order to address the need of the group to deepen their knowledge regarding the disease process. 3. The developed functional health program be used and reproduced not only by the authorities of Bulacan Medical Center but also the educators and nursing students who would want to enrich their knowledge, attitude and compliance in the management of diabetes mellitus. 4. The hospital administrators must be vigilant in motivating their team in conducting and attending a follow-through diabetes education among diabetic patients. 5. A replication of the study be made in other settings; may it be school based, community based or another hospital based research. 6. The replication of this study may be done with other diseases like hypertension, cerebro-vascular diseases, asthma and other chronic illnesses that need attention. references Ambigapathy, Ranjini S. (2003). A knowledge, attitude and practice (kap) study of diabetes mellitus among patients attending Klinic Kesihatan Seri Manjung. NCD Malaysia, Vol. 2, No. 2. 2003. Alterman, Setmour L. (2006) How to control diabetes: a complete guide and meal planner. New York. Ballatine Books. Batuyog, Mary Jacqueline O. (2005). The extent of knowledge and compliance of type 2 diabetic patients regarding the treatment regimen. Philippine Journal of Nursing, Vol. 17, October 2007. Beck, Jessica. (2003). Implications of Glucose Monitoring. American Journal of Nursing, February 2003. Birnbaum, Morris J. (2005). Rejoinder: genetic research into the causes of type 2 diabetes mellitus. Anthropology and Medicine, Vol. 12, No. 2, August 2005, pp. 129-134. Bjorner, John D. (2002). Self-rated health: a useful concept in research, prevention and clinical medicine. Stockholm, Sweden, 2002. Brunner and Suddarth. (2003). Textbook of medical surgical nursing. (10th Edition). Philadelphia, J.B. Lippincott Company. Bullock, Barbara. (1998). Pathophysiology adaptations and alterations in function. Philadelphia: Lippincot Raven Publishing Company. 1998. Calderon, Jose P. (1999). Methods of research and thesis writing. Manila, National Bookstore Inc., 2000. Center for Disease Control and Prevention. (2007) National Diabetes Fact Sheet: General Information and National Estimates on diabetes in the United

conclusions 1. Awareness on the disease process appears to be at limited levels, thus a health education program starting at the cause and disease process was developed to address the needs of the patients. 2. As to the extent of attitude on the disease, the respondents possessed a positive attitude regarding diet modification, regular exercise, weight monitoring, lifestyle modification, and self-care. A positive attitude is highly desirable among patients as this could mean greater chances of following the treatment regimen prescribed for them. 3. As to the extent of compliance of the patient with their treatment regimen, the respondents were moderately compliant with exercise, diet modification, weight monitoring, glucose monitoring and medication while having full compliance with the measures on preventing complication. 4. Age and gender were significantly related with the patients knowledge and attitude regarding diabetes mellitus and the compliance in their treatment regimen. 5. Average monthly income, educational attainment and a family history of diabetes were all found to be independent of the patients knowledge and attitude regarding diabetes mellitus and the compliance in their treatment regimen. RecOMMENDATIONS

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