Introduction
Alarge proportion of elderly diabetics have poor treatment adherence, which is a significant barrier to treatment for these patients [9]. According to studies by Walker et al., using the Pender Health Promotion Model (1982), individuals' lifestyles can be assessed [21]. Despite scientific advances, treatment adherence among people with diabetes is still poor and their Hb A1C levels are high, so creating a comprehensive educational program based on an educational model for elderly diabetics seems very necessary [20]. It seems that intervention is necessary to increase adherence to treatment and reduce Hb A1C in the elderly and requires further studies [29]. Therefore, this study was designed and implemented with the aim of determining the level of adherence to treatment in the elderly with type 2 diabetes based on an educational intervention based on the Pender Health Promotion Model.

Materials & Methods
Hemoglobin A1c levels were measured using a Dirui CS-1200 device made in China and a control and calibrator kit made in Iran. After selecting individuals based on inclusion criteria and completing an informed consent form, a demographic questionnaire, a health-promoting lifestyle questionnaire, a Morisky questionnaire, blood pressure, patient height and weight, and Hb A1C levels were measured. In the intervention group, the training duration was 8 sessions, each session lasting 45 minutes, twice a week, based on the Pender Health Promotion Model and including six areas of health responsibility, physical activity, interpersonal relationships, nutrition, stress management, and spiritual health. Data were collected again three months later. In the control group, routine intervention was performed, and data were collected at the beginning of the study and three months later in the control group. The collected data were analyzed using SPSS23 software and independent t-test, paired t-test, and linear regression (in simultaneous examination of the effects of the study groups, considering the outcome before the intervention) at a significance level of 5%.

Results
The results showed that the mean age of patients in the control group was 67.18±6.08 and the intervention group was 67.90±5.62 (P=0.581). Also, there was no significant difference in the mean duration of diabetes between the intervention group (8.03±6.4) and the control group (8.58±6.4) (P=0.67). The two study groups were similar in terms of frequency distribution of marital status, education, income, living situation, and age (P=0.524).
The frequency distribution of gender was different in the two groups (P=0.518). In the regression analysis, gender variable had no statistically significant effect on any of the variables under study (P<0.50).
Between-group results showed that the scores of the Morisky Medication Adherence and Health Promoting Lifestyle Questionnaires in the intervention group had significantly increased compared to the control group three months after the intervention, and this increase was significant in all dimensions. (P<0.001) The Hb A1C level in the intervention group had significantly decreased compared to the control group.

Conclusion
This study showed that the educational intervention based on the Pender Health Promotion Model had a significant effect on treatment adherence (pharmacological and non-pharmacological) and HbA1C laboratory index in elderly people with type 2 diabetes three months after the intervention.Elderly diabetics were able to take steps towards improving their health and increasing treatment adherence by changing their lifestyle and its subcategories, including awareness and responsibility, nutrition, physical activity, stress management, interpersonal relationships, and spiritual excellence.
This model gives nurses more opportunities to examine individuals, families, and communities to work towards improving health, promoting functional ability, and improving lifestyles. Given that today, nurse training and counseling are not limited to hospital settings, and their effective presence in the community and family environment is also essential. This group can play an active role in changing people's awareness, attitudes, and performance in order to adjust and improve health behaviors by using educational models and various health strategies.

Ethical Considerations

Compliance with ethical guidelines
All ethical principles were considered in this study. Ethical approval was obtained from the Research Ethics Committee of the North Khorasan University of Medical Sciences (Code: IR.NKUMS.REC.1401.043). The study was registered by the Iranian Clinical Trials Database (Code: IRCT20221013056162N1).

Funding
This research was supported by the Deputy of Research and Technology at North Khorasan University of Medical Sciences.

Authors' contributions
Fatemeh Khorashadizadeh, Rezvan Rajabzadeh, HabibehSadat Shakri, Adeleh Sahebnasagh, Zahra Salehee: Responsible for study design, implementation, data collection & analysiz, and article drafting; - Zohreh Abasi: Edited the draft of the article and prepared the final version.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgments
The article's authors would like to express their gratitude to the managers and employees of the North Khorasan Universiry of Medical Sciences, as well as all the participants involved in this research.



 

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