Nature Image Exposure in Type 2 Diabetes
Effects of Nature Image Exposure on Pain, Fear of Blood Glucose Testing and Fear of Self-injection in Patients With Type 2 Diabetes: A Randomized Controlled Trial
Type 2 diabetes often requires repeated procedures, including insulin self-injection and self-monitoring of blood glucose. These procedures may cause pain and lead to fear of self-injection and blood glucose testing, which may negatively affect treatment adherence and diabetes self-management. Nature-based visual stimuli may serve as a simple, non-pharmacological distraction method by directing attention away from painful or fear-inducing procedures.
This randomized controlled trial evaluated the effects of nature image exposure on pain, fear of self-injection, and fear of blood glucose testing in adults with type 2 diabetes. A total of 64 participants were randomly assigned to either the intervention group (n=32) or the control group (n=32). Participants in the intervention group viewed a standardized nature image displayed on a fixed wall-mounted screen for 3-5 minutes immediately before insulin self-injection and self-monitoring of blood glucose. Participants in the control group received standard care without nature image exposure. Outcomes were assessed using the Diabetes Fear of Injecting and Self-Testing Questionnaire and the Visual Analog Scale.
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Study design This was a randomized controlled trial with blinded participants and blinded statistical analysis.
Setting and time The study was conducted between November 2023 and November 2024 in the Endocrinology Service Dicle University. The service consists of 8 rooms and 22 beds and is staffed by 5 faculty members, 4 residents, 1 diabetes education nurse, 9 clinical nurses, and 2 podologists. The diabetes education nurse provides individual education to all newly admitted patients with diabetes. This education includes insulin injection technique and rotation, insulin storage conditions, self-monitoring and follow-up, medical nutrition therapy, and exercise management. Education is also provided to patients' relatives.
Population and sample The study population consisted of 64 patients with type 2 diabetes who were followed in the Endocrinology Service of ---University -- between November 2023 and November 2024 and met the inclusion criteria. Inclusion criteria were: having been diagnosed with diabetes for at least one year, current use of insulin, ability to understand and speak Turkish, no prior exposure to nature image exposure interventions, performing insulin injections at least twice daily, and conducting blood glucose monitoring at least twice daily. Exclusion criteria included having a psychiatric diagnosis, refusal to participate, vertigo, visual or hearing impairment, and cognitive disability. Based on these criteria, eligible participants were identified, and a total of 64 patients were included in the study.
Sample size and power analysis Sample size estimation was performed a priori using G*Power version 3.1 [21] based on the fear of self-injection scale scores reported in the study by Aktura and Sarıtaş. [22] Assuming a large effect size (Cohen's d = 0.80), a statistical power of 80%, and a significance level of 5% (α = 0.05), the minimum required sample size was calculated as 42 participants, with at least 21 participants in each group. To compensate for potential participant loss and to increase the statistical robustness of the study, the sample size was expanded, and 32 participants were included in each group.
Blinding This was a randomized controlled trial in which participants were blinded to group allocation, and statistical analyses were performed by an independent statistician who was blinded to group assignments. However, outcome assessment and data collection were performed by the researcher, who was aware of group allocation; therefore, outcome assessors were not blinded.
Data collection instruments Data were collected using a Participant Information Form, the Diabetes Fear of Self-Injecting and Self-Testing Questionnaire (D-FISQ), and the Visual Analog Scale (VAS).
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Locations
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Di̇yarbakir
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Diyarbakır, Di̇yarbakir, Turkey (Türkiye), 21280
- Dicle University Hospitals
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Diagnosis of type 2 diabetes mellitus for at least one year Current use of insulin Ability to understand and speak Turkish No previous exposure to a nature image exposure intervention Performing insulin self-injection at least twice daily Performing self-monitoring of blood glucose at least twice daily Willingness to participate and provision of written informed consent
Exclusion Criteria:
Poor mental health Having gestational diabetes mellitus or Type 1 Diabetes Vertigo Visual impairment Hearing impairment
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Supportive Care
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Single
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
|---|---|
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Experimental: Nature Image Exposure Group
On Day 1, participants underwent routine self-monitoring of blood glucose and insulin injection without any intervention, and baseline measurements were obtained. On Day 2, participants viewed a standardized, high-resolution nature-themed visual displayed on a fixed wall-mounted screen for 3-5 minutes immediately before self-monitoring of blood glucose and insulin injection. Post-intervention measurements were then obtained using the same instruments. |
Participants were individually exposed to a standardized, high-resolution nature-themed visual depicting natural environments such as forests, rivers, waterfalls, and green landscapes. The visual was displayed on a fixed wall-mounted screen in the diabetes education room for 3-5 minutes immediately before self-monitoring of blood glucose and insulin injection. Environmental conditions were standardized, including uniform room lighting, minimal noise, a fixed seating position, and a consistent viewing distance. The visual display was removed immediately after each session. |
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No Intervention: Standard Care Control Group
Participants received standard care without nature image exposure. On Day 1, baseline measurements were obtained following routine self-monitoring of blood glucose and insulin injection. On Day 2, participants continued routine self-monitoring of blood glucose and insulin injection without any visual intervention, after which post-test measurements were obtained using the same instruments. |
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Change in Pain Intensity Assessed Using the Visual Analog Scale (VAS)
Time Frame: Baseline on Day 1 and post-intervention on Day 2, over two consecutive days
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Pain intensity associated with self-monitoring of blood glucose and insulin injection was assessed using the Visual Analog Scale (VAS). The VAS consists of a 10-cm (100-mm) horizontal line anchored by "no pain" at one end and "worst imaginable pain" at the other end. Participants marked the point that best represented their current pain intensity. Scores range from 0 to 10, with higher scores indicating greater pain intensity. Baseline pain was assessed on Day 1 following routine self-monitoring of blood glucose and insulin injection without any intervention. Post-intervention pain was assessed on Day 2 following nature image exposure and the procedures in the intervention group or following the same procedures under standard care in the control group. |
Baseline on Day 1 and post-intervention on Day 2, over two consecutive days
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Change in Fear of Self-Injection and Self-Testing Assessed Using the D-FISQ
Time Frame: Baseline on Day 1 and post-intervention on Day 2, over two consecutive days
|
Fear of self-injection and fear of blood glucose testing were assessed using the Diabetes Fear of Injecting and Self-Testing Questionnaire (D-FISQ). The questionnaire consists of 15 items and includes two subscales: fear of self-injecting (6 items) and fear of self-testing (9 items). Each item is rated on a four-point Likert scale ranging from 0 ("almost never") to 3 ("almost always"). The fear of self-injecting subscale score ranges from 0 to 18, the fear of self-testing subscale score ranges from 0 to 27, and the total D-FISQ score ranges from 0 to 45. Higher scores indicate greater fear. Baseline measurements were obtained on Day 1 following routine self-monitoring of blood glucose and insulin injection without any intervention. Post-intervention measurements were obtained on Day 2 following nature image exposure in the intervention group or standard care in the control group. |
Baseline on Day 1 and post-intervention on Day 2, over two consecutive days
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Collaborators and Investigators
Sponsor
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
- DICLE-ARDASURUCU-001
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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