European Journal of Cardiovascular Medicine

Diabetes mellitus is a metabolic disorder characterized by a persistently elevated blood glucose associated with absent or inadequate pancreatic insulin secretion, with or without concurrent impairment of insulin action¹. Diabetes is majorly of two types, type 1 diabetes (insulin dependent diabetes mellitus) is most severe form of the disease, is usually seen in individuals less than 30 years of age. It is lethal unless promptly diagnosed and treated¹. T2DM is the most common form of DM, which accounts for 90% to 95% of all persons with diabetes³. In 2019, an estimated 1.5 million people died from consequences of high blood sugar. Out of those, 80% people were from low and middle-income countries. The long-term specific effects of diabetes include retinopathy, neuropathy and nephropathy. People with diabetes are also at the risk of other diseases including heart, peripheral arterial and cerebrovascular disease, obesity, cataract, erectile dysfunction, and non-alcoholic fatty liver disease and also more risk for infectious diseases. Micro vascular complications are serious health problems resulting in deterioration of quality of life and pre mature death. Lower limb amputations are 10 percent more common in diabetic due to lack of self-care than non-diabetics¹.

 The International Diabetes Federation (IDF) estimates that 537 million people had diabetes in 2021, a number that is projected to continue to increase in the coming years^2,3. Particularly noteworthy is that 58.9 million diabetes-related disability-adjusted life-years (DALYs), or 76.5% of DALYs associated with type 2 diabetes⁴.According to ICMR-INDIAB study estimates that 101 million people in India -11.4% of the country's population - are living with diabetes. This study also found that 136 million people - or 15.3% of the people - could be living with pre-diabetes⁵. The prevalence of Diabetes was high in urban population with the prevalence of 10.2% when compared to rural area which has got prevalence of 6.9% globally. There is evidence from the previous studies that increasing prevalence of diabetes in rural areas is due to rapid urbanization and industrialization⁶.

In developing countries like India, self-care practices are cost effective approaches in management of diabetes with least economic burden and thus fasten the progress towards achieving the sustainable developmental goal. Diabetes self-care requires the patient to make many lifestyle modifications in addition with the supportive role of healthcare staff for maintaining a higher level of self-confidence leading to a successful behaviour change⁷. So, self-care is crucial element in secondary prevention to prevent from dangerous complications¹. Self-care includes Adherence to diet, drug regimens, examination of urine, blood glucose monitoring, self-administration of insulin, abstinence from alcohol, checkups and so on¹.  Non-adherence to the prescribed treatment regimen in patients with type 2 diabetes mellitus is quite high. Furthermore, it has been associated with higher rates of hospital admissions, suboptimal health outcomes, increased morbidity and mortality, and increased health care costs. The American Diabetes Association (ADA) recommends those diagnosed with type 2 diabetes receive diabetes self-management education and support, including training to improve diabetes knowledge and self-care behaviours as well as clinical care to support glycaemic control⁸. At least 45% of patients with type 2 diabetes mellitus (T2DM) fail to achieve adequate glycaemic control (HbA1c<7%) and one of the major contributing factors is poor treatment adherence⁹. A key dimension of healthcare quality is adherence to prescribed medications. According to the World Health Organization, non-adherence to the medical regimen consists a major clinical problem in the management of patients with chronic illness¹⁰.

Now a days diabetics are increasing more in number and the physicians in the tertiary care hospitals are unable to educate them, due to time constraints and patient load. The proposed research study will make patients to know about self-care practice, dietary control, regular follow up, regular blood glucose monitoring, importance of drug adherence and its benefits in control of blood glucose. So that complications will be delayed, morbidity and mortality with diabetes will be decreased.

The setting of the study was at OPD of General Medicine department of GGH, Government Medical College, Kurnool. A one year observational study was conducted during the period from May 2023  to April 2024. The sample size was calculated using the proportion of diabetes mellitus self-care practice from the previous study conducted by Tefra Ketal (50.8%) ¹¹, with the assumption of 7% of absolute error and 95% CI, sample size was calculated as follows         

  N = (zα\2 )²pq    =9997.44   =204

                  D²              49

5% non-response rate, then 215 is the final sample size.All the cases of clinically diagnosed and  as per the the standard case definitions and known cases of Type 2 Diabetes Mellitus attending the OPD during the above period up to reach the required sample size was included in the study after duly following the inclusion and exclusion criteria as indicated below. Inclusion criteria: Those who are diagnosed with type 2 diabetes and able to participate without any mental disability and physical disability that could affect his\her decisions and self-care and being over 30 years of age.Exclusion criteria: Those who are mentally disable to say decisions and physically disable for their self- care although diagnosed with type 2 diabetes.Objectives:1.

To study the sociodemographic profiles & risk factors and comorbidities associated with the disease and to assess knowledge, attitude and practices regarding self-care towards control and prevention of complications of Diabetes 2. To knoow the treatment adherence towards diabetes among the study subjects. After receiving the Ethical committee clearance from the institution, the study was began and the required data was collected by using a pretested proforma pertaining to their socio-demographic profiles, Evaluating Risk factors, comorbidities and assessing their KAP related to self care towards control & prevention of complications of Diabetes etc; and also treatment adherence information was collected through the Morisky Medication Adherence Scale

Finally, the collected data was analyzed by using appropriate statistical tools like percentages, proportions, measures of central tendency, measures of dispersion, standard error of mean and tests of significance by using SPSS version 21computer software etc.  The study results were compared and discussed in the light of published material of various similar studies belongs to different authors and there by conclusions and recommendations was framed.

Table1: Socio-demographic variables of study subjects

• Majority of the study subjects were males (67.5%) and belonged to 51-60 years age group (35.6%). Majority of the study population were Hindus (75%) and were married (79.6%). Majority of the study subjects belonged to rural area (82.8%). Approximately 30% of study subjects were illiterates and un-skilled workers.43.9% of study subjects belonged to nuclear family.

TABLE2: DISTRIBUTION OF STUDY PARTICIPANTS BASED UPON KNOWLEDGE

Majority of study participants were not aware on self-care related knowledge components.

Study revealed that 12% were aware on examination of feet daily, 6% were aware on regular eye checkup, 12.5% were aware on physical activity/exercise for their blood glucose control, 32.5% were aware on signs and symptoms of hypoglycemia, 29.6% were aware on self-remedy for hypoglycemia and 7.3% were aware on complications of DM

TABLE3: DISTRIBUTION OF STUDY PARTICIPANTS BASED UPON ATTITUDE

• Majority of study participants had positively responded to all attitude related questions.
• Study revealed that 94.9% of participants were having good attitude towards reporting health care provider if problem seen in their feet, 78.2% of participants were having good attitude towards responsibility of eye check-ups, 93.5% of participants were having good attitude towards medication intake, 91.2% of participants were having good attitude towards their responsibility in addition to doctor and family in the care of diabetes and 90.7% of participants were having good attitude towards prevention of complications of diabetes by using self-care practices appropriately.

TABLE4: DISTRIBUTION OF STUDY PARTICIPANTS BASED UPON THEIR SELF CARE PRACTICES

• Study revealed that 43.5% of study participants were checking their feet regularly, 87% of study participants were following dietary recommendations, 73% of study participants were doing physical activity regularly, 57.4% of study participants were regularly checking their glucose levels, 40.7% of study participants were smoking and 96.2% of study participants were taking medication as recommended by doctor.

FIGURE1: Distribution Of Mmas Scoring Among Study Participants.

• About 165(76.3%) study participants were having low MMAS score and it reflects poor treatment adherence.

TABLE5: Association Between Knowledge and Treatment Adherence

• The study revealed significant association between treatment adherence with knowledge on foot care (P=0.00001), eye care (P=0.003), physical activity (P=0.00001) and long-term complications (P=0.0003

The present study was a cross-sectional study conducted within the hospital setting. Self-care practices and treatment adherence played a crucial role in effectively managing type 2 Diabetes. So, our study objectives were to evaluate knowledge, attitude, self-care practices and treatment adherence adopted by individuals diagnosed with type 2 Diabetes mellitus attending the outpatient department of GGH, Kurnool. In this study, knowledge on foot care examination were unsatisfactory as only 12 %of all study participants (both urban and rural)and 11.1% of rural study participants were having knowledge but in study conducted in Ethiopia by Yimer Mekonnen, Nezif Hussien¹² reported 55.5% of study participants had good knowledge on purpose of feet examination.  And in a study from tamilnadu¹³show almost same results like present study of 13% knowledge on foot care in rural areas. Regarding attitude on foot care, in this study, 94.9% of all participants have good attitude to report to health care provider, if any problem found in foot. In Ethiopia¹² study almost same results (91.9%) are seen and with reference to self care practices on foot care, in this study reports on self-care of foot examination showed 44.1% of rural study participants are doing regular foot care practice. In a study

conducted by Suguna etal¹⁴ stated that low adherence is reported in foot care of just 4% in rural areas of Bangalore. In the Present Study rural study participants (44.1%) were practicing better foot care than Bangalore rural area study participants (4%). In this study 43.5% of all participants were having good practice of foot care. Study of Ethiopia ¹² showed adherence in domain of foot care of 57.4%.

And pertaining to knowledge on eye care by self practice, in our study knowledge on regular eye checkups is very inadequate of only 6% of all study participants. A study conducted in tamilnadu by Sharmila¹³ showed only 3.5% of rural study participants had knowledge on eye care. On contrary in study of Ethiopia¹², reported 53.1% of participants have better knowledge on importance of eye care. A study conducted by Chandrasekhar¹⁵ in rural field practice of Kurnool, showed that 40.4%of all study participants are going for eye clinics for screening of eye complications. In the study conducted by the Balasubramaniyan N etal¹⁶ reported that 74.3% of the study participants know that DM can affect the eye. In the present study there are 179 study participants were from rural areas out of them only 10(5.5%) were visiting the eye clinic for

screening. In the study conducted by Saydah¹⁷ in USA stated that 49% of study participants were making good

regular eye check-ups. In the present study total knowledge

on eye care and self-care practices were unsatisfactory when compared to other studies^12,15,16,17. In this study attitude towards responsibility of regular eye check-ups is about 78.2% which was similar in a Study  of Ethiopia¹²showed almost same attitude towards eye checkups of 82.4%.

Related to knowledge on physical activity in our study, only 12.5% participants have knowledge on physical activity in controlling blood glucose. Study in Ethiopia¹² showed that 38% of all study participants were given correct response of knowledge on physical exercise.This study stated that practice of physical exercise was about 73% of all study participants were doing regular physical exercise. In present study, Physical exercise practices were good inspite of less knowledge on physical activity. This was observed because more participants belong to rural areas and doing farming. And pertaining to self care practices on physical activity, the present study showed that 73% of all study participants were doing regular physical activities. The present study results were consistent with sharmila study¹³ which was conducted at salem district, Tamilnadu in which 66.6% of all rural participants were doing regular physical activities and contrary with Shrivastava et al¹⁸ study (30%), Raith Atha S J etal¹⁹ study (24.33%), and Gopichand ran v et al²⁰ study (20%). The present study stated that 87% of all study participants show good dietary practices. The present study results were consistent with Raith Atha S J etal¹⁹ study (70.42%) ^and contrary with Dinesh etal^{21 study} (24%) and Mohandas etal²² study (31%).

In this study results for the treatment adherence were, 76.3% of study participants have low treatment adherence, 18.5% were having medium treatment adherence, and only 5.2% have high treatment adherence, measured by MMAS scale where as 96.2 % participants responded positively that they were taking medication regularly. On contrary to present study, Manjusha Sajith etal²³ study which was conducted in 2014 at pune, 40.95% have high treatment adherence and Arulmozhi S, Mahalakshmy T²⁴ etal study conducted at Pondicherry, 49.3% have high treatment adherence. In this study, 29.6% of all study participants had knowledge on problem solving skills on hypoglycemia. On contrary the study conducted by Swetha T etal²⁵showed 81% were having good problem-solving skills towards hypoglycemia. In the Ethiopia ¹² study stated that 21.3% were having good problem-solving skill. In this study, 32.5% of all study participants had knowledge on signs and symptoms of hypoglycemia. In Ethiopia¹²study showed that 72% of all study participants were having good knowledge on signs and symptoms of hypoglycemia. The present study results were not consistent with the Ethiopia¹² study.

In the present study significant association between treatment adherence and awareness components like foot care, importance of eye care, physical activity, complications of diabetes mellitus. (p value < 0.05).

Like present study, the study conducted by Pradeep.B²⁶ showed significant relation between knowledge on physical activity, complications with treatment adherence. (p value < 0.05)

• Present study concluding that MMAS scoring show its importance in revealing the correct adherence and recommended its use in daily routine checkups of DM patients
• Self-care practices rearding foot care, eye care, problem solving skills, regular glucose monitoring and treatment adherence were very poor in the present study, So Continuous health education and reinforcement by health care providers is essential in order to enhance self-care activity.
• Diabetes education should include guidance on drug adherence and mandatory monitoring of blood glucose during any illness, ensuring that it becomes an integral component of every encounter.
• The backbone of diabetes management lies in all seven domains of self-care activity. Researchers need to conduct further investigation in order to comprehend the perceived barriers and self-efficacy associated with promoting these aspects.

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