Assessment of self-care practises among patients with type 2 diabetes mellitus attending urban health training centre of a tertiary health care institute in Central India: a cross-sectional study

INTRODUCTION

Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys, and nerves. The most common is type 2 diabetes, usually in adults, which occurs when the body becomes resistant to insulin or doesn’t make enough insulin. In the past 3 decades, the prevalence of type 2 diabetes has risen dramatically in countries of all income levels. For people living with diabetes, access to affordable treatment, including insulin, is critical to their survival. There is a globally agreed target to halt the rise in diabetes and obesity by 2025. About 422 million people worldwide have diabetes, the majority living in low-and middle-income countries, and 1.5 million deaths are directly attributed to diabetes each year. Both the number of cases and the prevalence of diabetes have been steadily increasing over the past few decades.¹ In India, there are an estimated 77 million people above the age of 18 years suffering from diabetes (type 2) and nearly 25 million from prediabetics (at a higher risk of developing diabetes in near future). More than 50% of people are unaware of their diabetic status which leads to health complications if not detected and treated early.²

Effective diabetes management demands a multifaceted approach, of which self-care constitutes a fundamental component. Self-care in diabetes encompasses a spectrum of activities individuals undertake to manage their condition, optimize health outcomes, and reduce the risk of complications. These activities include dietary modifications, regular physical activity, medication adherence, blood glucose monitoring, stress management, foot care, and regular medical evaluations.³ Because the vast majority of day-to-day care in diabetes is handled by patients and/or families, there is an important need for reliable and valid measures for self-management of diabetes. There are several essential self-care behaviours in people with diabetes that predict good outcomes. These are healthy eating, being physically active, monitoring blood sugar, adherence to medications, good problem-solving skills, healthy coping skills, and risk-reduction behaviors.⁴ Given the growing prevalence of diabetes and the critical role of self-care in managing the disease and preventing complications, it is essential to assess and strengthen self-care practices among individuals with diabetes. Hence this study aimed to assess the self-care practises among patients with type 2 diabetic mellitus.

METHODS

A cross-sectional study was conducted among type 2 diabetic patients aged 18 years and above at the urban health training centre of Indira Gandhi Government Medical College, Nagpur, from January to April 2023. Participants were included if they had a minimum of one-year disease duration and consented to participate. Pregnant women, newly diagnosed diabetic patients, and those declining participation were excluded. Informed consent was obtained from all participants.

Data collection

Data were collected through face-to-face interviews using a pre-tested structured questionnaire. This questionnaire included sociodemographic information and assessed self-care practices using the summary of diabetes self-care activities (SDSCA) scale. The SDSCA scale comprises six domains: diet, exercise, blood glucose monitoring, medication compliance, foot care, and smoking.

Although the SDSCA is a self-report instrument, in this study, the interviewer recorded responses for each item based on the number of days the participant engaged in a particular self-care activity during the previous week (on a scale of 0-7). Higher scores indicated better self-care practices. For participants who were sick during the previous week, data were collected for the preceding healthy week. More number of days reflected the better self-care practices and to allow for comparison in terms of percentages the given self-care activity was considered good if it was followed on most of days (≥5 days) in a week.

The number of items included for scoring in each domain was as follows: diet (4 items), exercise (2 items), blood glucose monitoring (3 items), medication compliance (1 item), foot care (4 items), and non-smoking behaviour (1 item). The total score for each domain was calculated by summing the responses for all items. For medication compliance and non-smoking behaviour, scores were either 0 or 7.

To obtain an overall self-care score, the total scores for each domain were added and divided by the total number of items, assigning equal weight to each domain. The final scores ranged from 0 to 7, with scores less than 5 considered indicative of poor self-care practices.⁵

Sample size estimation and data analysis

The sample size for this study was determined based on a previous study by Goyal et al which reported a 44% prevalence of good self-care practices among type 2 diabetics.⁵ Using a suitable sample size formula, n=z²pq/e², with a 10% absolute error and 95% confidence interval, a sample size of 95 was calculated, and a total of 100 patients were consecutively recruited. Data entry was performed using Microsoft Excel. Statistical analysis was conducted using SPSS Statistics version 20.0. Results were presented as proportions and percentages. Chi-square tests were employed to assess the association between various factors and their influence on self-care practices. A p value of less than 0.05 was considered statistically significant.

RESULTS

Table 1 shows the socio-demographic factors of the study participants. The majority (82%) of the participants were more than 50 years and females were 67%. Almost all the participants (89%) were married and belonged to a nuclear family (68%). About religion, participants following Hindu religion were 66% followed by Buddha (19%). Occupations of the respondents were varied like homemaker (35%) followed by retired (21%) and unemployed (15%). One-fourth (28%) of the respondents were educated up to high school. Three-fourths (74%) of the participants had no family history of diabetes while 86% had been living with the condition for less than 10 years. For 61% of the participants, the diagnosis of diabetes was made based on symptomatic presentation.

Table 2 illustrates the self-care practices of study participants. The majority (80%) of the participants tested blood sugar at least once in three months. Almost all the participants (95%) had adherence to oral hypoglycemic agents on most of the days of the week. However, fewer participants included fruits/vegetables (42%) in their diet, dried between toes (36%), examined feet (40%), or inspected shoes (31%). A very few (3%) smoked in the past seven days.

*Modified Kuppuswamy scale

Figure 1 illustrates that 68% of the participants had poor self-care practices while 32% had good self-care practices.

Table 3 shows the association between various socio-demographic factors and self-care practices. Gender (p=0.04) and education (p=0.013) had a significant association with good self-care with males and literate individuals practiced better self-care. In contrast, other factors like age, occupation, duration of illness, and family history of diabetes showed no significant relationship with self-care behavior.

DISCUSSION

The present study was undertaken to assess self-care practices among type 2 diabetes mellitus patients. Various studies have revealed that good self-care practices can prevent the complications in diabetic patients like cardiovascular disorders, nephropathy, neuropathy and retinopathy to a certain extent. With this background our study mainly focussed to assess self-care practices among type 2 diabetic patients using SDSCA scale.

Most of the participants in the current study were more than 50 years similar to the findings of Shah et al ⁹ and Suguna et al.⁷ Self-care practices were poorer among 65.85% of patients aged more than 50 years but was not found to be significant which is in contrast to the findings of Goyal et al study wherein self-care practices were significantly poorer among younger generation.⁵

In the present study, 67% patients were females which is consistent to the findings of Dasappa et al and Selvaraj et al studies.^8,10 Also, there was significant association between gender and self-care practices. On the contrary Veerakumar et al study showed no significant relation.¹²

Most of the patients were literate in our study as in various other Indian studies by Dinesh et al and Kartik et al.^6,11 A significant association was observed between education and self-care practices similar to the findings of Goyal et al study.⁵ Education plays a major role in inculcating good self-care practices among individuals.

In this study, duration and family history of diabetes failed to show a significant association with self-care practices similar to the finding of Karthik et al.¹¹ Veerakumar et al found no significant association between self-care practices and occupation and family history of diabetes supporting our findings.¹²

Six domains were checked like diet, exercise, blood glucose monitoring, medication compliance, foot care and non-smoking behaviour according to SDSCA scale and overall, 68% patients were found to have poor self-care practices. Similar findings were observed in Goyal et al study with 43.45% patients with poor self-care practices.⁵ Many Indian studies were conducted with similar tool assessment.^6-8

For an effective glycaemic control, patients often tend to follow a diet similar to their family’s daily meals with the exclusion of fatty and sweet foods. In the present study, 42% of the participants had incorporated fruits or vegetables in the diet on most of days of the week similar to Chittoor et al study.¹³ At least 30 minutes of daily physical activity is necessary to attain glycaemic control by reducing insulin resistance. In the present study 59% of patients performed 30min of daily physical activity on most of days of the week. Many studies conducted in India support our findings.^14,15

Being affected by a life long illness like diabetes, individuals tends to underestimate the severity of the condition and often neglect their anti-diabetic medications in the long run. However, the findings from our study shows a promising shift, suggesting that individuals are becoming more informed and aware of their condition. More than three fourth of the patients tested blood sugar once in every three months in our study which was similar to study done by Maheshwari et al study.¹⁴ Very few patients gave history of smoking in the past one week in our study. Heterogenous findings could be observed in various Indian studies.^5,14 This could be due to the unwillingness from the side of patients to reveal their personal habits like smoking.

There were certain limitations to the present study. Patients were purely assessed based on recall method and glycemic control was not evaluated. Our study was cross sectional and was purely hospital based and hence cannot be generalised.

CONCLUSION

Self-care practices among diabetic patients were found to be poor in 68% of the participants. Among the various domains assessed, foot care was the least practiced, primarily due to a lack of awareness. There is a clear need for improvement across all areas of self-care, which may be achieved through regular training sessions and behaviour change communication strategies. Emphasis should be placed on educating patients about the importance of self-care, especially since good self-care practices were found to be significantly associated with factors such as gender and education level.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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