INTRODUCTION:

Diabetes Mellitus (DM) is a major public health problem, globally and is ever growing as an epidemic in both developed as well as developing nations.^1-2 Diabetes mellitus occupies a special place among non communicable diseases as it is one of the leading killers of the present time.

The dynamics of the diabetes epidemic are changing rapidly. Once the disease of the west has now spread to every country, once the disease of affluent, it is now increasingly common among poor.³Demographic transition combined with urbanization and industrialization has resulted in drastic changes in lifestyles globally. Consequently, lifestyle related diseases like diabetes mellitus, have emerged as a major public health problem.⁴The prevalence of the diabetes is increasing at an alarming rate particularly in developing countries. Estimate of global diabetes prevalence predict 6.4%, affecting 285 million adults in 2010, and will increase to 7.7% and 439 million adults by 2030.⁵ In 2014, the global prevalence of diabetes was estimated to be 9% among adults aged above 18 years. ⁶India is the second most populous country to have a large number of people affected with diabetes. In India, 65.1 million people are affected by diabetes and this number will increase to 109 million by 2035. Recent estimates suggested that the prevalence of diabetes among adults (aged 20-79 years) was about 8.6%.⁷Recent surveys indicate that diabetes now affects a staggering 10-16% of urban population and 5-8% of rural population in India and Sri Lanka. Even in countries like United Kingdom and Iran, the prevalence rate of diabetes was found to be less with 6% and 8.6% respectively.⁸ World health statistics 2012, published by WHO reveals that, the prevalence of raised fasting blood sugar in those aged ≥25 years is 11.1% and 10.8 % among Indian males and Indian females against an overall global prevalence of 9.8% in males and 9.2% in females.⁹

NEED FOR THE STUDY:

Diabetes Mellitus is also recognized as one of the leading cause of death and disability worldwide. Diabetes is also a major risk factor for cardiovascular disease, stroke, and kidney failure.¹⁰ Often, people become aware of their diabetic status for the first time after developing complications related to diabetes.¹¹ More than 80% of diabetics live in middle- and low-income countries , where health systems are already burdened with infectious diseases, maternal and child health problems.⁸ Diabetes being a chronic illness requires continues self care practices by diabetic clients so that they can contribute meaningfully in the management of their disease. The self-care practices are found to have an association with good glycemic control and thereby controlled incidence of macro- and micro vascular complications.¹². A situation, where diabetes patients visits clinics regularly and their blood glucose levels still remains high despite the treatment they receive is a problem that calls for attention. This is very common observation in many diabetic clients. A good number of them report to hospitals with severe complications, like gangrene that may lead to amputation and possible premature death, this might be because of lack of appropriate self care practices.¹³ Self-care in diabetes is defined as behaviors undertaken by people with or at risk of diabetes in order to successfully manage the disease on their own.¹⁴ Self-care in the form of adherence to diet and drug regimens, blood glucose monitoring, self-administration of insulin, maintenance of optimum weight, blood pressure, recognition of symptoms associated with glycosuria and hypoglycemia etc. are crucial elements in prevention of complications.¹⁵ Hence, it is essential to promote self-care practices among diabetic clients as these practices help in avoiding or delaying the complications of diabetes. Poor awareness and practices among diabetic patients are some of the important variables influencing the progression of diabetes and its complications, which are largely preventable through education and involvement of the patient.^16.Unfortunately, there is still inadequate awareness about the existing interventions for prevention and control of diabetes and its complications among general public and among diabetic clients. Achieving control over the blood sugar and complete cure is a distant reality. Thus it becomes the responsibility of the patient to acquire certain skills, and modify some of the behaviors to achieve a good glycemic control and thus prevent complications. Assessment of patient’s knowledge and practices about diabetes is imperative in developing various intervention strategies for effective management of the disease. There have been very few studies addressing self-care practices in diabetic clients far fewer at grass root level of the community where people lack knowledge and self care practices in relation to management of disease. Hence this study has been conducted to assess the self care practices of diabetic clients in selected urban area of Bangalore district in Karnataka.

MATERIAL AND METHODS:

Research Approach and Design:

A quantitative research approach with descriptive research design was used as this study aimed to assess the self care practices of diabetic clients regarding management of Type II diabetes mellitus.

Setting of the study:

The study was conducted in a selected urban area of Bangalore district in the state of Karnataka. The setting was selected purposively. The criteria for selecting the setting were availability of the subjects, feasibility of conducting the study, economy of time and easy access, familiarity of the investigator with the setting and the expected cooperation and administrative approval for conducting the study.

Sample and sampling technique:

The sample of the study comprises 60 diabetic clients who were diagnosed to with type II diabetes mellitus and on treatment were selected by using Non probability sampling –Purposive sampling technique. The following criteria were considered for sample selection:

Inclusion criteria:

· Clients with type II diabetes mellitus

· Clients willing to participate in the study

· Clients available during data collection

· Clients who can understand English/Kannada/Tamil.

Exclusion Criteria:

· Clients with type I diabetes mellitus

· Clients who are bed ridden or dependant for their care on others

Data collection tool and technique:

After extensive review of relevant literature, a structured self care practice assessment questionnaire was developed to assess the self care practices of diabetic clients regarding management of type II diabetes mellitus. The questionnaire comprised of two sections: Section I: comprised of (11) items related to the sample characteristics. Section II: comprised of (36) items related to the self care practices of diabetic clients under the following heads –diabetes life style and practice domains (4items), diabetes and monitoring of blood glucose (4 items), Diabetes and diet (4 items), diabetes and exercise (4 items), foot care (4 items), medication practice (4 items), diabetes and hypoglycemia (4itmes), diabetes and eye care (4 items) and managing complications (4 items). Content validity of the self care practice assessment questionnaire was determined through a panel of experts. Reliability of the questionnaire was computed by using K-R ₂₁ formula. The correlation coefficient was found to be r=0.82 which was statistically acceptable. The data was collected by using interview technique. Institutional Ethical clearance, administrative approval was obtained from the concerned authorities; written informed consent was taken from the sample before commencement of the study.

Procedure of data collection:

Prior to the data collection formal administrative permission was obtained from the concerned Medical officer of Primary Health Centre that provides health care services to this village. Permission was also obtained from the administrative head of the area, explaining the nature and purpose of the study. The data collection was in the month of November 2015. The data was collected from 11-11-15 to 03-12-15. 60 clients who were fulfilling the inclusion criteria were selected by using purposive sampling. Self-introduction was given and the nature of the study was explained to the study subjects. Written consent was obtained from each of the subjects. Data was collected by using self care practice assessment questionnaire involving interview technique. The clients were assured of confidentiality and anonymity of their responses. The diabetic clients were interviewed on nine key areas of self care –Practices related to life style, monitoring of blood glucose level, diabetes and diet adherence , diabetes and exercise , diabetes and foot care ,medication practice , diabetes and hypoglycemia , diabetes and eye care, and managing complications . There were 36 items in total in the questionnaire. The diabetic clients were asked to respond to the statements in the questionnaire as “yes” or “no” based on their practices adopted or followed. The “yes” for a statement corresponds to patient’s adherence to the practice and “no” corresponds to patient is not practicing or following that behavior or practice. Every correct response of- “yes” was given a score of one and wrong response –“no” was given a score of zero. Thus the maximum score was thirty six and minimum score was zero. The score from each domain was added up to get a total self care score (Maximum of 36). The subjects were then categorized into three levels, based on their total self-care scores into: poor (<18), moderate (19-25), Good (36-36) self care.

RESULTS:

The researcher used the appropriate statistical means for analysis of the data -descriptive statistics and presented under the following sections:

Section –I: Findings related to the sample characteristics

Table No: 1 Frequency and Percentage distribution of diabetic clients based on their sample characteristics. N=60

Sl. No

Sample Characteristics

Frequency (f)

Percentage (%)

Age of (in years):

35-45

46-55

56-65

25.0%

33.3%

41.6%

Gender :

Male

Female

36.7%

63.3%

Marital Status:

Unmarried

Married

3.33%

96.6%

Religion :

Hindu

Christian

Muslim

76.6 %

10.0%

13.3%

Dietary pattern :

Vegetarian

Non Vegetarian

Ova vegetarian

13.3%

83.3 %

3.33%

Type of family :

Nuclear

Joint family

85.0%

15.0%

Educational level:

Illiterate

Primary education

Secondary education

Graduate and above

20.0%

38.3%

28.3%

13.3%

Occupation :

Employed

Unemployed

If employed then ,

Government

Private

Self employed

46.6%

53.3%

14.2%

32.1%

53.5%

Total monthly Income

<Rs.5000

Rs.5001-7000

Rs.7001-10000

>Rs.10000

10.0%

31.6%

36.6%

21.6%

Family history of type 2 diabetes mellitus

Yes

45.0%

55.0%

History of Personal Habits :

Smoking / Alcohol / Tobacco usage

No unhealthy Habits

21.6%

78.3%

Data presented in table-1 reveals that the majority of the diabetic clients 25 (41.6%) were in the age group of 56-65 years, followed by 20 (33.3%) in the age group of 46-55 years and 15 (25%) was in the age group of 35-45 years. Data presented in the table further shows that most of the diabetic clients 38 (63.3%) were females and 22 (36.7%) were males. Majority of them 58 (96.6%) are married and 02 (3.33%) were unmarried. In relation to religion, 46 (76.6%) of them belonged to Hindu religion whereas 08 (13.3%) belong to Muslim and 06 (10%) were Christians. Assessment of dietary practices revealed that, 50 (83.33%) were non vegetarian, followed by 08 (13.33%) were vegetarian and 02(3.33%) are ova vegetarian.

Majority of the sample 51(85%) were from nuclear families and 09(15%) were from joint family. Data further reveals that, with regard to their educational level, 23 (38.3%) of them have completed their primary education followed by 17 (28.3%) with secondary education and 12 (20%) of the clients were illiterates with no formal education and only 08 (13.3%) had completed education up to graduation level and above. In relation to the occupation status of the sample, 28 (46.6%) were employed and 32 (53.3%) of the sample were not employed. In relation to the total monthly income of the families, most of them i.e., 22 (36.6%) were having an income of Rs.7001-10,000 per month, 19 (31.6%) with income of Rs.5001-7000 and 13 (21.6%) with an income of > Rs.10000.Only 06 (10%) was earning below Rs.5000 per month. With regard to their family history of diabetes mellitus, 33 (55%) did not have any family history whereas 27 (45%) had history of diabetes in their families. Data further showed that 47 (78.3%) did not have any unhealthy habits like smoking, alcohol consumption and use of tobacco products and 13 (21.6%) of them had history of these habits.

Section II- Assessment of self care practices of diabetic clients

Section-II describes frequency and percentage distribution of diabetic clients in terms of their self-care practices.

Table- 2: Mean, Median, Standard deviation and range of practice score of diabetic clients

Group	Self practice score
Diabetic clients (N=60)	Range	Mean	Median	S.D
Diabetic clients (N=60)	06-25	18.2	19	3.89

Maximum score=36, Minimum Score=0

The data presented in the table -2 reveals that, the mean self practice score was found to be (18.2±3.89).The data further indicate the median was 19 and the range of obtained score was 06-25.

Table- 3: Frequency and Percentage distribution of diabetic clients based on their self care practice scores N=60

Level of self care practice	Range of score	Frequency (f)	Percentage (%)
Good	26-36 (71-100%)	00	-
Moderate	19-25 (51-70%)	32	53.33%
Poor	1-18 (<50%)	28	46.66%

Data presented in the table-3 reveals that most of the diabetic clients 32 (53.33%) had moderate self care practices in relation to management of diabetes mellitus followed by 28 (46.66%) with poor self care practices. None of them had good self care practices that will help them to manage the disease effectively.

Table No: 4 Area wise mean, mean percentage self care practices of diabetic clients. N=60

Domain/Area	Max. Score	Mean	Mean %	Rank
Practices related to life style	4	1.96	49%	IV
Monitoring of blood glucose level	4	2.90	72.5%	I
Diabetes and diet adherence	4	2.33	58.25%	II
Diabetes and Exercise	4	1.11	27.75%	VII
Diabetes and Foot Care	4	1.91	47.75%	V
Medication Practice	4	2.20	55%	III
Diabetes and Hypoglycemia	4	1.50	37.5%	VI
Diabetes and Eye Care	4	1.08	27%	VIII
Managing complications	4	2.20	55%	III
Total	36

The data presented in the above table shows area wise mean and mean percentage of and ranking of self practices of diabetic clients. In relation to the domain /area wise analysis of self care practices of diabetic clients, the area/domain with the highest mean percentage indicate area with adequate self care practices and the area or domain with the lowest mean percentage indicate the maximum deficit existed in this area related to self care practices regarding management of diabetes mellitus. Data given in the above table shows that, the highest mean percentage was obtained in the area of monitoring of blood glucose levels (72.5%) and was ranked I. Diabetes and diet adherence was ranked II with mean percentage of (58.25%). Medication practice and management of complications were ranked as III with mean percentage of (55%). In the area of practices related to life style the mean percentage obtained by the clients was (49%) and was ranked as IV, followed by diabetes and foot care ranked V with mean percentage of (47.75%). Diabetes and hypoglycemia was ranked as VI as the mean percentage was (37.5%), diabetes and exercise (27.75%) with VII rank and diabetes and eye care was ranked as the last rank i.e. VIII with mean percentage of (27%).

Table-5: Frequency and percentage distribution of diabetic clients based on their self care practices. N=60

Sl. No	Selected statements on self care practices	Yes		No
Sl. No	Selected statements on self care practices	Freq (f)	Per (%)	Freq (f)	Per (%)
1	Monitors weight frequently. (at least once in a month)	23	38.33	37	61.66
2	Undergoes blood sugar level test in a health care facility. (at least once in 3 months)	38	63.33	22	36.66
3	Avoids fried foods (> 5 days in a week)	40	66.66	20	33.33
4	Use of more vegetables in diet (>5 days in a week)	38	63.33	22	36.66
5	Practice or do exercises as advised by doctor ( 5 days / week for 30 min)	21	35.00	39	65.00
6	Avoid exercises after having heavy meals.	24	40.00	36	60.00
7	Examine the foot daily for any change.	27	45.00	33	55.00
8	Examined my eye after I was diagnosed with diabetes.	32	53.33	28	46.66
9	Takes medications as per doctor’s instructions ( all the days/ week - time, dosage)	39	65.00	21	35.00
10	Keeps additional dosage of medications always.	38	63.33	22	36.66
11	Wear or carry some kind of diabetes identification card, wallet, etc.	16	26.67	44	73.33
12	Carry some sweets or candy or chocolate while going out.	17	28.33	43	71.67
13	Identifies symptoms like excess hunger as sign of hypoglycemia	33	55.00	27	45.00
14	Any discomfort in the body like changes in vision or urinary infection or feeling drowsy or report to doctor immediately.	46	76.67	14	23.33
15	Had a meeting with health worker/ educator to understand complications of diabetes.	25	41.66	35	58.33

The findings given in the above table reveals the self care practices of the diabetic clients with regard to their practices adopted to manage the diabetes mellitus. In relation to the life style practices, 23 (38.33%) of the clients monitor their weight frequently i.e. at least once in a month to keep their weight under control and thus manage the disease in an effectively, whereas 37 (61.66%) were not in the habit of monitoring of their weight regularly which places them in a disadvantaged position of identifying the complications at an early stage. With regard to monitoring of blood glucose levels in a health care facility, as none of them had glucometers at their home , 38 (63.33%) of the clients have undergone blood sugar test at least once in three months whereas 22 (36.66%) do not undergo blood sugar test in the recent past. In relation to the modification made in the dietary practices to control diabetes, it was found that 40 (66.66%) avoided fried foods and 20 (33.33%) were not adhering to the dietary modifications as suggested by their health care providers. It was also observed that, 38 (63.33%) started to use more vegetables in their diet for 3-4 times in a week whereas 22 (36.66%) were not.

In relation to the exercise regimen, 21 (35%) of the diabetic clients practice or do exercise as advised by physician like walking for minimum of 30 minutes for 4-5 times in a week and 39 (65%) do not follow any exercise regimen. 24 (40%) of them avoid doing exercise after heavy meals and 36 (60%) do not accept to this statement. In relation to foot care, 27 (45%) of the subjects examine their foot for any change, and 33 (55%) do not practice any foot examination. In relation to examination of eye, 32 (53.33%) of them examined their eyes after they were diagnosed with diabetes to rule out complications related to their disease and 28 (46.66%) had never undergone an eye examination.

With regard to adherence to intake of medication, the 39 (65%) of the subjects adhere to intake of medication regularly as advised by the physician and 21 (35%) do not adhere to medication regimen. 38 (63.33%) of the clients always have extra stock of medications whereas 22 (36.66%) do not carry or have additional dosage of medications with them. In relation to practices related to travel, 16 (26.67%) wear or carry some kind of identification card and 17 (28.33 %) carry some sweets or candy whereas 44 (73.33%) do not have or carry any identification related to their disease status and 43 (71.67%) do not carry candy or sweets during travel. While managing the complications related to diabetes mellitus, 33 (55%) of the subjects understand that, symptoms like excessive hunger, sweating, dizziness are the signs of hypoglycemia, whereas 27 (45%) were not able to identify the symptoms related to hypoglycemia. 46 (76.67%) of the clients report to doctor immediately and 14 (23.33%) of them do not see a doctor when they experience any discomfort like blurred vision etc. It is heartening to know that 25 (41.66%) had meeting with the health worker or health professionals to know about the disease better whereas 35 (58.33%) did not make any attempt to know about the disease.

DISCUSSION:

The present study is a community based cross sectional descriptive study conducted among diabetic clients having type II diabetes and mainly focuses on assessment of the self care practices in relation to management of their disease. The individuals will change their behavior and attitude regarding diabetes only if they perceive themselves to be at high risk and if they are likely to get affected with diabetes in near future. The management of diabetes mellitus not only requires the prescription of appropriate nutritional and pharmacological regimen by the physician but also intensive self-care education and counseling of the patient.¹⁷ The study showed that , most of the diabetic clients 32 (53.33%) had moderate self care practices in relation to management of diabetes mellitus followed by 28 (46.66%) with poor self care practices. None of them had good self care practices that will help them to manage the disease effectively. The findings of this study is congruent with the study conducted in Bijapur Karnataka and Kathmandu ,where majority of the respondents had fair self care practices or inadequate self care practices regarding management of diabetes mellitus.^4,18In relation to the self-care practices of the study participants, it was observed that only 38.3% monitored their weight frequently and monitoring of blood glucose levels was done by 63.3% study participants at least once in 3 months. The findings of this study are in congruent with the study conducted in southern India.²³

In this study, 66.6% of the study subjects avoided fried food items and 63.3% of them used more vegetables in their diet showing their awareness about beneficial effects of dietary modification. Similar results were also obtained in various other studies done in Andhra Pradesh, Gujarat and Karnataka respectively.^{20, 21,
22} It was also noted that, although almost all the subjects were aware about the beneficial effects of exercise, only 35% of the diabetic clients practiced or did exercise for at least 5 days in a week minimum for duration of 30 minutes. Similar results were obtained in a study done in Warangal and Tiruchirappally. ^{16, 22}

In the current study only 45% of the study subjects examined their foot for changes daily which similar to the findings of the study conducted in Gujarat. ²⁰It was also noted that, 53.33% of the study participants examined their eye after they were diagnosed with diabetes and this is in contrast with the findings of the study conducted in Nagpur where only 16.2% of the study subjects had an eye examination in the previous year.²⁴ The present study also depicted that, 65% of the study subjects took medications as per doctor’s advice and 63.3% kept additional doses of medication always, and few of them believed that anti-diabetic drugs can be adjusted once the sugar levels are controlled by themselves based on dietary intake of food. Similar results were obtained in a study conducted in Gujarat ²⁰. The findings suggest need for adequate counseling of all diabetic patients not only at the time of diagnosis but time and again at each and every follow up visit in order to reinforce the importance of drug compliance. In the present study, 26.67% of them carried some kind of diabetes identification and 28.33% of them carried some sweets or candy while they were travelling. 55% of them were able to identify the symptoms of hypoglycemia with symptoms like excessive hunger and immediately take measures to prevent complication. 76.67% reported immediately to a health care facility when they experienced changes in vision or drowsy sensing some complications. It was heartening to note that, 41.6% of the subject had a meeting with the health worker or educator to understand about the disease and to prevent complications. The awareness about diabetes complications in the present study is similar to that reported by a study conducted in Pakistan.²⁵

LIMITATIONS:

The current study had its limitation in the form of the sample size was not large enough to generalize the results to the entire population. Also only self reported self care practices were taken into consideration.

CONCLUSION:

Patients who were more self aware about the disease, having knowledge and regularly involved in self care practices will be able to achieve better glycemic control and better management of disease. Regular inculcation of health education, making the patient aware regarding the disease and encouraging self care management during treatment will reduce health care burden and help achieve optimal control of the disease with minimal long term complications. More awareness about self-care practices, with emphasis on various domains of self-care among diabetic clients should be created. Education is the key factor in achieving good self care practices.

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Received on 15.06.2016 Modified on 29.06.2016

Int. J. Nur. Edu. and Research. 2016; 4(4): 449-455.

DOI: 10.5958/2454-2660.2016.00083.1