INTRODUCTION:

Diabetes mellitus is increasingly widespread and has become the leading cause of chronic kidney disease (CKD) and kidney failure. Diabetic nephropathy affects approximately 20–40% of individuals who have diabetes making it one of the most common complications related to diabetes.¹ This is caused by damage to the small blood vessels in the kidneys. A kidney affected by diabetes can look normal under an ultrasound but under the microscope the kidney can show damage to the filtering units. It is this damage to the filtering units, which causes protein to leak into the urine, which is an important marker for diabetic kidney disease. Urine infections are also more likely to happen if you have diabetes. These can be treated with antibiotics. This is more likely to occur if there is glucose in urine, so maintaining good control of diabetes will reduce the risk of infection.²

Chronic kidney disease involves progressive, irreversible loss of kidney function. As the stage of kidney disease progresses, the mortality rate also increases. Diabetes, accounting for approximately 50%, and hypertension, accounting for about 25%, are the primary causes of CKD CKD is significantly more prevalent than AKI (Acute Kidney Injury). The rising prevalence of CKD is partly due to increased risk factors such as an aging population, higher obesity rates, and a greater incidence of diabetes and hypertension.³

Because the kidneys are highly adaptive, kidney disease is often not recognized until there has been considerable loss of nephrons. Individuals with CKD are frequently asymptomatic resulting in CKD being underdiagnosed and untreated. It has been estimated that about 70% of people with CKD are unaware that they have the disease.

BACKGROUND OF THE STUDY:

Chronic Kidney Disease (CKD) is becoming increasingly prevalent worldwide, with diabetes being a major risk factor for its development. The prevalence of CKD is rising significantly in both developed and developing countries.⁴ The global prevalence of CKD is estimated to be 16%. In 2010, CKD led to 7,35,000 deaths worldwide, compared to 4,00,000 deaths in 1990. India is known as the diabetes capital of the world, with Kerala holding the highest prevalence of Diabetes mellitus. Lack of awareness among at-risk groups about the development of kidney disease is the primary issue that needs immediate attention.⁵

NEED AND SIGNIFICANCE OF THE STUDY:

A cross-sectional study was conducted at the outpatient department of endocrinology at Hakeem Abdul Hameed Centenary (HAHC) Hospital, Jamia Hamdard, New Delhi, India, to evaluate awareness of chronic kidney disease (CKD) among type 2 diabetic patients. The study identified diabetes and hypertension as the primary causes of CKD. Epidemiological research has highlighted a general lack of knowledge about CKD among the population. The study concluded that there is inadequate awareness about kidney disease among Indian patients with type 2 diabetes mellitus and hypertension. The researchers suggested implementing a government-sponsored CKD awareness program to address this serious co morbid condition, emphasizing its potential for cost-effective prevention.⁶

A community-based cross-sectional study was conducted, revealing that chronic kidney disease (CKD) is emerging as a significant public health concern associated with premature mortality and costly treatment, especially in low-resource settings where diabetes prevalence is high. The study found that diabetes is more prevalent among males under 60 years old. On average, participants had been living with diabetes for 5.26 years, with an average onset age of 48.6 years. Notably, 62% of the sample was in an advanced stage of the disease. The study concluded that there is an urgent need to enhance diabetes management to delay the onset of End-Stage Renal Disease (ESRD).⁷

PURPOSE OF THE STUDY:

To enhance the understanding of dietary practices among individuals with type 2 diabetes, with the goal of reducing the risk of chronic kidney disease (CKD) and preventing complications, we propose the implementation of a structured educational program.

PROBLEM STATEMENT:

A study to assess the effectiveness of planned teaching program on knowledge regarding dietary awareness to reduce the risk of chronic kidney disease among type 2 diabetic patients attending a selected NCD clinic at Pathanamthitta District.

OBJECTIVES OF THE STUDY

1. To assess the knowledge among type 2 diabetic patients regarding dietary awareness to reduce the risk of chronic kidney disease using a structured knowledge questionnaire.

2. To implement planned teaching program regarding dietary awareness to reduce the risk of CKD in type 2 diabetic patients.

3. To assess the effect of planned teaching programme on dietary awareness to reduce the risk of CKD through the comparison of pretest and posttest knowledge scores.

4. To find out the association between pretest knowledge scores and selected baseline variables.

OPERATIONAL DEFINITIONS:

Effectiveness of planned teaching programme:

In this study, the effectiveness of the structured teaching program lies in its ability to impart dietary awareness aimed at mitigating CKD risk in individuals with type 2 diabetes.

Knowledge Regarding Dietary Awareness:

In this study, knowledge regarding dietary awareness refers to awareness of type 2 diabetic patients regarding dietary management to reduce the risk of CKD.

Non-Communicable Disease (NCD) Clinic:

Is a clinic where comprehensive examination of patients with noncommunicable disease such as cancer, diabetes, hypertension, cardiovascular diseases and stroke are referred by primary health facility or health worker.

CONCEPTUAL DEFINITION:

Chronic Kidney Disease (CKD):

It is a progressive irreversible loss of kidney function and glomerular filtration rate less than 60ml/minute for 3 months or longer.

Type 2 Diabetic Patients:

Refers to patients with noninsulin dependent diabetes mellitus with high blood glucose level.

HYPOTHESIS:

H₁: There is a significant difference between the mean pre test and post test knowledge score of Type 2 diabetic patients regarding dietary awareness to reduce the risk of CKD.

H₀: There is a significant association between the mean pre test knowledge score of Type 2 diabetic patients regarding dietary awareness to reduce the risk of CKD and selected baseline variables.

ASSUMPTION:

1. Knowledge on dietary management of CKD among type 2 diabetes patients will enhance expectancy or quality of life.

2. Appropriate dietary pattern adopted by Type 2 Diabetes Mellitus patients will prevent the risk of CKD.

CONCEPTUAL FRAMEWORK:

Conceptual framework is based on general system theory by Van Bertolanffi.

REVIEW OF LITERATURE

The research literature is arranged in chronological order and described under following heading:

· Studies related to prevalence of CKD among type 2 diabetic patients.

· Studies related to knowledge of diabetic patients regarding CKD.

· Studies related to dietary awareness of diabetic patients regarding CKD.

Studies Related to Prevalence of Ckd Among Type 2 Diabetic Patients:

A cross-sectional study was conducted at the NCD clinic of the health center in Ettumanoor. The study result was found that individuals with confirmed type 2 diabetes mellitus have a prevalence of chronic kidney disease (CKD) three times higher than that of the non-diabetic population. The study, conducted between February 2017 and April 2017, revealed an overall CKD prevalence of 45.3% among the study population.

Furthermore, the prevalence of CKD was observed to increase with the duration of diabetes:

· Among those with diabetes for less than 5 years, the prevalence of CKD was 31.2%.

· For individuals with diabetes duration between 5 to 10 years, the prevalence increased to 47.8%.

· Those with diabetes duration of 10 to 15 years had a higher prevalence of 52.6%.

· Individuals who had diabetes for more than 15 years had the highest prevalence of CKD at 55%.

These findings highlight a significant association between the duration of diabetes and the increased likelihood of developing CKD, underscoring the importance of early detection and management strategies in diabetes care to prevent complications such as CKD.⁹

A Cross sectional study was conducted to investigate the prevalence and risk factors of chronic kidney disease among 1096 primary care type 2 diabetes patients in northern Thailand. A total of 1368 T2DM patients were screened between October 1, 2016 and September 30, 2017. Of them, 274 were excluded and consequently 1094 patients were included in the analysis. The study identified that overall prevalence of CKD was 24.4% (21.9-27.0), with severities of 11.4% (9.7-13.4), 6.8% (5.5-8.5), 4.6% (3.5-6.0) and 1.6% (1.0-2.5) for stages 3A, 3B,4 and 5 respectively. A high prevalence across CKD stages in elderly T2DM patients (<65yrs) was observed, particularly in individuals older than 75 years. Similarly, there was a high prevalence across CKD stages among patients with poor glycemic control, particularly in individuals with a hemoglobin A1c >8%. Nonetheless, there was no substantial difference in the sex specific prevalence of CKD. Of these, the unadjusted CKD prevalence according to sex specific was 24.5% and 24.3% in male and female respectively. They concluded that early identification may help to target optimize care and prevention programs for CKD among T2DM patients.¹⁰

Studies Related to Knowledge of Diabetic Patients Regarding Ckd:

A quantitative, cross-sectional study was conducted using a validated questionnaire involving the residence of Islamabad, earlier diagnosed with T2DM and CKD, equal to or above 25 years of age, who visited their family physicians during the study period. Eligible participants were identified using purposive sampling. Questions about knowledge, attitude, and practices of disease management were asked. This study aimed to identify the knowledge, attitude and practices of patients with T2DM and CKD of patients in Islamabad. The result showed a high level of knowledge, attitude and practice in majority of study participants and some low-level areas were noticed. The study concluded that targeted interventions or public health programs catering to the needs of all communities should be implemented and evaluated for their effectiveness to improve the overall level of health care in the country. Similar studies should be conducted among other population subgroups in other parts of the country.¹⁴

In a cross-sectional study conducted among diabetic patients to evaluate their knowledge, attitude, and practices (KAP) regarding type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD), researchers found generally poor knowledge levels among T2DM patients with CKD. Only a minority demonstrated good knowledge and positive attitudes towards CKD.

Specifically, the study highlighted that younger individual who were employed and had higher educational attainment tended to have better knowledge scores. However, overall, the majority of T2DM patients with CKD exhibited inadequate knowledge levels, and there was ambiguity regarding their attitudes and practices towards CKD management.

The study concluded that there is a significant gap in understanding the determinants influencing KAP among T2DM patients with CKD. This gap represents an area ripe for further research to better elucidate factors affecting knowledge acquisition, attitude formation, and practical application of health management strategies in this vulnerable population.¹⁵

Studies Related to Dietary Awareness of Diabetic Patients Regarding Ckd:

A cross sectional study was conducted among diabetic patients in Malappuram block panchayat. A total of 365 patients participated in the study, of which 42 were excluded, as they did not fulfill the inclusion criteria. The study identified that the prevalence of type 2 diabetes is very high in Kerala when compared to other states. Result showed that the prevalence of self reported diabetes and good dietary practice among diabetic patients is 11.6% and 20.4% respectively. Factors like self reported difficulty in consuming a healthy diet, presence of family support and frequent blood sugar monitoring practice were significantly associated with good dietary pattern. The study concluded that good dietary pattern among diabetic patients was found to be very low. So, improvement can be done only with strategies like diet counseling, support from family members etc.¹⁸

A cross sectional study was conducted using a pretested questionnaire among 100 type 2 diabetic patients attending the medicine outpatient department of a Tertiary Care Hospital, Delhi. The aim of the study was to assess the degree of awareness of diet, physical exercise and life style modifications among type 2 diabetics among the urban population of Delhi. The mean age of the study population was found to be 50. An estimated 74% were well aware of the foods to be included, 54% were familiar with the quantity of food in food plate. The awareness of life style modification was good among 29% and practice was followed by 15% of diabetic patients. The study concluded that despite the clear attitudes of type 2 diabetes patients towards dietary pattern and healthy life style modification, the life style awareness and practices were poor among the study group. ⁽¹⁹⁾

RESEARCH METHODOLOGY:

RESEARCH APPROACH:

Quantitative research approach.

RESEARCH DESIGN:

Quasi experimental research design.

Variables

· Independent Variable: Planned teaching programme on dietary awareness to reduce the risk of CKD among Type 2 Diabetic patients.

· Dependent Variable: Knowledge on dietary awareness to reduce the risk of CKD among Type 2 diabetic patients.

Setting of the study:

NCD Clinic in a municipality area in Pathanamthitta District.

Population of the study:

Target population: Type 2 diabetic patients.

Accessible population:

Type 2 Diabetic patients residing in a particular municipality area in Pathanamthitta district.

Sample: Type 2 Diabetic patients attending NCD clinic in a minuicipality area in pathanamthitta district.

Sample Size: Sample size of the present study is 30.

Sampling Technique: Non- probability purposive sampling technique was used in the study.

Data Collection Instrument:

Development / Selection of tool

A structured knowledge questionnaire with multiple choice answers was prepared to assess the knowledge regarding dietary awareness to reduce the risk of CKD among Type 2 Diabetic patients prepared for the planned teaching programme.

Tools:

· Section A: Socio demographic data including age, sex, educational qualification, monthly income, duration of the illness.

· Section B: Structured knowledge questionnaire to assess the knowledge regarding dietary awareness to reduce the risk of CKD among Type 2 Diabetic patients in the form of multiple choice questions developed by the researchers.

Content Validity:

We obtain the validity of content and tool from experts in the field of community and nursing. Suggestions given the experts were incorporated after discussion with guide.

Reliability of tool:

The reliability of the tool was established by administering the structured knowledge questionnaire to 30 patients in a selected NCD clinic. The reliability was estimated by using paired t-test. The tool was found to be reliable.

METHODS OF DATA COLLECTION:

Pilot Study:

The pilot study was conducted in a selected NCD Clinic at a Municipal area after getting formal approval to conduct from Municipality. The researcher explains the purpose of the study and gave assurance of the confidentiality of the data. After getting the informed consent the pilot study was conducted with 5 samples that they were excluded from the main study. Pretest was conducted by giving structured questionnaire which was followed by a planned teaching programme. The post test was done after 7 days. After the post test, data analysis were done by descriptive and inferential statistics by using SPSS. Findings of pilot study revealed that it is feasible and practicable. So, investigators carried out main data collection thereafter.

Data Collection Process:

The following steps are included in the process:

· Attained permission from concerned authorities.

· The structured knowledge questionnaire was given to the samples to assess the knowledge regarding dietary awareness to reduce the risk of CKD among type 2 diabetic patients.

· Planned teaching programme was conducted on the same day.

· Then the same questionnaire was given to reassess the knowledge level after 7 days.

ANALYSIS AND INTERPRETATION:

Section- 1: Distribution of Type 2 Diabetic patients according to selected baseline variables.

Table 1: Distribution of subjects according to age.

Age	Frequency (f)	Percentage (%)
50-59	5	16.66
60-69	12	40
70-79	8	26.66
80 and above	5	16.66

Table 1 shows that majority (26.66%) of subjects were under the age group of 70-79 yrs.

Table 2: Distribution of subjects according to sex.

Sex	Frequency (f)	Percentage (%)
Male	9	30
Female	21	70
Others	0	0

Table 2 shows that majority (70%) of the subjects were female.

Table 3: Distribution of subjects according to their educational status.

Education	Frequency (f)	Percentage (%)
Primary	13	43.33
High School	10	33.33
Higher Secondary	3	10
Graduate and Post Graduate 4	13.3

Table 3 shows that majority (43.33%) of the subjects had only primary education.

Table 4: Distribution of subjects according to their monthly income.

Monthly Income (in Rs)	Frequency (f)	Percentage (%)
Below 10000	23	76.66
10000-20000	5	16.66
Above 20000	2	6.66

Table 4 shows that the majority (76.66%) of the subjects were getting a monthly income of below Rs.10000.

Table 5: Distribution of subjects according to their duration of illness.

Duration of illness	Frequency (f)	Percentage (%)
0-5 years	13	43.33
6-10 years	5	16.66
11-20 years	7	23.33
Above 20 years	5	16.66

Table 5 shows that the majority (43.33%) of the subjects had their duration of illness 0-5 years.

Section- 2: Analysis of pretest and posttest knowledge scores of the Type 2 diabetic patients regarding the dietary awareness to reduce the risk of CKD.

Table 6: Distribution of subjects according to pre test and post test knowledge scores regarding dietary awareness to reduce the risk of CKD.

Knowledge scores	Pre test	Frequency Percentage	Post test	Frequency Percentage
Good	0	0	19	63.33
Average	17	56.66	10	33.33
Poor	13	43.33	1	3.33

Figure 3: Analysis of pretest and posttest knowledge scores regarding dietary awareness to reduce the risk of CKD.

The above table and figure shows that in the pretest knowledge score, 43.33% of the samples had poor knowledge scores, 56.66% had average knowledge scores and none of them had good knowledge scores.

In the post test knowledge score, majority of them had good knowledge score (63.66%), 10% had average knowledge scores and 3.33% had poor knowledge scores.

Section- 3: Effectiveness of planned teaching programme on knowledge regarding the dietary awareness to reduce the risk of CKD.

Table 7: Effectiveness of planned teaching programme on dietary awareness to reduce the risk of CKD.

Knowledge	Mean	Standard deviation	t value
Pre test	11	3.43
Post test	19.26	2.5	11.154 0.000
Difference	-8.26	4.05

The analysis revealed that there is a significant difference between the pre test and post test knowledge level regarding dietary awareness to reduce the risk of CKD among type 2 diabetic patients (z= -11.154; p<0.05). So, the research hypothesis was accepted and the null hypothesis was rejected.

Section 4: Association between the pretest knowledge scores of Type2 diabetic patients regarding the dietary awareness to reduce the risk of CKD.

Table 8: Association between pre test knowledge scores and selected baseline variables of Type 2 diabetic patients in a selected NCD clinic of Pathanamthitta district.

Baseline variables	X²	P
Age	35.708	0.482 NA
Sex	10.556	0.567 NA
Educational status	44.210	0.164 NA
Monthly income	31.374	0.143 NA
Duration of illness	42.053	0.225 NA

Significance at 0.05 levels

NA = No association

The above table shows the findings of association between selected baseline variables and pre test knowledge scores. No significant association was found between the selected baseline variables and pretest knowledge scores.

RESULTS:

Section- 1: Distribution of Type 2 diabetic patients as per the selected baseline variables.

· Among 30 participants, 12(40%) of them were between 60-69 years of age, 8(26.66%) of them within 70-79, 5(16.66%) of them within 50-59 years of age and next 5(16.66%) of them within 80 and years of age.

· Among 30 participants, 21(70%) of them were females and 9(30%) of them were males

· Among 30 participants, majority (43.33%) of them has primary education, (33.33%) of them has high school education, (13.33%) of them are graduates and post graduates, and (10%) of them has higher secondary education.

· With regard to monthly income, majority (76.66%) of them had monthly income of below 10000, (16.66%) of them had monthly income of 10000- 20000 and (6.66%) of them had monthly income of above 20000.

· With regard to their duration of illness, majority (43.33%) of them have 0-5 years of duration of illness, (23.33%) of them have 11-20 years of duration of illness, (16.66%) of them have 6-10 years of duration of ilness and (16.66%) of them have above 20 years of duration of illness.

Section – 2: Analysis of pre test and post test knowledge score of Type 2 diabetic patients on knowledge regarding dietary awareness to reduce the risk of CKD.

The investigator identified that, in pre test 43.33% of the sample had poor knowledge level, 56.66% had average level of knowledge and none of them had good level of knowledge. After the administration of planned teaching programme, 63.33% had good knowledge level, 33.33% had average knowledge level and none of them had poor knowledge level.

Section- 3: Effectiveness of planned teaching programme on dietary awareness to reduce the risk of CKD.

By applying Wilcoxon signed-rank test, the result shows that the mean value of the pre test and post test were 11 and 19.26 respectively and the standard deviation were 3.43 and 2.5 respectively. This shows that the planned teaching programme regarding dietary awareness to reduce the risk of CKD was effective.

Section-4: Association between pre test knowledge scores and selected baseline variables:

The association between pre test knowledge score and selected baseline variables was analysed using chi-square.

No significant association was found between the pre test knowledge score and selected baseline variables like age (chi² = 35.708, p value=0.482), sex (chi² = 10.556, p value= 0.567), Educational status (chi² = 44.210, p value= 0.164), monthly income (chi² = 31.374, p value= 0.143), duration of illness (chi² = 42.053, p value= 0.225).

DISCUSSION:

Section- 1: Distribution of Type 2 diabetic patients as per the selected baseline variables:

Among 30 participants, 12(40%) of them were between 60-69 years of age, 8(26.66%) of them within 70-79, 5 (16.66%) of them within 50-59 years of age and next 5(16.66%) of them within 80 and above years of age. Among 30 participants, 21(70%) of them were females and 9(30%) of them were males. Among 30 participants, majority (43.33%) of them has primary education, (33.33%) of them has high school education, (13.33%) of them are graduates and post graduates, and (10%) of them has higher secondary education. With regard to monthly income, majority (76.66%) of them had monthly income of below 10000, (16.66%) of them had monthly income of 10000- 20000 and (6.66%) of them had monthly income of above 20000. With regard to their duration of illness, majority (43.33%) of them have 0-5 years of duration of illness, (23.33%) of them have 11-20 years of duration of illness, (16.66%) of them have 6-10 years of duration of ilness and (16.66%) of them have above 20 years of duration of illness.

Section – 2: Analysis of pre test and post test knowledge score of Type 2 diabetic patients on knowledge regarding dietary awareness to reduce the risk of CKD.

Section- 3: Effectiveness of planned teaching programme on dietary awareness to reduce the risk of CKD.

Section-4: Association between pre test knowledge scores and selected baseline variables:

The association between pre test knowledge score and selected baseline variables was analyzed using chi-square.

No significant association was found between the pre test knowledge score and selected baseline variables like age (chi² =35.708, p value = 0.482), sex (chi² = 10.556, p value = 0.567), educational status (chi² = 44.210, p value = 0.164), monthly income (chi² = 31.374, p value = 0.143), duration of illness (chi² = 42.053, p value = 0.225).

SUMMARY:

The present study was aimed at finding the effect of community awareness program on knowledge regarding dietary awareness to reduce the risk of CKD among type 2 diabetic patients. Conceptual framework used for present study was based on Ludwig von Berttolanffi’s general system model. The research approach used for the study was quantitative approach and the research design was pre-experimental one group pre test post test design. The tool used for the study was self administered knowledge questionnaire with 25 questions developed by researchers. Content validity of the tool and content was obtained from subject experts and reliability was confirmed. After validating the tool pilot study was conducted among 5 residents at Mathilbhagom area. The pilot study was conducted to check the feasibility and practicability of the research study. In the main study 30 residents are selected by non-probability convenient sampling technique after getting their valuable consent for participating in the study.

For the main study, pre-test knowledge score on dietary awareness to reduce the risk of CKD among type 2 diabetic patients was assessed using structured knowledge questionnaire and planned teaching program on dietary awareness to reduce the risk of CKD among type 2 diabetic patients was given on the same day. On the 7th day post test was conducted by using the same tool.

The data was tabulated and analyzed using descriptive and inferential statics. The questionnaire score was analyzed using non parametric test. For baseline variable frequency and percentage was used. Distribution of score obtained by residents for knowledge was interrupted under three categories such as poor, average and good. Mean and standard deviation of pre test, post test knowledge was analyzed. Inferential statistics were used to test hypothesis. Analysis with paired sample T test was used to determine the effect of community awareness programme. Association with selected baseline variable and pretest knowledge score was obtained by chi square test.

Level of significance was tested at 0.05 to interpret the hypothesis and other findings. It shows that there is no significant association was found between the pre test knowledge score and selected baseline variables like age (chi² = 35.708, p value=0.482), sex (chi² = 10.556, p value=0.567), educational status (chi² = 44.210, p value=0.164), monthly income (chi² = 31.374, p value=0.143), duration of illness (chi² = 42.053, p value=0.225).

CONCLUSION:

The study aimed to evaluate the effectiveness of a planned teaching program on enhancing knowledge about dietary awareness to reduce the risk of chronic kidney disease (CKD) among type 2 diabetic patients in a selected NCD clinic in Pathanamthitta district. The findings of the study indicated a notable increase in knowledge among participants regarding dietary practices aimed at reducing CKD risk. The analysis demonstrated a highly statistically significant improvement in knowledge scores from pre-test to post-test among the participants. The significance level was set at 0.05, indicating strong evidence that the planned teaching program had a positive impact on participants' understanding of dietary practices related to CKD risk reduction. This outcome suggests that the educational intervention effectively enhanced awareness and knowledge among type 2 diabetic patients regarding dietary strategies to mitigate CKD risk factors.

The study concluded that the planned teaching program was successful in achieving its objective, as evidenced by the significant improvement in participants' knowledge levels regarding dietary awareness to reduce CKD risk among type 2 diabetic patients. The findings support the implementation of structured educational initiatives in clinical settings to empower patients with essential knowledge for better self-management and prevention of complications associated with chronic conditions like diabetes and CKD.

IMPLICATIONS FOR PRACTICE:

· Health practitioners and educators can use these findings to advocate for and design similar educational interventions aimed at improving patient outcomes through enhanced knowledge and awareness.

· Continuous evaluation and refinement of educational programs based on research outcomes are essential to ensure ongoing effectiveness and relevance in healthcare settings.

· Overall, the study provides valuable insights into the positive impact of targeted educational interventions in improving health literacy and promoting proactive health behaviors among diabetic patients at risk of CKD.

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Received on 02.02.2024 Revised on 13.09.2024

Accepted on 15.01.2025 Published on 22.02.2025

Available online from March 20, 2025

Int. J. Nursing Education and Research. 2025;13(1):1-9.

DOI: 10.52711/2454-2660.2025.00001

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