Introduction: Self-care activities are behaviors adopted in order to enhance one’s health. Self-care behaviors and activities are studied in their role to enhance glycemic control, reduce diabetes-related complications, and contribute to enhancing overall quality of life in people with diabetes. The aim of this observational study was to evaluate the impact of diabetes self-care activities and behaviors on glycemic control in people with diabetes.
Methods: This observational, cross-sectional study was conducted at the outpatient department of a secondary care hospital in Karachi, Pakistan from 1st September 2019 till 30th November 2019. Patients with known type II diabetes of age ≥45 years visiting the hospital for routine follow-up visit were included. Diabetes Self-Management Questionnaire (DSMQ) in Urdu version was used to assess their status of self-management. For data entry and statistical analysis SPSS for Windows version 21.0 was used.
Results: There were 174 (54.9%) males and 152 (47.9%) were of age 45-60 years. Glycemic control was good (HbA1c <7%) in 125 (39.4%) and poor (HbA1c ≥7%) in 192 (60.6%) patients. Patients with good glycemic control scored significantly better on DSMQ overall (5.53 ± 0.35 vs. 4.32 ± 0.61; p<0.0001), and on three sub-scales - dietary control (4.24 ± 1.04 vs. 3.63 ± 0.98; p<0.0001), physical activity (4.16 ± 0.56 vs. 3.47 ± 1.17; p<0.0001), and healthcare use (4.22 ± 0.78 vs. 3.98 ± 0.65; p=0.003).
Conclusions: The self-care activities that impact glycemic control in patients with diabetes include dietary control, physical activity, and healthcare use.
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For chronic illnesses including diabetes mellitus (DM), healthcare providers continue to struggle with the forever evolving needs of their patients. Keeping the patients connected to a healthcare facility through regular follow ups is crucial in instilling a sense of self-reliance in them and also in preventing long-term complications [
According to the figures from American Diabetes Association (ADA), only one half of people with diabetes (PWD) are maintaining their glycated hemoglobin (HbA1c) at the recommended levels of <7% [
According to American Association of Diabetes Educators, self-care activities in PWD are assessed by seven major parameters including healthy diet, physical activity, regular blood sugar monitoring, medication adherence, effective approach to problem-solving, strong coping skills, and risk-reduction behaviors [
In light of the existing literature, an observational study was conducted to evaluate the impact of diabetes self-care activities and behaviors on glycemic control in PWD.
This observational, cross-sectional study was conducted at the outpatient department of a secondary care hospital in Karachi, Pakistan. The study duration was from 1st September 2019 till 30th November 2019. It was conducted after attaining approval from the ethical review board.
In this study, patients of both genders, of age 45 years and above, known cases of type II DM visiting the hospital for routine follow-up visit were included. Patients with any of the diabetes-related complications, patients being seen in the emergency or in-patient department, patients who did not have at least one available record of HbA1c from the last six months, and patients who could not read and/or understand written Urdu were excluded. All patients were included after attaining informed consent.
In order to record patient information, a semi-structured questionnaire was constructed. It included patient gender, age, marital status, education, occupation, duration and treatment for DM, and their HbA1c record from the last six months. In order to assess their status of self-management, Diabetes Self-Management Questionnaire (DSMQ) in Urdu version was used. DSMQ has been designed to evaluate the relationship between patients’ activities of self-care and their glycemic control [
For data entry and statistical analysis SPSS for Windows version 21.0 (SPSS Inc., Chicago, IL, USA) was utilized. Patient characteristics were presented as frequency and percentages and compared using Chi square test. For DSMQ overall and its subscales mean and standard deviation (SD) were calculated and for comparison independent sample t-test was applied. The p value ≤0.05 was taken as significant.
There were 317 PWD in the study. Among them, 174 (54.9%) were males and 152 (47.9%) were of age 45-60 years. Most of the participants were married (n=195; 61.5%), educated till university level (n=156; 49.2%), and had office-based jobs (n=137; 43.2%). In our study sample, 125 (39.4%) had good glycemic control (HbA1c <7%) and 192 (60.6%) had poor glycemic control (HbA1c ≥7%). Most of these patients had type II DM for 5-10 years (n=135; 42.5%) and the most common form of treatment was oral hypoglycemic agents (n=114; 35.9%). The patients were categorized according to their glycemic control and their characteristics are shown in Table
Baseline characteristics | Glycemic control | p value | |
Good glycemic control; (n=125; 39.4%) | Poor glycemic control; (n=192; 60.6%) | ||
Gender | |||
Male | 71 (56.8%) | 103 (53.6%) | 0.58 |
Female | 54 (43.2%) | 89 (46.3%) | |
Age | |||
45-60 years | 72 (57.6%) | 80 (41.7%) | 0.005 |
> 60 years | 53 (42.4%) | 112 (58.3%) | |
Marital status | |||
Single | 18 (14.4%) | 29 (15.1%) | 0.04 |
Married | 87 (69.5%) | 108 (56.3%) | |
Divorced | 08 (6.4%) | 16 (8.3%) | |
Widow | 12 (9.6%) | 39 (20.3%) | |
Education | |||
No schooling | 02 (1.6%) | 06 (3.1%) | 0.36 |
Primary to secondary level | 56 (44.8%) | 97 (50.5%) | |
University level | 67 (53.6%) | 89 (46.4%) | |
Occupation | |||
Unemployed | 07 (5.6%) | 36 (18.7%) | 0.004 |
Office job | 54 (43.2%) | 83 (43.2%) | |
Outdoor job | 39 (31.2%) | 41 (21.4%) | |
Stay at home | 25 (20.0%) | 32 (16.7%) | |
Duration of diabetes | |||
< 5 years | 43 (34.4%) | 63 (32.8%) | 0.04 |
5-10 years | 61 (48.8%) | 74 (38.5%) | |
> 10 years | 21 (16.8%) | 55 (28.6%) | |
Diabetes treatment | |||
Insulin therapy | 48 (38.4%) | 63 (32.8%) | 0.09 |
Oral hypoglycemic agents | 36 (28.8%) | 78 (40.6%) | |
Insulin + oral hypoglycemic agents | 41 (32.8%) | 51 (26.5%) |
In Table
DSMQ, Diabetes Self-Management Questionnaire; SD, standard deviation
DSMQ (mean ± SD) | Glycemic control | p value | |
Good glycemic control; (n=125; 39.4%) | Poor glycemic control; (n=192; 60.6%) | ||
DSMQ overall score | 5.53 ± 0.35 | 4.32 ± 0.61 | <0.0001 |
Glucose management subscale | 4.01 ± 0.44 | 3.87 ± 0.76 | 0.06 |
Dietary control subscale | 4.24 ± 1.04 | 3.63 ± 0.98 | <0.0001 |
Physical activity subscale | 4.16 ± 0.56 | 3.47 ± 1.17 | <0.0001 |
Healthcare use subscale | 4.22 ± 0.78 | 3.98 ± 0.65 | 0.003 |
In this study, patients with good glycemic control scored significantly better on DSMQ overall and on three sub-scales - dietary control, physical activity, and healthcare use. The scores on glucose management subscale were not significantly different in patients with good and poor glycemic control groups.
In our study, 61% PWD had poor glycemic control (HbA1c >7%). The proportion is higher as compared to other local literature. In a study by Athar et al., 45% were reported to have HbA1c >8% and in a study by Malik et al., 53% had HbA1c >7% [
In the present study, both groups were further categorized into strata according to their various demographic characteristics. It was observed that patients who were older than sixty years were more likely to have a poorer glycemic control compared to those who were younger (p<0.05). This could be because older individuals have impaired cognitive skills and as they age, their executive functioning starts to decline which is necessary to accomplish glycemic control. This finding is in accordance with the previously published literature [
We observed that about half of the participants with good glycemic control had a high education status with a bachelor’s degree at the least. This finding is in coherence with a recent exploratory study published by Turrin and Trujillo, which reported that patients who were not able to measure their carbohydrate intake or calculate their insulin dose had a poorer glycemic control with a mean A1C of 8.0 + 1.4 percent, compared to those with a better understanding of their condition (p=0.04) [
In the present study, it was observed that marital status was significantly associated with poor glycemic control. This can be explained by the lack of social support among those who were divorced or widowed, subsequently resulting in the impairment of self-efficacy and self-management of DM. A study by Gunggu et al. reported that among patients with DM, family support was found to be a strong predictor for optimal level of diabetes-related self-management, as the social support received by the patients improves their self-perception resulting in effectual self-management and better disease control [
In our study, it was found that a combination of oral hypoglycemic drugs and insulin was more effective in achieving a good glycemic control among patients (p=0.09). This finding is further reinforced by a recent report published by the National Program for Prevention and Control of Diabetes (NPPCD-2018), which is indicative of a negative correlation between poor glycemic control and using a combination of insulin and oral hypoglycemic drugs (p=0.001) [
The present study reported that about one-fourth patients with poor glycemic control were unemployed. They also scored significantly low on their overall DSM questionnaire. We can speculate that the patients who were unemployed were unable to afford basic healthcare facilities including access to medication as indicated by their low mean score on the healthcare use subscale, henceforth, resulting in poor glycemic control. Rak et al., in their work reported that there was an indirect relationship between efficacy of self-management of diabetes and unemployment among his study population. Although he did not find any direct link between the two variables, it was interesting to observe that patients who were employed were more physically fit and their activities of daily living were less likely to be affected by their condition [
Diabetes self-management education and awareness has been shown to improve the patient outcome among patients with diabetes. According to a systematic review , it was reported that the A1C levels improved significantly among 60% of the patients who received diabetes self-management education [
The current study has many strengthening points that makes it an invaluable contribution to the scientific community, nevertheless, it is not completely devoid of limitations. Language barriers were faced while recruiting the patients for the study. As the validated Urdu version of DSMQ was used, the patients who did not speak Urdu language were inevitably excluded from the study. Since, self-management techniques differ significantly by ethnicity, we cannot generalize the current study to all ethnicities of Pakistan. Further research should evaluate the diabetes-related self-management and ethnic disparities.
The present study indicates that the diabetes-related self-management was directly linked with glycemic control among patients. Patients who had scored badly on DSMQ had poorer glycemic control compared with patients who scored higher on DSMQ. Age, marital status, employment status, duration of illness, and anti-glycemic therapy were significantly associated with the glycemic control among patients. It is essential to promote self-management education related to DM as a strategy to improve self-management and improve the overall patient outcome.
The authors have declared that no competing interests exist.
Consent was obtained by all participants in this study. Liaquat College of Medicince and Dentistry issued approval 2019/22-1