Assessment Of Self - Management For Patients With Type 2 Diabetes During The Syrian Crisis

doi:10.21203/rs.3.rs-5082552/v1

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Assessment Of Self - Management For Patients With Type 2 Diabetes During The Syrian Crisis

https://doi.org/10.21203/rs.3.rs-5082552/v1

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Diabetes mellitus (DM) is a long-term metabolic disease in which blood glucose levels are elevated due to the complete absence or incomplete absence of the insulin hormone. The requirements for people with diabetes are not controlling blood glucose levels only; there is also an urge to prevent complications and side effects of the disease. Studies show that good self-care for individuals with this disease has led to good outcomes. Diabetics who do self-care have shown positive results by reducing diabetes complications and its development, which leads to a significant reduction in the burden of diabetes. Despite these positive changes, people who adhere to these self-care practices are very few, especially when we see broad and chronic changes. There are many factors that play a major role in adherence to self-care practices, such as social factors, demographic factors, and various economic factors. While the role of doctors plays an important role in increasing self-care practices for diabetic patients to achieve the desired result.

Materials and methods used in this study

A sample of 200 diabetic patients was assembled with electronic questionnaire that included a number of questions controlled to achieve the study objective, in Damascus; Syria, within specific inclusion and exclusion criteria mentioned later. The data were processed using SPSS version 26, a general descriptive study of the sample's answers was conducted, followed by appropriate statistical tests to reach scientific results documented by previous medical literature.

Results

By presenting the results of the descriptive study on the degree of availability of an organized community response that provides the greatest amount of assistance to enhance self-care for diabetes, and help patients to live with their disease and avoid its complications as much as possible. In addition to surveying the degree of patients' awareness and knowledge of the steps of self-care and their ability to manage the disease. An analytical study was conducted on some axes related to developing self-care from attending educational workshops and others; where the effect of some demographic indicators was studied from the effect of the patient's gender on his attending training workshops. The results of the study we conducted, indicated that there is no significant difference between males and females and patient's social status in their commitment to attending educational workshops. In the study we conducted, the impact of community response and promoting the concept of self-care for diabetes among patients (as one axis) on their level of awareness and dealing with the complications of the disease and their ability to manage the symptoms of the disease was studied. A one-way Anova test was conducted and its results indicated the existence of a significant impact of promoting the concept of self-care on patients’ lives and helping them avoid complications of the disease.

Internal Medicine

Endocrinology & Metabolism

Epidemiology

Diabetes mellitus

Syrian Crisis

Self-Management

Diabetes is a chronic disease that occurs when the pancreas fails to produce enough insulin, or when the body is unable to effectively use the insulin it produces. Hyperglycemia, a common result of poor blood sugar control, can over time seriously damage many of the body's systems.

Type 1 diabetes is characterized by a lack of insulin production and requires daily insulin administration. Type 2 diabetes affects how the body uses sugar (glucose) for energy. It is characterized by insulin resistance, which prevents the body from using insulin properly, which can lead to high blood sugar levels if left untreated. Gestational diabetes is hyperglycemia in which blood glucose levels are higher than normal during pregnancy but not high enough to be diagnosed w/ diabetes.

People with type 1 diabetes need insulin injections to survive, and some people with type 2 diabetes need to take medications to help control blood sugar levels. These medications may include insulin injections or other medications such as metformin, sulfonylureas, and type 2 sodium-glucose co-transporter inhibitors.

The most prominent complications of diabetes include general complications such as a gradual increase in blood pressure, distinctive disorders in blood lipids, low levels of HDL, and distinctive damage to the kidneys, retinas, and nervous system; short-term complications that require immediate treatment; long-term complications may eventually lead to disabilities or even death.

Training related to personal care and self-management of diabetes begins with the proper knowledge of the instructions, which depend on the patient's needs. Self-care practices are a set of behavioral practices that individuals with diabetes use to manage and control the disease themselves. Various studies and evidence show that when the patient have self-care practices in a proper and systematic manner, he can improve blood sugar control, and these practices have proven effective in achieving the treatment goals of diabetes.

The most important self-care practices are daily exercise, diet, smoking cessation, foot care, fiber intake, dental care, eye care, and stress management.

Self-care includes various approaches aimed at taking care of physical, emotional and mental health, as any patient with a chronic disease may experience impacts on their overall health and lifestyle as a result of changes in their choices and behaviors. These practices include different things to take care of, such as medications, exercise, food, sleep, emotions, medical facilities, and care.

The American Diabetes Association (ADA) states that monitoring carbohydrate and fiber intake, losing weight, and reducing cholesterol, saturated fat, trans fat, and salt intake are the basic things that should be done to manage this disease.

Obesity is one of the main issues for individuals with type 2 diabetes, so dietary changes are the main factor in managing diabetes because they can lead to weight loss and help in managing obesity, which helps in managing diabetes.

Personal care with physical exercise is an important internal part of managing this disease and maintaining skeletal muscle activity and movement. The goal of physical exercise is to achieve blood sugar regulation, improve insulin action, improve protein and fat metabolism, avoid complications of diabetes, and increase quality of life and life expectancy.

Adequate physical exercise also leads to decrease levels of glycated hemoglobin (HbA1c). Therefore, young generations should be educated and informed about the importance of regular exercise, which helps them lose calories, lose weight, and maintain blood glucose levels.

The American Diabetes Association has conducted studies and reviewed the results of diabetes self-care and self-management measures and recognizes that there is a four-fold increase in diabetes complications in people who did not receive any advice or education regarding self-care practices.

However, this improvement in blood glucose levels declines after one to three months of stopping self-care activities, suggesting that self-management education is beneficial in reducing HbA1c.

Adherence to diabetes treatment regimen is an important area of concern. In diabetes, individuals need to adapt to and follow the management plan carefully, which should include positive lifestyle changes, including dietary planning and regular physical exercise; taking proper medications daily, including insulin or oral hypoglycemic agents; monitoring blood sugar levels; managing diabetes-related symptoms; having foot care guidelines; and taking care of diabetes or other health-related problems.

However, despite the life-saving benefits of these activities, adherence to these self-care activities has been found to be very low.

In a study of diabetics, the results showed that only 30% of individuals were adherent to the treatment regimen, and non-adherence was higher, especially among groups with lower socioeconomic status.

Practical study

Research Objective:

A scientific study using a questionnaire on the application of self-care for diabetes patients in the Syrian Arab Republic, to study the importance of self-care and community response within it and the reflection of its effects on patients' awareness and management of disease symptoms.

Study location: Damascus, Syrian Arab Republic.

Sample design: A sample of 200 diabetes patients was assembled using a directed electronic questionnaire that included a number of questions that were controlled to achieve the study's objective.

Inclusion criteria: The criteria for including individuals in the sample included several aspects and aspects, including:

1- The individual participating in the questionnaire agreed to be part of the sample of this study, before self-filling out the questionnaire with personal information and responses to the questions within the questionnaire.

2- Confirming that the individual participating in the sample has diabetes of either type 1 or type 2.

3- The individual's answer to the questions presented to him in the questionnaire directed to this study, especially the questions that have an important impact on the research results and study statistics.

Exclusion criteria: A number of individuals were excluded from the sample according to specific criteria, which are:

1- The individual's refusal to participate in the sample studied in this research.

2- Confirming that the individual is not with either type-1 or type-2 diabetes.

3- The individual's refusal to answer many questions in the questionnaire, which may affect the statistical results and the normal distribution of sample.

Research method:

The study was conducted within the framework of three axes; demographic indicators (gender, age...), the social response axis (availability of special care centers, educational workshops, psychological support workshops...), the knowledge and awareness axis of patients and their ability to disease manage.

Statistics and data processing

The data were processed using SPSS version 26, a general descriptive study of the sample's answers was conducted, followed by appropriate statistical tests to reach scientific results documented by previous medical literature; such as Chi-square, one-way Anova, T-student.

1- Descriptive study

a- Study of demographic aspects of the sample:

In the sample of 200 diabetic patients, 45.5% of the sample were males and 54.5% of the sample were females.

The average age of the sample was 39 years, with the youngest age in the sample being 18 and the oldest 89. The largest percentage of the sample, about 50.5%, was between 30 and 60 years old, while 8.5% of the sample was between 60 and 90 years old.

About 55% of the sample were married, while the largest portion of the sample, about 65%, had a university degree, while 31% were uneducated, and 52.5% of the sample were smokers.

Table (1) Distribution of the sample according to demographic factors.

	Distribution	Frequency	Percentage
Gender	Male	91	45.5%
	Female	109	54.5%
	Total	200	100.0%
Age	< 30 (18–30) years	81	40.5%
	30–60 years	101	50.5%
	60–90 years	17	8.5%
	Total	199	99.5%
	Missing value	1	0.5%
Educational level	Uneducated	62	31%
	University degree	130	65%
	Postgraduate studies	8	4%
	Total	200	100%
Smoking	Smoker	105	52.5%
	Non-Smoker	95	47.5%
	Total	200	100%

b- Study of community response to diabetes care:

In the study of community response to diabetes care; 57% of the sample held scientific seminars within the city to educate them about diabetes and self-care steps, only 8% of the sample were committed to attending these workshops regularly.

Plus, 80.5% of the sample indicated the existence of health care centers and educational teams that the patient can visit and review periodically.

In addition to 49% of the sample confirming the existence of seminars to support mental health and provide necessary consultations for diabetes patients.

34% of the sample indicated that their family received awareness about diabetes and the steps to control it and its complications.

Table (2) Sample’s answers of community response to diabetes care.

	Distribution	Frequency	Percentage
Are there any educational seminars held in your city to educate about diabetes and self-care steps?	Yes	114	57%
	No	86	43%
	Total	200	100.0%
Do you attend these educational workshops on a regular basis?	Yes	16	8%
	No	184	92%
	Total	200	100%
Are there educational teams that you can visit when needed and review periodically to monitor diabetes complications?	Yes	161	80.5%
	No	39	19.5%
	Total	200	100%
Are there mental health support seminars that a diabetic patient needs to manage stress in your governorate?	Yes	98	49%
	No	102	51%
	Total	200	100%
Has your family received awareness about diabetes, steps to control it and quickly deal with its complications?	Yes	68	34%
	No	132	66%
	Total	200	100%

c- Study of patients' response and their level of awareness and knowledge of diabetes care steps

In a study of patients' response and their level of awareness and knowledge of diabetes care steps; 54% of the sample quit smoking after being diagnosed with diabetes, while 33.5% of the sample confirmed that they exercise regularly.

About more than half of the sample, 67%, have good knowledge about diabetes complications (diabetic foot, ketoacidosis, etc.).

Plus, the vast majority, about 71% of the sample, answered that they know the normal values for blood sugar levels according to the time of measurement and the type of medication used.

Table (3-a) Sample’s answers and their level of awareness and knowledge of diabetes care steps.

	Distribution	Frequency	Percentage
Are you still a smoker after being diagnosed with diabetes?	Yes	92	46%
	No	108	54%
	Total	200	100.0%
Do you exercise regularly as a routine part of your daily life?	Yes	67	33.5%
	No	133	66.5%
	Total	200	100%
After attending the training and educational workshops, were you able to manage your blood sugar level better?	Yes	42	21%
	No	158	79%
	Total	200	100%
Do you have knowledge about complications of diabetes (diabetic foot, ketoacidosis, diabetic retinopathy)?	Yes	134	67%
	No	66	33%
	Total	200	100%
Do you know what your normal blood sugar levels are based on the time of measurement and the type of medication used?	Yes	142	71%
	No	58	29%
	Total	200	100%

About 60.5% of the sample indicated that they are aware of methods for managing stress, controlling sugar, and the importance of getting enough sleep.

While the patients who visit the doctor regularly decreased, only 34% of patients indicated that they are committed to periodic visits.

Regarding drug treatment, 60.5% of the sample were able to obtain the medication regularly and easily, while 85% of the sample confirmed that they were committed to taking the prescribed drug doses regularly.

As for the diet, a relatively small percentage, about 38.5% of the sample only, indicated that they were committed to the doctor’s dietary instructions.

Table (3-b) Sample’s answers and their level of awareness and knowledge of diabetes care steps.

	Distribution	Frequency	Percentage
Are you aware of the importance of getting enough sleep to manage your stress and control your blood sugar?	Yes	121	60.5%
	No	79	39.5%
	Total	200	100.0%
Do you visit your doctor regularly?	Yes	68	34%
	No	132	66%
	Total	200	100%
Are you able to get your medication regularly?	Yes	121	60.5%
	No	79	39.5%
	Total	200	100%
Do you take your medication regularly every day?	Yes	171	85.5%
	No	29	14.5%
	Total	200	100%
Are you adhering to your doctor's diet instructions?	Yes	77	38.5%
	No	123	61.5%
	Total	200	100%

2- Analytical study

a- Study of the impact of demographic indicators

1- Study of the correlation between the patient's gender and commitment to attending the educational workshops held:

By discussing the results shown in Table 4, we note that 5.5% of males are committed to attending the educational workshops held in the governorates, while only 10.1% of females are committed to attending these workshops.

Considering the independence test, we note that the probability value is equal to 0.233, which shows that there is no significant correlation or statistically significant association between the patient's gender and his attendance at the training workshops.

Table (4) results of chi-independence test to find the correlation between the patient's gender and commitment to attending the educational workshops.

2. Studying the effect of the gender and attendance at educational workshops:

To study the effect of the patient's gender on the average attendance at training workshops, we conducted the T-Student's test for independent samples and we note that the average commitment among males was greater than that of females, but based on the probability value equal to 0.22, we note that there is no statistical significance for this difference, and therefore there is no effect of the patient's gender on his attendance at educational workshops.

Table (5) results of T-Student's test for independent samples to find the correlation between gender and attendance at educational workshops.

T-Student	Mean	Probability
Male	1.95	0.22
Female	1.90	0.22

3. Studying the correlation between social response and its impact on knowledge about diabetes complications

Based on the importance of self-care and its impact on improving patients' lives, the impact of the means that help achieve self-care on patients' response was studied. Where questions related to social response were grouped under one axis (social response axis), and questions related to the patient's ability and awareness to manage symptoms according to a regular life routine (awareness axis), a one-way analysis of variance test was conducted and the results were presented in the table.

By discussing the results included in Table 6 and based on the probability value equal to 0.002, we note the existence of a significant effect of social response from holding educational seminars, the availability of health care centers, and holding mental health support workshops, on the degree of knowledge and awareness among patients in terms of their knowledge about complications and the importance of managing stress and getting enough sleep and adhering to regular periodic visits and nutritional instructions prescribed by the doctor and taking medications regularly.

This is due to the importance of communication between the doctor and the patient, and the community health institutions concerned with improving the lives of patients suffering from chronic diseases, and anticipating the exacerbation of the disease.

It increases the patient's knowledge of the symptoms of his disease and the possibility of managing them and preventing their severity by following studied scientific methods that are compatible with the patient's culture and awareness, in addition to educating the patient's family about these methods and prevention steps.

Table (6) results of the one-way analysis of variance test to find the correlation between social response and its impact on knowledge about diabetes complications.

Anova	Variance	Probability
Variance between groups	78.50	0.002
Variance within groups	882.512	0.002

4. Studying the correlation between the presence of permanently available health care centers and the possibility of having medication regularly

As part of the study to provide community support to help implement self-care, a pivot table was conducted showing the correlation between the presence of health care centers and the possibility of having medication regularly, as 84.6% of patients who have medication regularly confirmed the presence of care centers available in their city, while 41.9% of patients who cannot have medication comfortably and regularly indicated the absence of health care centers within the city.

Based on the probability value of the Chi-square test of independence, which is equal to 0.001, we note the presence of a significant correlation between the availability of health care centers and the possibility of obtaining medication regularly, which reflects the great community role in helping the patient control diabetes symptoms and medication doses, and shows the importance of the availability of diabetes medications in medical clinics and the availability of specialized care centers, which constitutes a fundamental pillar in supporting self-care for diabetics and helping them implement the appropriate steps and routine by providing medication easily and regularly without material cost or effort.

Table (7) results of the chi-independence test to find the correlation between the presence of permanently available health care centers and the possibility of having medication regularly.

5. Studying the correlation between holding seminars to support the mental health of diabetics, which provide useful advice for stress management, and patients' knowledge of stress management methods

Since effective self-management of diabetes requires a great deal of personal motivation and behavioral change to achieve a healthy and satisfying life, the correlation between the availability of psychological support and symptom and stress management was studied.

We note from the table that 54.5% of patients who are able to manage stress and have knowledge about the most important useful methods and principles in this regard had mental health support seminars held in the city, while 59.5% of patients who do not have the knowledge or ability to manage stress indicated that there were no mental health support seminars within the governorate in which they reside.

Based on the probability value of the Chi-square test of independence, which is equal to 0.05, we conclude that there is a significant effect of the presence of mental health support seminars on patients' ability to manage stress and their knowledge of the most important useful methods to anticipate the effect of stress on blood sugar levels, as we note that patients who have psychological support seminars held in their city had greater knowledge of stress management.

Table (8) results of the chi-independence test to find the correlation between holding seminars to support the mental health of diabetics, and patients' knowledge of stress management methods.

A cross-sectional study was conducted on a sample of 200 diabetic patients, 45.5% of the sample were males and 54.5% of the sample were females. The average age of the sample was 39 years. The largest percentage of the sample, about 50.5%, was between 30 and 60 years old, while 8.5% of the sample was between 60 and 90 years old.

In terms of marital status, 55% of the sample were married, while the largest percentage of the sample, about 65%, had a university degree, while 31% were uneducated. 52.5% of the sample were smokers.

In the study of community response to diabetes care; 57% of the sample held scientific seminars within the city to educate them about diabetes and self-care steps. Only 8% of the sample were committed to attending these workshops on a regular basis. 80.5% of the sample indicated the existence of health care centers and educational teams that the patient can visit and review periodically, in addition to the fact that 49% of the sample confirmed the existence of seminars to support mental health and provide necessary consultations for the diabetic patient, 34% of the sample indicated that their family received awareness about diabetes and the steps to control it and its complications.

In a study of patients' response and the degree of their awareness and knowledge of the steps of diabetes care; 54% of the sample quit smoking after being diagnosed with diabetes, while 33.5% of the sample confirmed that they exercise regularly, about more than half of the sample at a rate of 67% have good knowledge about the complications of diabetes (diabetic foot, ketoacidosis.....), and the vast majority of about 71% of the sample recorded that they know the normal values for blood sugar levels according to the time of measurement and the type of medication used.

While 60.5% of the sample indicated that they are aware of stress management methods, blood sugar control and the importance of getting enough sleep, the percentage of patients who visit the doctor regularly decreased, as only 34% of patients indicated that they are committed to regular visits. Regarding drug treatment, 60.5% of the sample are able to obtain the medication regularly and easily, while 85% of the sample confirmed that they are committed to taking the prescribed drug doses regularly. As for the diet, a relatively small percentage, about 38.5% of the sample only, indicated that they are committed to the doctor's nutritional instructions.

After presenting the results of the descriptive study on the degree of availability of a complete and organized community response that provides the greatest amount of assistance to enhance self-care for diabetes, and help patients to live with their disease and avoid its complications as much as possible.

In addition to surveying the degree of patients' awareness and knowledge of the steps of self-care and their ability to manage the disease.

An analytical study was conducted on some axes related to developing self-care from attending educational workshops and others; where the effect of some demographic indicators was studied from the effect of the patient's gender on his commitment to attending training workshops.

The results of the study we conducted indicated that there is no significant difference between males and females in their commitment to attending educational workshops.

There was no significant effect of the patient's social status on his commitment to attending educational training workshops.

In the study we conducted, the effect of community response and promoting the concept of self-care for diabetes among patients (as one axis) on their level of awareness and dealing with the complications of the disease and their ability to manage the symptoms of the disease was studied.

A one-way analysis of variance test was conducted and its results indicated the existence of a significant effect of promoting the concept of self-care on the lives of patients and helping them avoid complications of the disease.

This is consistent with the instructions of the American Society for Endocrine Diseases, as the American Diabetes Association conducted studies and reviewed the results of the standards of self-care and personal management of diabetes, and the results indicated that there was a four-fold increase in diabetes complications among people who did not receive any advice or education related to self-care practices. (Toljamo & Hentinen, 2001)

An analytical study also revealed (G. C. Williams et al., 1998) that self-management education for adults with type 2 diabetes resulted in an improvement in blood sugar control when they were followed up after applying the self-care steps.

In light of the study of the availability of aids to enhance self-care, the effect of the availability of health centers on facilitating access to medications for diabetes patients was studied.

The results of the study showed that cities that had health care centers enabled patients to obtain medication more regularly than patients whose cities did not have health care centers.

Since psychological support is an essential step and a decisive role in the success of self-care, the effect of mental health support workshops on patients’ ability to manage stress and prevent its effects on blood sugar levels was studied.

The test results showed that patients who attended mental health support workshops were aware of the importance of stress management and were able to deal with its effects on blood sugar levels more than patients who did not attend psychological support workshops, which reflects the importance of mental health support workshops in managing stress in patients as a fundamental pillar of self-care.

According to the Chilean Pediatric Society, special teams should be created consisting of specialists responsible for controlling diabetes management in young adult patients, in addition to educating and encouraging them to maintain control over diabetes, to make health care centers more effective. (Henríquez-Tejo and Cartes-Velásquez, 2018.

In a similar study by Gonzalez et al., 2008, a positive association was found between depressive symptoms and poor adherence to medication and diabetes self-care after 9 months, which constitutes a major barrier to achieving adequate self-care.

Similarly, another study showed that persistent depressive symptoms were associated with poor self-management in terms of diet and exercise over the following 5 years.

(Katon et al., 2009)

This reflects the importance of psychological support and behavioral therapy for diabetes patients as a fundamental pillar in implementing self-care and achieving its primary goal.

Recommendations

1- In the context of the importance of applying self-care for diabetics and promoting this culture, we recommend:

2- Instructing patients on the importance of monitoring blood sugar levels regularly and following a healthy diet.

3- Encouraging patients to exercise regularly to maintain a healthy weight.

4- Raising awareness of the importance of following medical instructions and taking medications regularly.

5- Ensuring the provision of specialized healthcare centers that patients can access.

6- Providing psychological and social support to patients, and providing a supportive environment to maintain a healthy lifestyle.

7- Encouraging participation in educational events about diabetes to increase awareness and motivation to follow a healthy lifestyle.

Ethics approval and consent to participate.

All methods were carried out in accordance with relevant guidelines and regulations. Ethical approval for the current study has been obtained from the Syrian Ethical Society for Scientific Research (HFE783253). Informed consent was obtained from all subjects.

Consent for publication

Not applicable.

Competing interests

None

Funding

N/A

Availability of Data and Materials

The authors have access to and have saved all of the data necessary to support this paper's conclusion. All data are accessible upon reasonable request from the corresponding author.

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The authors declare no competing interests.

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Assessment Of Self - Management For Patients With Type 2 Diabetes During The Syrian Crisis

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Abstract

Introduction

Research Objective:

Materials and Methods

Research method:

Statistics and data processing

Results

1- Descriptive study

a- Study of demographic aspects of the sample:

b- Study of community response to diabetes care:

c- Study of patients' response and their level of awareness and knowledge of diabetes care steps

Discussion of Results

Declarations

References & Resources

Additional Declarations

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