Diabetes Self-Care Activities and Glycaemic Control among Adults with Type 2 Diabetes in Sri Lanka: A Cross-Sectional Study

The prevalence of Type 2 Diabetes Mellitus (T2DM) and its complications continue to rise across the globe including Sri Lanka. Diabetes Self-care activities (DSCA) are promising behaviors to reduce complications and to achieve good glycaemic control. There is a lack of data regarding DSCA and its association with glycaemic control among adults with T2DM in Sri Lanka. A descriptive cross-sectional study was conducted among purposively selected adults with T2DM (n = 300) in a teaching hospital, Sri Lanka to determine the association between DSCA and glycaemic control. Apre-tested interviewer-administered questionnaire which includes socio-demographic, diabetes-related information and Summary of Diabetes Self-care activities questionnaire was used to collect data. Data were analyzed by using descriptive statistics and Chi-square test. General diet (Healthy eating plan) (OR = 3.04, 95% CI = 1.04 8.88, p = 0.034), Physical activities (OR = 2.26, 95% CI = 1.29 3.97, p = 0.004), Medication adherence (OR = 2.87, 95% CI = 1.24 6.64, p = 0.011) were significantly associated with HbA1c. Medication adherence was significantly associated with poor fasting blood sugar (FBS) (OR = 1.90, 95% CI = 1.07 3.37, p = 0.028). The findings highlight the need for health professionals to implement health education programs on diabetes self-care activities for adults with T2DM to enhance their adherence to DSCA, as well as to maintain glycemic control.


Introduction
T2DM has become a global epidemic that affects over 377 million people worldwide, with estimated prevalence rates rising to an alarming 642 million people by 2040 [1]. Most people with diabetes live in low-and middle-income countries, and these countries will experience the highest increase in cases of diabetes over the next two decades [2]. Diabetes Mellitus (DM) is a group of illnesses characterized by high blood glucose levels that result from defects in the body's ability to produce and/or use insulin. T2DM is the most common form of diabetes in which the body is unable to produce adequately to overcome insulin resistance and affects various organs and systems [3]. In Sri Lanka, DM is a significant health problem; with an unprecedented current level of prevalence [4].
According to a recent study, the age-adjusted prevalence for T2DM was 20.3% for males and 19.8% for females in an urban cohort, and of those diagnosed with T2DM, only23.8% were optimally controlled [5]. However glycaemic control has an effect on improving diet, exercise, medication, foot care efficacy and behaviors [6]. As there is no cure for diabetes, self-care activities are promising activities in blood sugar control among patients with T2DM. In Sri Lanka, the majority of the adults with T2DM did not involve recommended DM management strategies including restricting refine sugar, regular exercises or checking blood sugar regularly [7] and the majority of adults with T2DM did not achieve desired glycaemic control [8].

Literature Review
Several previous studies have shown that high levels of patients adherence to diabetes self-care behaviors resulted in better metabolic control [9] [10] [11] [12] and self-care skills play a crucial role in optimal diabetes control [13]. Diabetes self-care Activities (DSCA) include a range of activities such as self-monitoring of blood glucose, eating a healthy diet, being physically active, taking the recommended medication and consulting health care professionals [14]. A Chinese study revealed that; effective-patient communication, social support, and higher self-efficacy were associated with performing diabetes self-care behaviors; that were directly linked to glycaemic control [15]. A study suggested that interactive health education programs should be introduced to increase patient adherence to the treatment, and the importance of family members' involvement in encouraging patients' glycaemic control [16].
According to studies, Sri Lanka is among the countries with the highest diabetes prevalence rates in the world [17]. Sri Lankan studies revealed that one in five adults has either diabetes or pre-diabetes condition [18]. A national survey conducted in 2005 to 2006, explored that the prevalence of T2DM was twice as high in persons from urban areas (16.4%) as compared to persons from rural areas (8.7%) [18]. In 2016, the number of death attribute due to the high blood glucose level in Sri Lanka was 4660 males and 2470 females of the age limit between 30 to 69 which is significantly higher compared to the universal figure of  [19]. In the same year, the prevalence of diabetes in Sri Lanka was among males 7.3% females, and 8.4% [19]. Further, the researchers revealed that the incidence of diabetes risk factors such as the prevalence of overweight among males was 18.9%, and females 32.9% [19]. Prevalence of obesity among men was 3.5% and among women was 10.0%. Prevalence of physical inactivity is higher in women (30.2%) compared with men (16.9%) [19]. There is an apparent deficiency in self-care practices; medication adherence, dietary practices, physical exercises, foot care practices and identification and prevention of complications among patients with diabetes; however the majority of the participants in their study preferred to learn more about how to control their DM [20]. Self-care activities are much crucial to glycaemic control among adults with T2DM. Hence it is important to determine the association between DSCA and the glycaemic control.

Design
A descriptive, cross-sectional design was used and 300 purposively selected adults with T2DM were selected based on inclusion and exclusion criteria.

Participants and Setting
This study was conducted at a diabetic clinic at Sri Jayewardenepura General This study included adult participants (age 18 and above) with a diagnosis of T2DM, and a minimum duration of >6 months of diagnosis was required because the participants need some time to adapt to their illness and to practice diabetes self-care. Adults with T2DM who had physical or cognitive impairments, pregnant women, adults who have diagnosed with diabetes less than six months and adults who were severely ill were excluded from the study.

Data Collection
An Interviewer-administered questionnaire was developed by the researcher, using the revised version of the Summary of Diabetes Self-care Activities (SDSCA) that is used to measure self-care activities of diabetic patients [14]. DSCA over the past 7 days. If they were sick during the past 7 days, they were asked to reflect on the 7 days before they became ill. The questionnaire was pre-tested among 10 patients with T2DM to determine acceptability, feasibility, comprehensibility and appropriateness and these participants did not participate in this study.

Ethical Considerations
Ethical approval was obtained from the Ethics Review Committee of Faculty of Medical Sciences University of Sri Jayewardenepura, Sri Lanka and Ethics Review Committee of SJGH. Without disturbing to the clinic routines, the convenient time for participants was used for data collection. Informed written consent was obtained from all participants after a detailed explanation of the purpose and procedures used for the study. All the participants were informed that the privacy and confidentiality would be ensured during all steps of the study.
Hence, all the participants had the right to avoid participation at any time of the study. All data collected were treated as private and confidential to maintain anonymity. Data were stored on password secure digital storage which could only be accessible for the investigators.

Diabetes-Related Information of Adults with T2DM
Clinical characteristics of adults with T2DM are presented in Table 2

Summary of Diabetes Self-Care Activities of Adults with T2DM
According to the results, 262 (87.4%) of the adults with T2DM followed General Diet (Healthy eating plan) and 170 (56.6%) not followed a specific diet (fruits and vegetables, less meat and dairy products), 3 or more than 3 days from 7 days. Exercise regimen (30 minutes and specific exercise) was followed by 166 (55.3%) participants on 3 or more than 3days in the past 7 days, and 71 (23.7%) did not follow exercise regimen in even a single day. More than half (60.3%) of the participants did not perform self-monitoring of blood glucose (SMBG) even a single day while 59 (19.7%) performed SMBG 3 or more than 3 days in the past 7 days. Nearly half (49.7%) did not perform foot care (Checked feet, wash feet, soak feet, dry between toes after washing) even a single in the past seven days.

Associations of DSCA with Glycemic Control
Associations of DSCA with Glycemic control are presented in Table 5

Discussion
Even though this study findings clearly indicate more than half of the participants had good FBS level; the majority of the participants had poor HbA1c value. Results from other studies have also reported poor glycaemic control among adults with T2DM.According to another Sri Lankan study, most participants did not achieve the recommended fasting blood glucose level (<126 mg/dL) [8]. Iranian study also indicated 42.9% did not reach the target FBS level [21]. In this study, the majority of the participants had a family history of diabetes. Another cross-sectional national survey which was conducted among 5000 adults in Sri Lanka have also shown, the prevalence of diabetes was significantly higher in patients with a family history (23.0%) than those without (8.2%) family history (p < 0.001) [22]. The current study findings also revealed that more than half (51.7%) had a healthy BMI (18.5 -24.99). This finding is consistent with another study that showed nearly half (48.3%) of the study participants had a healthy BMI (18.0 -24.9) [8].  In the present study, even though the majority (87.3%) of the adults followed General Diet 3 or more than 3 days in the past 7 days (Healthy eating plan), 56.7% not observed specific diet 3 or more than 3 days in the past 7 days. As the Sri Lankan diet is high in calories from carbohydrates, the main message for dietary change should focus on the reduction of rice consumption with supple-  [23]. However, a Sri Lankan study has shown the majority of participants (71.7%) practised some dietary control [8]. According to another Sri Lankan study, among the participants, 56.7% had poor dietary practices in relation to T2DM [21].
The current study also revealed more than half of participants (55.3%) followed exercise regimen on 3 or more than 3 days in the past 7 days. Even though adults with T2DM have poor knowledge regarding exercise, the majority had an adequate level of physical activity during their daily activities, and they have a positive attitude towards physical activity [24]. In a Sri Lankan study, among the participants, 34.56% followed the recommended exercise [21]. However, a Sri Lankan study has shown the majority of participants (85.2%) did not practice any form of exercise [8]. In this study more than half of the participants not performed SMBG even a single day. According to another Sri Lankan study of 146 adults with T2DM, only 5 (3.6%) have practised SMBG (at least monthly) [25].
Nearly half (49.7%) did not perform foot care even a single day in the past seven days. Only 43.7% followed foot care 3 or more than 3 days in the past 7 days. In similar to the present study another Sri Lankan study also showed a large proportion (75.3%) of the participants have not engaged in foot care adequately [21]. However, in the current study, a majority of the participants who participated in foot care were women. This may be due to, females more concern of their body and as most of the women in the sample are housewives as they have more time to engage foot care practices. In Oman, of 350 adults with T2DM, 73.9% followed foot care practices and Omani adults' foot care practices were high when comparing to the current study [26]. This may be due to lack of foot care clinics in Sri Lanka. As similar to the present study, the same Omani survey has shown, significant associations between gender and foot care [26].
Even though the present study showed the majority of the participants (80%) adhered to medication regularly, in contrast to these results another Sri Lankan study revealed, among the participants, 59.73%, showed poor medication practices [21]. According to the Omani study medication adherence was 77%, 3 or more than 3 days in the past 7 days [26]. The Omani study further reviled, less than half percentage (45.5%) of the adults smoked at least 1 puff in the past 7 days [26]. In contrast to this study, among the Omani adults smoking was high.
This may be due to the Sri Lankan government's new legislation that enforced to include graphic warnings covering 60% of the surface area of packets of cigarettes. A Sri Lankan study also reviled 71.93% of the 119 participants were of the view that the demonstrated pictorial warnings would persuade the smokers to give up smoking [27]. In this study, general diet, physical activity and medication adherence were significantly associated with HbA1c. According to the results of a cross-sectional study; its bivariate analysis indicated the same three variables were significantly associated with HbA1c: adherence to diet, physical exercise, and medication-taking regimen [16]. based teaching hospital, and there is reduced the ability to generalize findings to the whole country. As weight and height also recorded by patient's medical records, inconsistency may be high.

Conclusion and Implications for Practice
According to the findings, the majority of the participants followed the General Diet and more than half not followed a specific diabetic diet. A considerable amount of adults did not pursue an exercise regimen for even a single day. More than half of the participants did not perform SMBG even a single day. Nearly half of the participants did not perform foot care even a single in the past seven days. Majority of the participants, (80%) reported adhering to recommended medication regularly. Nearly half of the participants had a good fasting blood glucose level (≤126 mg/dl) while the majority (75.7%) demonstrating poor HbA1c value (≥7%). Both general Diet and specific diet were highly significant with FBS. Physical activities were significantly associated with HbA1C. Female participants showed more adherence to foot care practices compared with male participants. Age was associated with considerably physical activities. Thus all these findings indicate that adults with good control of HbA1c and FBS reported better adherence to DSCA. The findings prove that there is an urgent need for improving DSCA among adults with T2DM. This study can guide diabetes nurse educators to understand the extent to which different self-care behaviors that affect glycaemic control. Health educational interventions are necessary to improve glycaemic control. Most of the adults' SMBG practice was poor. This may be due to financial cost. Therefore health policies should introduce to facilitates SMBG. We suggest further improvement into this model with a prospective and longitudinal study to observe the association between SDSCA and HbA1c in the long term.