Diabetes Self-Care Activities and Their Relationship With Glycemic Control in Patients Visiting Hayatabad Medical Complex, Peshawar

Background A significant portion of the Pakistani population is affected by diabetes, which has emerged as a global healthcare concern. Objective This study aimed to assess the correlation between glycemic control in diabetes patients and their engagement in diabetes self-care activities (DSCA). Methodology Cross-sectional research was conducted at Hayatabad Medical Complex in Peshawar between June 2019 and May 2020. A total of 280 carefully selected patients with type 2 diabetes mellitus (T2DM) were included. Data collection involved an interviewer-administered questionnaire encompassing sociodemographic information, diabetes-related data, and the summary of the Diabetes Self-Care Activities (SDSCA) scale. Descriptive statistics and Pearson's chi-square test were employed for data analysis. Results The study observed that the majority of participants (40.36%) were females, and the age range of the participants was between 42 and 53 years (68.22%). According to the study, 55.00% of participants had a normal body mass index (BMI), and 71.08% of participants had diabetes in their family. Regarding glycemic control, 55.71% of individuals exhibited good control based on fasting blood sugar (FBS) levels while 74.64% showed poor control according to hemoglobin A1C (HbA1c) values. HbA1c was substantially linked with a general diet (healthy eating plan), physical activities, and adherence to medication ((odds ratios (OR): 3.12), (95% confidence interval (CI): 1.02 - 8.78), (P value: 0.031)); ((OR: 2.19, 95%), (CI:1.18 - 3.79), (P value: 0.003)); ((OR: 2.85), (95% CI: 1.22 - 6.59), P value: 0.021)). Conclusion The findings indicated that health professionals need to create health education programs on DSCA in order to increase DSCA adherence in people with T2DM while maintaining glycemic control.


Introduction
In Pakistan, diabetes affects a considerable portion of the population, with 26.7% of adults being affected by the condition in 2022, as reported by the International Diabetes Federation. This high prevalence creates a significant healthcare burden for the country. Achieving optimal glycemic control is necessary for good diabetes management and a consequent reduction in complications. Therefore, it becomes crucial to comprehend how diabetes self-care activities (DSCA) and glycemic control are related. DSCA covers a range of actions, including taking medications as prescribed, checking blood sugar levels, choosing healthy foods, getting regular exercise, managing stress, and obtaining the right medical assistance. However, Pakistan's distinct cultural, societal, and economic characteristics might affect how well these activities work and how they affect glycemic control [1][2][3][4]. The successful implementation of self-care actions may be hampered by elements including ingrained food habits, restricted access to healthcare services, and cultural views toward diabetes. Therefore, researching these obstacles and adjusting therapies as necessary might help the Pakistani population's management of diabetes and glycemic control [5][6][7].
The goal of this study was to determine the relationship between DSCA and glycemic control, revealing 1 1 1 crucial information on the factors influencing self-care behaviors and their implications for the management of diabetes. In the end, our research aims to empower people, enabling them to take charge of their health and perhaps lowering the risk of complications from diabetes. This research can aid in the creation of focused treatments and personalized strategies by finding effective self-care practices unique to the Pakistani setting, thereby improving the quality of life for people with type 2 diabetes mellitus (T2DM).

Study setting and duration
This cross-sectional study was conducted at Hayatabad Medical Complex Peshawar, Pakistan, from June 2019 and May 2020, and 280 adults with T2DM were selected. Adults with T2DM who were 18 years of age or older and had the diagnosis for at least six months were sought out for this study. The inclusion criteria gave people enough time to become used to their condition and take part in self-care for diabetes. To guarantee a more homogenous sample and reliable results, however, adults who were extremely ill, with a recent diabetes diagnosis of a minimum of six months, were excluded from the study along with individuals who had physical or mental disabilities, pregnancy, and recent diabetes diagnosis.

Ethical statement
The Ethics Review Committee of the Hayatabad Medical Complex Hospital in Peshawar, Pakistan, provided the research approval under endorsement number 27220 in May 2019.

Data collection
The researcher's interviewer-administered questionnaire for this study was based on the Summary of Diabetes Self-Care Activities (SDSCA) measure, which is often used to evaluate diabetes patients' behaviors about self-care [8]. The survey was divided into three sections. The first section collected sociodemographic data, the second section collected diabetes-related data (including the duration of the condition, a person's family history, the results of hemoglobin A1C (HbA1c) tests, etc.), and the third section contained the validated SDSCA scale. The SDSCA scale evaluated self-care practices such as food, exercise, blood glucose monitoring, medication adherence, and foot care. Participants answered questions on how frequently they had engaged in these activities during the previous seven days, taking into account, if necessary, the days before any sickness had developed. The seven-day cut-off was chosen to standardize data collection, capture recent behavior, and minimize recall biases while considering any impact of illness on participants' activities. Ten people with T2DM validated the survey that was provided before the trial to make sure it was acceptable, feasible, understandable, and suitable; these individuals weren't included in the actual study.

Data analysis
Sample characteristics were evaluated using descriptive statistics and SPSS (Statistical Package for Social Sciences) 20.0 version (IBM Corp., Armonk, NY). Pearson's chi-square test was used to examine the relationships between the degree of self-care practices, HbA1c, fasting blood sugar (FBS), body mass index (BMI), and socio-demographic characteristics. For all tests, a confidence interval of 95% and a probability of 0.05 were regarded as statistically significant. Table 1 provides an overview of key socioeconomic and demographic features common to individuals with T2DM. According to the gender distribution, 31.78% of people were male and 68.22% of people were female. The bulk of participants were between the ages of 42 and 53 (40.36%), followed by the 54 to 65 age range (32.50%). According to the participant's marital status, 83.21% of them were married, 6.79% were single, and 10.00% were in another category. The biggest percentage (42.50%) of people had at least an intermediate education, followed by graduates (33.21%), in terms of educational standing. In terms of occupation, housewives (45.36%) made up the biggest category, followed by retirees (24.64%). A monthly income of between 40,001 and 60,000 Pakistani rupees was earned by 53.21% of the families.   The link between DSCA and glycemic control in people with T2DM is summarized in Table 3. FBS and HbA1c levels, as well as odds ratios (OR) and 95% confidence intervals (CI) for the relationships, are some of the factors that are included. Participants who followed the general and particular diets had better glycemic control than those who did not practice good self-care in these areas. HbA1c and overall food consumption were significantly linked ((OR: 3.12), (95% CI: 1.02 -8.78), P value: 0.031)). Physical activity was also significantly linked with HbA1c ((OR: 2.19, 95%), (CI:1.18 -3.79), (P value: 0.003)); FBS was strongly correlated with both the overall diet and the specific diet ((OR: 3.46), (95% CI: 1.69 -7.97), (P value: 0.001)) and ((OR: 2.36), (95% CI: 1.46 -3.77), (P value: 0.001)), respectively). There was a significant correlation between adherence to medication and both HbA1c and FBS ((OR: 2.85), (95% CI: 1.22 -6.59), P value: 0.021)) and ((OR: 1.88), (95% CI: 1.05 -3.29), (P value: 0.021)), respectively). Glycemic control and other DSCA outcomes are not significantly associated.

Discussion
The research study conducted at Hayatabad Medical Complex in Peshawar, Pakistan, aimed to investigate the relationship between DSCA and glycemic control among patients with T2DM. The findings from this study provide valuable insights into the factors influencing self-care practices and their impact on diabetes management within the Pakistani population. The results of this study clearly show that while the majority of patients had low HbA1c values, more than half of the subjects had excellent FBS levels. Adults with T2DM have been shown to have poor glycemic control, according to the findings of other investigations [9][10][11].
In this study, 71.08% of the participants had a family history of diabetes. Another cross-sectional nationwide study of 4890 people in Sri Lanka revealed that patients with a family history of diabetes had a considerably greater prevalence of the disease (29.0%) than patients without a family history (7.2%) [12]. Additionally, the results of the current study showed that over half, i.e., 55.0% had a standard BMI. This result is in line with the results of another research, which showed that 47.8% of the subjects had a standard BMI [13].
Even though the majority of participants in the current research (88.57%) followed a general diet for three or more days in the previous seven (healthy eating plan), 57.14% did not follow a specific diet for three or more days in the previous seven. Because the Pakistani diet is high in calories from carbohydrates, the main message for dietary change should be on reducing rice intake while increasing quantities of vegetables and green leaves [14]. However, another study found that 54.2% of participants had ineffective eating habits linked to type 2 diabetes and that the majority of people (69.2%) used some food constraint [15].
The present research also showed that 55.71% of participants adhered to an exercise schedule on three or more days during the course of the previous seven days. But according to different research, the majority of individuals (67.18%) did not engage in any type of physical activity [16]. In this study, over 50% of individuals were not involved in self-monitoring of blood glucose (SMBG) for a single day. Another research found that only seven (4.26%) of the 164 persons with T2DM had engaged in SMBG at least monthly [17].
In the previous seven days, over half (56.78%) did not take care of their feet on even a single day. Only 43.22% of people in the preceding week adhered to foot treatment for three or above days. Similar to the current study, a different investigation revealed that a significant majority of patients (71.2%) did not take good care of their feet [15]. The current research displayed that most participants (81.42%) regularly took their medications; a different study's findings revealed that among the participants, 69.37% displayed poor medication practices [15], while the study conducted by Omani found that adherence to medication was 78%, with three or more days in the previous seven days [18].

Study limitations
Although the study offers insightful information, it is vital to recognize its limits. First, because the sample was restricted to patients at the Hayatabad Medical Complex in Peshawar, Pakistan, it may be difficult to extrapolate the results to a larger population. The study's external validity would be improved by including individuals from various medical facilities. Second, using only self-reported data exposes you to memory and social desirability biases, among other possible biases. Data may be more accurate if objective metrics are used such as wearable technology or medical records. Future studies that address these issues will improve our knowledge of the connection between DSCA and glycemic management in T2DM patients.

Conclusions
The results showed that most patients adhered to the recommended diet; however, more than half failed to follow a particular diabetes diet. Many folks didn't stick to their fitness routine for even one day. Over 50% of the individuals were not involved in SMBG for a single day. In the last seven days, over half of the patients didn't even attempt to take care of their feet once. The majority of participants said they routinely took the prescribed prescription. While the majority of subjects had low HbA1c values, nearly half of them had excellent fasting blood glucose levels. Diet, both general and particular, was significantly linked to FBS. HbA1C and physical activity were highly correlated. Compared to male participants, female individuals showed greater adherence to foot care procedures. Age and physical activity were significantly correlated. Thus, all of these findings suggest that persons who had good HbA1c and FBS management reported greater DSCA adherence.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Hayatabad Medical Complex Hospital in Peshawar, Pakistan issued approval 27220. The Ethics Review Committee of the Hayatabad Medical Complex Hospital in Peshawar, Pakistan, provided the research approval under endorsement number 27220 in May 2019. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.