Knowledge and Practices of Patients Regarding Diabetes Self-Management: A Mixed Method Approach

this study at a tertiary care hospital in KP Pakistan from April to September 2021. Information on patients' demographic characteristics, diabetes knowledge, and diabetes self-practices, patients' lived experiences of diabetes self-practices, and barriers to self-care activities were collected. Data were collected through a structured questionnaire and in-depth (IDIs) interviews for measuring diabetes knowledge, and its management. Results: Out of 215 recruited participants, the majority 90% had inadequate knowledge (score=0-4). 3.2% (n=07) had average knowledge (score=5-8) of diabetes, and its self-management. 60% of the participants were from the age group 50-59 years. 70% (n=151) of participants were from poor socioeconomic classes. The results showed an association between illiteracy, poverty, diabetes knowledge, and self-management (p-Value 0.001). The qualitative results expressed that the illiterate and low socioeconomic participants had inadequate diabetes self-management practices. Conclusions: The study inferred that the participants, who had inadequate knowledge about type-II diabetes and its management, were having poor self-care practices of diabetes.


Original Article
DM is a major source of deaths globally [1].It accounts for the ninth major cause of worldwide death by disease and has shaken middle-income and low-income countries including Pakistan [2,3].It is an emerging health issue confronted by developing countries within the last few decades [4].According to World Health Organization (WHO 2016) report, the prevalence of DM is increasing globally [5].International Diabetes Federation (IDF) reported the global burden of diabetes as 463 million with an estimated gure of 700 million by the year 2045 [6].According to IDF,6.6 million people are living with Diabetes in Pakistan with an expected gure of 14.5 million by the year 2025 [7].Moreover, a study"Diabetes Prevalence Survey of Pakistan" conducted (2019) reports the prevalence of Diabetes type-II as 16.98%.This gure shows an alarming increase in the prevalence of diabetes Mellitus in Pakistan [8].The aim of diabetes self-management was to manage the symptoms, endorse wellbeing, avoid acute complications of hypo, and hyperglycaemia, and stop the onset, and development of long-lasting problems.DM is a chronic condition that Knowledge and Practices Regarding Diabetes Self-Management

I N T R O D U C T I O N
Diabetes Mellitus is a major source of death globally and has shaken middle-income and lowincome countries including Pakistan.Objective: To determine diabetes knowledge, and explore the patient's experiences of type-ii diabetes along with its self-management.Methods: A mixed-method design was used to carry out this study at a tertiary care hospital in KP Pakistan from April to September 2021.Information on patients' demographic characteristics, diabetes knowledge, and diabetes self-practices, patients' lived experiences of diabetes self-practices, and barriers to self-care activities were collected.Data were collected through a structured questionnaire and in-depth (IDIs) interviews for measuring diabetes knowledge, and its management.Results: Out of 215 recruited participants, the majority 90% had inadequate knowledge (score=0-4).3.2% (n=07) had average knowledge (score=5-8) of diabetes, and its self-management.60% of the participants were from the age group 50-59 years.70% (n=151) of participants were from poor socioeconomic classes.The results showed an association between illiteracy, poverty, diabetes knowledge, and self-management (p-Value 0.001).The qualitative results expressed that the illiterate and low socioeconomic participants had inadequate diabetes self-management practices.Conclusions: The study inferred that the participants, who had inadequate knowledge about type-II diabetes and its management, were having poor self-care practices of diabetes.

A R T I C L E I N F O A B S T R A C T
requires continuous decisions about diet intake, blood glucose monitoring, physical activities, and medication compliance [9,10].For attaining optimal blood sugar control in some persons with diabetes, proper diet, regular exercise, and maintenance of ideal body weight are required [11].Moreover, failure to compliance could have a profound impact on the quality of life of the individual [12,13].Chronic complications include macro-vascular disease and micro-vascular diseases [14].The current study is therefore aimed to determine diabetes knowledge and self-care practices.Moreover, the study ndings may contribute to long-lasting prevention, performance, and control over diabetes mellitus.This study emphasizes the need to expedite lifestyle interventions, and encourages diabetic patients to better accomplish control over their diabetes.

M E T H O D S
knowledge) of diabetes, and its management was conducted.Consents were taken again from the participants for in-depth interviews.The questions were explained to the participants before data collection.Indepth face-to-face interviews were conducted with participants to explore their experiences with diabetes and its management.The topic guide was followed during the interview to simplify the data collection.The interviews were audio recorded and saved keeping the con dentiality of the participants in view.The data were also recorded on paper using handwritten notes, to avoid data loss.The thematic analysis was done to explain the quantitative ndings [16].All the statistical analysis was carried out using SPSS V.22.0.Descriptive Analysis was used to nd the frequencies (f) and percentages (%) of gender, age, marital status, and socioeconomic status.Inferential statistics were used to nd association between literacy, socioeconomic status and diabetes knowledge.The thematic analysis approach was used and for data analysis Braun and Clark's six steps were followed [17].In stage one, the data were explored for thematic analysis, and to get familiar with the data the audio record had been listened several times.In the second stage, codes were generated based on semantic and conceptual reading.In the third stage, themes were extracted from the codes.In the fourth stage, the entire themes were checked for representation with the data.In the fth stage, naming the extracted themes was done, and nally, in the last stage, all the themes were written.
After approval from ERB and AS&RB Institute of Nursing Sciences, Khyber Medical University, and Ethical Committee Department of Endocrinology Hayatabad Medical Complex Peshawar Pakistan, a mixed method study was conducted on diabetes type-ii knowledge, and its practices from April to September, 2021 in a tertiary care hospital.The study setting was Outpatient Department, Hayatabad Medical Complex Peshawar, Pakistan.It is a 500-bed tertiary care government hospital.The setting was selected based on feasibility, availability of samples and expectation of collaboration from medical and nursing professionals for collection of data.Recruited participants were adult men or women with known diabetes type-ii for two or more than two years, and aged 40-70 years.Participants with other comorbidities and unwillingness were excluded from the study.Sample size was calculated as 215 through Rao-soft calculator.A consecutive sampling technique was used for data collection [15].Ten in-depth (IDIs) interviews were taken for the qualitative part of the study.All the participants who ful lled inclusion and exclusion criteria were initially recruited in the qualitative phase of the study.The data were collected through an adopted diabetes questionnaire during May 2021 to June 2021.Informed written and verbal consent was taken before data collection.The questionnaire consists of two parts; demographic variables 14 questions and diabetes knowledge and practice 12 questions.The total score was 12.A score of one (1) mark was given to every correct answer, and a score of zero (0) was given to every incorrect answer.Level of knowledge and practice was assessed as a score of (0-4) was given for poor knowledge, a score of (5-8) was given for average knowledge, and a score of (9-12) was given for good knowledge.In the qualitative phase of the study, 10 in-depth interviews with participants (05 having had average to good knowledge and 05 having had poor

R E S U L T S
The participant's characteristics are described in Table 1.The statistics shows that out of the total 215 participants, 123 illiterate participants were having poor knowledge (0-4 score).Seven matriculate participants were having average knowledge (5-8 score) of the total 0-12 score, while the remaining 15 intermediate participants were having average knowledge and the rest of the 8 participants were having good knowledge of diabetes (9-12).The statistics on educational level shows that 89.8% were illiterate, 7.0% were intermediate and 3.3% were matriculated.The result shows that most of the participants were illiterate, and their diabetes knowledge was inadequate in comparison to the participants with higher educational levels.Exercise knowledge and practice, and Non-adherence to a healthy diet (See Figure 5).
A total of 80 varied codes were generated from the collected data.Axial coding was done and needless codes were removed.Only 12 codes were identi ed, after removing the needless codes.Four themes were created after arranging and categorizing the codes.These themeswere insu cient knowledge about diabetes, Knowledge, and practice of monitoring blood glucose, The association of educational level with Thedacare score is shown in (Figure 1).The participants demonstrated insu cient knowledge about diabetes (Table 2).Insu cient knowledge about diabetes

Unpredictable to come "Diabetes is an untreatable and dirty disease. It does not look into the age of humans and does not let you know when it comes in life." (Participant 2)
Ban of all blessings of the world.
"DM is a condition in which when I eat something sweet, it excretes in my urine.It is the ban on all blessings In our bodies, there is the pancreas which divides the sugar but when it becomes diseased ……..in urine.The power of the body excreted in the urine."(Participant 9).The participants demonstrated inadequate knowledge about self-monitoring of blood sugar levels.Furthermore, they stated as their urine output increased think their blood glucose level is increased (Table 3).Table 6 shows qualitative and quantitative results of two domains of diabetes.Domain 1: Diabetes knowledge.Domain 2: Practice of diabetes self-management (monitoring blood glucose level, exercise, and non-adherence to a healthy diet).
The participants expressed insu cient understanding of exercise knowledge and its practices (Table 4).The majorities of the participants were reluctant to diet plan and expressed, compliance with the diet plan is tough to accomplish (Table 5).The illiterate and poor participants were having inadequate diabetes knowledge(0-4 score) while the participants from good socio-economics and literate classes had average to good knowledge (5-8 score) On expression, the participants revealed no or little knowledge about diabetes mellitus while the educated and participants from the middle class expressed adequate knowledge about diabetes Domain 1: Diabetes Knowledge "I check my sugar level from the laboratory when my diabetes hurt me.Self-monitoring of blood sugar is useful, but "I don't have glucometer… checking… …sugar".(p03) "Exercises have huge bene ts in controlling my blood sugar, but I cannot walk due to my amputated leg….(p03)""Diet is a blessing, I cannot avoid it, and having no concern with diabetes, it is just by God….."(p6) The participants belonged to low socio-economic families and were illiterate having had inadequate practices of diabetes self-management and vice versa T h e i l l i te ra te p a r t i c i p a n t s d e m o n s t ra te d inadequate practices of diabetes self-management while the literate and good socioeconomic par ticipants verbalized and demonstrated adequate practices of DSM.This mixed method approach was the rst study on diabetes knowledge and its management in Khyber Pakhtunkhwa Pakistan.In this study most of the participants were found illiterate and were having inadequate knowledge of diabetes-II and its self-practices.There is a direct relationship between diabetes knowledge, D I S C U S S I O N its practices, and education level.Most of the participants were from poor socioeconomic class and their diabetes knowledge and self-management was poor.Moreover, there was also an association between poverty, and d i a b e t e s m a n a g e m e n t .T h u s e d u c a t i o n a n d socioeconomics levels profoundly impact on diabetes and its self-management.A study reported (2018) stated that Figure 2: Educational Level of the Participants

Domain 2 :
Practice of Diabetes self-management (monitoring Blood glucose level, Exercise, and non-adherence to a healthy diet)

Table 2 :
Theme 1-Insu cient knowledge about diabetes and its management

Table 3 :
Theme 2-Self-Monitoring of Blood Glucose Level

Table 4 :
Theme 3-Knowledge and Practice about Exercise Exercise, my blood pressure gets high, with exercises the blood get soft which….affectsmysugar level.On the other hand, when I don't go exercise my blood becomes clotted which could be the reason for a heart attack.(participant02,  age=55)

Table 5 :
Theme 4-Non-adherence to a healthy diet Increased urine output "I use glucometer for checking my blood sugar level but I cannot run it, and not knowing the values of normal sugar range.Selfmonitoring is useful for controlling diabetes.I check up my sugar level when my urine output increased".(Participant 10) All diabetic patients should know when his/her sugar level is high, and when it is low.Self-monitoring of blood sugar is necessary, and I used to check my blood sugar level with a glucometer.When my sugar is normal I am happy and satis ed otherwise sad.I am always curious about checking my blood sugar level".(Participant 03, Age=) Exercises have huge bene ts …..Blood sugar, but I can't…to my amputated leg.I pray for all….sufferingfrom diabetes.They should care for themselves because if I knew that my leg will be removed, I will have kept my legs in a cotton swab.Every diabetic patient should exercise on daily basis".(participant 03, age=60) Burn out glucose "Exercise is useful in controlling my blood sugar.It burns out glucose and decreases blood sugar level.It also increases my blood pressure.I walk out daily for 10 minutes".(participant09, age=50) eating and eating everything available, I have never planned for diet control, but I eat food at divided times.I like fruits whatever may be.I eat rice and bread.I get hurt when someone does not allow me to eat according to my wish".(participant02, age=63) Avoiding anything in the diet is the toughest job for me.But compliance with something is more di cult.DM is the worst disease in which the subjects wish to eat those entire things which raises your blood sugar level" (participant 05, age=57) ""Diet is a blessing, I cannot avoid it, and having no concern with diabetes, it is just byGod".(participant 06, age=50)

Table 6 :
Integrated Results Matrix