ABSTRACT
Objective
To prevent complications of diabetes mellitus (DM) and to maintain health in the best way possible, the knowledge level of patients regarding diabetes should be increased, and every step of treatment and self-care management should be adopted by the patient. This study aimed to determine the relationship between self-care management and treatment compliance in patients with DM who applied to the University of Health Sciences Turkey, Adana City Training and Research Hospital Endocrinology and Metabolism Polyclinic.
Material and Methods
In this cross-sectional study, 320 patients aged between 18 and 85 years who applied to University of Health Sciences Turkey, Adana City Training and Research Hospital Endocrinology and Metabolism Polyclinic between 02.01.2023 and 02.04.2023, and who were diagnosed with diabetes for at least 1 month were included in the study. The socio-demographic data form consisting of 23 questions, the chronic disease self-care management scale (SCMP-G) consisting of 35 questions, and the Morisky medication adherence scale consisting of 8 questions were applied to the patients. The data were analyzed using the SPSS 24.0 package.
Results
61.9% of the patients with DM who participated in the study were female, and the mean age was 55.08 ± 12.39 years. The mean body mass index of the participants was 30.31 ± 6.42 and the hemoglobin A1c (HbA1c) values were found to be 8.65 ± 2.68. A chronic disease accompanying diabetes was found in 71% of the participants, and the most common chronic disease was hypertension. In the treatment of diabetes, 37.5% of the participants used only oral antidiabetic (OAD), 27.8% OAD + insulin, 14.4% only insulin. It was found that 61.6% of the participants went to check-ups regularly, 15.9% performed physical activity, and 63.8% made changes in their eating habits. A weak negative correlation was found between the self protection subdimension and the number of drugs, duration of diabetes diagnosis, and HbA1c values. Participants who received diabetes education had high SCMP-G scores, which was a significant difference (p=0.008).
Conclusion
Disease self-care management will increase as self-protection and social protection for individuals with diabetes increase. Treatment compliance of individuals with high self-care management will also increase. Therefore, diabetes education should be given importance to individuals with diabetes.
INTRODUCTION
Diabetes mellitus (DM) is a chronic metabolic disorder that is often characterized by hyperglycemia, which is caused by a multisystemic attitude in which the body does not receive sufficient carbohydrates, fats, and proteins, and requires constant medical attention (1, 2). Diabetes, one of the most important health problems of the 21st century, is increasing worldwide and, in parallel, the number of patients and incidence of diabetes are rapidly increasing in our country. Diabetes can cause disorders in all systems unless diagnosed early and treated properly. Diabetes may be prevented or delayed by identifying high-risk individuals and undergoing lifestyle changes (3). The treatment of DM is a life-long complex process (4). In addition to medical treatment, self-care management is a key component of diabetes treatment (5). Diabetes self-care management should be effective for individuals with diabetes. Diabetes management consists of self-care activities such as glycemic control, appropriate treatment, smoking and alcohol use, patient adjustment to treatment, checking at regular intervals, foot care, physical activity, and nutrition (6). Patient self-care management has been shown to be beneficial, reduce mortality and diabetes complications, reduce healthcare costs, and improve quality of life (7).
The aim of this study was to determine the relationship between self-care management and treatment adjustment in patients with DM who applied to the University of Health Sciences Turkey, Adana City Training and Research Hospital, Endocrinology and Metabolism Polyclinic.
MATERIALS and METHODS
This cross-sectional study was conducted with individuals diagnosed with diabetes aged 18-85 years who applied to the University of Health Sciences Turkey, Adana City Training and Research Hospital, Polyclinic for Endocrinology and Metabolism between 02.01.2023 and 02.04.2023. The sample size was calculated at a minimum of 319. At least 400 diabetic patients have been investigated. Patients diagnosed with diabetes for at least a month were included in the study. Eighty newly diagnosed patients with diabetes were excluded. Informed consent was obtained from all participants.
The data were collected through 23 question-dependent variables, including independent variables such as age, gender, educational level, duration of diabetes, treatment method, other chronic diseases (if any, the number of medications used, hemoglobin A1c (HbA1c) value, dietary habits, physical activity, the chronic disease self-care management scale (SCMP-G), and the Morisky medication adherence scale-8. The data were collected using face-to-face survey forms for patients who agreed to participate in the study after being informed by the researcher. After Jones and Preuett (8) defined the concept of self-care management process (SCMP), SCMP conservation was developed with the validity of the concept being tested and the characteristics of the protection concept being explained and added (9). SCMP-G, comprising a total of 35 items, has two sub-dimensions, namely, self-protection and social protection. The rating of the scale has been developed from a Likert-like form of 5 (I totally agree) and 1 (I never agree). A minimum of 35 points and a maximum of 175 points are awarded on the scale. The low SCMP-G score indicates that self-care management is poor, whereas the high score indicates that self-care management is good. Turkish validity and credibility studies were conducted in 2018 by Hançerlioğlu and Şenuzun Aykar (5). The Morisky treatment adjustment scale developed a four-question survey in 1986 to assess Morisky et al. compliance with antihypertensive drug therapy. In 2009, Morisky finalized eight questions to improve the validity and reliability of the survey. The first seven questions in the survey are closed-ended questions with answers in the form of yes or no. Yes answers questions 1 to 6 and 7 and yes answers question 5 are awarded 1 point. The last question was a five-choice question and “never/rarely” is rated 1 and all other answers are rated 0 points. A total score of <6 indicates low treatment compliance, 6-7 points moderate compliance, and 8 points indicates high therapy compliance (10). The study was approved by the University of Health Sciences Turkey, Adana City Training and Research Hospital Ethics Board (decision number: 2338, date: 29.12.2022)
Statistical Analysis
The statistical analysis was performed using the SPSS 24.0 package. Categorical measurements were expressed as numbers and percentages, and numeric variables were given as the mean +/- standard deviation with minimum (min) and maximum (max) values. In determining whether the parameters included in the study had a normal distribution, the scale scores of the scales were considered. The independent Student’s t-test was used for binary group analysis of normal distribution parameters and the one-way ANOVA test for three or more groups. Spearman’s correlation analysis was used to evaluate the relationships among the numerical data. Linear regression analysis was performed to determine the relationship between scales and subdimensions. The difference was considered statistically significant at a p-value was <0.05.
RESULTS
Of the 320 patients diagnosed with diabetes included in the study, 61.9% (n=198) were women and 38.1% (n=122) were men. The mean age of the participants was 55.08 ± 12.39 years. (min: 19, max: 79) (Table 1). The mean body mass index (BMI) of the participants was 30.31 ± 6.42 kg/m2 (min: 17.9, max: 55.77). The average HbA1c was 8.65 ± 2.68 gr/dL (min: 4.6, max: 17.9). The response to the question “Do you have any physical or mental illness that requires medication?” was yes in 71% (n=227) and no in 29% (n=93). For chronic diseases, 49.1% (n=157) had hypertension, 33.8% (n=108) had hyperlipidemia, 20.3% had coronary artery disease, 7.8% had thyroid disorders, 7.5% had asthma/chronic obstructive pulmonary disease, and 19.1% had other diseases (anemia, anxiety, depression, arrhythmia, gastritis, chronic kidney failure, and chronic heart failure). The question “How many months/years ago did you get a diagnosis of diabetes?” was answered by 12.2% (n=39) from one month to one year, 21.6% (n=69) from 1 to 5 years, 23.4% (n=25) from 5-10 years, 15.9% (n=51) from 10 to 10 years, 14.4% (n=46) from 15 to 20 years, and 12.5% (n=40) from 20 years and above. When the treatment patterns of the participants were studied, no patient received dietary therapy combined with exercise, diet alone, or exercise. Treatment methods are presented in Table 2.
The distribution of scores of the SCMP-G and Morisky treatment adjustment scale are presented in Table 3.
When the Morisky treatment adaptation scale was used to evaluate participants’ treatment compliance, 47.5% (n=152) showed low therapy compliance (<6 points), 27.5% (n=88) showed moderate therapy adaptation (6 to 7 points), and 25% (n=80 points) showed high therapeutic compliance (8 points).
A comparison of the participants’ self-protection and social protection subdimension revealed that the overall scores of the SCMP-G and the Morisky treatment adjustment scale scores did not show a significant difference between age, sex, smoking status, and alcohol use (p>0.05).
The average self-protection and SCMP-G scores of those who were regularly checked, had regular physical activity, and who had changed their dietary habits were significantly higher (p≤0.001) compared to those who did not go to regular checkups, did not exercise regularly, and did not change their eating habits.
When a comparison was made according to the total scores of the Morisky treatment compliance scale, no significant difference was found between those who exercised and those who did not exercise, between those who dieted and those who did not diet, between those who used oral antidiabetics (OAD) and those who did not use them, and between those who used insulin and those who did not use it (p>0.05).
The average SCMP-G score of participants who received diabetes education was significantly higher than that of participants who did not receive diabetes education (p=0.008).
There was a weak negative correlation between self-protection and the number of medications, duration of diabetes diagnosis, and Hb A1c values. (r=0.127; r=-226; r=-150). We could not find a relationship between other variables (Table 4).
There was a positive and medium strong relationship between the SCMP-G and the self-protection subdimension (r=0.552; p<0.001). There was a strong positive link between SCMP-G and the social protection subdimension (r=0.733; p<0.001).
There is a positive weak relationship between the Morisky treatment adjustment scale and the self-protection and SCMP-G (r=0.162; p=0.004) (Table 5).
When the effect of the SCMP-G variable on the Morisky treatment adjustment scale was studied, it was found that SCMP-G had a positive effect (F=8.524, p=0.004). SCMP-G improves Morisky treatment alignment.
When the impact of the self-protection and social protection variables on the Morisky treatment adjustment scale was examined, it was found that self-protection was positive (F=7.494, p<0.001), that social protection was ineffective (p>0.05). Self-protection sub-size enhances Morisky’s therapeutic fit. The under-sized social protection did not affected Morisky’s treatment compatibility.
DISCUSSION
When the Turkey Diabetes, Hypertension, Obesity and Endocrinologic Diseases Prevalence Study-II (TURDEP II) study was examined, the prevalence of diabetes was higher in women than in men (11). In a study of patients diagnosed with diabetes in 28 countries, the mean age was 54.0 ± 12.0 years (12). In our study, 30.9% of patients were aged 56-64 when grouped by age. According to the International Diabetes Federation 2021 data, the peak of diabetes occurred between the ages of 55 and 59 (13). The gender and age in our study are parallel to those of previous studies, and the age averages appear to be consistent with the age ranges in which diabetes was increasing (14-17). The most common chronic disease associated with diabetes is hypertension, and the same conclusion was reached in the studies of TURDEP II (11), Khawaldeh et al. (18), and Naous et al. (19). And our work supports that. In a study conducted with patients with DM in Nigeria, similar to the present study, no statistically significant difference was found between the duration of diagnosis and treatment adherence. (20). Sayiner et al. (21) found that as the duration of diabetes increased, treatment compliance was poor and explained that long-term therapies caused fatigue in patients. In a retrospective cohort study of patients with diabetes in the United States, the response rate for the first 3 months of treatment was 45%, and the response to the 12th month of treatment was 35% (22). According to these data, chronic diseases are not adapted to treatment as time passes. The patient’s idea of taking medication throughout his life might distract him from receiving treatment. A previous study found a meaningful relationship between BMI and the subdimension of self-protection on the scale, and as BMI increased, self-protection decreased (23). Wallston et al. (24) found an inverse ratio between BMI and self-care management in patients with diabetes. HbA1c is an important indicator of diabetes self-management in individuals diagnosed with diabetes. The study by Mumcu and İnkaya (25) showed a positive improvement in HbA1c values as patients improved in self-care and quality of life. In a meta-analysis study by Wu et al. (26), mobile health practices were shown to strengthen self-management in individuals with diabetes and significantly reduce HbA1c values in individuals with increased self-management. In our study, patients’ HbA1c values decreased as their self-protection increased. The decrease in HbA1c was seen to contribute to strengthening self-management. A study by Khalooei and Benrazavy (27) found that those who participated in diabetes education were better at self-care and self-management than those who did not receive education. A randomized, controlled study in China showed improvement in the self-management, clinical, lifestyle, and psychosocial conditions of patients undergoing diabetes education programs (28). Our findings suggest that people with diabetes education have better disease self-care management.
A study by Alanyali and Arslan (29) found that individuals with physical activity have good self-management. The study, which examined the levels of self-sufficiency among individuals with diabetes, found that individuals who performed regular physical activity had higher levels of self-sufficiency (30). Regular nutrition, accompanied by adequate and regular physical activity, were one of the important determinants of self-management. A study that evaluated the dietary habits and diabetes management of 100 patients with diabetes between the ages of 18 and 64 found that individuals who changed their eating habits had better diabetes management (31). This is parallel to our findings.
In France, a study on therapeutic adjustments in patients with type 2 DM showed no significant difference in treatment adjustments between OAD and insulin (32). A study conducted by Kara and Kara (33) examined the treatment adjustment and quality of life of diabetic patients compared with OAD + insulin patients and found that OAD patients adjusted better to treatment. In a study of hypertensive patients, Melnikov (34) found that taking blood pressure measurements at home and self-monitoring increased disease control and treatment compliance in patients. The previous study, which evaluated epilepsy and self-management, found that individuals with good self-care management have high convictions regarding both drug compliance and treatment (35).
Study Limitation
The study was cross-sectional in nature and did not report cause and effect. The fact that the study was conducted in a single center was one of the limitations of the study.
CONCLUSION
In conclusion, the higher the level of self-protection and self-care management, the greater the therapeutic compliance, and individuals with higher levels of self-protection and social protection would manage the disease better. The longer the diagnosis duration, the fewer the patients’ protection. Patients with regular physical activity had higher levels of self-protection and self-care management.
Individuals who changed their dietary habits showed good self-protection and self-care management and high treatment adherence. Patients should be monitored during diabetes treatment and should be included in the treatment phase. Patients should be encouraged to acquire the necessary skills for self-care management of chronic diseases, and their compliance with and satisfaction with treatment should be evaluated.
ACKNOWLEDGEMENT
This article is derived from the thesis titled “Evaluation of the relationship between self-care management and treatment compliance in diabetes mellitus patients”.