South Asia contributes to 25% of the world's population, where non communicable diseases (NCDs) are becoming more prevalent due to an Epidemiological transition and India is facing with most to the burden of NCDs (1). Diabetes is a lifelong disease and if neglected may lead to a variety of consequences including micro vascular (retinopathy, neuropathy, and nephropathy) and macrovascular (peripheral artery disease, stroke, and coronary artery disease) problems. International Diabetes Federation (IDF) reports Diabetes as a global health challenge, with an estimated 537 million adults affected worldwide in 2021. India suffers significantly to this burden, with over 77 million cases and is often referred as the diabetes capital of the world (2), Furthermore, the burden of undiagnosed diabetes remains a concern (3), with nearly 50% of cases going undetected globally (4). Epidemiological shift coupled with urbanization, industrialization and unfavourable lifestyle changes like sedentary lifestyle, high saturated fat intake, increase in consumption of alcohol and stress can be attributed to increased prevalence in India (5). Diabetes, as a chronic condition, can significantly impact patients' quality of life. Achieving optimal glycemic control is essential for enhancing this quality of life, but it cannot be accomplished through pharmacotherapy alone. Patients must engage in a comprehensive management approach that includes adherence to a balanced diet, regular physical activity, frequent monitoring of blood glucose levels, and the development of effective problem-solving and coping strategies (6). Additionally, minimizing the risk of complications is crucial for overall health management. Hence knowledge of diabetes is critical for effective disease management. Studies have consistently demonstrated that inadequate knowledge is a barrier to achieving glycemic control.

WHO defines self-care as the ability of individuals, families and communities to promote their own health, prevent disease, maintain health, and to cope with illness with or without the support of a health or care worker. (7) Diabetes self-care is fraught with difficulties and obstacles as patients frequently do not change their behavior even after receiving a reasonable amount of information regarding the risk factors for diabetes, treatment options, target blood values, self-care techniques, the significance of medication compliance, frequent blood sugar checks, etc.(8) According to the American Diabetes Association (ADA), key components for managing diabetes include monitoring carbohydrate and fiber intake, pursuing weight loss, and reducing consumption of cholesterol, saturated fats, trans fats, and salt. Additionally, patients benefit from incorporating practices that address both individual and social factors to enhance their diabetes management. (7)

Despite the self-care practices having paramount importance and raising prevalence of diabetes, very few studies have been conducted in Andhra Pradesh and no research has been done in urban population of Ongole city. Hence this research was initiated with an aim of assessing the Knowledge on diabetes and self-care practices and its determinants among diabetic population who are residing in the urban field practice area of tertiary hospital. This study determines the prevalence of adherence to recommended self-care behaviors (diet, physical activity, medication, and blood glucose monitoring) among adult patients with type 2 diabetes and also to identify the factors associated with the knowledge-practice gap in self-care behaviors. So that it will serve as a benchmark for future comparisons to assess the effectiveness of any educational training program for diabetic patients.

A community based Cross Sectional Survey was conducted among adult diabetic population with 18 and above years of age in Balaji Nagar, an Urban field practice area of a government medical College, Ongole   from October to November 2024. It is Ayushman Arogya Kendra, the designated Urban Health and Training center for the Tertiary care Hospital with population of 23817 and the services are provided through 7 Secretariats. Those who are residents of this area only were included in the study and individuals with conditions other than diabetes that could affect self-care practices as severe cognitive impairment and Gestational diabetes were excluded from the study.

As per the previous study ^(6), the prevalence of self-care practices (p=32.6), a sample size at 95% confidence interval was calculated according to formula n= 4pq/l² (where n is sample size) l= relative error (taken as 20%) q= 1-p = 67.4%, n= 4(32.6) (67.4)/42.51= 206; the final sample size was rounded off to 210.  There are 7 secretariats under Balaji Nagar UHC which includes areas of Ram Nagar, Santhapeta, Maratipalem, Balaji Nagar, Sarada Bala kuteer and Ranguthota. From each secretariat, a sample of 30 Diabetic patients residing in the area were identified by simple random sampling method with the help of records maintained by the Auxillary Nurse Midwife (ANM) of the respective areas. Study tool included semi-structured questionnaire with three components, socio demographic information in the First section, second section includes the Diabetes Knowledge Questionnaire (DKQ) to gather information about knowledge on diabetes and third section includes questions about self-care behaviors that were taken from a related survey done in Chittoor, Andhra Pradesh^{. (6),}

Personal face to face interview was conducted by the investigator in local language and the responses were recorded in google forms. Data of knowledge regarding diabetes and self-care practices were meticulously evaluated and scored as per the structured questionnaire which was modified to fit with the patient’s local language and practices. Participant confidentiality was maintained by adopting anonymous data collecting procedures and securely stored and it was analysed using descriptive statistics, test of significance for associated factors, and chi square test to determine the association between various Sociod demographic determinants and self-care practices and knowledge. The aid of special statistical software such as SPSS was used for data analysis.

Diabetes Knowledge Questionnaire (DKQ) ⁽⁹⁾ -The DKQ is a 24-item questionnaire designed by the Starr County Diabetes Education Study that asks patients about their knowledge of blood glucose levels, food, physical activity, issues related to their diabetes, and how the disease started. On DKQ, there are three possible responses: "yes," "no," and "don't know." For each right answer, a score of one was awarded, whereas for wrong or ―don’t know responses were awarded zero. The responses of the participants were recorded digitally with the help of google forms and the points that each participant receives were added together to determine their final score. A higher score denotes a greater understanding of the condition. Patients with scores of 12 and above indicate that they have good levels of knowledge regarding diabetes.

Self-care practices - The participants' self-care practices were examined in relation to the seven domains identified by the American Association of Diabetes Educators (AADE) as the "AADE 7 measures of outcome measurement." These domains include diet modification, physical activity, glucose monitoring, drug adherence, problem-solving, risk reduction (including foot care, smoking, alcoholism, and screening for complications), and healthy coping (or psychosocial adjustment). After taking into account several scales, including the "Diabetes self-management questionnaire (DSMQ)," the "Summary of diabetes self-care activities measure (SDSCA)," and the patient health questionnaire-2, this was modified by chandrashekar.ch et al in a study conducted in Chittoor district AP ⁽⁶⁾ and formulated the questions pertaining to the practice of self-care activities and adjusted the questionnaire's items to reflect local customs.

Self-care practice questions were scored, a minimum of 0.25 was assigned for inadequate practice, while a maximum of 1.00 was assigned for excellent practice (Table 1). Five is the lowest possible total score, while 20 is the highest. The overall self-care score was divided into three categories: poor self-care (scores between 5.00 and 10.00), moderate self-care (scores between 10.25 and 15.00), and good self-care (scores between 15.25 and 20.00).

Table -1 Components of self-care practices

Ethical statement: Ethical approval for the study was obtained from the Institute Ethics Committee of the Government Medical College, Ongole (Ref No. IEC GMC-OGL/234/2024)

Out of total 210 participants females (54.3%) slightly outnumbered males (45.7%) with mean age of 54.8 years (SD: 11.191) and majority were aged between 50 and 59 years (30.9 %). Hindus constituted the largest group (72.4%), followed by Christians (22.4%) and Muslims (5.2%). A quarter of participants were illiterate (25.2%), and only 13.8% had graduate-level education or higher. Socioeconomic status (SES) as per modified B.G. PRASAD classification showed that 43.3% belonged to the upper middle class, while only 1.4% were in the lower class. (Table-2)

Table-2: Sociodemographic Characteristics of Study Population

The majority (64.3%) were on a single-drug oral hypoglycemic agent (OHA), with a smaller proportion on combination therapy or insulin. While 54.8% of participants had undergone HbA1C testing, a significant proportion (28.1%) were unaware of this essential diabetes monitoring tool.  This gap highlights the need for increased awareness and accessibility of diagnostic facilities (Table-3).

Table 3: Type of Treatment Received& Ever Tested for HbA1c among Study Population (N=210)

Knowledge on diabetes is measured using Diabetes knowledge questionnaire (DKQ) with 24 questions. A score of 12 and above is said to be having good knowledge. The mean knowledge score was 12.41 (SD: 4.89), with 60.5% of participants demonstrating good knowledge of diabetes.(fig-1)

Table 4:  Self Care Practices (Diet Modification and Physical Activity) for Diabetes among Study Population (N=210)

55.1% of participants checked blood glucose levels as per doctor's advice. Only 19% checked blood glucose levels during illness episodes. 62.9% of participants reported taking medications regularly.  Only 33.1% carried sugar packets to tackle hypoglycemia. 62.3% did nothing when blood glucose levels exceeded 200 mg/dl.67.8% checked their feet regularly for cracks, and 54.6% washed their feet regularly. Only 23.7% of current smokers had stopped smoking after diabetes diagnosis, 78.8% reported no lack of interest in doing things due to the disease or treatment. Mean score of self-care practices was 14.8 with a SD of 2.14. (Table-5)

Table 5:  Self Care Practices (Glucose Monitoring. Drug Adherence, Problem Solving, Risk Reduction, and Healthy Coping) for Diabetes among Study Population (N=210)

The overall self-care score was divided into three categories: poor self-care (scores between 5.00 and 10.00), moderate self-care (scores between 10.25 and 15.00), and good self-care (scores between 15.25 and 20.00) 52% of study population is found to be adhering to self-care while only minimal (1%) showed poor practices (Fig-2)

Females showed a significantly higher proportion of good self-care practices compared to males (p=0.043).Hindus had a significantly higher proportion of good self-care practices compared to Muslims and Christians (p=0.002). Illiterate individuals had a significantly lower proportion of good self-care practices compared to those with higher education levels (p=0.001). Individuals from lower socioeconomic strata (Lower and Lower Middle) had significantly lower proportions of good self-care practices compared to those from higher strata (Upper Middle and Upper) (p<0.001). However, age did not show a significant association with self-care practices (p=0.215). (Table-6)

Table 6: Association of Diabetes Self Care Practices with Sociodemographic Factors (N=210)

       *: P value of <o.o5 is considered as significant association

Out of 210 participants in this study  majority were above 50 years and females were slightly outnumbered (54%), similar finding were  found in the studies done by sarada et al in Visakhapatnam(5), Anu Mohandas et al in east delhi(10) and chandrasehkhar et al in Chittoor(4) Jaysurya et al in Hyderabad (11). The present study illustrates that illiterates were 25.2%, which is similar to the study conducted by karthi et al (22%)(12) but higher in the study conducted by Anu Mohandas et al(10) , 13% of the study population belong to lower soci economic status   in the present study  which is  similar to the study conducted by Karthik et al(12)  and higher in studies conducted by sarada et al (5) Anu Mohandas et al (10) More than two third   population are using oral Hypo Glycemic agents with single drug therapy and it is similar to the study conducted by  Montazeri et al in Iran (13). Patients only on insulin (7%) and it is 11% in a study conducted by Anu Mohandas et al (10). Hb A1C status is known for about half of the study population. It is similar to the study conducted by Almutairi JS et al in Saudi (14) and by Nikhitha et al in Kuppam (15) .The mean knowledge score of 12.4 indicates moderate awareness of diabetes among participants, with 60.5% demonstrating good knowledge. Whereas it was 51.2% in a study conducted Alemayehu AM Et al in Ethiopia (16). 71.5 % in study conducted in Thailand (17). But only 30% in a study conducted in Lucknow, India (18) and 18% in Tamilnadu (19), 26% in Odisha (20).

Notably, the present study highlights female gender, Higher education status, upper socio economic status as a significant determinant exhibiting better knowledge scores (p<0.001), demonstrated significantly better diabetes knowledge compared to males (p< 0.05). Association of better knowledge in Diabetes in female gender was found to be contradicting the similar in the studies conducted by Alemayehu AM Et al (16). Higher education and  higher income as a determinants of better knowledge appear to be  similar in the studies done by Phoosuwan, Net al(17), Praveen Kumar Sharma et al Lucknow, India(18), MacDonald et al in Tamilnadu (19), Pradhan et al in Odisha(20). Age and Religion did not show significant associations with diabetes knowledge (p>0.05). However higher age associated with better knowledge was found in as study conducted in Ethiopia by Alemayehu AM Et al (16).  A study in Saurashtra region, Gujarat has found out that majority of the patients do not even know what the diabetes (63%) is and its complications (60%) (21). a cross-sectional study in Vietnam has shown that those with higher educational status had a higher mean total score (p = 0.0001).(22)

Self-care practices were categorized into poor, moderate, and good, with 52.4% achieving good self-care, and  the study conducted by Chandra Sekhar Chittooru et al(6) showed one-third of the participants are following a good self-care practice and only 5.6% in a study conducted by Karthick RC et al (12). 58% restricted salt intake, limited fruit and green leafy vegetable consumption, and high consumption of fried foods and sweets persisted among some of our study participants. These findings align with, Krishna et al. (2020) (23), who identified dietary non-compliance as a significant barrier to effective diabetes management in resource-limited settings. Research in the United States by Hill-Briggs et al (24), showed that patients with higher nutritional knowledge were more likely to follow recommended dietary guidelines. Only 45% engaging in exercise ≥4 days/week and 30% meeting the recommended duration of ≥30 minutes/day. Similarly was seen in a study in Vijayawada, Andhra Pradesh (Chandrika et al) (25), revealed that only 30% of diabetic patients engaged in regular physical activity. Adherence to medication was relatively high (62.9%) in our study, similar findings (56.3%) were found in same study (25) and lower (70%) than study conducted by Narayana et al. (26).  Female participants demonstrated significantly better knowledge and self- care practices compared to males. This aligns with Chandra Sekhar Chittooru et al (6).  In a study conducted in Ethiopia, Gebre et al (27) reported that 60% of participants adhered to their medication schedules. Only 19% checked blood glucose levels during illness episodes in our study In Andhra Pradesh, a study by Ramesh et al. (2021) (28) reported that only 20% of patients owned a glucometer, and less than 10% used it regular basis.  Illiterate participants and those from lower socioeconomic strata exhibited poorer self- care practices, similar with the study conducted by W Syed et al in Telangana (29), and  Sarada V et al (5).This present study confirms that Participants with good knowledge were significantly more likely to engage in effective self-care practices (p<0.001). Whereas No significant relationship was found between knowledge of diabetes and diabetes self-care practices in study conducted in Nigeria by Famakinwa et al (30)

A significant proportion (28.1%) were unaware of this essential diabetes monitoring tool HbA1C testing. This gap highlights the need for increased awareness and accessibility of diagnostic facilities.  Good adherence was observed with 62.9% of participants reported taking medications regularly. Only 45% engaging in exercise ≥4 days/ week and 30% meeting the recommended duration of ≥30 minutes/day. Female gender, Higher education status, upper socio economic status as a significant determinant exhibiting better knowledge scores (p<0.001), and exhibited good self-care practices with significance level of <0.05. Female participants demonstrated significantly better knowledge and self- care practices compared to males. Focused education programs and monitoring during follow-up visits will improve self-care among Diabetic patients.

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