PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

DISSERTATION PROPOSAL

A STUDY TO COMPARE THE KNOWLEDGE ON SELF CARE

ACTVITIES REGARDING PREVENTION OF DIABETES MELLITUS

AMONG RURAL AND URBAN ADULTS WITHIN 30-50 YEARS OF

AGE AT SELECTED AREAS OF BELLARY WITH A VIEW TO

PREPARE A HEALTH INFORMATION GUIDE SHEET.

SUBMITTED BY,EBY M PETERIST

YEAR, M.SC., NURSING

(COMMUNITY HEALTH NURSING)

INDIAN COLLEGE OF NURSING. BELLARY

Date : 09.12.2008Place : Bellary

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKASYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. NAME OF THE CANDIDATE

AND ADDRESS

EBY M PETER

I YEAR M.SC.NURSING

INDIAN COLLEGE OF NURSING,

BELLARY

2 NAME OF THE INSTITUTION

INDIAN COLLEGE OF NURSING,

BELLARY

3 COURSE OF STUDY AND

SUBJECT

1st YEAR MSC., NURSING COMMUNITY HEALTH NURSING

4 DATE OF ADMISSION TO

COURSE30.06.2008

5. TITLE OF THE STUDY:

2

A STUDY TO COMPARE THE KNOWLEDGE ON SELF CARE

ACTVITIES REGARDING PREVENTION OF DIABETES MELLITUS

AMONG RURAL AND URBAN ADULTS WITHIN 30-50 YEARS OF AGE

AT SELECTED AREAS OF BELLARY WITH A VIEW TO PREPARE A

HEALTH INFORMATION GUIDE SHEET.

6. BRIEF RESUME OF INTENDED WORK

INTRODUCTION:

"Wounds that don't heal, Nerves that don't feel,No food I can eat at ease What a disease I have - Diabetes"

- Dr. Rajan1

According to WHO, “Health is state of complete Physical, Mental and Social well being and not merely the absence of disease or infirmity”. 2

The World Health Organization has passed the alarm bell for guarding against Diabetes Mellitus in the Asian region, attribution a lot of factors like genetic make up, diet, sedentary lifestyle that increase the national risk of Asians contracting this silent killer. Care of diabetic patient is a team work. Patient is the most important component of that team. It is important that they learn about the disease, its nature, course of events, approach in treatment of diabetes, selection of diet, role of exercise, diabetic discipline, use of drugs for diabetes, self monitoring of blood and urine test for early recognition and prevention of disease.

The term “Diabetes mellitus is derived from a Greek word which means “to go through or a siphon” and the word “Mellitus” is derived from a Latin word “Me” (honey) describes the sweet odour of the urine. Diabetes Mellitus is a silent disease and is now recognized as one of the

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fastest growing threat to public health in almost all countries of the world. It is also called the disease of prosperities. 3

Diabetes Mellitus is a nutritional disorder characterized by a lack of the hormone insulin in the blood which leads to abnormalities in the assimilation of carbohydrate by the body. Every fifth person who suffers from diabetes in the world today is an Indian. Out of total number of persons suffering from diabetes in the world, which is around 150 million roughly, 35 million are Indians. In India, the ratio of the diagnosed with those undiagnosed is 1:3. 4

By 2030 Indian will have 79.4 million diabetic projects the WHO that’s more than twice the current number over 35 million cases. No wonder India is the “Diabetic Capital of the World”. 5

Patient education is the essential component of nursing practices and it is particularly in the consumer based health care setting. Increasingly, patients are requesting information that will promote them in becoming more knowledgeable consumer and active participant in their own health care. As it is one of the iceberg disease, partnering opportunities that will change the course of diabetes, for good increased awareness of need for improving self management. Timely knowledge, timely detection and timely prevention of this lifestyle are the vital driving force that inspired the medical personnel. 6.1 NEED FOR THE STUDY

“Prevention is better than cure and is less expensive”

Diabetes is the fourth leading cause of death in most developed countries and typically reduces life expectancy by 8-10 years. Globally there are currently about 150 million people diagnosed with diabetes but this is projected to double to 300 million by 2025. It has been hailed as the epidemic of the 21st century. Diabetes is highly dreaded as entry point to varied complications affecting almost every important body organ starting from kidney, eyes, liver to feet. 6

The purpose of the therapeutic programme in diabetes is not to cure

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the disease, but to keep the disease under self control. And moreover, the recent epidemiological data of India about diabetes has found that 33 million, 20% of the world diabetics are Indians. More than 1/5th total world diabetics are Indians. 12% Diabetics are in India's urban area. 14% are pre-diabetes. 30% of Diabetics in urban India are below the age of 40 years. 7

A study on level of knowledge and awareness of diabetic patients about their disease and its complications revealed that awareness of the study participation was low. This study concludes that the awareness about the disease in majority of diabetic patients was not adequate. Routine individual teaching and counseling represents an effective educational model. And also the knowledge, attitude and practice of selected aspects of self care management concludes that the patient who had been previously admitted in hospital only had shown significant improvement in the degree of knowledge of certain aspects. 8

There is no disease which provokes greater thought on diet than diabetes. Many unfortunate diabetics, dreading a strict regiment for the rest of their lives, try pills, herbs and infusions recommended by friends and relatives who claim to have tried them and become symptom-free without diet control. The euphoria continues till suddenly a complication of diabetes like paralytic stroke, coronary heart diseases, blindness or coma strikes.

Education allows people with diabetes to take control of their condition, integrating the daily routines of self-monitoring and discipline into their life-style rather than permitting this condition to overwhelm them and control their lives. It has been suggested also, that education trains people to take the necessary actions to improve their metabolic control which it is postulated, may help to maintain health and well being and reduce the risk for diabetic complications. The well educated person with diabetes may also decrease the costs related to the conditions, both the direct cost of medical care and the indirect costs related to lost income or productivity.

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All these data provoked the researcher to take this initiation of conducting the study to assess the knowledge on self care activities of adults within 30-50 years regarding nature, meaning, dietary practice, exercise, blood sugar level and investigation regarding prevention of diabetes and also compare knowledge over the urban and rural population with a view to provide an health information guide sheet. 6.2 REVIEW OF LITERATURE

Researcher had done extended review of literature related to diabetes and divided the review of literature under three categories as studies pertaining to:

1. Prevalence and Risk factors of diabetes 2. Knowledge on self care activities of prevention of diabetes

I. Prevalence and Risk factors of diabetes 1. Diabetes mellitus is a growing public health problem both in

developing and developed nations. The prevalence of diabetes globally is projected to rise from 2.8% in 2000 to 4.4% in 2030. A study was conducted to assess the prevalence of diabetes among 492 eligible respondents, a sub sample of 199 persons was recruited using a systematic sampling technique had their fasting blood glucose levels determined. Three subjects had fasting blood glucose of more than 7.0 mmol/L; one participant a previously known diabetic on medication had a good glycaemic control. The overall prevalence of diabetes was 2.0%. Five participants (2.5%) had impaired fasting glucose. Among the diabetics, one was overweight and one was obese, while among those with impaired fasting glucose two were overweight. Forty-three subjects (21.6%) were overweight and 15 (7.5%) were obese. The prevalence of diabetes mellitus in this semi-urban community is keeping with what had been reported earlier from across the country. 9

2. A study aimed to assess the glycaemic status and prevalence of comorbid conditions such as obesity, hypertension and dyslipidaemia in people with diabetes in a southern Indian

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community. A cross-sectional community survey of adults > 18 years of age was done in central Kerala among 3069 subjects. 276 were known to have diabetes. Of these, 169 who had type 2 diabetes underwent a detailed physical examination and anthropometric measurements, and determination of levels of fasting blood glucose, glycosylated haemoglobin, fasting lipid, serum creatinine and urine protein. In 60% of patients, the glycosylated haemoglobin level was above the recommended target of 7%. Obesity (31%), hypertension (51%), low-density lipoprotein cholesterol > 100 mg/dl (90%) and serum triglyceride levels > 150 mg/ dl (38%) were present in the study population. Only 29% of patients were on antihypertensive treatment and 5% on lipid-lowering agents. In this population, only 40% of people with diabetes had adequate glycaemic control. This indicates a lack of proper diabetic care in this community, which could lead to an increase in the burden of cardiovascular disease in the future. 10

3. A study was conducted to analyse and compare the clinical profile and glycaemic outcome in known diabetic cases in South Indian urban and per urban populations (n=524, M:F, 256:268) were analyzed. Mean age at diagnosis was 45.3 +/- 10.1 years, prevalence of hypertension was 57.4% (32% known), 48% were obese and a larger percentage (63.3%) had abdominal obesity Dyslipidaemia was present in nearly 50%. Abnormalities were more in urban areas than in PUV. Glycaemic target was met by 28.8% only; better results were seen in PUV. In PUV 46% were not taking any diabetic treatment. As expected, majority of patients in all areas were treated with oral drugs. This population-based data indicated that the clinical outcome in known diabetic cases was far from satisfactory even in the city, where specialized diabetes care was available. 11

4. A study on prevalence of diabetes mellitus and other abnormalities of glucose tolerance in young adults aged 20-40 years in North India among 3032 subjects from Kashmir Valley of India. The study included a questionnaire, anthropological measurements, blood

7

sampling, and a standard OGTT. Eight (0.3%) of surveyed subjects were previously diagnosed to have diabetes. Of 3024 subjects screened, prevalence of diabetes, impaired glucose tolerance (IGT), and impaired fasting glycemia, IFG was 2.5%, 2.0%, 11.9% and 26.7%, respectively. The difference in diabetes prevalence was significant by age, habitat, family history of diabetes and BMI. The ratio of known-to-unknown diabetes was 1:10. This is the first large scale study from North India on prevalence of type 2 diabetes in the younger age group of 20-40 years. Abnormal glucose tolerance including undiagnosed T2DM is common in young adults. 12

5. A study was to determine the incidence of diabetes and prediabetes in an urban south Indian population. Chennai Urban Population Study [CUPS], At follow-up, 501 [47.0%] subjects had moved out of these colonies and was lost to follow-up. Of the remaining 564 individuals, 513 [90.9%] provided blood samples for biochemical analysis. Regression analysis was done using incident diabetes as dependant variable to identify factors associated with development of diabetes or pre-diabetes. The incidence rate of diabetes was 20.2 per 1000 person years and that of pre-diabetes was 13.1 per 1000 person years among subjects with NGT. Of the 37 individuals who were pre-diabetic at baseline, 15 (40.5%) developed diabetes, 16 (43.2%) remained as pre-diabetic and 6 (16.2%) reverted to normal during the follow-up period. Regression analysis revealed obesity, abdominal obesity and hypertension to be significantly associated with incident diabetes. The Indian Diabetes Risk Score showed the strongest association with incident diabetes. The study shows that the incidence of diabetes is very high among urban south Indians. While obesity, abdominal obesity and hypertension were associated with incident diabetes, IDRS was the strongest predictor of incident of diabetes in this population. 13

II. Knowledge on self care activities of prevention of diabetes

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6. The object of the study was to find out which self-care activities patients with diabetes perform to prevent diabetic foot syndrome and to look for differences between patient groups. A secondary analysis of the data used in the study for the development of the 'Frankfurter Catalogue of Foot Self-Care - Prevention of Diabetic Foot Syndrome'. 269 patients with type 1 and type 2 diabetes were included. Patients who had participated in more than three education programmes performed significantly better self-care than patients who had no or only one training programme. Patients with a foot at risk for the development of diabetic foot ulcer perform more adequate self-care regarding professional assistance in foot care, but are not more active in the self-control of the feet, shoes and socks. There are self-care deficits regarding self-control of feet, shoes and socks. The findings supported that it might be helpful to identify patients with self-care deficits and therefore to improve patients daily foot self-care.14

7. As the incidence of chronic disease increases, empowerment of patients with chronic disease to adopt self-care responsibilities becomes paramount. The development of such skills can compensate for the lack of traditional health education provided for diabetes patients and plays a significant part in the prevention of acute and chronic complications. The aims of this report were to undertake a literature review on self-efficacy and counseling skills used as the theoretical framework in a health education training program for diabetes and to analyze cases when a counseling guide based upon a self-efficacy framework was used by health counselors to help patients improve their self-confidence and self-care ability. This report revealed it is important to promote the application of counseling skills in nursing interventions in the clinical practice field. 15

8. A study reviewed a comprehensive conceptual framework in the context of learning theory to explain patient compliance and to derive approaches for enhancing compliance. The conceptual

9

framework is the health belief model expanded to include the concept of perceived self-efficacy. This expanded model may both serve as an agenda for future research as well as a set of guidelines for the education of patients with diabetes. A variety of educational interventions is recommended for use in patient education provided they succeed in reinforcing relevant health beliefs, behavioral skills, and the sense of self-efficacy. The problem of long-term maintenance, of particular significance in chronic disease management, is addressed by the relapse prevention model derived from social learning theory and emphasizing self-efficacy and the learning of coping skills.16

9. The purpose of this study was to translate the Diabetes Management Self-Efficacy Scale into Chinese and test the validity and reliability of the instrument within a Taiwanese population. A two-stage design was used for this study. Stage I consisted of a multi-stepped process of forward and backward translation, using focus groups and consensus meetings to translate the 20-item. Stage II established the psychometric properties of the scale. The sample for Stage II comprised 230 patients with type 2 diabetes aged 30 years or more from a diabetes outpatient clinic in Taiwan. The study revealed the scale for brief and psychometrically sound measure for evaluation of self-efficacy towards prevention and management of diabetes in Chinese populations. 17

10. A study was conducted to elucidate the focusing on the transition towards autonomy in prevention and self-management among teenagers regarding diabetes. Data were collected using interviews, and a qualitative phenomenological approach was chosen for the analysis. Thirty-two teenagers were interviewed about their individual knowledge on prevention and self-management of diabetes. In striving for autonomy, teenagers needed distance from others, but still to retain the support of others. A stable foundation for prevention and self-management includes

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having the knowledge required to prevent diabetes and management.18

6.3. STATEMENT OF THE PROBLEM AND OBJECTIVES OF THE

STUDY

A STUDY TO COMPARE THE KNOWLEDGE ON SELF CARE ACTVITIES REGARDING PREVENTION OF DIABETES MELLITUS AMONG RURAL AND URBAN ADULTS WITHIN 30-50 YEARS OF AGE AT SELECTED AREAS OF BELLARY WITH A VIEW TO PREPARE A HEALTH INFORMATION GUIDE SHEET.OBJECTIVES

1. To assess the knowledge on self care activities regarding prevention of diabetes among rural adults.

2. To assess the knowledge on self care activities regarding prevention of diabetes among urban adults.

3. To compare the knowledge on self care activities regarding prevention of diabetes between rural and urban adults.

4. To find out the association between knowledge and socio demographic characters of adults in rural and urban adults

5. To prepare and distribute the health information guide sheet regarding knowledge on self care activities of rural and urban adults

6.4. RESEARCH HYPOTHESIS:

H1 : There will be a significant difference between knowledge regarding on self care activities regarding prevention of diabetes among rural and urban mothers.

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H2 : There will be a significant association between knowledge regarding on self care activities regarding prevention of diabetes and socio demographic characters of rural and urban mothers.6.5. OPERATIONAL DEFINITIONS:

i. Knowledge: In this study it refers to the awareness and correct responses of the adults regarding self care activities regarding prevention of diabetes.

ii. Self care activities: Awareness and practice of meaning, dietary practice, exercise, blood sugar level and investigation regarding prevention of diabetes.

iii. Adults: The persons who are all staying in the selecting rural and urban area within the age of 30-50 years

iv. Diabetes Mellitus: A disturbance in the oxidation and utilization of glucose which is secondary to a mattunction of the function of the beta cells of the pancreas, whose function is the production and release of insulin.

v. Health information guide sheet: The material which contains health information regarding preventive aspects diabetes mellitus.

6.6. ASSUMPTIONS:

i. The adults may have inadequate knowledge regarding prevention of diabetes mellitus.

ii. The knowledge on self care activities regarding prevention of diabetes will vary according to the demographic characters of urban and rural adults.

6.7 PILOT STUDY

A pilot study will be conducted to assess the feasibility of the original study by taking 10 adults, 5 in rural and another 5 in urban.

7. MATERIALS AND METHODS OF THE STUDY

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7.1. SOURCES OF DATA:

The adults who are living in the selected rural and urban areas in the age group 30-50 years are the source for conducting the study.

7: 1.1 RESEARCH DESIGN A non- experimental study of descriptive study design.

7: 1.2 RESEARCH APPROACH A comparative approach

7.1.3. STUDY SETTING Study originated at selected urban and rural areas of 7.1.4. POPULATION:

All the adults within the age of 30-50 years from the selected areas of rural and urban areas.

7.2 METHOD OF DATA COLLECTION Structured questionnaire will be used to collect the data on self care

activities regarding prevention of diabetes with the questions related to meaning, dietary practice, exercise, blood sugar level and investigation regarding prevention of diabetes among rural and urban mothers.7.2.1. SAMPLING TECHNIQUE

A non random sampling technique of convenient sampling will be used to select the sample of rural and urban adults.

7.2.2. SAMPLE SIZE: A sample of 120 adults (n=120) will be chosen in such way that 60 from rural and 60 from urban area.

7.2.3 CRITERIA FOR SAMPLE SELECTION:Iinclusive criteria:

i. Adults who are residing at selected rural and urban areas.

ii. Adults who are within the age of 30-50 years.iii. Adults who are available during the study.

Exclusive criteria:i. Adults who are not willing to participate

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ii. Adults not able to read Kannada7:2.5. INSTRUMENT:

A structured tool on self care activities regarding prevention of diabetes

7.2.6. PLAN FOR DATA ANALYSIS:The collected data will be analyzed by the descriptive and inferential analysis

Frequency and percent will be used to describe the demographic characters of adults from rural and urban areas

Descriptive measures such as mean, standard deviation will be used assess the knowledge on prevention of diabetes

Unpaired t-test, ANOVA will be used compare the mean knowledge score of rural and urban adults.

Chi-square analysis will be carried out to bring out the association between knowledge on prevention of diabetes and socio demographic characters of rural and urban adults.

7.2.7. TIME & DURATION OF THE STUDY:

The study is proposed to conduct 8- 10 weeks with the permission of institution and consent of the adults.7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENT OR OTHER HUMAN OR ANIMALS?

No, Since the study is conducted as non experimental type of descriptive study, it does not involve any intervention.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3?The main study will be conducted after the approval of research committee. The purpose and details of the study will be explained to the study subjects and an informed consent will be obtained from them. Assurance will be given to the study subjects on the confidentially of the data collected from them.

8. LIST OF REFERENCES: (Vancouver style followed)

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1. Rajan. Helping diabetic patients treat their feet right, (1997), No. 97.27 (6), 64-65.

2. Park. K. Textbook of preventive of social medicine. 2002, 17th edition. Bhanot Jabalpur, Banarsidas.

3. Suzanne C, Brenda G. Text book of medical surgical nursing. 10th

edition Philadelphia. Lippin cott. 2004. 1194-1195.4. Lalitha Sridhar. A major health problem: The Hindu 2003, August 04,

Page 1-4.5. Marta S. Prevention of chronic disease. American Journal of Nursing,

Jan 2007, LXXII, 935-938.6. Delycia. E., Feustel, (1996). Nursing Student's knowledge about

diabetes mellitus, Nursing Research, XXVI, 1-4. 7. Dawn W, Volansky M. Community based lifestyle interventions to

prevent diabetes mellitus. Diabetes education. 2005, 31(1), 75-83.

8. Adil MM, Alam AY, Jaffery T. (2004). Evaluative baseline level of knowledge and awareness of diabetic patients about their disease and it's complications [online]. Post graduate medicine, 150(7): 76-81.

9. Dahiru T, Jibo A, Hassan AA, Mande ATPrevalence of diabetes in a semi-urban community in Northern Nigeria. Niger J Med. 2008 Oct-Dec;17(4):414-6.

10. Menon VU, Guruprasad U, Sundaram KR, Jayakumar RV, Nair V, Kumar H.Glycaemic status and prevalence of comorbid conditions among people with diabetes in Kerala. Natl Med J India. 2008 May-Jun;21(3):112-5.

11. Ramachandran A, Mary S, Sathish CK, Selvam S, Catherin Seeli A, Muruganandam M, Yamuna A, Murugesan N, Snehalatha C.Population based study of quality of diabetes care in southern India. J Assoc Physicians India. 2008 Jul;56:513-6.

12. Zargar AH, Wani AA, Laway BA, Masoodi SR, Wani AI, Bashir MI, Dar FA.Prevalence of diabetes mellitus and other abnormalities of glucose tolerance in young adults aged 20-40 years in North

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India (Kashmir Valley). Diabetes Res Clin Pract. 2008 Nov;82(2):276-81. Epub 2008 Sep 23

13. Mohan V, Deepa M, Anjana RM, Lanthorn H, Deepa R.Incidence of diabetes and pre-diabetes in a selected urban south Indian population (CUPS-19). J Assoc Physicians India. 2008 Mar;56:152-7.

14. Schmidt S, Mayer H, Panfil EM.Diabetes foot self-care practices in the German population. J Clin Nurs. 2008 Nov;17(21):2920-6.

15. Wang SF, Li YC, Chang JR, Courtney M, Chang YL.The application of self-efficacy counseling skills to health education in patients with diabetes. Hu Li Za Zhi. 2007 Feb;54(1):70-7

16. Rosenstock IM.Understanding and enhancing patient compliance with diabetic regimens. Diabetes Care. 1985 Nov-Dec;8(6):610-6.

17. Vivienne Wu SF, Courtney M, Edwards H, McDowell J, Shortridge-Baggett LM, Chang PJ.Development and validation of the Chinese version of the Diabetes Management Self-efficacy Scale. Int J Nurs Stud. 2008 Apr;45(4):534-42. Epub 2006 Oct 19

18. Karlsson A, Arman M, Wikblad K.Teenagers with type 1 diabetes--a phenomenological study of the transition towards autonomy in self-management. Int J Nurs Stud. 2008 Apr;45(4):562-70. Epub 2006 Oct 16.

9 SIGNATURE OF THE CANDIDATE

10 REMARKS OF THE GIDEThe research topic selected by the student is quite appropriate and forward it for acceptance

11 11.1 NAME AND DESIGNATION OF GUIDE

Smt. BUELA

H.O.D Department of Community

16

Health Nursing

Indian College of Nursing, Bellary.

11.2 SIGNATURE

11.3 CO-GUIDESunitha

Lecture, Department of Community

Health Nursing,

Indian College of Nursing Bellary.

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT

Smt. BUELA H.O.D Department of Community

Health Nursing,Indian College of Nursing, Bellary.

11.6 SIGNATURE

12 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL.

I discussed with the research

Committee I felt research problem is

good and feasiable.

12.2 SIGNATURE

17