RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. Name of the candidate and address Ms. G. Rekha

M.Sc Nursing I year,

Dr.Syamala Reddy College of Nursing,

No. 111/1, SGR Main Road, Munnekolala,

Marathahalli - Post,

Bangalore-560037.

2. Name of the Institution Dr. Syamala Reddy College of Nursing.

3. Course of study and subject M.Sc Nursing I year.

Community Health Nursing

4. Date of admission to course June – 2010

5. Title of the topic A descriptive study on assessment of

compliance among diabetic clients

regarding diabetic management in

Kadugudi PHC at Bangalore.

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6. BRIEF RESUME OF INTENTED WORK:

INTRODUCTION :-

“This is the day when people reciprocally offer, and receive, the kindest and

the warmest wishes, though, in general, without meaning them on one side, or

believing them on the other. They are formed by the head, in compliance with

custom, though disavowed by the heart, in consequence of nature”

- Philip Dormer Stanhope

“He in a few minutes ravished this fair creature, or at least would have ravished her, if

she had not, by a timely compliance, prevented him”

- Hendry Fielding

The pancreas is a long, slender gland lying behind the stomach and in front of the

first and second lumbar vertebrae. The pancreas has both exocrine and endocrine functions.

The exocrine function of the pancreas contributes to the process of digestion. Endocrine

function occurs in the islets of langerhans, whose beta cells secrete insulin, alpha cells

secrete glucagon; delta cells secrete somstostatin; and F cells secrete pancreatic

polypeptide1.

Insulin is the principal regulator of the metabolism and storage of ingested

carbohydrates, fats and proteins. Insulin facilitates glucose transport across cell membranes

in most tissues. When the blood glucose rises, insulin is released from the pancreas to

normalize the glucose level1.

Diabetes is an iceberg disease. It is a complex condition with global health

consequences. The term “diabetes mellitus” is derived from the Greek word, “diabetes”

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means “to go through” or a siphon and the word “mellitus” is derived from the Latin word

“mel” meaning honey describing the sweet odour of urine2.

Diabetes Mellitus is a chronic multisystem disease related to abnormal insulin

production, impaired insulin utilization, or both. Diabetes Mellitus is a serious health

problem throughout the world and its prevalence is increasing rapidly1.

According to WHO (1994) diabetes mellitus is characterized by hyperglycemia and

disturbance of the carbohydrate, fat and protein metabolism that is associated with the

absolute or relative deficiencies of insulin action or secretion3.

The American Diabetes Association uses the acronyms “DIABETES” and

“CAUTION” help to identify the warning signs of diabetes.

Drowsiness, Itching, A family history of diabetes, Blurred vision, Excessive Weight,

Tingling numbness or pain in extremities, Easy fatigue, Skin infection, slow healing of cuts

and scratches especially on the feet.

Other signs are, Constant urination, Abnormal thirst, Unusual hunger, The rapid loss of

weight, Irritability, Obvious weakness and fatigue, Nausea and vomiting4.

India has now been declared by WHO as the diabetes capital of the world. The

choice of treatment and compliance is important for the metabolic control to be achieved by

the patients. While diet, exercise and oral drugs are useful in controlling diabetes in many

patients, it is now recognized that a large number of Type 2 diabetic patients require insulin

therapy5

India has the world’s largest population of people with diabetes- 50.8 million as

per latest statistics of International Diabetes federation. Diabetes is the leading cause of

adult blindness, end-stage renal disease and non traumatic lower limb amputations. It is also

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a major contributing factor for heart disease and stroke. Adults with diabetes have heart

disease death rates two to four times higher than adults without diabetes. The risk for stroke

is also two to four times higher among people with diabetes. In addition, about 73% of

adults with diabetes have hypertension6

A study was conducted for one and half years by the Manipal Hospital Bangalore with

diabetes and Hypertension patients and it revealed that almost 40% to 60% of patients had

both the conditions. And 50% had at least two risk factors like high cholesterol or

overweight. About 20% to 30% were smokers. Compliance became a major issue.

Explaining the lack of compliance and integrated diabetes support- Earlier patients used to

come with a predisposed idea that if they are asked to take insulin, they would refuse and try

to avoid it for at least a year. Hypertension did not receive as much attention as diabetes

mainly because “diabetes is a silent killer and the onset is very early” 6.

The latest Compliance is on drug how well a patient follows the instructions for taking

his/her medication. Poor compliance is a leading cause of failed medical treatment and drug-

resistant conditions. Diabetes is the fourth leading cause of death in developed world; it

affects the blood vessels, nerves, heart, kidneys and eyes7.

6.1 NEED FOR STUDY :-

One of the challenges faced by the modern world is diabetes mellitus. Diabetes

mellitus has been recognized as a chronic condition that challenges every aspect of

personal, emotional, social, physical, psychological and spiritual life of an individual. It is

the leading cause of non traumatic amputations and blindness8.

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Diabetes is a chronic disease that occurs when the pancreas doesn’t produce enough

insulin or alternatively. Diabetes is currently considered an epidemic disease that is largely

preventable and treatable through diet, exercise and life style changes. Diabetes is among

the leading causes of kidney failure and 10-20% of people with diabetes die of kidney

failure. Diabetes increases the risk of heart diseases and stroke; 50% of people with

diabetes die of cardio vascular diseases9.

According to the American Diabetes association, the prevalence of Diabetes

mellitus has increased dramatically during the past few decades, and it is expected to

increase even more in the future. In the United States an estimated 20.8 million people, or

7% of the population have diabetes mellitus and more than 2 million Canadians have

diabetes. Over 6 million people with diabetes mellitus are not diagnosed, and these

individuals are unaware that they have the diabetes. Diabetes mellitus is the fifth leading

cause of the death in the United States, but it is under reported10.

India’s diabetic population is around 51 million now and is expected to touch 87

million by 2030. Every minute, six people die due to diabetes and its complications.

Despite an adult prevalence rate of 6.2%, only 6-7 million people are treated. The

increasing incidence of multi-organ complications arising from diabetes has become a

major cause for concern. Complications include cardiovascular diseases, diabetic

neuropathy, diabetic nephropathy, stroke, blindness and limb amputation6.

While incidence if Type1 diabetes is increasing, Type 2 is also being found in

younger age groups. The problems are lifestyle- related. Infact, nutrition and proper diet

should start at the fetal stage, because most development happens then6. In regard with

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diabetes control, an observational study to collect information on prevalence of diagnosed

and undiagnosed diabetes and hypertension cases in outpatient clinics in major Indian

cities and to understand the extent of risk factors among these patients. Also now mass

screening program for diabetes and hypertension has been initiated by TamilNadu

Government11.

According to WHO, in India 31 million people are affected by diabetes which is

highest in the world (2002) and 5% of Bangaloreans have diabetes and about 30,000 of

these develop foot problem annually12. According to the new Indian press (2004)

Hyderabad and Chennai is the diabetes capital of India. Hyderabad tops the metropolitan

cities in the prevalence of diabetes (16.6%) followed by Chennai (23.5%), Bangalore

(12.4%) Kolkata (11.6%) and Mumbai (9.3%). The most important aspect of diabetes in

occurrence of complications that increases the cost of management13.

There are approximately 3.5 crore diabetic clients in India, and this figure is

expected to increase up to 5.2 crore by 2025. Every fifth client visiting a consulting

physician is a diabetic and every seventh client visiting a family physician is a diabetic14.

In 2005, an estimated 1.1 million people died from diabetes. Almost 80% of the

deaths occur in low and middle income countries with half of the deaths occurring in

people under the age of 70 years. WHO projects that deaths due to diabetes will be more

than 50% in the next ten years without appropriate measures. Deaths due to diabetes are

projected to increase by over 80% in upper middle income countries between 2006-2015.

In another estimate by International Diabetes Federation (IDF) 200 million people around

world have diabetes by 2025 and it is expected to increase to 333 million15.

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Self care is the practice of activities that individuals initiate and perform on their

own behalf in maintaining life, health and well being. Self care in diabetes is crucial. It has

been claimed that as much as 98% of diabetes care is self care. Self-care in diabetes falls

mostly on the patients and their families. It is essential that individuals with diabetes

adhere to self care and to prevent the complications associated with diabetes16.

Diabetes self management education is the process of teaching individuals to

manage their diabetes and has been considered an important part of the clinical

management of individuals. The goals of the self management education are to optimize

metabolic control, prevent acute and chronic complications and optimize quality of life,

while keeping costs acceptable17.

A cross sectional survey was conducted in a resettlement colony of Chandigarh

about knowledge and practices regarding diet, hygiene, care of foot, wound, complication

of diabetes and medication. This study has concluded that there is a need to reorient and

motivate health personnel in educating diabetics about self- care18.

During the clinical experience the investigator has noticed that majority of patients

with diabetes mellitus do not take prescribed treatment, neglecting the do’s and don’ts of

diet and do not know the importance of exercise and foot care which leads to

complications. The investigator has observed that a number of diabetic patients are

hospitalized because of uncontrolled hyperglycemia, ulcers on foot, diabetic nephropathy,

neuropathy, hypertension and artherosclerosis19.

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Patient noncompliance is a major medical problem in America. Consequently,

numerous studies and reports have been performed to articulate the meaning of the problem

and to suggest improvements. The literature however, in its effort to explore all facets of the

current compliance situation, has produced a complex construct, making it exceedingly

difficult for clinicians and researchers to understand the problem. This report was undertaken

to unify the current spectrum of compliance literature, to make sense of the adherence

situation. A variety or research methods was used, including MEDLINE and PubMed

searches, university medical library searches, general Internet searches, and clinical text

reviews. The result was a categorization of the literature into six segments, including articles

identifying adherence as a problem, identifying the causes of noncompliance and exploring

possible solutions, analyzing adherence with respect to specific ailments, and exploring the

patient's role, the pharmacist's role, and the physician's role with respect to compliance. After

the exploration and synthesis of the current literature, we suggest that future research

concentrate on the practitioner for a better understanding of the compliance situation and the

creation of a universal method of ensuring compliance39.

Diabetes imposes life long demands on client’s families. They have to make a multitude

of decisions related to managing diabetes and compliance, as diabetes affects all age group

worldwide. People with diabetes need to monitor their blood glucose, take medication,

exercise regularly and modify life styles. As outcomes are largely based on the decision they

take, it is of paramount importance that people with diabetes receive ongoing, high-quality

diabetes education that is tailored to their need and delivered by skilled health care providers.

During the clinical experience the investigator has noticed that majority of patients with

diabetes mellitus do not take prescribed treatment, neglecting the do’s and don’ts of diet and

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do not know the importance of exercise and foot care, etc which leads to complications. The

investigator felt the need to assess the level of compliance among patients. Which would help

community health nurses to plan implement culturally focused teaching program.

6.2. REVIEW OF LITERATURE:

“Man can learn nothing except by going from the known to unknown”

- Claude Bernard

Diabetes mellitus is silent disease and recognized as one of the fastest growing threats to

public health in almost all countries of the world. It is also called the “Disease of

prosperity”. It’s a chronic disorder with elevated blood sugar level and it requires careful

monitoring and control.

THE LITERATURE REVIEW HAS BEEN ARRANGED AND

PRESENTED IN THE FOLLOWING HEADING:

1. Studies related to Incidence and Prevalence of the Diabetes mellitus.

2. Studies related to self management and education.

3. Studies related to compliance of Diabetic Clients.

1. INCIDENCE AND PREVALENCE OF DIABETES MELLITUS:

World Health Organization (WHO) in 2007 reported that worldwide there are 246

million diabetic clients. 17.7 million in united states (US), 20.8 million in china, and 6.8

million in Japan. In the United Kingdom the prevalence of known diabetes is about 2% and

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the age standardized prevalence of undiagnosed diabetes is 2% among the over frontier and

31.7 million cases in India. In the year 2008, India was estimated to have 40.2 million

diabetes. WHO forecasts that the number will rise to 14.5 million by the year 2025 21. But by

the year 2030, the estimated prevalence of diabetes mellitus was 30.3 million in US, 42.3

million in China, 13.9 million in Japan and 79.4 million in India. Diabetes Mellitus is the

fourth leading cause of death22. Arab Diabetes Survey 2006 reported that 10% of the

population was affected by diabetes mellitus. Out of which, 5.7% exists in urban areas, 4.1%

in rural areas and 1.5% among desert communities. Serious complications may affect a

considerable proportion of the population if the disease is not properly managed23.

According to the new data released by the International Diabetes Federation (IDF)

November 2009, 285 million people worldwide have diabetes which affects 7% of the

world’s adult population, 50.8 million of diabetes in India, 43.2 million in China, 26.8

million in US, 9.6 million in Brazil, 7.5 million in Germany, 7.1 million in Pakistan, 7.1

million in Japan, 7 million in Indonesia and 6.8 million in Mexico. It indicates that people in

low and middle income countries are bearing the brunt or burden of the epidemic, and that

the disease is affecting far more people of working age than previously believed24.

Diabetes is now emerging as one of the main threats to human health in the 21st

century. The past two decades have seen an explosive increase in the number of people

diagnosed world-wide. In recent years, India has witnessed a rapidly exploding epidemic of

diabetes. Indeed India today leads the world with its largest number of diabetics in any given

country. It has been estimated that in 1995, 19.4 million individuals were affected by

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diabetes in India and these numbers are expected to increase to 57.2 million by the year

2025 (one sixth of the world total) 25.

In the recent National Urban Diabetes Survey (NUDS) the prevalence of diabetes was

found to be 13.5% among Chennai residents, in Bangalore-12.4%, Hyderabad-16.6%,

Kolkata-11.7%, New Delhi-11.6% and Mumbai-9.3%. The survey also concluded that there

is a large pool of individuals with impaired glucose tolerance (IGT) at risk of conversion to

diabetes especially among the younger age group below 40 years25.

In the 14 year study conducted in 8793 hospitalised diabetics in Mumbai, 81.8%

developed complications. Hypertension was observed in 42.2%, ischemic heart diseases in

27.2%, cerebrovascular complications in 9.2% and peripheral vascular disease in 4.2%25.

A study conducted to estimate the prevalence of diabetes and the number of people

with diabetes who are less than 20 years of age in all countries of the world for three points

of time in 1995, 2000, and 2025. The data obtained by WHO was collected from 75

communities in 32 countries, was analysed for developing and developed countries

separately. Prevalence of diabetes in adults worldwide is estimated to be 4.0% (135 million)

in 1995 and is expected to rise to 5.4% (300 million) in 2025. Thus by the year 2025, more

than 75% of people with diabetes will reside in developing countries as compared to 62% in

1995. In developing countries the majority of people with diabetes are in the age group of

45-64 years and in the developed countries more than 64 years. Thus the study has

concluded that diabetes is a global burden26.

2. STUDIES RELATED TO SELF MANAGEMENT AND EDUCATION

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Management of clients with diabetes includes restoring and maintaining blood

glucose levels to near normal as possible by balancing the diet, exercise, and the use of oral

hypoglycemic agents or insulin. The treatment of diabetes is highly individualized, and it

depends on type of diabetes, complications, and presence of other active medical problems,

age and general health at the time of diagnosis. Diabetes can be managed with proper care,

clear understanding of the problem, proper treatment and regular follow up27.

The effects of a culturally competent diabetes self management education was studied

among Mexican Americans with Type 2 diabetes at Texas Mexican border. A total of 256

patients between 35 to 70 years of age with Type 2 diabetes were randomly assigned to

experimental and control group. The intervention involved 3 months of weekly instructional

sessions on nutrition, self – care topics, exercise and self-monitoring of blood glucose. Data

was analyzed by descriptive statistics. Experimental group showed significantly lower levels

of HbA1c and fasting blood glucose at 6 and 12 months and higher diabetes knowledge score

(r=0.88, p< 0.01) than the control group. This study confirms the effectiveness of culturally

competent diabetes self-management education on improving health outcomes particularly

for those individuals with HbA1c levels >10%28.

An evaluative study was conducted in Hawaii to assess the effectiveness of Diabetes

Out patient Intensive Treatment Program (DOIT) over educational mailing (Edupost).

Diabetic patients (Type 1 and 2) with poor glycemic control were randomly assigned to

DOIT and educational mailing .Group education and skills training experience combined

with daily medical management was carried out over a period of 6 months. The result

showed a significant drop in HbA1c values in both treatment groups and greater glycemic

13

control was evidenced in DOIT group. DOIT group also repo rted significant improvement

in self-care (blood glucose monitoring, exercise and diet) whereas Edupost patients showed

no improvement. For DOIT patients glycemic improvement was significantly associated

with self-reported change in diet (r=0.41, p<0.02) 29.

A study conducted to evaluate the efficacy of self-management education on

Glycosylated Hemoglobin (GHb) in adults with Type 2 diabetes. They analyzed 31

randomized control studies conducted during 1980 to 1999 to evaluate the efficiency of

Diabetes Self- Management Education (DSME). A total of 4263 patients participated.

DSME interventions were classified into one of the following categories by their primary

educational focus on knowledge, lifestyle behavior (including diet and physical activity)

skill development, including skills to improve glycaemic control and to prevent and identify

complications. The result showed significant decrease in GHb by 0.76% on average

intervention than the control group at immediate follow up, by 0.26% at 1-3 months of

follow up. GHb decreased more with additional contact time between participant and

educator. Study concluded that self- management education improves GHb levels at

immediate follow up and increased contact time increased the effect17.

A study conducted on “Diabetes self- Management reported recommendation and

patterns in a large population” concluded that comparisons on level of self management

across diabetes type revealed significant differences for diet and glucose testing. Diabetes

self- Management is the cornerstone of over all diabetes management20.

14

According to A comprehensive Guide to Diabetes (2001) the management of diabetes is

one of the most important subjects in clinical practice. Every 5th patient visiting a consulting

physician and every 7th patient visiting a family physician has diabetes.

3. STUDIES RELATED TO COMPLIANCE OF DIABETIC CLIENTS

A study was conducted in Bangalore to examine the efficacy of a comprehensive

behavioral intervention program in management of compliance to regimen in Type 1

diabetes and its effect on glycemic control. Clients suffering from Type 1 diabetes between

the ages of 15-22 years were randomly selected from local general hospital or diabetology

units. The experimental group had undergone 15 individual therapies over a period of three

months and the control group was seen three times for assessment. The findings of the study

revealed that both groups were non-compliance at pre treatment. The experimental group

improved significantly at post treatment (t=9.15, p<0.05). Similarly there has been

statistically at post treatment on Glycosylated hemoglobin with experimental group having

lower values (t=2.89, p<0.05)31.

A study was conducted to determine whether medication adherence is associated with

clinical outcomes in patients with diabetes. The study setting was a large integrated delivery

and financial system serving the residents of south eastern Michigan. The study population

consisted of 677 randomly selected patients aged ≥18 years with a diagnostic of diabetes,

hypercholesterolemia and hypertension. The main outcome measures were HbA1c LDL,

cholesterol level and blood pressure. Non-adherent patients had both statistically and

15

clinically worse outcome than adherent patients. A 10% increase of 0.14% in HbA1c and an

increase of 4mg/bl in LDL cholesterol level. The study highlighted the need for adherence to

medication32.

A study was conducted to evaluate the factors affecting medication adherence in

geriatric diabetic patients treated at private clinics and tertiary hospitals. We included 108

diabetic patients older than 65 years treated at one tertiary hospital and 157 patients older

than 65 years treated at two private clinics. The medication adherence based on Morisky's

self-report was significantly higher in tertiary hospital patients (61.1%) compared to private

clinic patients (43.2%) (P < 0.01). The results showed that drug storage and self-efficacy

were factors affecting adherence to medication in tertiary hospital patients (P < 0.05). The

adherence was high in cases of proper drug storage (odds ratio [OR], 5.401) and in cases

with high self-efficacy (OR, 13.114). In private clinic patients, financial level (P < 0.05),

recognition of the seriousness of diabetes complications (P < 0.05) and self-efficacy (P <

0.01) were associated with medication adherence The medication adherence was

significantly lower in patients whose financial state were moderate than those with lower

(OR, 0.410), and medication adherence was significantly higher in patients who had higher

perceived severity (OR, 2.936) and in patients with higher self-efficacy (OR, 4.040)33.

A study was to identify factors affecting the compliance of diabetes patients and to

examine the relationship between the compliance of the patients and the levels of HbA1c.

The subjects included 274 type 2 diabetes mellitus patients attending the diabetes mellitus

outpatient clinic of Somdet Prayannasangworn Hospital in Chiang Rai Province. The results

of this study were statistically significant differences in patient’s compliance behavior

16

regarding the relationship between the selected relationship between doctor and patients and

the patient’s perception of self-efficacy34.

This community-based study was undertaken in a rural primary health center area

near Chennai (Madras) in order to better understand treatment-seeking behavior, compliance

patterns, and reasons for noncompliance among rural diabetics. Compliance was indirectly

measured through patient interviews and drug use charts. Of the 112 patients interviewed,

72% had some symptoms at the time of diagnosis, and the majority of them were diagnosed

in government health centers. Noncompliance was seen in 57% of the 112 patients

interviewed, and reasons were elicited. Interruption of treatment was significantly associated

with lack of education. The study identified the lack of a patient-friendly, flexible health

care system as the primary reason for noncompliance35.

STATEMENT OF THE PROBLEM:-

A descriptive study on assessment of compliance among diabetic clients regarding

diabetic management in Kadugudi PHC at Bangalore.

6.3 OBJECTIVES :-

1. To assess the level of compliance among Diabetic clients regarding diabetic

management.

2. To determine the relationship between the level of compliance and selected socio

demographic variables.

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HYPOTHESIS :-

H1: There is a significant relationship between level of compliance and selected

socio demographic variables among diabetic clients.

OPERATIONAL DEFINITIONS :-

ASSESSMENT: Measuring the compliance of diabetic clients regarding diabetic

management using structured interview technique.

COMPLIANCE: Adherence to a recommended course of management by diabetic client

in relation to diet, medication, exercises, follow up, etc...

DIABETIC CLIENT: Clients who are diagnosed to be diabetes mellitus and taking

treatment for minimum 1 year.

DIABETIC MANAGEMENT: It is a measures taken by diabetic clients to control the

diabetes mellitus and prevent its complications.

ASSUMPTION:-

A1: The level of compliance differs among diabetic clients.

A2: Socio demographic variables influences the level of compliance

A3: Mass Medias impacts the compliance level of diabetic clients.

7. MATERIALS METHODS : -

7.1. SOURCE OF DATA: - Diabetic Clients attending Kadugudi PHC at Bangalore.

7.2 METHOD OF DATA COLLECTION PROCEDURE:-

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RESEACH APPROACH: Non Experimental research approach.

RESEARCH DESIGN: Descriptive Research design.

SAMPLING TECHINIQUE: Convenience sampling technique.

SAMPLE SIZE: 100

SETTING OF THE STUDY: The descriptive study will be conducted among diabetic

clients in Kadugudi PHC at Bangalore. The Kadugudi PHC covers the area of 25 kilometers

and it is 23 kilometers from Dr.Syamala Reddy College of Nursing. It covers the population

of 42,809 with the bed strength of 12. The services provided by the Kadugudi PHC are

emergency treatment, medical care, control of communicable disease, health education,

family planning, immunization, MCH services, etc…. Kadugudi PHC has 2 medical officers

with other 12 staffs.

SAMPLING CRITERIA :-

INCLUSION CRITERIA:

Diabetic clients those who are willing to participate in the study.

Diabetic clients those who can able to understand Kannada & English.

Diabetic clients with age up to 65 years.

Clients with history of diabetes for minimum 1 year.

EXCLUSION CRITERIA:

Diabetic clients with other chronic illness such as Hypertension, Asthma, Arthritis,

Cancer etc.

DATA COLLECTION TOOL: -

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Section I-Socio demographic variable such as age, sex, education, occupation, income,

religion, marital status, type of family, dietary pattern, age at the onset of diabetes, nature

of treatment, etc…

Section II – Structured Interview schedule on compliance of diabetic clients in relation to

diet, medication, exercise, follow up, etc..

7.3. DATA COLLECTION PROCEDURE :-

This descriptive study will be conducted in Kadugudi PHC at Bangalore, with a

sample of 100 Diabetic clients. A structured interview schedule will be used to

collect the relevant information regarding level of compliance. The duration of data

collection will be for 4 weeks.

DATA ANALYSIS METHOD :-

The collected data will be analyzed using descriptive statistics such as frequency

distribution, percentage, mean and standard deviation for socio demographic variables and

compliance, and inferential statistics such as chi square to see the association between the

socio demographic variables and compliance.

7.4 ETHICAL CLEARNCE

Yes

Ethical clearance will be obtained from PHC and oral consent from participants.

Confidentiality of the subjects will be maintained.

20

8. LIST OF REFERENCE:-

1) Lewis heitkemper, Medical- Surgical Nursing, 7th edition, Mosby Elsevier publishers,

India, 2009.

2) Black JM, Luck Mann, Sorenson’s Medical Surgical Nursing, A psychosocial

Approach, 4th edition, Toronto, W.B. Saunder’s company: 1993

3) Park K, Text book of preventive and social medicine, 17th edition, Jabalpur, M/S

Banarasidas Bhanot Publishers: 2002.

4) http://www.care diabetes journal-org/cgi/content/full/25/supp 1/80

5) Diabetes Desk Reckoner, A comprehensive guide to diabetes, Bangalore: Novo nor disk

India Private Ltd, 2002.

6) Times of India, 14th November 2010.

7) http:/www.madicalnewstoday.com

8) Indian journal of continuing nursing education, volume-9, No-2, July-December 2008.

9) Prism’s Nursing practice, volume-4, Number-3, July-September, 2004.

10) www.diabetes.org , American Diabetes Association, Total prevalence of

diabetes and prediabetes.

11) www.dinakaran.com , 30th November 2010.

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12) World Health Organization Technical report of Diabetes Mellitus: journal of

diabetic care 16(4);11-20p.p

13) Warnart, P.D. threat of a pandemic. The Indian express first newspaper.2002.

December 16th -31st , 3.10

14) Lalitha Sridhar, A major health problem, which study establishing the over all

prevalence of diabetes in India. The Hindu Business line: Section A August (col 2) 1-4.

15) National centre for Health Statistic Mortality data from the National vital statistic

system, 2004, December, vol(16), 9,11

16) Anderson RM. Patient empowerment and the traditional model-A case of irreconcable

differences? Diabetes care 1995; 18: 412-15.

17) Norris SL, Lau J smith JS, Schmid CH, Engelgau MM. self management education for

adults with type 2 Diabetes. Diabetes care 2002, Jul; 25(7): 1159-65.

18) Kaur K, Singh MM, Kumar, Walia I, Knowledge and self care practices of diabetics in

a resettlement colony of Chandigarh. Indian J Med.Sci 1998, Aug: 52(8): 341-7.

19) Madras Diabetes Research Foundations: key messages for diabetes prevention. The

Hindu. Mangalore 2004. Nov 14 pg 9 (col 7).

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out patient department of Ghurki Trust Teaching Hospital. PROF-1265; Mar 2008;

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21) Kavita Venkataraman, AT Kannan, et al. challenges in Diabetic Management with

particular reference to India. 2007

22) Arab diabetic the Asian Journal of Dialectology survey. 2006.4 (4);53-57p.p\

23) Brunner and Suddarth’s; Medical and Surgical Nursing ; 11 th edition, vol.2(2008);

Lippincott; 1377-1436p.p

24) Pradeepa R. Mohan V, The changing scenario of the diabetes epidemic: Implications

for India. Indian J Med. Research.2002.oct.116:121-32

25) Hilary K, Ronald EA, William HH. Global burden of diabetes, 1995-2025. Diabetes

care.1998 Sep:21(9): 1414-31

26) Phipps, Cass Meyer, Sands Lehman. Medical and Surgical Nursing; Concept and

Clinical practice (5th edition). Elsevier publications. 132-1345p.p

27) Brown SA, Garcia AA, Kouzekanani K, Hanis CL. Culturally competent Diabetes self

Management Education for Mexican Americans. Diabetes care.2002 Feb; 25(2): 259-

65.

28) Polonsky WH, Earles J, Smith S, Pease DJ, Macmillan M, Christensen R et al.

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29) Ruggiero Laurie et al (1997) “self reported recommendations and patterns in a large

population”, 92 August 568.

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30) Kumaraiah MP, Kumar MC, Arvind S. behavioral intervention in the management of

compliance in young type 1 diabetes, Journal of Association of physicians in India 2000

Oct; 48 : 961-71.

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32) Journal of korian Diabetes Association, february 2010,55-65

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34) Srinivas G, suresh E. Tamilnadu Dr.MGR Medical University, Chennai Apr-02, 420-4

35) The Journal of applied research in clinical and experimental Therapeutics.

9 Signature of Candidate

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10 Remarks of the Guide

11 Name and Designation

11.1 Guide

11.2 Signature

11.3 Co-guide

11.4 Signature

11.5 Head of the Department

11.6 Signature

12 12.1 Remarks of the Chairman and Principal

12.2 Signature

25