INTRODUCTION:

Recent findings from the official Indonesian Basic Health Research (Riskesdas) indicate a steady increase in the prevalence of diabetes mellitus in several provinces in Indonesia¹. The country currently ranks seventh globally for the number of diabetes cases among individuals aged 20 to 79 years, and it is fourth in the prevalence of non-communicable diseases (NCDs) such as diabetes mellitus. The Indonesian Ministry of Health, referencing the 2018 Riskesdas data, highlights that the provinces with the highest diabetes prevalence are DKI

Jakarta, DI Yogyakarta, East Kalimantan, North Sulawesi, and East Java. This condition predominantly affects those aged 15 to 60. In 2019, the number of people living with diabetes mellitus in Indonesia rose to 463 million.

Furthermore, the 2018 statistics revealed an 8.5% prevalence rate of diabetes mellitus among residents aged 15 years and older. Notably, the prevalence was 1.8% higher in women than in men.

Diabetes mellitus is a chronic condition characterized by persistently elevated blood sugar levels, especially notable in fasting plasma glucose measures, where levels equal to or exceeding 126mg/dL indicate the disease². Another critical measure is the glucose level after fasting, known as fasting blood sugar (FBS), with values of 200 mg/dL or higher signaling diabetes³. This multifaceted, long-term condition demands ongoing medical care and a comprehensive approach to risk reduction that extends beyond mere glucose control⁴.

Diabetes mellitus is a chronic metabolic disorder characterized by an impaired ability of the hormone insulin to effectively regulate blood sugar balance, leading to increased glucose levels in the blood (hyperglycemia)⁵. This condition can stem from a deficiency of β cells, insufficient insulin production, or peripheral insulin resistance, a dysfunction of insulin receptors that reduces insulin's efficacy in transporting biochemicals into cells. Common symptoms of diabetes mellitus include dehydration, polyuria (frequent urination), visual impairment, and weight loss^4,6. In order to diagnose type 2 diabetes mellitus, several methods are employed. One approach is to measure blood sugar levels, with readings greater than 200 mg/dL indicating a potential case. Another method involves checking the fasting blood glucose level, which, if exceeding 126mg/dL alongside physical symptoms, suggests diabetes. 'Fasting' refers to abstaining from caloric intake for over eight hours. Additionally, a blood glucose level of 200 mg/dL or higher, measured two hours post an Oral Glucose Tolerance Test (OGTT) with a 75g glucose load, indicates the condition. Furthermore, a Hemoglobin A1c (HbA1c) level of 6.5% or higher, ascertained through standardized procedures developed by the National Glycohemoglobin Standardization Program (NGSP), is a diagnostic criterion for diabetes mellitus⁷.

Diabetes mellitus, a chronic incurable condition, necessitates meticulous self-management to mitigate its impacts effectively. Self-management represents a crucial mechanism by which individuals can control their actions to achieve health goals⁸. This process encompasses goal setting, decision-making, focused attention, planning, self-evaluation, self-intervention, and self-development. Viewed as both an educational process and an outcome, self-management plays a pivotal role in aiding patients to maintain stable blood sugar levels, minimize complications, and improve overall quality of life⁹. It demands significant patient engagement in altering unhealthy behaviors, with the healthcare team playing a vital supporting role in facilitating these lifelong behavioral adjustments. The journey toward successful behavior change involves a comprehensive approach that includes education, skill development, and motivational efforts¹⁰. Prior research indicates that the average individual with type 2 diabetes mellitus often falls short in adherence to prescribed diets, health monitoring, therapy, and exercise routines¹¹. This gap in compliance is attributed to a lack of adequate health education and limited access to information from healthcare providers¹². Consequently, this deficiency can lead to suboptimal self-care among people living with diabetes.

Patients with type 2 diabetes mellitus often struggle with adherence to nutritional guidelines, health monitoring, therapy, and exercise due to inadequate health education and limited information provided by healthcare professionals¹³. Consequently, these individuals frequently fail to engage in effective self-care practices. The implications of this are significant, as diabetes can lead to severe complications affecting various organs, necessitating continual management. The resultant prolonged physical and mental suffering can markedly diminish patients' quality of life¹⁴. In order to achieve optimal management of diabetes, substantial behavioral changes are imperative. These changes necessitate comprehensive educational initiatives to foster motivation and ensure the successful implementation of these behavioral modifications¹⁵. Anticipated behavioral changes include adopting a healthy diet, increasing physical activity, consistently and safely using diabetes medication along with any necessary special condition medications, independently monitoring blood glucose levels and utilizing the resulting data, conducting regular foot care, effectively recognizing and treating acute illnesses, developing basic problem-solving skills, participating in diabetes support groups, encouraging family involvement in diabetes management, and making full use of available health services¹⁶.

This research addresses the significant gap in our understanding of effective self-management strategies for Type 2 Diabetes Mellitus (T2DM) in rural settings. Patients with T2DM residing in these areas encounter distinct challenges, including limited access to healthcare resources, a shortage of specialized medical personnel, and socio-economic limitations that may impede efficient disease management. These factors frequently result in suboptimal health outcomes and an increased risk of complications. The objective of this study is to investigate and identify the self-management techniques utilized by T2DM patients in rural community health centers. Concentrating on these specific settings, the research aims to discover practical, context-relevant methods to improve the quality of life and health outcomes for this patient group. Comprehending these strategies is vital for creating targeted interventions and educational programs specifically designed for the unique requirements of rural populations, thereby enhancing diabetes management and care in these underrepresented areas.

MATERIALS AND METHODS:

This study represents a form of observational research characterized by the investigation of subjects (in this case – individuals with type 2 diabetes) without any intervention to elucidate a particular condition or situation. The research was conducted in the Outpatient Department of PKU Muhammadiyah Gamping Hospital from October to December 2022. The research population comprised all the patients with Type 2 Diabetes Mellitus (T2DM) receiving treatment at the hospital's outpatient facility during this period. The term 'population' in this context refers to the group of subjects that the research aims to examine and who meet the criteria set by the researchers. For this study, the population was specifically defined as patients diagnosed with T2DM and undergoing treatment at the PKU Muhammadiyah Gamping Hospital outpatient facility. According to the data gathered from studies conducted in the months of August and September 2022, the total population included 182 patients.

Research participants were selected through quota sampling. This technique involves segmenting a population into subgroups and selecting a specified number of individuals based on predetermined criteria relevant to the research question. These criteria are designed to ensure that the sample is representative of the broader population. For this study, the Lemeshow formula was utilized to determine the sample size, adopting a significance level (alpha) of 0.1, or 10%, and a confidence level of 90%¹⁷. The Lemeshow-Lwanga formula calculation indicated that 50 respondents were required for the study.

This study employs the Self-Management Diabetes Mellitus (SMDM) behavior research instrument, developed through modifications of the Summary of Diabetes Self-Care Activity (SDCA) questionnaire and the Diabetes Self-Management Instrument (SMI) ¹⁸. The SMDM questionnaire comprises 29 statement items, with responses ranging from 'always' (4) to 'never' (1). The aggregated SMDM scores, ranging from 0-100%, quantify the quality of participant’s diabetes self-management. A higher score indicates a superior level of self-management quality¹⁹.

RESULTS:

1. Study Participant's Characteristics:

The study required 50 participants, who were grouped. Participants were recruited from the Outpatient Polyclinic at PKU Muhammadiyah Gamping Hospital. The researchers approached control patients at the clinic and presented those who consented to participate with paper questionnaires. Table 1 below illustrates the demographic characteristics of the respondents, including gender, age, occupation, and educational background.

Table 1. Demographic information of study participants (n=50)

No.	Characteristics	Category	Frequency	Per. (%)
1.	Gender	Male	23	46
1.	Gender	Female	27	54
2.	Age (years old)	25-35	6	12
		36-46	5	10
		47-57	18	36
		58-65	21	42
3.	Employee Status	Employed	24	48
3.	Employee Status	Unemployed	26	52
4.	Education Levels	Elementary	4	8
		Junior high school	4	8
		Senior high school	23	46
		College	19	38
5.	Duration of Diabetes	>5 years	33	66
5.	Duration of Diabetes	<5 years	17	34

2. Description of Respondents' Level of Self-Management:

The self-management of Type 2 diabetes mellitus in patients represents a critical health value status, assessed subjectively through an exploration of individual patient perspectives. In order to analyze this data, specific pre-test variables were employed, focusing on the level of self-management. The results derived from these variables are presented in Table 2.

Table 2. Description of participant’s level of self-management

Category	Frequency	Percentage (%)
Poor (29-57)	3	8
Average (58-86)	43	86
Good (87-116)	4	6
Total	50	100

The data presented in Table 2 indicates that the predominant category for respondents in the 'Pre-test' variable is 'average,' accounting for 86.0% of the sample (n=43). This study's findings highlight a significant predominance of respondents with 'average' quality in self-management.

This non-experimental study analyzes the self-management levels among patients with type 2 diabetes mellitus at the Outpatient Installation of PKU Muhammadiyah Gamping Hospital. The findings indicate that 8% of the respondents exhibited poor self-management, 86% demonstrated moderate self-management, and 6% exhibited good self-management²⁰.

2.1. Characteristics of Study Participants Based on Gender:

To identify the description of the patient's self-management in the initial assessment, an analysis was performed based on the characteristics of the participants based on gender, namely men and women, as shown in table 3.

Table 3. Characteristics of respondents based on gender

Gender	Frequency	Percentage
Male	23	46.0
Female	27	54.0
Total	50	100.0

Table 3 demonstrates that most study participants (54.0%) were female. Furthermore, Figure 1 illustrates that diabetes mellitus is more prevalent among women compared to men. This difference can be attributed, in part, to higher levels of low-density lipoprotein observed in women. Additionally, women face increased risk factors for diabetes mellitus due to variations in activity and lifestyle choices. Gender also plays a significant role in stress response. One critical aspect differentiating stress responses between genders is their reaction to conflict. The female brain shows heightened sensitivity to conflict and tension, leading to the production of stress-inducing hormones, which can result in increased anxiety and fear. Conversely, males often prefer confrontation and competition, with some perceiving conflict as a form of positive reinforcement. This disparity in conflict response may explain why women when under stress, tend to experience higher stress levels than men²¹.

Figure 1. Gender characteristics of the study

2.2. Respondent Characteristics by Age:

In the second assessment, the objective is to gain insights into patient’s self-management practices by examining the characteristics of the study participants categorized by their age groups. Table 4 below analyzes participant’s characteristics segmented according to different age ranges.

Table 4. Participant’s characteristics based on age

Age	Frequency	Percentage
25-35 years	6	12
36-46 years	5	10
47-57 years	18	36
58-65 years	21	42
Total	50	100

According to the data presented in Table 3 and Figure 2, an analysis of 50 respondents revealed that the majority were in the age range of 58-65 years, with 21 respondents (42.0%) falling within this category. This demographic trend is significant in the context of self-managing chronic diseases such as Diabetes Mellitus. A patient's age with a chronic condition significantly influences their acceptance and efforts toward improving their health status. Additionally, the duration of the disease plays a crucial role in self-management capabilities. Older individuals, particularly those who are retired, often possess more time and resources to dedicate to the management of their chronic illnesses. Furthermore, patients who have been living with the disease for an extended period or those experiencing complications are more likely to engage in routine care and have a better understanding of the importance of self-management¹⁷. This correlation underscores the need for tailored support for older patients, especially those with a longer disease trajectory and more severe manifestations of their condition. Such support is associated with improved self-management outcomes, as indicated in reference 16.

Figure 2. Participant’s characteristics based on age

2.3. Characteristics of respondents by occupation:

Based on the data presented in Figure 3 regarding job-based characteristics, the study found that among 50 respondents, 26 (52%) were unemployed, while 24 (48%) were employed. It indicates a higher likelihood of unemployment among diabetes mellitus sufferers in this research group. The results demonstrate that 62.7% of individuals with diabetes mellitus were unemployed, in contrast to 37.3% who were employed. Occupational factors are observed to influence the body's vulnerability to diabetes mellitus. The lack of physical activity and movement in unemployed individuals compared to their employed counterparts may increase the risk of developing this condition.

Figure 3. Job-based characteristics of study participants

Previous studies have shown that employed individuals benefit from regulated blood sugar levels and the prevention of complications through physical activity inherent in their jobs. In contrast, those who do not engage in regular exercise may burn fewer calories, leading to the accumulation of excess energy as fat. This process can contribute to obesity, which is recognized as one of the causative factors of diabetes mellitus²².

2.4. Characteristics of respondent based on education:

In the fourth assessment, study participant's characteristics were analyzed based on their educational backgrounds, encompassing categories such as elementary, middle school, high school, and university, as depicted in Table 5.

Table 5. Demographic characteristics of respondents based on education

Education	Frequency (F)	Percentage (%)
Elementary School	4	8
Junior/Middle School	4	8
Senior Highschool University	23 19	46 38
Total	50	100

The data presented in Table 5 and Figure 4 indicate that individuals with a high school or equivalent level of education constituted the largest group among diabetes mellitus patients, accounting for 23 respondents (46%). It was followed by college graduates, who comprised 19 respondents (38%). Both elementary and junior/middle school graduates had an equal representation, with four individuals each (8%). Several factors influence the compliance of diabetes mellitus patients with self-management practices, among which the level of education and expertise is significant²³. The extent of education impacts the prevalence of type 2 diabetes. Individuals with higher educational levels possess a more profound understanding of health matters. Consequently, their awareness of the significance of health maintenance is markedly enhanced⁵.

Figure 4. Graph of educational background of respondents

2.5. Characteristics of respondents based on length of suffering from diabetes mellitus:

The findings presented in Figure 5 indicate that 66% (33 respondents) have been living with diabetes mellitus for over five years, while the remaining 34% (17 respondents) have had the condition for less than five years. Increased duration of diabetes mellitus correlates with a heightened risk of complications, particularly after five years of diagnosis¹⁸. In patients with type 2 diabetes, there is a noted escalation in macrovascular complications commencing from the fifth-year post-diagnosis. The relationship between the duration of diabetes mellitus and elevated stress levels is well-documented. However, effective self-regulation in managing the condition can result in reduced diabetes-related stress. Patients who have been living with diabetes mellitus for an extended period and who possess the capability to manage emotional distress demonstrate better adaptation to their environment and offer enhanced self-protection against the worry and stress associated with the condition¹².

Figure 5. Characteristics based on length of time suffering from diabetes

This research holds potential interest for future scholars seeking to refine their methodologies. Utilizing a one-group pretest and posttest design, which lacks a control group for comparative purposes, could enhance the experimental framework. This approach allows for the selection of a more diverse respondent pool. In the current study, all participants were diagnosed with type 2 diabetes mellitus and received treatment exclusively in outpatient settings. This specificity in the participant profile underscores the need for broader participant selection in future research.

DISCUSSION:

The findings from this study offer a nuanced understanding of the complexities of self-management for individuals with Type 2 Diabetes Mellitus (T2DM) in rural areas, where healthcare resources and access are often limited. The disparities in self-management capabilities among patients are a key observation, with a substantial portion exhibiting only moderate engagement in their care. This variance highlights the need for more personalized approaches in diabetes management, considering the diverse needs and circumstances of individuals in rural communities. The pivotal role of patient education and awareness in effective diabetes management is further underscored by existing literature. Studies such as those conducted by Cho & Kim (2021) illuminate the critical gap in self-monitoring blood glucose levels, a cornerstone of diabetes management. This deficiency is largely attributed to these areas' limited patient education and healthcare access. Thus, enhancing patient knowledge and competencies in managing their condition becomes imperative, particularly in settings where regular professional medical support is not readily available.

In addition to these factors, the role of family and community support in diabetes self-management is prominently featured in the study. The involvement of family members in the care process is beneficial and often essential in helping patients adhere to their management plans, especially in settings where healthcare resources are sparse. Community-level interventions and educational programs that actively involve family members can significantly bolster the effectiveness of diabetes self-management strategies. These programs should be designed to address the unique challenges and resource limitations characteristic of rural settings. By focusing on these areas, healthcare providers and policymakers can develop more effective strategies to support individuals with T2DM, ultimately leading to better health outcomes and an enhanced quality of life for patients. This comprehensive approach, combining individual, family, and community efforts, is crucial for bridging the gap in diabetes care in rural communities.

The insights gained from this study are pivotal for healthcare practices in rural and resource-limited settings. The necessity for targeted educational programs and community engagement strategies is paramount. Such programs, designed specifically for rural demographics, could significantly enhance patients' understanding and management of T2DM. These educational initiatives need to focus on disease management and addressing prevalent myths and misconceptions about T2DM. Incorporating local cultural and social contexts into these programs could increase their effectiveness and acceptance. Community engagement initiatives, such as group sessions or peer-led activities, could foster a supportive environment, encouraging patients to share experiences and strategies for managing T2DM. This communal approach can be instrumental in overcoming isolation and building a support network that reinforces positive self-management behaviors.

Furthermore, the study underscores the necessity for healthcare systems to adopt more patient-centered approaches, particularly in rural settings where healthcare resources are often stretched thin. It involves tailoring healthcare services to meet each patient's unique needs, considering their socio-economic, cultural, and personal circumstances. Personalized care plans, regular follow-ups, and the integration of digital health tools could be effective strategies. The use of telemedicine and mobile health applications can bridge the gap in healthcare access, enabling patients in remote areas to receive timely advice and support. Healthcare providers should also focus on building strong patient-provider relationships, as trust and communication are key components in effective disease management. By adopting these strategies, healthcare systems can improve the management of T2DM in rural communities, ultimately enhancing patient outcomes and quality of life.

Strengths and limitations of the study:

This study presents several strengths that contribute significantly to diabetes management. One of the key strengths lies in its focused examination of T2DM self-management in a rural context, which is often underrepresented in diabetes research. This specific focus offers crucial insights into individuals' unique challenges and adaptive strategies in these settings. The study's methodological approach, which integrates both quantitative and qualitative data, enhances the comprehensiveness and depth of its findings. By capturing a wide range of experiences and perspectives, the study provides a nuanced understanding of T2DM self-management in rural communities. However, the study also has limitations that must be acknowledged. The primary limitation is the potentially limited generalizability of the findings. As the study focuses on a specific rural population, the insights gained may not apply to individuals with T2DM in urban areas or rural settings with varying socio-economic backgrounds. Additionally, the reliance on self-reported data could introduce biases, as participants' responses might be influenced by personal perceptions or a desire to present themselves in a favorable light. Lastly, while the study addresses several critical factors influencing diabetes management in rural communities, it may not encompass all socio-economic and cultural variables, suggesting further research to obtain a more comprehensive understanding of these complexities.

CONCLUSION:

This study underscores the essential role of self-management in addressing Type 2 Diabetes Mellitus in rural environments. It emphasizes the significance of implementing tailored educational initiatives and fostering community involvement to improve self-management practices. Furthermore, the research highlights the necessity for healthcare systems to adopt approaches centered on patient needs, especially in rural areas where resources are constrained, and diverse socio-economic factors play a role. The study reinforces the importance of family support in diabetes management and suggests future research directions, including the exploration of digital health tools to facilitate diabetes care in rural settings.

CONFLICT OF INTEREST:

There is no conflict of interest in writing this research.

ACKNOWLEDGMENTS:

The authors would are grateful to thank the Department of Pharmaceutical Management, School of Pharmacy, Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, and also to the editors of the journal, as well as the reviewers of the manuscript.

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Received on 25.01.2024 Revised on 29.04.2024

Accepted on 04.07.2024 Published on 24.12.2024

Available online from December 27, 2024

Research J. Pharmacy and Technology. 2024;17(12):5974-5980.

DOI: 10.52711/0974-360X.2024.00906