FACTORS INFLUENCING COMPLIANCE TO DIETARY REGIMEN AMONG DIABETIC PATIENT IN LADOKE AKINTOLA UNIVERSITY OF TECHNOLOGY TEACHING HOSPITAL OSOGBO. BY FOLARANMI BASIRAT TEMITOPE

FACTORS INFLUENCING COMPLIANCE TO DIETARY REGIMEN AMONG DIABETIC PATIENT IN LADOKE AKINTOLA UNIVERSITY OF TECHNOLOGY TEACHING HOSPITAL OSOGBO.

FOLARANMI BASIRAT TEMITOPE

MATRIC NO: 082061

A RESEARCH SUBMITTED TO THE DEPARTMENT OF NURSING, COLLEGE OF HEALTH SCIENCES, LADOKE AKINTOLA UNIVERSITY OF TECHNOLOGY, OSOGBO.

IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF BACHELOR OF NURSING SCIENCE

(BNSC)

JANUARY, 2013.

CERTIFICATION

This is to certify that Folaranmi Basirat Temitope, Matric No……..……carried out this research under my supervisor.

B.L. AJIBADE _______________

(Rn, Ph,D, FWAN) Signature & Date

Supervisor

FOLARANMI BASIRAT TEMITOPE ________________

Student Signature & Date

Dr. W.A. TIJANI

RN, RPHN, BNSC, MSc, PhD, FWAC ____________________

HEAD OF DEPARTMENT Signature & Date

DEDICATION

This study is dedicated to Almighty Allah and my beloved parent for their continual love and encouragement towards the success of this research. I wish you long life and prosperity (AMIN).

ACKNOWLEDGEMENT

I give all glory and adoration to Almighty Allah, the lord of the world, the long of the day of judgement, the most beneficent, the most merciful, for His guide and tutelage, over me throughout my training in Nursing Department, Ladoke Akintola University of Technology, Osogbo.

My unreserved thanks goes to my able, competent, enthusiastic, dynamic and indefatigable supervisor, or B.L. Ajibade for devoting his precious time to read and make necessary corrections before the final draft may God Almighty be with you in all your daily endeavours.

I would like to commend the effort of my parents, late Chief Mr. Folaranmi and Mrs. Folaranmi A.M for their parental support in making my dreams comes through. May you live long (matter) to reap the fruit of your labour in peace and good health.

Also, I equally extend my special thanks to the head of the department Dr. W.A. Tijani and other lecturers in the department for their unflinching support during the court of my study.

My profound gratitude goes to my loving, caring and understanding husband Mr Omolola Adams Olatayo, for his support financially, spiritually and morally, may God Almight continue to bless our union. My sincere apprication also go to my siblings, friends, loved one and colleagues most importantly Shittu Adebowale for their moral support and encouragement.

Conclusively, I also appreciate my respondents for taking time, to fill my questionnaire, God bless you all.

Folaranmi B.T.

ABSTRACT

This research work examined the factors influencing Compliance to dietary regimen diabetes patient in Lautech Teaching Hospital Osogbo. The study was carried out using descriptive design. A self designed questionnaire having three number of section, section A is the demographic Data containing seven items, section B is the knowledge on Diabetes and perception of dietary regimen containing Twenty-three items and section family support which contains six items, was administered to one hundred and nine (109) respondents that was chosen using purposive sampling technique. The finding shows that gender and type of management were not significantly associated with level of compliance to dietary regimen. Similarly it also revealed that educational status, family support and socio-economics status were significant to compliance to dietary regimen among, diabetes mellitus patient.

Sequel to the findings of this research, It was concluded that all efforts should be made to address factors like level of education, family support and socio-economic status etc, that influence the level of compliance of respondents toward there dietary the level of compliance of respondents toward there dietary regimen.

TABLE OF CONTENTS

FRONT PAGE i

CERTIFICATION ii

DEDICATION iii

ACKNOWLEDGEMENT iv

ABSTRACT v

TABLE OF CONTENT vi-ix

LIST OF TABLES

LIST OF FIGURES

CHAPTER ONE:

1.0 INTRODUCTION

1.1 BACKGROUND OF THE STUDY 1-2

1.2 STATEMENT OF PROBLEM 3

1.3 OBJECTIVE OF THE STUDY 3

1.4 SIGNIFICANCE OF PROBLEM 3-4

1.5 SCOPE OR DELIMITATION OF THE STUDY 4

1.6 DEFINITION OF TERMS 4-5

CHAPTER TWO:

2.0 LITERATURE REVIEW

2.1 INTRODUCTION 6

2.2 CONCEPTUAL LITERATURE REVIEW 6-27

2.2.1 THE MEANING OF DIABETES MELLITUS 6-7

2.2.2 CAUSES OF DIABETES MELLITUS 7

2.2.3 PATHOPHYSIOLOGY OF DIABETES MELLITUS 7-9

2.2.4 SIGNS AND SYMPTOMS OF DIABETES MELLITUS 9-10

2.2.5 DIAGNOSIS OF DIABETES MELLITUS 10-12

2.2.6 CLASSIFICATION OF DIABETES MELLITUS 13-14

2.2.7 TREATMENT OF D.M 4-19

2.2.8 DIETARY MANAGEMENT OF D.M. 19-22

2.2.9 NUTRITIONAL CARE 22-24

2.2.10 COMPLICATIONS OF D.M 24-27

2.3 EMPERICAL LITERATURE REVIEW 27-36

2.3.1 EMPERICAL STUDIES COMPLIANCE BEHAVIOR 27

2.3.2 NON COMPLIANCE TO DIET REGIMEN 27-28

2.3.3 FACTOR WHICH AFFECT COMPLIANCE TO DIET 29-30

2.3.4 INFORMATION NEEDED TO MAZIMIZE COMPLIANCE 30-31

2.3.5 FACTOR CONTRIBUTING TO PATIENT NOT

COMPLYING TO EATING AND DRINKING IN HOSPITAL 31-35

2.3.6 FACTORS INFLUENCING COMPLIANCE

TO DIETARY REGIMEN 35-36

2.4 CONCEPTUAL MODEL 37-41

2.5 CONCEPTUAL FRAMEWORK 41

2.6 RESEARCH QUESTIONS 42

2.7 RESEARCH HYPOTHESIS 42

CHAPTER THREE:

3.0 RESEARCH METHOLOGY

3.1 INTRODUCTION 43

3.2 RESEARCH DESIGN 43

3.3 RESEARCH SETTING 43

3.4 TARGET POPULATION 43-44

3.5 SAMPLE AND SAMPLING TECHNIQUE 44

3.6 PILOT STUDY 44-45

3.7 VALIDITY AND RELIABILITY OF THE INSTRUMENT 45

3.8 INSTRUMENT FOR DATA COLLECTION 45

3.9 TYPE OF DATA COLLECTION 45

3.10 LIMITATION OF THE STUDY 46

3.11 ETHICAL CONSIDERATION 46

3.12 ADMINISTRATION OF QUESTIONNAIRE 46

CHAPTER FOUR:

4.0 PRESENTATION OF RESULT

4.1 INTRODUCTION 47

4.2 PRESENTATION OF DATA IN TABULAR FORM 48-49

4.3 PRESENTATION OF DATA IN FIGURE 50-55

4.4 ANSWERING OF RESEARCH QUESTION 56

4.5 TESTING OF HYPOTHESIS 57-62

CHAPTER FIVE: DISCUSSION OF FINDINGS, SUMMARY, CONCLUSION AND RECOMMENDATION

5.0 INTRODUCTION 63

5.1 DISCUSSION OF FINDINGS 63-66

5.2 IMPLICATION FOR NURSES 66-68

5.3 SUMMARY 68-69

5.4 CONCLUSION 69-70

5.5 RECOMMENDATION 70

REFERENCES 68

Appendixes

Apendix i: Appendix for analysis of data

Appendix ii: Letter of permission to collect data/information

Appendix iii: Questionnaire.

Table 2.1: Showing type of insulin

Table 2.2: Showing some common sources of dietary fibres

Table 2.3: Showing selected sample meals for exchange lists

Table 2.5: Conceptual framework

Table 4.10: Showing demographic characteristic of the respondents.

Fig. 4-10 - 4.19 Showing knowledge on D.M & perception towards Dietary Regimen 50 - 55

Fig. 4.10: What is diabetes mellitus? 50

Fig. 4.11: If it can be treated through which means

can it be treated? 50

Fig. 4.12: Which of the means of treatment are you using? 51

Fig. 4.13: Have you been coping with dietary regimen given to you in the hospital? 51

Fig. 4.14: How often do you check your weight? 52

Fig. 4.15: Diabetes diet are expensive? 53

Fig. 4.16: Diabetes diet are complex? 53

Fig. 4.17: Diabetes diet causes diarrhea? 54

Fig. 4.18: Management of D.M is a daily discipline? 54

Fig. 4.19: Is any of your family members staying with them? 55

CHAPTER ONE

1.0 INTRODUCTION

1.1 Background of the Study

Diabetes Mellitus (DM) is derived from the Greek word ‘Diabeinnein’ meaning ‘To pass through’ describing copious urination, and Mellitus from the latin word meaning ‘sweetened with honey’ These two word signify sweetened urine or sugar in urine. Diabetes mellitus is a group of metabolic disease characterized by increased levels of glucose in the blood (hyperglycaemia) resulting from defects in insulin secretion, insulin action or both (American Diabetes Association (ADA, 2009). Normally, a certain amount of glucose circulate in the blood. The major sources of this glucose are absorption of ingested food in the gastro-intestinal tract and formation of glucose by the liver from food substances.

According to the (world Health Organization (WHO, 2008) DM, is a disease that occurs both in developed and developing countries. In developing countries like Nigeria DM affects over 1.5million people and in developed countries life in the United States more than 23 million people have diabetes mellitus, although about, one third of these cases are undiagnosed. In developed Countries, most patients having DM are over Sixty years of age but in developing Countries, diabetes mellitus is found to affect people in their prime. The number of people newly diagnosed with DM increases by about 1 million people per year (Centre for Disease Control and Prevention (CDC, 2008).By 2030, the number of cases is expected to exceed 30 million. (Centre for Disease Control and Prevention (CDC, 2008).

In 2000, the world estimate of the prevalence of DM was 171 million people and by 2030, this is expected to increase to more than 360 million. DM is especially prevalent in the elderly, as many as 50% of people older than 65 years and older account for almost 40% of people with DM (WHO, 2008).Minority of the populations are disproportionately affected by DM from 1980 through 2002, the age – adjusted prevalence of DM increased among all gender and race group but compared to Cavcasian, African. Americans and members of other racial and Americans are more likely to develop DM and they are at greater risk for many of the complications and have higher death rate due to DM (CDC, 2008). MD has far reaching and devastating physical, social and economic consequences including the following (Smeltzer & Bare 2008).

1. DM is the leading cause of non traumatic amputations, blindness in working age adults and end-stage renal disease (CDC 2008).

2. DM is the third leading causes of death from disease, primarily because of the high rate of cardio vascular disease (myocardial infection, stroke and peripheral vascular disease among people with DM)

3. Hospitalization rates for people with DM are 2.4 times greater for adults and 5.3 greater for children than for the general population.

The economic cost of DM continues to increase because of increasing health care costs and an aging population of half of all people who have DM are older than 65 years of age and are hospitalized each year because of the severe and life threatening complications which often contribute to the increased rate of hospitalization.

One can decide to carry out a research due to hunt having gone through these studies. I have seen that the kind of management given to diabetes client when been admitted into the hospital, they still come back to the hospital within a very short of time with one complain or the other. This prompted me to research the factors influencing the level of compliance to dietary regimen among diabetes patient in LAUTECH teaching hospital Osogbo.

1.2 STATEMENT OF THE PROBLEM

It has been discovered that majority of D.M patient having being discharged, within a short time they come back to the hospital either for problem or a complication associated with DM, and it has been discovered that majority of the D.M patient may either refuse to comply with the dietary regimen or find it difficult to purchase or cook the prescribed dietary regimen therefore this research tried to find our factors influencing level of compliance to dietary regimen.

1.3 OBJECTIVE OF THE STUDY

The objective of the study is to

1. Identify medical factors that are associated with compliance to dietary regimen.

2. Examine the factors that are associated with compliance along the gender variables.

3. Examine the support of significant others towards compliances with dietary regimen.

4. Identify the factors that are associated with compliance with dietary regiment through the level of education.

5. Examine the influence of socio-economic status towards compliance to dietary regimen.

1.4 SIGNIFICANCE OF THE STUDY

1. The result of the research will be communicated to the LAUTECH Teaching Hospital in order to have a policy on the compliance of client to dietary regimen at the diabetic clinic.

2. It will reduce the alarming incidence of complications due to non-compliance to dietary regimen.

3. It will enlighten diabetic client on the need for compliance to dietary regimen and to improve their attendance at diabetic clinic.

4. The outcome of the study shall also contribute to existing knowledge in planning nursing care and health education programmes for patients with diabetes mellitus.

1.5 SCOPE OR DELIMITATION OF THE STUDY

This study is delimited to D.M patients attending out patient clinic and in patient in Ladoke Akintola University Teaching Hospital, Osogbo, Osun State, before the respondent was selected he or she will have come to the hospital twice and was selected during the clinic. This research work will cover diabetic patients both male and female between the age of twenty year and fifty year plus, whether they have formal education or not.

1.6 DEFINATION OF TERMS

For the purpose of this study both operational and conceptional definitions have been adopted.

Compliance: This means that willingness to follow a prescribed course of treatment (www.the free dictionary.com) retrieved 28/12/2012.

Gender: This is a state of being male or female (en.wikipedia.org/wiki/Gender) retrieved 28/12/2012.

Low-Income Earners: are those patients that are earning less than minimum wage of the Country.

Attitude: It can be defined as a positive or negative evaluation of people, objects, event, activities, ideas, or just about anything in your environment (en.wikipedia.org/wiki/Attitude Retrieved 28/12/2012).

Diabetes Mellitus (D.M.) a disturbance in the oxidation and utilization of glucose, which is secondary to a malfunction of the beta cells of pancreas, whose function is the production and release of insulin. (Barbara 2009).

High Income Earners: According to this study they are those patients that their salaries are scaled using the minimum wage of the Country.

Dietary Regimen: Are the selected types of foods that are prescribed to help the treatment and management of DM.

Out Patients: This refers to clients who come from home to receive health education on the new life style, nutrient and medical treatment suitable for the improvement of their diseased condition.

Level of Education: This is the individuals’ academic qualification or attainment.

Family support: This is the assistance render by the family in terms of money, following the patient to the hospital, given moral support and even social support.

CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 Introduction

This part of the research deals with the review of pertinent literature, towards this end both empirical and conceptual literature review will be carried out.

2.2 Conceptual Literature Review

2.2.1 The Meaning of D.M.

DM is a group of metabolic disorder in which the body has a deficiency of and/or a resistance to insulin (Jerreat 2003). It is the most common endocrine disorder and is an insidious disease, with the risk of developing it increasing with age. It is a variable disorder of carbohydrate metabolism caused by a combination of hereditary and environmental factors and usually characterized by in adequate secretion or utilization of insulin, by excessive urine production, by excessive amounts of sugar in the blood and urine and by thirst, hunger and loss of weight (Merriam-webster, 2011, M-W. Com).

The term “diabetes mellitus” refers to a group of diseases that affect how the body uses blood glucose, commonly called blood sugar Glucose, is vital to one’s health because it’s an important source of energy for the cells that make up the muscles and tissues. It’s the brain’s main source of fuel. If one has DM, no matter what type, it means one have too much glucose in the blood, although the reasons may differ. Too much glucose can lead to serious health problems.

Chronic DM conditions include type 1 DM and type 2 DM potentially reversible diabetes conditions include prediabetes mellitus. When your blood sugar levels are higher than normal, but not high enough to be classified as DM and gestational diabetes, which occurs during pregnancy (http//www. Mayo clinic. Com, retrieved March 30, 2012).

2.2.2 Causes of D.M.

Insulin plays a very important part in regulating how much glucose is available in blood for energy and how much is stored away in the liver as glycogen insulin is an hormone produced by special collection of cells in the pancreas known as islet of langerhans. The islets of langerhans pour a lot of insulin into the blood stream after a large quantities of insulin are necessary to store excessive glucose in the liver (Hortwitz,2002).

2.2.3 Pathophysiology of D.M.

In DM something goes wrong. The islets of langerhans are damaged, not enough insulin is produced and instead of excess glucose being stored in the liver, it simply, accumulates in the blood stream, when the sugar in the blood rises above certain level of threshold, the kidney-excretes the excess sugar in the urine. Hence large quantities of urine are passed to get rid of the excess sugar. The excessive urination soon leads to thirst, while the continuous drain of glucose from the body depletes the tissues of their vital energy supplies.

In persons hereditarily disposed to DM persistent over eating and obesity coming on in middle age may lead to the on set of DM, which may be precipitated by an infection, an accident or by pregnancy.

In children, the exact cause of DM (Juvenile DM) remain unknown realm for medical scientists. The accurate and definite cause of the disease is still a mystery, though there is an accepted beliefs on it that it is due to some risk factors. Juvenile D.M. is basically a condition in which the body’s defence system attacks and damages its very own cells called Auto immune response when such a problem takes place, the vital cells in the pancreas that makes insulin cease to function resulting in the absence of the hormone (insulin) in the body. Insulin is a very important part in the energy processing in our body. It helps in the proper absorption of the sugar called glucose into the different cells in our body.

Some experts have suggested that juvenile DM may be called by heredity. According to scientists, people who have the genetic tendency to develop coxsackle, rubella and mumps viruses may also develop juvenile D.M. This is because such viruses can trigger the onset of the disease (www. What caused diabetes net reviewed on March 30, 2012).

Some conditions that damage or destroy the pancreas such as pancreatutis, pancreatic surgery or certain industrial chemicals can cause D.M.

Certain drugs can also cause temporary DM including corticosteroids, beta blockers and phenytoin. Rare genetic disorders (Klinefelter syndrome, Huntington’s cholera, wolfram syndrome, leprechaunism, Rabson-mendenhall syndrome, lipoatrophic diabetes and others) and hormonal disorders (acromegally, cushing syndrome, pheochromocytoma, hyperthyroidism, somatostatinoma, aldostaronoma) also increase the risk for D.M (Alemzadeh & wyatt 2007).

Carbohydrate foods are the main supplier of the blood sugar. If one eat more carbohydrate foods, the blood glucose level will go up, the level of inflammation in the body will go up too and inflammation is the cause of disease development including damages to beta cells of the pancreas. When damages of the beta cells happen some of the beta cells would die, others would try to work as hard they used to. However, the number of healthy beta cells has decreased and those damaged ones cannot work in their full capacity, thus damaged ones can not work in their full capacity, thus the production of insulin has decreased too. Therefore the blood sugar level would stay increased.

Excessive intake of carbohydrate foods also leads to gaining of weight (obesity) which predisposes one to D.M. so eating too much carbohydrate foods, especially those refined, processed foods including grains, grain products or flour products, starching foods such as potato, sweet potato and sugary foods and beverages including fruit juice with added sugars or high fructose corn syrup, sugars, cola are associated with the risk of obesity. D.M. and other disease including cancers. (Robert 2011, www carbohydrate can kill. Com. Reviewed March 30, 2012).

2.2.4 Signs and Symptoms of Diabetes Mellitus

The early symptoms of untreated diabetes are related to elevated blood sugar levels and loss of glucose in the urine can cause increase urine out put and lead to dehydration. Dehydration causes increased thirst and water consumption.

The inability of insulin to perform normally has effects on protein, fat and carbohydrate metabolism. Insulin is an anabolic hormone, i.e, one that encourages, storage of fat and protein. A relative or absolute insulin deficiency eventually leads to weight loss despite an increase in appetite. Some untreated diabetes mellitus patients also complain of fatigue, nausea and vomiting patient with D.M. are prone to developing infections of the bladder, skin and vaginal areas. Fluctuations in blood glucose levels can lead to blurred vision to lethargy and coma.

When the blood sugar level rises above 160 to 180mgld glucose passes into the urine when the level rises even higher, the kidneys excrete additional water to dilute the large amounts of glucose lost. Because the kidneys produce excessive urine a person with D.M. urinates large volumes frequently (polyuria). The excessive urination creates abnormal thirst (polydipsia). Because excessive calories are lost in the urine, the person loses weight, to compensate. The person often feels excessively hungry (polyphagia) other symptoms include drowsiness, decreased endurance during exercise.

In people with type 1 D.M. the symptoms begin abruptly and may progress rapidly to a condition called diabetic keto acidosis. Despite high levels of sugar in the blood, most cells can’t use sugar without insulin thus, they turn to other sources of energy far cells begin to break down, producing ketones, tonic chemical compounds that can make the blood acidic (keto acidosis). The initial symptoms of diabetic keto acidosis include excessive thirst and urination, weight loss nausea, vomiting, fatigue and particularly in children abdominal pain. Breathing tends to become deep and rapid as the body attempts to correct the blood’s acidity. The person’s breath smells like nail polish remover, without treatment, diabetic keto acidosis can progress to come, sometimes within a few hours.

People with type II D.M. may not have any symptoms for years is or decades, when insulin deficiency progresses, symptoms may develop, keto acidosis is rare. If the blood sugar level becomes very high (often exceeding 1,00mg/dl) - usually as the result of some super imposed stress such as an infection or drug the person may develop severe dehydration, which may lead to mental confusion, drowsiness, seizures, and a condition called non ketotic hyperglycaemic - hyperosmolar coma (Yin Yang 2002).

2.2.5 Diagnosis

The fact that insulin dependent diabetes mellitus (IDDM) is thought to result from interaction between genetic and environmental factors has lead to research methods directed at prevention, early diagnosis and early control of the disease. These methods include the identification of generically susceptive and early intervention in newly diagnosed person with D.M.

The use of fasting plasma glucose (FPG) only has been proposed for the screening and diagnosis of diabetes, but its sensitivity has been reported to be unsatisfactory. The use of HbA1C, alone or combined with FPG, has been suggested for the screening of D.M. and impaired glucose tolerance (IGT) (Mannucci, 2003).

A fasting plasma glucose (FPG) test measures blood glucose in a person who has not eaten anything for at least 8 hours. This test is used to detect diabetes and prediabetes mellitus. An oral glucose tolerance test (OGIT): It measures blood glucose after the person drinks a glucose - containing beverage. This test can be used to diagnose diabetes and prediabetes mellitus.

A random plasma glucose test, also called a casual plasma glucose test, measures blood glucose without regard to when the person being tested last. This test, along with an assessment of symptoms, is used to diagnose D.M. but not prediabetes mellitus. Test result indicating that a person has D.M. should be confirmed with a second test on a different day.

The FPG test is the preferred test for diagnosing D.M. because of its convenience and low cost. How ever, it will miss some diabetes or prediabetes mellitus that can be found with the OGTT. The FPG test is most reliable when done in the morning. Result and their meaning are shown below.

Table 1: People with a fasting glucose level of 100 - 125 milligram per deciliter (mg/dl) have a form of pre-diabetes mellitus called impaired fasting glucose (IFG). Having IFG means a person has an increased risk of developing type 2 D.M. but does not have it yet.

A level of 12.6mg/dl or above, confirmed by repeating the test on another day, means a person has D.M.

Table 1 FPG Test

Plasma Glucose Result (mg/dl) Diagnosis 99mg/dl or below – normal.

100 to 125mg/dl - pre-diabetes mellitus (impaired fasting glucose)

126mg/dl or above - D.M. confirmed by repeating the test on a different day.

OGTT (Oral glucose toletance test).

Research has shown that the OGTT is more sensitive than the FPG test for diagnosing prediabetes mellitus, but it is less convenient to administer. The OGTT requires fasting for at least 8 hours before the test. The plasma glucose level is measured immediately before and 2 hours after a person drinks a liquid containing 75grams of glucose dissolved in water. Results and their meaning are shown in Table 2, if the blood glucose level is between 140 and 199mg/dl 2 hours after drinking the liquid, the person has a form of prediabetes mellitus called impaired glucose tolerance (IGT). Having IGT, like having IFG, means a person has an increased risk of developing type 2 D.M. but does not have it yet. A 2 hour glucose level of 200mg/dl or above, confirmed by repeating the test on another day means a person has diabetes.

Table 2: OGTT

2 – hours plasma glucose result (mg/dl) diagnosis 139mg/dl and below – normal.

140 to 199mg/dl – prediabetes mellitus (impaired glucose tolerance) 200mg/dl and above – D.M. confirmed by repeating the test on a different day.

2.2.6 Classification

DM may first appear to any age, its prevalence rises dramatically in other population from less than two cases per thousand children to almost two per hundred adult in their sixties (Horwitz, 2002). The national commission on D.M. in United States of America estimated that 16.5% of person aged 56 years and 26% of 85 years old are diabetics (Horwitz, 2002)

· Type 1 D.M. was previously called insulin dependent diabetes mellitus (IDDM) or juvenile - onset diabetes mellitus. Type 1 D.M. develops when the body immune system destroys pancreatic beta cells. The only cell in the body that make the hormone insulin, that regulate blood glucose. This form of D.M. usually strikes children and young adults, although disease onset can occur at any age. Type 1 D.M. may account for 5% to 10% of all diagnosed case of D.M. risk factor for type 1 D.M. may include auto immune, genetic and environmental factors.

· Type 2 D.M. was previously called non-insulin dependent diabetes mellitus (NIDDM) or adult onset diabetes mellitus. Type 2 diabetes mellitus may account for about 90% to 95% of all diagnosed cases of D.M. It usually begins as insulin resistance, a disorder in which the cells do not use insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce insulin. Type 2 D.M. is associated with older age, obesity, family history of D.M., history of gestational diabetes mellitus, impaired glucose metabolism, physical in activity and race/ethnicity. African Americans, is Hispanic/latino americans and some Asian Americans and native hawarians or other pacific islanders are at particularly high risk for type 2 D.M. Type 2 D.M. is increasingly being diagnosed in children and adolescents.

· Latent Auto immune Diabetes in Adults (LADA).

It is a type 1 diabetes mellitus diagnosed in adults over 30 years, sometime known as type 1.5 D.M. LADA is often misdiagnosed as type 2 D.M. because of age, however people with LADA do not have insulin resistance like those with type 2 D.M., a gradual increase in insulin requirements, positive antibodies and decreasing ability to make insulin as indicated by a low C-peptide. A fourth and very rare form of D.M. called monogenic D.M. is also sometimes mistakes for type 1 D.M. but typically strikes new borns.

· Gestational D.M. is a form of glucose intolerance that is diagnosed in some women during pregnancy. Gestational D.M. occurs more frequently among African Americans, Hispanic/latino Americans and American Indians. It is also more common among obese women and women with a family history of D.M. during pregnancy, gestation diabetes mellitus requires treatment to normalize maternal blood glucose levels to avoid complications in the infant. After pregnancy 5% to 10% of women with gestational D.M. are found to have type 2. D.M. women who have had gestational D.M. have a 20% to 50% chance of developing D.M. in the next 5 - 10 years.

· Other specific types of D.M. result from specific genetic conditions (such as maturity on set D.M. of youth), surgery, drugs malnutrition, infections and other illnesses such types of D.M. may account for 1% to 5% of all diagnosed cases of D.M.

2.2.7 Treatment of D.M.

The objective of the treatment is to help the patient to live a comfortable and useful life for as long as possible D.M. is a chronic disease which cannot be cured except in very specific situations. Management concentrates on keeping blood sugar level as close to normal (“euglycemia”) as possible without causing hypoglyceamia. This can usually be accomplished with diet, exercise and use of appropriate medications (insulin in the case of type 1 d.M. oral medications as well as possible insulin in type 2 D.M.)

· Patient education

Understanding the participation is vital since the complications of D.M. are far less common and less severe In people who have well managed blood sugar levels. Attention is also paid to other health problems that may accelerate the deleterious effects of D.M. These include smoking, elevated cholesterol levels, obesity high blood pressure and lack of regular exercise.

· Life Style

There are roles for patient education, deistic support, sensible exercise, with the goal of keeping both short term and long term blood glucose levels within acceptable bounds. In addition given the associated higher risk of cardio vascular disease. Lifestyle modifications are recommended to control blood pressure.

· Medications

Oral medications (Anti-diabetic medications) met form in is generally recommended as a first line treatment for type 2 D.M. as there is good evidence that it decreases mortality.

Routine use of aspirin however has not been found to improve outcomes in uncomplicated D.M.

Insulin - Insulin therapy

Type 1 D.M. is typically treated with a combinations of regular and NPH insulin (Neutral protamine Hagedorn/Aumulin N) or synthetic insulin analogs. When insulin is used in type 1 D.M. a long acting formulation is usually added initially while continuing oral medications. Dosage of insulin are then increased to effect (Rother 2007).

Transplantation: In recent years, researchers have focused increasing attention on transplantation for people with type 1 D.M. current procedures include.

pancreas transplantation - pancreas transplants have been performed since the late 1960s. Most are done in conjunction with or after a kidney transplant. Kidney failure is one of the most common complications of D.M. and receiving a new pancreas when you receive a new kidney may actually improve kidney survival.

Furthermore, after a successful pancreas transplant many people with D.M. may no longer need to use insulin, Unfortunately, pancreas transplants aren’t always successful. The persons body may reject the new organ days or even years after the transplant, which means the person will need to take immune suppressive drugs the rest of his/her life. These drugs are costly and can have serious side effect including a high risk of infection and organ injury. Because the side effects can be more dangerous to ones health than the D.M. transplantation is not always advisable unless the person is experiencing serious complications.

islet cell transplantation - pancreas contains about 1 million islet cells, 75 percent to 80 percent of which produce insulin. The beta cells that produce insulin reside in the islets. Although still considered an experimental procedure, transplanting these cells may offer a less inuasive, less expensive and less risky options than a pancreas transplant for people with D.M. (Mayo 2012).

· Treatment modalities for older patients

Treatment modalities available for older person with D.M. are not different from those used in younger patients. However a number of special consideration arise in their application to the elderly. For instance the person already being treated with insulin may as he grows older finds that stiffening joints make it difficult to fill the syringe accurately or warning visual acquity leads to insulin does errors. (Horwitz, 2002). If appetite decreases or the patient become too frail to eat regularly, glucose control may change even mild degree of senile dementia may lead to poor compliance by a previously consecutive patient or leading to increasing errors in diet or medications. Therapuetic modalities include diet, exercise, hypoglyceamic drugs (insulin or oral agents) and patient education (Horwitz, 2002).

Moreover, the initial manifestation in other patients are more subtle, a symptomatically and vague constitutional symptoms (loss of energy, fatigue) which make diagnosis and treatment difficult (Horwitz, 2002). A particular severe consequence of this may be non-ketotic hyperosmolar coma, which has high mortality rate if not promptly and effectively treated. In the absence of this life threatening presentation. However patients sometime do not accept the need for treatment. Insulin is destroyed by the gastric juice hence it cannot be given by mouth but has to be administered through subcutaneous injection, clear insulin known as soluble insulin, when injected leads to a fall in the blood sugar but it is short acting, that is why the use of intermediate and long acting insulin is included in the treatment.

TABLE 2.1: SHOWING TYPE OF INSULINE

TYPES OF INSULINE	ONSET OF ACTION (HRS)	PEAK OF ACTION	DURATION OF ACTION (HPS)
Short acting or regular acting	30 mins-1 hour	2-5hours	5-8hours
Intermediate Acting (NPH) N	1-2 hours	4-12 hours	18-24 hours
Long Acting (ultralented) (u)	30mins - 3hours	10-20hours	30-36 hours
Rapid Acting	15-30minutes	30-90minutes	3-5 hours
Pre-mixed (Humulin 70/30)	3.0 minutes	2-4hours	14-24 hours

Rapid-Acting insulin covers insulin needs for meals eaten at the same time as the injection. This type of insulin is used with longer acting insulin.

Short-Acting insulin covers insulin needs for meals eaten with 30-60 minutes.

Intermediate-Acting insulin covers insulin needs for about half the day or overnight. This type of insulin is often combined with rapid or short acting insulin.

Long-acting insulin covers insulin needs for about one full day. This type of insulin is often combined, when needed, with rapid or short acting insulin.

Pre insulins – these products are generally taken twice a day before meal time. They are combination of specific proportions of intermediate-acting and short acting insulin in one bottle or insulin pen (the numbers following the brand name indicate the percentage of each type of insulin) (Brunilda 2011).

NOTE: Insulin reacts differently in individuals and the above chart is intended only as a general guideline based upon. Insulin manufacturer, information. The peak and duration of insulin is affected by many things including individual response, time of the day, exercise, stress, sickness and content of a meal (high-fat means can lead to hypoglycemica).

· Diabetes Needing Tablet

Many adult patient who develop D.M. can be controlled with out resort to insulin. If they are overweight the weight need to be reduced through reduction in the caloric intake. This is referring to non-insulin dependent diabetes mellitus (NFDDM). Several types of sulphonylurea tablets are in common use to bring down the blood sugar. These compounds stimulate the pancreas to produce more insulin. Tolbutamide and glipizide have a short duration of action and are normally taken twice a day. Chloropropamide and tolazamide has a longer action and once a day is effective.

Glibenclamide has an intermediate strength of action, all these tablets are well tolerated by the patients. Unfortunately they became ineffective if the diet is not adhere to and they often give rise to increase in weight if the patients over eats. Since the development of insulin, oral agent and to some extent also antibiotics, there has been a considerable improvement in the survival rate and general prognosis for D.M. must accept a major role in the management of his diseased condition. His education must be updated continuously since D.M. is a long life disease.

2.2.8 Dietary Management of D.M.

A proper dietary management is the first and perhaps the most essential part of D.M. treatment. There is a list of dietary do’s and don’ts that are associated with D.M. In fact the dietary restrictions are so severe that it may lead to mental trauma. In the patient, and make the disease much more insufferable. Yet dietary management is extremely necessary for people who wish to keep their disease to a controllable level and to lead a longer life. The purpose of dietary management is to attain or maintain ideal body weight and ensure normal growth when insulin is given or taken special consideration must be given to ensure adequate carbohydrate intake to correspond to the time when the insulin is most effective and less carbohydrate when insulin is least effective (Smeltzer & Bare 2002).

Although diet cannot cure D.M. but at least it can be brought in control. Diet will help to monitor the level of the blood sugar. The following are some suggestions to make a health diet for controlling D.M. All bitter vegetables are excellent in reducing the blood sugar level. One must consume one bitter vegetable in every meal one take. One can choose between the vegetables such as bitter leave, bitter gourd and bitter variety of drumstick.

Sour foods containing high vitamin C in them are good for D.M. the Indian goose berry, popularly known as the Amalaki and a prime component of the Amalaki and a prime component of the Ayurvedic Triphala powder is very good in dissolving excess fats in the body and in bringing the blood sugar level down. Reduction of the total fat in take can be promoted/achieved by avoiding frying foods, instead try other options such as baking, roasting, steaming, grilling which requires little or no oil.

Red meats contain more fatty acids than white meats. Avoiding mutton pork and beef, but chicken and sea food are okay. The diabetic diet has traditionally been low in carbohydrate content. However recent studies have shown that the diet may be liberalized in this respect provided that complex carbohydrate are given (Smith, 2003) when given in amounts corresponding to 50g starch beans, in particular, raise the blood glucose level to only a small extent and less than various other food stuff tested (Smith, 2003) various vegetable provided about 50% of the plant fibre on diet, the content of insulin required by the patients was clearly reduced to maintain unchanged or even improve control.

This appeared that a diet rich in plant fibre and complex carbohydrate has definite advantage for diabetic patient. Recently studies clearly indicated that different sources of complex carbohydrate diet markedly different post prandial glucose and insulin response both in normal subjects and in subjects with impaired glucose tolerance (Smith, 2003)

In conclusion, treatment of D.M. with certain dietary fibre improve the diabetic control and also may be beneficial by virtue of the lipid reduction achieved (Smith, 2003). The diabetic diet is still in its developing stage. The function of different fibre fraction is not well known (Phillipson, 2003). It is wise to increase fibre food than to use supplements or fibre medications with a high fibre diet the diabetic patients can eventually decrease their insulin or tablet medication. Dietary fibre is defined as the substance in the cell wall, vegetable passing undigested through the upper part of the intestinal tracts no degradation taking place before they reach caecum (Phillipson, 2003). These are various type of fibre with different physiologic effect as it is shown below.

TABLE 2.2: SOME COMMON SOURCES OF DIETARY FIBRES

Fibre fraction sources

Cellulose	Bran, whole meal bread, dry beans nuts, and beefs
Hemi cellulose	Bran, whole meal, bread, raddish, beefs
Pectin Bran	Citrus fruits, apple, grapes, berries
Lignin	Bran, whole meal flour and nuts.

Adapted from (Phillipson, 2003) cellulose is made up of glucose units only, hemi cellulose also contains pentose while pectin, contains uronic acids. The fourth dietary fibre, lignin is not a carbohydrate in the cell wall (Phillipson, 2003).

Insulin, diet and exercise are the so called corner stones in joshns triad, which make up the means for good treatment in D.M. (holm & Strom bald, 2003). A diabetic diet must be sufficient in quantity to enable the patient to undertake his activities, to satisfy his appetite and to maintain his weight at a proper level A girl of slight physique learning a sedentary life may require a diet of 200chlories (8000kilo joules) a man doing a heavy labouring job may need 2,800chlories (11,500kj) or more. The diet must contain an adequate amount of protein (at least 75%) and carbohydrate (at least 180g). It must contain fruits and vegetables with a high fibre content, the meal must also be spaced during the day, with snacks in between meals, meals must be taken at regular times, as delayed meals may lead to hypoglycaemia attack. Compliance is best if diet is planned after a careful history to determine patient’s usual eating habits reduction of simple sugars may be the only change gradually rate than giving the patient a whole new diet at all once. It may be desirable to restrict fat consumption and emphasize polysaturated fats (Hortwitz, 2002).

2.2.9 Nutritional Care

Nutrition, meal planning and weight control are the foundation of D.M. management. The most important objectives in the dietary and nutritional management of D.M. are control of total caloric in take to attain or maintain a reasonable body weight, control of blood glucose levels and normalization of lipids and blood pressure to prevent heart diseases. Success in the area alone is often associated with reversal of hyperglycaemia in type 2 D.M. However, achieving these goals is not always easy. Because medical nutrition therapy (MNT, Nutritional management) of D,M. is complex. A registered dietitian who understands D.M. management has the major responsibility for designing and teaching this aspect of the therapeutic plan. Nurses and all other members of the health care team must be knowledgeable about nutritional therapy and supportive of patients who need to implement nutritional and lifestyle changes nutritional management of D.M. include the following goals American Diabetes Association (ADA, 2008b).

1. To achieve and maintain

v Blood glucose levels in the normal range or as close to normal as is safely possible.

v A lipid and lipo protein profile that reduces the risk for vascular disease.

v Blood pressure level in the normal range or as close to normal as is safely possible.

2. To prevent, or at least slow, the rate of development of the chronic complications of D.M. by modifying nutrient intake and lifestyle.

3. To address individual nutritional needs, taking into account personal and cultural preferences and willingness to change.

4. To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence.

For obese patients with D.M. (especially those with type 2 D.M.), weight loss is the key to treatment.

(It is also a major factor in preventing D.M.). In general, over weight is considered to be a body mass Index (BMI) of 25 to 29, obesity is defined as 20% above ideal body weight or a BMI equal to or greater than 30 (National Institute of health 2000). BMI is a weight to height ratio calculated by dividing body weight (in kilograms) by the square of the height (in metres).

Obese patients who have type 2 D.M. and who require insulin or oral agents to control blood glucose levels may be able to reduce or eliminate the need for medication through weight loss. A weight loss as small as 5% to 10% of total weight may significantly improve blood glucose levels (ADA, 2009b). For obese patients with D.M. who do not take insulin or sulfonylureas, consistent meal content or timing is important but not as critical. Rather, decreasing the overall caloric intake assumes more importance. However, meals should not be skipped spacing food intake throughout the day places more manageable demands on the pancreas.

Consistently following a meal plan is one of the most challenging aspects of D.M. management. It may be more realistic to restrict calories only moderately. For patients who have lost weight, maintaining the weight loss may be difficult. To help these patients in corporate new dietary habits into their lifestyles, diet education, behavioural therapy, group support and on going nutrition counseling are encouraged (Smeltzer & Bare, 2010).

Table 2.3: below give selected sample means from exchange lists

Exchange	Sample lunch 1	Sample lunch 2	Sample lunch 3
2 starch	2 slices bread	Hamburger bun	1 cup cooked pasta
3 meat	2 0z sliced turkey and 1 oz low fat cheese	3 oz lean beef patty	3 oz boiled stirimp
1 vegetable	Lettuce,Tomato,onion	Green salad	½ cup plum tomatoes
1 fat	1 teaspoon mayornaise	1 teaspoon salad dressing	1 teaspoon olive oil
1 fruit	1 medium apple	1 ¼ cup water melon	1 ¼ cup fresh stew barriers
“Free” items (optional)	Un sweetened iced tea mustard, pickle, hot pepper	Diet soda. 1 teaspoon, eat sup,pickle onions	Ice water with lemon, garlic basil.

2.2.10 Complications of D.M.

All forms of D.M. increase the risk of long term complications. These typically develop after many years (10-20 years), but may be the first symptom in those who have otherwise not received a diagnosis before that time (1) Diabetic ketoacidosis (DKA) is an acute and dangerous complication that is always a medical emergency. Low insulin level cause the liver to turn this ketone for five (i.e. ketosis) ketorne bodies are intermediate substance in the metabolic sequence. This is normal when periodic but can become a serious problem if sustained elevated blood level of ketone bodies decrease the blood’s ph, leading to DKA on presentation to the hospital. The patient with DKA is typically dehydrated, and breath rapidly and deeply, Abdomina pain is common and may be severe when DKA is severe it can lead to lethargy, hypotension, shock, brain oedema and death. Urine analysis will reveal significant level of ketone bodies (which have exceeded their renal threshold blood levels to appear in the urine, often before other over symptoms).

2.2.11 Hyperglycemia Hyperosomolar States (HHSS)

Non ketotic hyperosmolar coma/hyperosmolar non ketotic state (HNS) is an acute complication sharing many symptoms with DKA, but an entirely different origin and different treatment. A person with very high (usually considered to be above 300mg/dl (16mmol/l) blood glucose levels, water is osmotically drawn out of cells into the blood and the kidney eventually begin to dump glucose into the urine.

This result in loss of water and an increase in blood osmolarity. If fluid is not replaced (by mouth or intravenously) the osmotic effect of high glucose levels, combined with the loss of water will eventually lead to dehydration, electrolyte imbalance are also common and are always dangerous.

· Hypoglycemia, or abnormally low blood glucose, is an acute complication of several D.M. treatment. It is rare otherwise, either in diabetic or non-diabetic patients. Patient may become agitated, sweaty, weak and have many symptoms of sympathetic activation of the autonomic nervous system resulting in feelings a kin to dread and immbolized panic.

· Diabetic coma is a medical emergency in which a person with D.M. is comatose (unconscious) because of one of the acute complications of D.M. e.g. severe diabetic hypoglycemia, diabetic keto acidosis the advanced form, and hyperosmolar non ketotic come. The major long term complications relate to damage blood vessels D.M. doubles the risk of cardiovascular disease. The main “macro vascular diseases” (related to atherosclerosis of large arteries).

· Arteriosclerosis: Hardening of the arteries which leads to poor blood supply to the feet. A minor injury to toe may not heal on time and is prone to infection and eventually may also lead to gangrene with consequent amputation of the whole leg.

Stroke and peripheral vascular disease, angina pectoris and myocardial infarction are complication that are related to or due to damages to the vessel.

Macrovascular disease leads to cardiovascular disease to which accelerated atherosclerosis is a contributor.

Coronary artery disease leading to angina or myocardial infarction (“heart attack”).

v Diabetic myonecrosis (muscle wasting)

v Peripheral vascular disease, which contributes to intermiltent elaudication (exertion related leg and foot pain) as well as diabetic foot.

v Stroke (mainly the ischemic type)

D.M. also causes micro vascular complications damages to the small blood vessels.

Diabetic retinopathy! Which affects blood vessel formation in the retina of the eye, can lead to visual symptoms, reduced vision and potentially blindness. Diabetic nephropathy, the impact of D.M. on the kidneys can lead to scarring changes in the kidney tissue, loss of small or progressively chronic kidney disease requiring dialysis.

Diabetic neuropathy: Is the impact of diabetes on the nervous system, most commonly causing numbness, tingling and pain in the feet and also increasing the risk of skin damage due to altered Sensation. Together with vascular disease in the legs. Neuropathy contributes to the risk of skin damage due to altered sensation. Together with vascular disease in the legs. Neuropathy contributes to the risk of D.M. related to foot problem (such as diabetic foot ulcers) that can be difficult to treat and occasionally require amputation.

Respiratory infections: The immune response is impaired in individuals with D.M. cellular studies have shown that hyperglyemia both reduces the function, of immune cells and increases inflammation. The vascular effects of D.M. also tends to alter lung function, all of which leads to an increase in susceptibility to respiratory infections such as pneumonia and influenza.

Periodontal disease: D.M associated with periodontal disease (gum disease) and may make D.M. more difficult to treat. Gum disease is frequently related to bacterial infection by organisms such as porphyromonas gingivalis and actinobacillus and actinomycetem comitans. (Nathan & Mealey, 2006).

2.3 Empirical Literature Review

2.3.1 Emperical Studies of Compliance Behaviour

Compliance as related to diet: Can be defined as the extent to which a patient’s behaviour coincides with dietary advice (Wilkinson, 2008). Further in his studies reported that about 6-20% of patients fail to redeem their prescription and 30-35% delay or omit doses. Poor compliance may produce adverse effect on the quantity of medical care, may waste resources. Firstly, it interfered with therapeutic efforts by reducing the benefits of the preventive or curative services offered.

Secondly non-compliance to dietary regimen may cause unnecessary diagnostic and treatment procedures, thus generating further costs.

2.3.2 Non Compliance to diet regimen

Non compliance is defined as behaviour of person and/or care giver that fails to coincide with a health promoting or therapeutic plan agreed upon by the person (and/or family and/or community) and health care professional, what is important in the definition is that the patient for some reason (which will become the related factors) doesn’t follow it, making it behavioural issues.Factors affecting compliance, including the nurse/patient relationship, has allowed the evolution of “concordance”. Concordance views the patient as being the equal of the equal of the health care provider and as having a right to make informed decision. In a condition such as D.M. which has many potential long term complications, it is vital that concordance is embraced in the health care system. In order to improve care. D.M. is a life long disease condition that has a complex treatment, and requires behaviour changes on the part of the patient. If patient do not comply to the course of treatment and adjustment in the behavioural changes thus leads to complication from poorly controlled D.M.

Hence the holistic approach to the care of the control of D.M. is vital and will actually have a direct impact on the prevention of complication D.M.Rate of non-compliance vary with estimates ranging from 50% to 80%. Greater compliance may be associated with a decreased probability of diabetic complications. Non-compliance imposes an immense financial burden on modern health care systems. Such as the National Health Services (NHS), as well as imposing personal cost on the individual patient low compliance can have detrimental effects on medical research trials, reducing the value and the usefulness of studies.

Compliance can also be defined as the extent to which a patient’s behavour in terms of taking medication, following diets or implementing life style changes coincides with medical or health advice (Vermeire, 2011).

2.3.3 Factors which Affect Compliance to Diet

Factors which decrease compliance from the perspective of health care providers, therapeutic compliance is a major effect on treatment outcomes and direct Clinical consequences non-compliance is directly associated with poor treatment outcomes in patients with D.M.Poor compliance with dietary therapy is the most important reason for poorly controlled blood sugar level (Hajjar & Kotchen, 2008).

v The financial cost: Therapeutic non compliance has been associated with excess urgent care visits, hospitalizations and higher treatment costs; (Bond, Hussar & Suarstad, 2011). Some other factors that affect the compliance to diet regimen are patient centered factors, demographic factors, age, ethnicity, gender, education, marriage status, psychosocial factors, beliefs, motivation, attitude patient-prescriber relationship, health literacy, patient knowledge, physical difficulties, tobacco smoking or alcohol intake, forgetfulness, History of good compliance.

v Therapy - related factors: Preparation complexity, Duration of the preparation of the diets, degree of behavioral change required, taste of the diet quantity of food to be taken lack of accessibility.

v Social and economic factors: Inability to take time off work, cost and income, social support, disease factors, disease symptoms and severity of the disease (wal, wong, check, tan, chua, mak, Aung & Lims 2008). Non Compliance Due to Finance

From the investigation clinical exposure and experience affect the role of finance in the compliance to diet and during treatment regimen of D.M. can not be over emphasized. Many patients, who are well educated and known the implication of non-compliance to treatment are being in capacitated to produce expensive drugs (both oral agents and insulin, as well as expensive therapeutic diet that D.M. involved).

Therefore when patient cannot afford their medical care due to the high cost of treatment and cost of special diet is affecting compliance to such treatment. The economic barriers to medical care are the primary factors. There are so many cases in which the relative affordability of treatment affects degrees of compliance in patients who are able to pay at least some of their medical expenses.

There is no doubt that illness imposes a burden on our, resources in two ways. First resources are used up to prevent diagnosis and treat disease. These costs which include expenses of hospital care, consultations with physician , Nursing care rendered, drug diet, etc. are called direct economics costs. Secondly resources are lost because those afflicted by illness cannot take part in the production of goods and services, included in these indirect economic costs to the production cost due to short term illness permanent disability and death prior to retirement age. Smith (2012) state that failure to adhere to treatment instruction has been estimated to be reason for 25% of all Australians hospitals administration leading to avoidable examples

In conclusion, the investigation has been able to discuss D.M. extensively in this review in terms of its meaning, causes clinical manifestation, diagnosis, types or classification, treatment modalities in both IDDM and NIDDM, dietary management, exercise, complication and the meaning of compliance and non compliance as it affect D.M. factors which decreased it. Compliance factors which affects, its compliance, its non-compliance to drug and diet.

2.3.4 Information Needed to Maximize Compliance

Patients must be given the opportunity to tell the story of their unique illness experiences. Knowing the patient as a person allows the health professional to understand element that are crucial to the patients compliance, beliefs, attitudes, subjective norms, cultural context, social supports and emotional health challenges, particularly depression, physician - patient partnership are essential when choosing among various therapeutic options to maximize compliance.

Mutal collaboration fosters greater patient satisfaction, reduces the risks of non adherence, and improves patients health care outcomes.

The advice given to patients by their health care professionals to cure or control diseased condition is too often misunderstood, carried out incorrectly, forgotten or even completely ignored so this can be avoid by given the patient adequate, understand and using appropriate language the patient can understand when caring for them (Dimateo 2008).

2.3.5 Factors Contributing to patient Not Complying to Eating and Drinking in

Hospital

Problems with ordering of food is the first factor, patients should be given a choice of meals few when a special diet as the case in D.M. patient, they should be allowed to choose from their local diets that are not control indicated to their ailment in correct proportion.

Communication must be effective between the Nursing staff, catering staff and the patients. In some hospital, the distribution and collection of meals is shared by Nursing staff. For instance nurse may dish out the mutals and the catering staff may clear them away. Problem may arise because there is no system for monitoring and reporting whether food has been eaten, to the Nursing staff. For the out patient, the close relatives and friends should be educated on how to comply with the dietary, regimen for the majority of people the general appearance of a meal is important and contributes to whether or not a person will eat it. People who are ill often experience a loss of appetite, so the appearance of meals takes on great significance. A lack of variety of food on the menu can also have effect on patients. Unfortunately for developing Countries like Nigeria, not many people will be able to afford varieties because of the poor economic situation.

Food should be contently prepared and appropriate to patients needs. The available food may be unsuitable for patients with specify dietary requirement. For example, people from minority ethnic group may not be catered for and the Vegetarian. Moreover, a Yoruba man, in Nigeria for example may find himself being hospitalized in a hospital in a far Northern part of the Country or far Eastern part of the Country there is no doubt that such a patient will be confronted with problem of non-compliance with his diet. Therefore, patients should be asked about their personal dietary needs before admission so that his/her special diet will be tailored towards his food preference and this will enhance dietary compliance.

It is often suggested that hospitals should serve meals at times of the day which reflect the normal eating time of the majority of people instead of being dictated by the need of the catering and Nursing staffs, some hospitals give a wide gap before serving another meal. This wide gap is frequently a cause for compliant among many patients, eating environment in which meals are served plays an important role in whether or not patients eat their meals wherever possible, patient should be given the choice of eating in a designated dining area. Some people may be embarrassed about their eating habits and may want to eat alone. Other group of people may not feel able to socialize at meal time e.g. depressed patients and alternate place is suggested for these type of patients.

Dietary recommendations for the management of D.M. have changed over the past 16 years. There is now a reduced emphasis on the importance of carbohydrate in the diet.

v Non Compliance Due to Finance

There is no doubt that illness imposes a burden on our, resources in two ways. First resources are used up to prevent diagnosis and treat disease. These costs which include expenses of hospital care, consultations with physician, Nursing care rendered, drug diet, etc. are called direct economics costs. Secondly resources are lost because those afflicted by illness cannot take part in the production of goods and services, included in these indirect economic costs to the production cost due to short term illness permanent disability and death prior to retirement age. Smith (2012) state that failure to adhere to treatment instruction has been estimated to be reason for 25% of all Australians hospitals administration leading to avoidable examples.

A cross sectional study was conducted and multistage stratified random sample method was used for the selection of 600 diabetic patients. Data were collected by means of an interviewing questionnaire, an observation checks list, review of prescriptions and laboratory investigations. A scoring system was made for a diabetic patient is knowledge and skills, patient’s compliance, doctor - patient relationship, and glyemic control. Result showed that about 57% always took their medication as prescribed by doctor and on time, only 2.2% always complied with dietary regimen, while no one reported regular compliance with exercise regimen. Complications of the regimen were the exercise regimen. A complication of the regimen was the commonest cause (63.3%) of non compliance. A highly statistically significant difference was found between compliance with all regimens and patients knowledge of diabetes. The scores for doctor patient relationship were all unsatisfactory results of glycosylated hemogloblin (HbAIc) revealed that metabolic control of four - fifth of the patients was satisfactory, 12% had fair and 8% had poor metabolic control.

The personal and socio-demographic characteristics of the sample of 600 diabetic patients indicated that men represented 48.3% of the sample while women formed 51.7%; the men to women ratio being 1:11. The age of diabetic patients ranged from 25 to 81years, with a mean age 47.688+11.94 years. Marriage patients comprised 83.0% and 10.8% were single. About one-third (34.5%) of diabetic patients were illiterate and 42.2% were manual workers.

An analysis of result revealed that about two third (64.3%) of the sample got their knowledge from physicians, 19.3% from nurses, 18.7% from relative and 4.8% from other diabetic patients. Most patients gave more than one cause for non-compliance. About two third of patients (63.3%) said that the non-compliance was because they did not understand the drugs lack of knowledge about drugs was mentioned by 51.3% whereas the reason were financial for 27% of the patient www. Tochi. Nmmh - gov > journal list > J family common med > 11.17(3)l 01/09/12.

2.3.6 Factors influencing compliance to dietary regimen

patient satisfaction to the service given to them, diet and drug supervision by Nurses and Physicians, patients expectations, been met, physicians accept patients family agrees with physician degree of disability, adapted from nursing times, 2003 (by Barbara).

2.3.61 Information needed to maximize compliance

Food that the patient can avoid.
Some drugs react with certain foods and may make a patient feel III or pose a potential danger. The patient must know and understand the reason why these foods should be avoided.
The kind of food they should be eating should be explain to them, hell them the component and the importance of the food to there health. The mode of preparation.
The kind of language that will be understood by the patient should be used during health education or explanation to aid effective communication.

If the patient is unable to read the information and instructions on the label, it must be explained to the patient and his understanding of the instruction must be assessed list of food should be given to them and it should be made available in different languages they can understand and it should include food they can be eaten and those they should avoid. The reason for the avoidance should be stated and the complication of non-avoidance or adherence to the diet should be explained to them.

· Clients should be taught the means of preparation of the food and the places where the can get the food items and the diet regimen should be communicated to them.

For the successful attempts to improve patient compliance depend upon a set of key factors. These include realistic assessment of patient’s knowledge and understanding of the regimen, clear and effective communication between health professionals and their patients and the nurturance of trust in the therapeutic relationship. Patients must be given the opportunity to tell the story of their unique illness experiences. Knowing the patient as a person allows the health professional to understand element that are crucial to the patients compliance, beliefs, attitudes, subjective norms, cultural context, social supports and emotional health challenges, particularly depression, physician – patient partnership are essential when choosing among various therapeutic options to maximize compliance.

Mutual collaboration fosters greater patient satisfaction, reduces the risks of non- adherence, and improves patients health care outcomes. The advice given to patients by their health care professionals to cure or control diseased condition is too often misunderstood, carried out incorrectly, forgotten or even completely ignored so this can be avoid by given the patient adequate, understand and using appropriate language the patient can understand when caring for them (Dimateo 2004).

2.4 Conceptual Model

The theoretical framework for this study shall be behavior models by (Jacqueline Dunbar 2007). Management of diabetes typically requires the patient to make frequent alterations in her or his diet, physical activity level, glucose measurement. Schedule and medication administration. To encourage these changes or behaviour and to instruct patients on how to do so safely, the clinician must have a sound understanding of the relationship between the treatment elements and the clinical outcome they produce. In addition, most people with diabetes also have other conditions that require specific management regimens. Minimizing the patient’s self care burden by integrating the regimens can be a challenge for the diabetes educator.

2.41 Common Element In Behaviour Change Models

There are only a few effective strategies for promoting and sustaining behaviour change in people who have diabetes mellitus and con-comitant chronic conditions. These strategies usually basic education (to address low health literacy), help with setting goals, engendering a sense of control (self-efficacy), arranging for professional or social support and providing feed back. All successful models begin with clearly defining the desired change or behaviour, establishing a baseline and encouraging the patient to self monitor her or his progress. In most cases multiple interventions are necessary and only modest changes in behaviour can be espected.

2.42 Specifying the Behaviour

Instructing someone to “increase exercise” or “take your medication” and to work toward clinical goals such as “lower your cholesterol” are unlikely to be helpful. Patients are unlikely to change unless they are given aspeutic description of the behaviour to be undertaken. For example, saying walk at your normal pace for 30 minutes five days a week, either for 30 minutes at one time or for 15 minutes twice a day” gives patients a concrete goal on that clinicians then can use to monitor behaviour and evaluate its contribution to clinical outcomes.

2.43 Encouraging Self-monitoring

In all models of behaviour charge assessment is critical. It is important for the clinician to understand the patients existing behaviour and to establish the baseline behaviour. It’s not enough for the patient to know what to do and intends to do it, what matters is what the patient does how often, and under what conditions. It’s crucial for the clinician to understand the circumstances (environmental, social, financial and attitudinal) that help or hinder the patient in making changes. For example, the patient may not have the financial resources to join a health club and may live in a neighborhood that is unsafe for outside exercise or even walking on the other hand, the patient may live a 10 minutes bus ride form a community center with a gym where she or he can begin using an exercise bike. Understanding these circumstances can help the clinician and patient plan for behavior change.

Because memory for the specific details of behavior (what, when, how and under what circumstances) tends to be poor. Some form of recorded self monitoring is needed. For example, the patient may keep a daily or complete a daily checklist of activities. Self monitoring is very useful, but its requires the patient to recognize and record her or his behavior.

2.44 Help with setting goals

Research suggests that setting specific goals leads to greater behavior change than having vague or no goals. The patient must be interested in achieving the goal and it should not conflict with other goal. The patient must be interested in achieving the goal and its should not conflict with other goals. In complex situations such as a regimen designed to treat multiple conditions, including D.M. It is important that there be sub goals, a strategic plan for moving toward them and regular feed back on performance. Goals should be challenging but attainable, taking into account the person’s ability and perceived sell efficiency.

2.45 Engendering self-efficacy is critical for successful behavior change.

According to Bandura (2002) “Perceived self, efficacy is defined as people’s judgments of their capabilities to organize and execute courses of action required to attain designated types of performances. It is not concern with the skills one has self-efficacy theory suggests that goals should be attainable in the near future, because immediate success can provide motivation and enhance efficacy. Indeed, the strongest influence on self-efficacy is mastery. Successfully completing easy tax does not strengthen efficacy on the other hand failure can harm it.

2.46 Developing knowledge

To change behavior, the patient must understand what to do and how to do it. The patient needs enough knowledge to adjust the treatment or prevention regimen in response to changing circumstances. Learning relies heavily on the educator’s ability to adapt teaching strategies to the individual and on the patients ability to process information. Because poor glycemic control and cognitive dysfunction are associated, it is among the numerous tactors that can affect the ability of the patient with D.M. to process information. Health literacy the ability to apply skills such as reading and interpreting medication labels to functioning effectively as patient also contributes to the patient’s ability to comprehend and apply knowledge to modifying behavior. Patients with poor health literacy often do not understand dosing instructions and are not able to interpret a blood glucose value.

Instructional strategies can make it easier for the patient to change her or his behavior perhaps the most important strategy is to teach only a small amount at time just enough to support behavior change. The instructor should focus on the behavior and how to carry it out correctly, rather than on the reason for the change language should be simple group information into categories has been shown to increase recall. For example “let’s talk about self monitoring of what you eat. First we’ll review what goes into a food diary, next we’ll talk about when to do the recording. Then we’ll discuss how to review the diary to identify problem areas.

2.47 Giving Feed Back

Allow patients the opportunity to demonstrate their understanding and then give them feed back on their progress. Feed back may consist of verbal comments, modeling, or demonstration or chart or other graphics, such as a checklist for medication wage.Bandura (2002) noted that the type of feed back that is best varies according to the stage of behavior change initially, feed back should support the patient’s capabilities, as skills develop, feed back should be informative, with the educator advising the patient in a way that enhances suggested that feed back focus on the individual comparing the patient’s current performance to her or his past behavior rather than to that of other patients.

In conclusion, the investigation has been able to discuss D.M. extensively in

this review in terms of its meaning, causes clinical manifestation, diagnosis, types or classification, treatment modalities in both IDDM and NIDDM, dietary management, exercise, complication and the meaning of compliance and non compliance as it affect D.M. factors which decreased it. Compliance factors which affects, its compliance, its non-compliance to drug and diet. Information needed to maximize compliance.

2.5 Conceptual framework

Dependent Variables

2.51 Application of the framework

As earlier discussed Jacqueiline Dunbar Model said that management of diabetes typically requires the patient to make frequent alternations in his or her diet, physical activity level, glucose measurement, Schedule and medication administration.

However, various factors like unemployment status (finance) attitude of the care givers, cultural belief, family support, socio - economic status, level of education, contribute to the poor compliance of diabetic patient to dietary regimen at the diabetic clinic. The compliance can therefore be improved in all the intervening variables are properly controlled by the client.

2.6 Research Questions

1. Will the level of education affect level of compliance to dietary regimen among diabetic patients?

2. Will the gender influence level of compliance to dietary regimen among diabetic patients?.

3. Will the level of family support have anything to do with level of compliance to dietary regimen among diabetic patients?.

4. Will the socio-economic status influence level of compliance to dietary regimen among diabetic patients?.

5. Will the physician’s attitude influence level of compliance to dietary regimen among diabetic patients?.

2.7 Research Hypothesis

For this study 5 null hypothesis will be tested at 0.05 level of significant.

* There is no significant relationship between the level of compliance to dietary regimen and the educational status of respondent.

* There is no significant relationship between sex and level of compliance to dietary regimen.

* There is no significant relationship between level of compliance to dietary regimen and the level of family support.

* There is no significant relationship between socio-economic status and level of compliance to dietary regimen among respondents.

* There is no significant difference in the level of compliance to dietary regimen and other treatment modalities among respondents.

CHAPTER THREE

3.0 RESEARCH METHODOLOGY

3.1 Introduction

This chapter focuses on the research designs, the settings, ethical consideration, target population, sample technique, sample size research instrument, pilot study, procedure for data collection and plan for data analysis.

3.2 Research Design

This is a descriptive cross-sectional research. This design was adopted because the research was interested in explaining and describing the phenomenon of interest as they occur and no part will be manipulated.

3.3 Research Setting

The setting of the study was a purposively selected tertiary health institution in Osun State, known as Ladoke Akintola University of Technology Teaching Hospital Osogbo. It is cited at the central of Osogbo, with two main entrance, one at the Idiseke Area and the second gate opposite the Ansarudeen Central Mosque division towards Ajegunle Area in Osogbo. These category of patients receive out patient care and those that are on admission in the Hospital medical wards. The study will be conducted in Osogbo, in Osun State of Nigeria at the Ladoke Akintola University of Technology Teaching Hospital Osogbo where the out patient in the clinic and in patient will be used for the study.

3.4 Target Population

The target population for this study are patients receiving treatment in the medical wards in Ladoke Akintola University of Technology Teaching Hospital Osogbo, Osun State. This study was conducted on a population of patients in both the out patient clinic which have been previously diagnosed with D.M and those patient on the ward who have been diagnosed of having D.M. The age range was between 20 years and 50 years plus.

3.5 Sampling Technique

For this study purposive, accidental or convenience sampling techniques was used in selecting my sample. I attended the D.M. clinic for almost 10 day to get my sample size which was a total of (109) patients. All D.M. patient that have been previously diagnosed, and are attending clinic regularly were selected, and their names was written down so that they will not be reselected on another clinic day.

Sample Size

My sample size was selected by going to the Hospital to ask for the numbers of D.M. patients that previously attended the clinic in the previous year. The total was 150. Using Yamare (1967) in determination of my sample size

n = N where n = size, N = Total population of the study,

1+N (e)² e = significant level (0.05) n = 150___

1 + 150 (0.05)²

n = 150 =109

1.375

The sample size for the study was 109.

3.6 Pilot Study

The pilot study was conducted in Osun State Hospital Asubiaro Osogbo among the D.M. patient attending the clinic. The final draft of the instrument was used for the pilot study. The pilot study enables the researcher to access any problem that might come up during the administration of the instrument (Harthrone effect). It also help to determine the validity and reliability of the instrument that was used for the study.

3.7 Validity and Reliability of the instrument

The content validity of the instrument was ascertained the rough the effort of the researcher’s supervisor, has he went through the instrument and those ones that were ambiguous were removed hences, face validity of the instrument was determined. The reliability of the instrument was determined by administering the instrument to ten (10) respondent that has the same characteristic with the respondent were used, with the use of test – retest reliability method using the spearman - Brown correlation coefficient yield 0.78 which is 78% reliable which means this instrument is reliable to be used to tap the information needed for this research.

3.8 Instrument for Data Collection

The main instrument for data collection is a self administered questionnaires which comprised of both closed ended and an open ended questions. Observation technique will be used on patients at home during home visiting to do certain whether the patients were taking their diet as recommended and drugs as prescribed. Similarly the family members of D.M. patient was interview to confirm whether the patient is complying or not with dietary regimen.

3.9 Type of Data Collection and Analysis

The instrument/questionnaire was administer to patient and the information gathered from this instrument was now analyzed using descriptive and differential analysis. The demographic variables and the research questions was analyzed through descriptive analysis inform of frequencies, percentage and graphs. The hypothesis will be tested using chi-square.

3.10 Limitation of the Study

The limitation of this study was associated with the type of self-designed questionnaire administered which was subjected to face validity and the method of sampling. Another limitation were not unconnected with the number respondents because descriptive study requested the use of large number of subjects.

Moreso, many of the subject did not say the truth based on all the questions raised and some of the questions administered were not returned.

3.11 Ethical Consideration

Formal permission was taken from the institution involved in the study and informed consent was gained from all subjects that participates in the study.

3.12 Administration of the Questionnaire

One hundred and nine representatives from the target population was selected from the study.

Table 4.10: Showing the Demographic Variable of Respondents

Age
Valid	Frequency	Percent	Valid percent	Cumulative
20-29	23	21.1	21.1	21.1
30-39	11	10.1	10.1	31.2
40-49	32	29.4	29.4	60.6
50 years and above	43	39.4	39.4	100.0
Total	109	100.0	100.0
Sex
Male	22	20.2	20.2	20.2
Female	87	79.8	79.8	100.0
Total	109	100.0	100.0	100.0
Level of education
No formal education	20	18.3	18.3	18.3
Primary education	33	30.3	30.3	48.6
Secondary education	20	18.3	18.3	67.0
Post Secondary education	26	23.9	23.9	90.8
University education	10	9.2	9.2	100.0
Total	109	100.0	100.0
Occupational status
Civil servant	36	33.0	33.0	33.0
Farming	10	9.2	9.2	42.2
Self employed	41	37.6	37.6	79.8
Schooling	14	12.8	12.8	92.7
Pensineer	8	7.3	7.3	100.0
Total	109	100.0	100.0
Marital status
Single	11	10.1	10.1	10.1
Married	43	39.4	39.4	49.5
Divorced	22	20.2	20.2	69.7
Widowed	33	30.3	30.3	100.0
Total	109	100.0	100.0
Religion
Christianity	65	59.6	59.6	59.6
Islam	33	30.3	30.3	89.9
Traditional	11	10.1	10.1	100.0
Total	109	100.0	100.0
Ward
Male medical ward	38	34.9	34.9	34.0
Female medical ward	28	25.7	25.7	60.6
General out patient clinic	43	39.4	39.4	100.0
Total	109	100.0	100.0

According to table 4.10:

23 (21.1%) of the respondents were between the age 20-20years, 11 (10.1%) were between the age 30-39years, 32 (29.4%) were between the age 40-

49years, while 43 (39.4%) were 50 years and above.

Also 22 (20.2%) of the respondents were male, while 87 (79.8%) were female.

The table also shows that 20 (18.3%) of the respondents have no formal education, 33 (30.3%) have primary education, 20 (18.3%) have secondary education, 26 (23.9%) have post secondary education, while 10 (9.2%) have university education.

It is also shows from the table that 36(33.0%) of the respondents were civil servant, 10(9.2%) were farmer, 41 (37.6%) were self employed, 14 (7.3%) were student, while 8 (7.3%) were pensioner.

Also 11 (10.1%) of the respondents were single, 43 (39.4%) were married, 22 (20.2%) were divorced, while 33 (30.3%) were widowed.

The table also shows that 65 (59.6%) of the respondents were Christian, 33 (30.3%) were Moslem, while 11 (10.1%) were traditional religion worshippers.

Also 38 (34.9%) of the respondents were from male medical ward, 28 (25.7%) were from female medical ward, while 43 (39.4%) were from General out patient clinic.
Answering of Research Questions

Research Question 1: States that will level of education influence level of compliance to dietary regimen among D.M patients.

Inference: In Table 4.10 above, items showed that level of education influence level of compliance to dietary regimen among D.M patients because larger percentage of the respondents i.e 33% have primary school education.

Research Question 2: States that will gender influence level of compliance to dietary regimen among D.M patients.

Inference: In table 4.10 above, item 2 showed that 79.8% of the respondents are female.

Research Questions 3: States that will level of family support have any thing to do with level of compliance to dietary regimen.

Inference: In figure 4.19 above, item 31 showed that larger percentage of the respondents i.e. 76.1% of the respondents said their families are staying with them.

Research Question 4: States that will socio economic status influence level of compliance to dietary regimen.

Inference: In Table 4.10 above, item 5 showed that higher percentage i.e 37.6% of the respondents are self employed.

Testing of hypothesis

Hypothesis 1: There is no significant relationship between the level of compliance to dietary regimen and the educational status education and level of compliance to dietary regimen.

Level of Educational Status and Level of Compliance

		How often do you check your weight?
		6 months interval	3 months interval	Monthly	Weekly	Total
Level of education Total	No formal education Primary education Secondary education Post secondary education University education	0 22 0 11 0 33	11 11 0 0 0 22	8 0 20 15 0 43	1 0 0 0 10 11	20 33 20 26 10 109

Chi-Square Tests

	Value	Df	Asymp. Sig (2-sided)
Pearson Chi-Square Likelihood Ratio Linear-by-Linear Association N of Valid Cases	290 a 168.481 16.479 109	1 1 1	.780 000 .000

X2- Calculated = 0.780, X2-table = 0.290, df = 1, P = 0.05

Inference: Since the table value (0.290) is less than calculated value (0.780) at 0.05 level of significant, it implies that there is significant relationship between the level of compliance to dietary regimen and the educational status. Therefore the null hypothesis is significant and hence rejected.

Testing of hypothesis

Hypothesis 2: There is no significant relationship between sex and level of compliance to dietary regimen.

Sex and level of compliance

		Which of the following do you think can cause diabetes mellitus
		Bulk food containing carbohydrate	Plenty meat, vegetable and little water	Beans product and meat	Total
Sex Total	Male Female	0 56 56	0 20 20	22 11 33	22 87 109

Chi-Square Tests

	Value	df	Asymp. Sig (2-sided)
Pearson Chi-Square Likelihood Ratio Linear-by-Linear Association N of Valid Cases	63.479^a 67.630 51.881 109	2 2 1	.000 .000 .000

a. 1 cells (16.7%) have expected count less than 5. The minimum expected count is 4.04.

Inference: Since the table value (63.479) is greater than calculated value (0.000) at 0.05 level of significant, it implies that there is significant relationship between sex and level of compliance to dietary regimen. Therefore the null hypothesis is not significant and hence accepted.

Testing of hypothesis

Hypothesis 3: There is no significant relationship between level of compliance to dietary regimen and the level of family support.

Level of family support and level of compliance

		Management of diabetes mellitus is a daily discipline
		Yes	No	Total
Is any of your family members staying with you? Total	Yes No	64 25 89	19 1 20	83 26 109

Chi-Square Tests

	Value	Df	Asymp. Sig (2-sided)	Exact Sig. (2-sided)	Exact Sig. (1-sided)
Pearson Chi-Square Continuity Correction^a Likilihood Ratio Fisher’s Exact Test Linear-by-Linear Association N of Valid Cases	.793b .606 .128 749 109	1 1 1 1	1.029 .058 013 .029	.039	021

Computed only for a 2 x 2 table
1 cells (25.0%) have expected count less than 5. The minimum expected count is 4.77

X² – Calculated = 1.029, X2-table =0.793, df = 1, P=0.05

Inference: Since the table value (0.793) is less than calculated value (1.029) at 0.05 level of significant, it implies that there is significant relationship between level of compliance to dietary regimen and the level of family support. Therefore the null hypothesis is significant and hence rejected.

Testing of hypothesis

Hypothesis 4: There is no significant relationship between socio-economic status and level of compliance to dietary regimen among respondents.

Count Socio economic status and compliance

		Diabetes diet are expensive?		Total
		Yes	No	Total
Occupation Status Total	Civil servant Farming Self employed Schooling Pensiner	30 0 28 10 8 76	6 10 13 4 0 33	36 10 41 14 8 109

Chi-Square Tests

	Value	Df	Asymp. Sig. (2-sided)
Pearson Chi-Square Likelihood Ratio Linear-by-Linear N of Valid Cases	2.721a 3.260 .136 109	4 4 1	6.030 1.330 .712

a. 3 cells (30.0%) have expected count less than 5. The minimum expected count is 3.42.

X2 – Calculated – 6.030, X2 – table = 2.721, df = 4, P = 0.05

Inference: Since the table value (2.721) is less than calculated value (6.030) at 0.05 level of significant, it implies that there is significant relationship between socio-economic status and level of compliance to dietary regimen among respondents. Therefore the null hypothesis is significant and hence rejected.

There is no significant different in the level of compliance to dietary regimen and other treatment modalities.

Hypothesis 5: There is no significant between in the level of compliance to dietary regimen and other treatment modalities.

Count Drug management and compliance

		Have you been coping with dietary regiment given to you in the hospital
		Yes	No	Total
Which of the means of treatment are you using Total	Drugs only Drugs and diet Herbal preparation Insulin	10 41 20 15 86	1 11 7 4 23	11 52 27 19 109

Chi-Square Tests

	Value	df	Asymp. Sig. (2-sided)
Pearson Chi-Square Likelihood Ratio Linear-by-Linear Association N of Valid Cases	1.331a 1.509 .463 109	3 3 1	.722 .680 .496

a. 2 cells (25.0%) have expected count less than 5. The minimum expected count is

2.32.

X² – Calculated = 0.722, X2 – table = 1.331, df = 3, P = 0.05

Inference: Since the table value (1.331) is greater than calculated value (0.722) at 0.05 level of significant, it implies that there is no significant different in the level of compliance to dietary regimen and other treatment modalities. Therefore the null hypothesis is not significant and hence accepted).

The hypothesis revealed that

Ø There was significant relationship between the level of compliance of dietary regimen and the educational status of respondent.

Ø That there was no relationship between sex and level of compliance to dietary regimen.

Ø There was significant relationship between level of compliance to dietary regimen and the level of family support.

Ø There was significant relationship between socio-economic status and level of compliance to dietary regimen among respondent.

Ø There was significant relationship with type of management and level of compliance to treatment among respondent.

Table 4.24 shows that 28 (25.7%) of the respondents said they would note the spacing of their previous meal if their urine contain too much sugar, 69 (63.3%) said they would reduce the quality of all food to be taken, while 12 (11.0%) said they don’t know.

Section c: Family support

Table 4.25 shows that 36 (33.0%) of the respondents said their family member accompanied them to the clinic, while 73 (67.0%) said not they are not.

Table 4.26 shows that 79 (72.5%) of the respondents said they accept them and the type of treatment they are passing through, while 30 (27.5%) said no they are not.

Table 4.27 shows that 87 (79.8%) of the respondents said they encourage them in anyway to ensure that they take their drugs at home and carry out follow up care, while 22 (20.2%) said no they are not.

Table 4.28 shows that 79 (72.5%) of the respondents said they are encourage to discuss their health problem at home, while 30 (27.5%) said no they are not.

Table 4.29 shows that 77 (70.6%) of the respondents said their family member do assist them in the purchase of drugs or reinforce them financially in terms of their management, while 32 (29.4%) said no they are not.

Appendix

Section B: Knowledge on diabetes mellitus and perception of dietary regimen.

Table 4.11:

Do you think diabetes can be treated?

	Frequency	Percent	Valid Percent	Cumulative Percent
Valid Yes	87	79.8	79.8	79.8
No	22	20.2	20.2	100.0
Total	109	100.0	100.0

Table 4.12

Do you think is curable?

	Frequency	Percent	Valid Percent	Cumulative Percent
Valid Yes No Total	78 31 109	71.6 28.4 100.0	71.6 28.4 100.0	71.6 100.0

Table 4.1

Which of the following do you think can cause diabetes mellitus?

	Frequency	Percent	Valid Percent	Cumulative Present
Valid Bulk food containing Carbohydrate Plenty meat, vegetable and little water Beans product and meat Total	56 20 33 109	51.4 18.3 30.3 100.0	51.4 18.3 30.3 100.0	51.4 69.7 100.0

Table 4.14

If no to question 14 above 14 above, what is the reason?

Valid Complexity of the diet

Poor satisfaction

Financial constraints

Total

Missing System

Total

Frequency

109

Present

19.3

12.3

9.2

41.3

58.7

100.0

Valid Percent

46.7

12.8

22.2

100.0

Cumulative

Percent

46.7

77.8

100.0

CHARPTER FIVE

5.0 INTRODUCTION

This part of the study dealt with the discussion of findings concerning the factors influencing compliance to dietary regimen among out patient diabetic patient in Ladoke Akintola University Teaching Hospital, Osogbo.

In addition, the summary, conclusion implication to nursing and recommendation were dealt with in this chapter.

5.1 DISCUSSION OF FINDINGS

Result showed that about 43 (39.4%) of respondents are with the age range of 50 years and above and that only 11 (10.1%) are with the age range of (30-39) years also support. This finding support that of www.ncbi.n/m.nih.gov>journalist>Jfamilycommunitymed>v.17(3)

retrieved 01/09/12 which says that out of the sample of 600 diabetic patients used in the study, the age of diabetic patient ranged from 25 to 81 years, with a mean age 47.68 + 11.94 years.

An analysis of result revealed that about 87 (79.8%) of the respondents are female and 22 (20.2%) of the respondents are male. This finding support that of www.ncbi.n/m.nih.gov>journalist >Jfamilycommunitymed>v.17(3) retrieved 01/09/12 which stated that 48.3% of the sample while women formed 51.7% the men to women ratio being 1:11. The level of education among the respondents shows that 26 (23.9%) had post secondary education and just 10(9.2%) had university education and that 20 (18.3%). This finding support had no formal education that of www. ncbi.n/m.nih.gov>journalist>Jfamilycommunitymed>v.17(3) retrieved 01/09/12 that about one-third (34.5%) of diabetic patients were illiterate and 41.2% were manual workers. The findings collaborated that of the findings I have seen which show that education is no barrier to diabetes mellitus.

The first hypothesis stated that there was no significant relationship between the level of compliance to dietary regimen and the education status of respondent from the result of the research study the hypothesis tested revealed that there was significant relationship between the level of compliance to dietary regimen and the educational status of respondent. My findings was not congruent with a report that state that there was no significant relationship between the various aspects of compliance and the socio-demographic characteristics, of the patients such as education, occupation and marital status www.ncbi.n/m.nih.gov>journalist>Jfamilycommunitymed>v.17(3) retrieved in

01/09/12. The difference in the findings might not be unconnected with the number of respondents employed in the two researches and the level of awareness of such respondent.

The second hypothesis stated that there is no significant relationship between sex and level of compliance to dietary regiment after analysis it was found that there was no significant relationship between sex and level of compliance to dietary regimen findings was not in consonance with a report that state that there was minimal gender difference with no statistical differences in adherence to different aspects of the diabetic regimen, although this thus not show or says any specific level it was just a minimal difference. www.ncbi.n/m.nih.gov>journalist >Jfamilycommunitymed>v.17(3) retrieved 01/09/12

The third hypothesis stated that there is no significant relationship between level of compliance to dietary regimen and the level of family support. After the analysis is was tested that there is significant relationship between level of compliance to dietary regimen and the level of family support. This was supported by a report that said that the reason for non compliance by 27% of the patient was financial www.ncbi.n/m.nih. gov>journalist>Jfamilycommunitymed>v.17(3)

The fourth hypothesis states that there is no significant relationship between socio-economic status and level of compliance to dietary regimen among respondents. The Analysis verified that there was significant relationship between socio-economic status and level of compliance to dietary regimen among respondents. My findings was supported by a report that said that the reason for non-compliance by 27% of the patient financial.

The fifth hypothesis states that there is no significant difference between the level of compliance to diets regimen and other treatment modalities. The analysis showed that there was no significant difference between the level of compliance to diet regimen and other treatment modalities. The findings showed that it was not in congruent with a report that said that. Although adherence to medication is one of the most important aspects of the management of diabetes mellitus, low rates of adherence have been documented result of the present study revealed that about 57% of patients always took their medication as prescribed and on time. This means that many of them prefers taking drug than diet because the focus of this research was to finding out level of compliance to dietary regimen, but the literature review showed that majority of them preferred taking drug than dietary regimen but the literature review showed that majority of them preferred taking drug than dietary regimen www.ncbi.n/m.nih.gov>journalist>Jfamilycommunitymed>v.17(3) considering all these findings and the literature reviewed it will be better for patient suffering from diabetes to follow wholist approach of management form of exercise, diet and drug regimen.

5.2 IMPLICATION FOR NURSING PRACTICE

A symptomatic the hyperglycemia poses a great threat to the patients, life because these patients often peal no different. To ensure that these patient comply to dietary regimen, it is the duties of the nurses to health educate and give health information on the danger of not taking their diet as prescribed, as prescribed, as well as prompt testing of their urine and blood for glucose, similarly, routine testing of urine and blood test for glucose is necessary by the nurses and laboratory scientists respectively to be able to detect asymptomatic diabetes mellitus.

Poor financial status is one of the major factors that militate against compliance. Nurses should go through social worker to get philanthropist to assist patient that having financial problem. Similarly Government should also subsidize health or provide qualitative free medical services to the masses and those foods available, affordable and assessable to the community at large.

It is the duties of the nurses to give health information on the importance of procuring their food items with the limited resource and to place their health as priority, as a priority, as health is wealth.

Family support which is another significant factor in compliance among diabetic patients, should be encourage to play their role and come closer to their relationships even in ill health. It is the duties of the nurses to enlighten their relations to be more support to their clients in terms of moral, psychological, physical and financial as the case may be to compliance to dietary regimen.

Finally, the patients time should be judiciously utilized in the hospitals and prompt attention should be given to the patients in order to motivate them to be attending future clinic appointments. This role rests on the nurse and the physicians as well.

Poor financial status is one of the major factors that militate against compliance. Effort should be taken by members of the communities to assist the less privilege that might need financial assistance to procure drugs.

The nurse encourage should encourage the clients to adhere to there drug and the importance and benefit of adherence is made known to them.

When giving health education to client both in the clinic and in the wards, the health team, i.e nurses, Doctors, and Nutritionist etc. Should ensure that they use a language that is not to ambigious to understand by the client, and after any discussion or health talk given to the client they should ask question to see if effective communication have taken place i.e if the client really understood the message been passed to them. The nurse should understand that the client is of different educational status so the nurses should consider the level of understanding and educational status of the client before choosing the language that will be used, for effective communication to take place.

Health education should involve the preparation of all the types of diet that will be consumed by the client at home because evidence has shown that majority of the client is either they under cook or over cook the food and by so doing the nutrients will have gone.

The nurses should ensure that patient are adequately catered for and use a multifaceted approach in the treatment of client with diabetes mellitus. The nurse should make emphaze on the importance of complying to all the treatment regimen given to them and the nurses should also do a follow up visit to their given client and families that are involved in their case so that they can be sure that there client is complying to the treatment regimen/modalities been prescribed for him or her.

5.3 SUMMARY

This research is a descriptive study about the factors influencing level of compliance to dietary regimen among out patient diabetic. In Lautech Teaching Hospital Osogbo.

A purposive sampling methods were used in recruiting subjects for the study. A total number of 109 respondents were recruited and the response was 100%. 36 items structured questionnaire was developed. The research is delimited to diabetic patient attending the out patient clinic of LAUTECH Teaching Hospital Osogbo Osun State.

Data analyses were subjected to statistical package for social sciences reviewed through text book and relevant studies. It was discovered that factors like level of education, economic status, time spent in preparing those food, attitude of the health personnel cultural belief etc. were among the factors that influence the level compliance of diabetic patient to dietary regimen Hypotheses were tested using pearson’s chi-squar statistical method. The findings were discussed with relevant comparism and recommendations were also made.

Having carried out this research among the 109 subjects it was found that diabetes mellitus had highest prevalence in people between the age of 50 years and above, in female 87 (79.8%) than male. The study also show that majority of the respondents are have primary education (30.3%) while 20 (18.3%) have no formal education, 43 (39.4%) were from General out patient clinic.

The hypothesis also showed that there was significant relationship between the level of compliance to dietary regimen and the educational status of respondent.

There was no significant relationship between sex and level of compliance to dietary regimen.

There was significant relationship between level of compliance to dietary regimen and the level of family support.

There was significant relationship between socio-economic status and level of compliance to dietary regimen among respondents.

There was no significant difference in the level of compliance to diets regimen and other treatment modalities.

5.4 CONCLUSION

This result has shown that the treatment of diabetic mellitus should be mult faceted in the sense that no single approach of management can result in adequate management of the patient. Therefore drug management/therapy, exercise, and dietary regimen should come into play in managing patient with diabetes mellitus.

Also in other to enforce compliance to dietary management economic status, demographic variables and level of education of patient should be taken into cognizant. If this therapeutic indices / methods are use whollistically the patient will be relied / the clinical manifestations of diabetes mellitus will be controlled to the bearest minimum of it can not be eliminated.

5.5 RECOMMENDATION

In view of the finding of the study, the researcher therefore recommends the following:

(1) That all efforts should be intesited on the education of diabetic patient and the society as a whole on the importance of compliance to dietary regimen.

(2) That health workers especially the physicians, nurse and nutritionist, social workers should health educate diabetic patient on the importance and implication / complication of non - compliance to dietary regimen.

(3) That foods that consume less time to be prepared and that are readily available should be prescribed to prevent them from spending much time and energy in preparing those foods.

(4) That the government should subsidize or make those foods readily available for the diabetic patient at a charge prize they will be able to afford.

(5) Patient on diet should be advice to adhere to the drug regimen and take there medications as prescribed, on time and always adhered to dietary regimen to have better glycaemic control compared with others.

(6) There is need to consider the source of income of client so as to know if they will be able to comply with the treatment regimen given to them.

(7) The level of family support of the patient should be consider before setting basis for there treatment.

(8) The lack of educational status of client should be considered in other to enforce compliances.

(9) Gender variable should not compromise the care to be given to the client management of diabetes mellitus should be carried out irrespective of sex differences.

I am encouraging people to carry out there research studies on attitude of patient towards health care givers.

Finally, this research is recommended for further studies to increase the body of knowledge in Nursing Profession to provide solutions to the immediate challenges and to draw acceptable strategies and modalities to factors that can influence level compliance to dietary regimen among the diabetic patients.

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Section c: Family support

Table 4.25 shows that 36 (33.0%) of the respondents said their family member accompanied them to the clinic, while 73 (67.0%) said not they are not.

Table 4.26 shows that 79 (72.5%) of the respondents said they accept them and the type of treatment they are passing through, while 30 (27.5%) said no they are not.

Table 4.28 shows that 79 (72.5%) of the respondents said they are encourage to discuss their health problem at home, while 30 (27.5%) said no they are not.

Appendix

Section B: Knowledge on diabetes mellitus and perception of dietary regimen.

Table 4.11:

Do you think diabetes can be treated?

	Frequency	Percent	Valid Percent	Cumulative Percent
Valid Yes	87	79.8	79.8	79.8
No	22	20.2	20.2	100.0
Total	109	100.0	100.0

Table 4.12

Do you think is curable?

	Frequency	Percent	Valid Percent	Cumulative Percent
Valid Yes No Total	78 31 109	71.6 28.4 100.0	71.6 28.4 100.0	71.6 100.0

Table 4.1

Which of the following do you think can cause diabetes mellitus?

	Frequency	Percent	Valid Percent	Cumulative Present
Valid Bulk food containing Carbohydrate Plenty meat, vegetable and little water Beans product and meat Total	56 20 33 109	51.4 18.3 30.3 100.0	51.4 18.3 30.3 100.0	51.4 69.7 100.0

Table 4.14

If no to question 14 above 14 above, what is the reason?

Valid Complexity of the diet

Poor satisfaction

Financial constraints

Total

Missing System

Total

Frequency

109

Present

19.3

12.3

9.2

41.3

58.7

100.0

Valid Percent

46.7

12.8

22.2

100.0

Cumulative

Percent

46.7

77.8

100.0

QUESTIONNAIRE

Factors Influencing non-compliance to dietary regimen among out patient.

Department of Nursing,

College of Health Sciences,

LAUTECH,

Osogbo,

Osun State.

Dear Respondent,

This questionnaire is distributed for a scientific study on the perception of diabetic patients toward dietary regimen. I sincerely plead for your responses and all information given will be kept with utmost confidentiality.

Thanks for your willingness to participate.

Folaranmi Basirat Temitope

400 Level

Matric No. 082061

Section A Demographic Data

1. Age (a) 20-29 (b) 30-39 (c) 40-49

(d) 50years and above

2. Sex (a) Male (b) Female

3. Level of education (a) No formal education (b) Primary education

(e) University education

4. Occupational status (a) Civil Servant (b) Farming

5. Marital Status (a) Single (b) Married

6. Religion (a) Christianity (b) Islamic (c) Traditional Others specify ……………………

7. Ward (a) male Medical ward (b) female medical ward

Section B Knowledge on D.M. and Perception of dietary regimen

8. What is diabetes mellitus?

(a) It is an elevation of the blood glucose level

(b) It is an elevation of blood level

9. Do you think diabetes mellitus can be treated? Yes No

10. If it can be treated through which means can it be treated?

………………………………………………………

11. Do you think is correctable? Yes No

12. Which of the means of treatment are you using?

(a) Drugs only (b) Drugs and diet

13. Which of the following do you think can cause diabetes mellitus (a) Bulk food containing carbohydrate (b) plenty meat, vegetable and little water (c) Beans product and meat

14. Have you been coping with dietary regimen given to you in the hospital?

(a) Yes (b) No

15. If No to question 14 above, what is the reason?

(a) complexity of the diet (b) poor satisfaction

16. What was your weight before the onset of the illness?

17. What was your weight after the onset of the illness?

18. How often do you check your weight? (a) 6 months interval

(b) 3 months interval (c) monthly (d) weekly

19. Diabetic diet are expensive (a) Yes (b) No

20. Diabetic diet are complex (a) Yes (b) No

21. Diabetic diet are time consuming (a) Yes (b) No

22. Diabetic diet causes diarrhea (a) Yes (b) No

23. Diabetic diet causes constipation (a) Yes (b) No

24. Management of Diabetes mellitus is a daily discipline

(a) Yes (b) No

25. Diabetic diet are not easily accessible (a) Yes (b) No

26. Diet of a diabetic patient are not palatable (a) Yes (b) No

27. If you feel dizzy what should you do? (a) Eat some food or four cubes of sugar (b) Go to sleep (c) Do little exercise

(d) I don’t know

28. If you want to do exercise you must have what in your pocket or bag

(a) four cubes of sugar (b) Bulky foods (d) I don’t know

29. Which food items should be increased? (a) Yam, Garri, Rise

(b) Vegetable and Beans (c) I don’t know

30. If you test urine and there is too much sugar, what would you do to your food intake? (a) Note the spacing of the previous meal

(b) Reduce the quantity of all food to be taken

SECTION 3 (Family Support)

For each of the following questions, please tick “Yes” If it is generally tune to you and “No” if it is not

Items Yes No

31. Is any of your family members staying with you?

32. Have any of them accompanied you to the clinic?

33. Do they accept you and the type of treatment you

Are passing through?

34. Do they encourage you in a ways to ensure that you

Take your drugs at home and carry out follow

Up cares

35. Are you encouraged to discuss your health problem

at home?

36. Does anyone of them assist in the purchase of drugs

for you or reinforces you financially in terms of your

management?

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FACTORS INFLUENCING COMPLIANCE TO DIETARY REGIMEN AMONG DIABETIC PATIENT IN LADOKE AKINTOLA UNIVERSITY OF TECHNOLOGY TEACHING HOSPITAL OSOGBO. BY FOLARANMI BASIRAT TEMITOPE

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