A Field Work Investigation Report

On
Exploring the Stroke Survivors’ Perspective of
Diabetes Self-management

By

Fatema Shafiqul Shoshi

February 2022, held in March 2023

This project work is submitted in total fulfillment of the requirement for the subject
Field Work Investigation & partial fulfillment of the requirement for the degree of

Bachelor of Science in Occupational Therapy

Bangladesh Health Professions Institute (BHPI)
Faculty of Medicine,
University of Dhaka
.
Field work investigation completed by:

Fatema Shafiqul Shoshi

4th year, B.Sc. in Occupational Therapy
Department of Occupational Therapy
Bangladesh Health Professions Institute (BHPI) Signature
Centre for the Rehabilitation of the Paralysed (CRP)
Chapain, Savar, Dhaka-1343

Supervisor’s name and signature:

Nayan Kumer Chanda

Assistant Professor
Department of Occupational Therapy
Bangladesh Health Professions Institute (BHPI) Signature
Centre for the Rehabilitation of the Paralysed (CRP)
Chapain, Savar, Dhaka-1343

Head of department’s name and signature:

Sk. Moniruzzaman
Associate Professor & Head
Department of Occupational Therapy
Bangladesh Health Professions Institute (BHPI) Signature
Centre for the Rehabilitation of the Paralysed (CRP)
Chapain, Savar, Dhaka-1343

i
 Board of Examiner

Sk. Moniruzzaman
Associate Professor & Head
Department of Occupational Therapy
Bangladesh Health Professions Institute (BHPI) Signature
Centre for the Rehabilitation of the Paralysed (CRP)
Chapain, Savar, Dhaka-1343

Shamima Akter
Assistant Professor
Department of Occupational Therapy
Bangladesh Health Professions Institute (BHPI) Signature
Centre for the Rehabilitation of the Paralysed (CRP)
Chapain, Savar, Dhaka-1343

ii
 Title Page

Exploring the Stroke Survivors’ Perspective of Diabetes Self-management

iii
 Statement of Authorship

Except where it is made in the text of the fieldwork investigation report, this

fieldwork investigation report contains no material published elsewhere or extracted

in whole or in part from a publication presented by me for any other degree or

seminar. No other person’s work has been used without due acknowledgment in the

main text of the fieldwork investigation report. This fieldwork investigation report has

not been submitted for the award of any other degree in any other tertiary institution.

In case of dissemination of the findings of the fieldwork investigation report for future

publication, the research supervisor will be highly concerned, and it will be duly

acknowledged that it has been done for the partial fulfillment of the Bachelor of

Science in Occupational Therapy degree.

Fatema Shafiqul Shoshi

4th year, B.Sc. in Occupational Therapy

……...……………………………
Bangladesh Health Professions Institute (BHPI)

Centre for the Rehabilitation of the Paralysed (CRP) Signature

Chapain, Savar, Dhaka: 1343

iv
 Dedication

Dedicated to my honorable and beloved parents, my respected all teachers of

Bangladesh Health Professions Institute, and my respected mother.

v
 Acknowledgement

Firstly, I would like to thank to the Almighty for giving me the ability to carry out this

fieldwork and complete this work appropriately. Then, I would like to thank my

parents for their constant love, support, and inspiration.

I am grateful to my supervisor, Nayan Kumer Chanda, Assistant Professor,

Department of Occupational Therapy, BHPI, for giving me proper and continuous

guidance, and support during the whole fieldwork period. I am also thankful to Sk.

Moniruzzaman, Associate Professor and the Head of the department, Department of

Occupational Therapy, BHPI, for giving me the permission to conduct this fieldwork.

I would like to thank Md. Tauhidul Islam; Head of Department of Occupational

Therapy, for giving me proper support and guideline during this fieldwork at Adult

Neurology Unit at CRP.

vi
 Table of Content

Title Page ................................................................................................................................. iii

Statement of Authorship .........................................................................................................iv
Dedication ................................................................................................................................. v
Acknowledgement ................................................................................................................... vi
Table of Content .....................................................................................................................vii
List of Table ...........................................................................................................................viii
List of Abbreviation ................................................................................................................ ix
Abstract ..................................................................................................................................... x
CHAPTER I: INTRODUCTION ........................................................................................... 1
1.1. Introduction ................................................................................................................ 1
1.2. Background of Fieldwork ...........................................................................................2
1.3. Rationale of the Investigation .................................................................................... 3
CHAPTER II: METHODS ..................................................................................................... 4
CHAPTER III: RESULT ........................................................................................................ 7
3.1. Part A: Findings from literature review .......................................................................... 7
3.1.1. Table 1: Literature Matrix ........................................................................................ 7
3.1.2. Summary from literature review ............................................................................ 17
3.2. Part B: Findings from clinical placement ......................................................................21
CHAPTER IV: DISCUSSION .............................................................................................. 24
4.1. Discussion ..................................................................................................................... 24
4.2. Strengths and limitations of the investigation ............................................................... 27
CHAPTER V: CONCLUSION ............................................................................................. 28
REFERENCES ....................................................................................................................... 30
APPENDICES ........................................................................................................................ 34

vii
 List of Table

Serial number of Name of the Table Page

the Table no

Table 1 Literature Matrix 7

Table 2 Stroke participants’ 22

characteristics

viii
 List of Abbreviation

BHPI = Bangladesh Health Professions Institute

CRP = Centre for the Rehabilitation of the Paralysed

DSM = Diabetes Self-management

ix
 Abstract

1. Introduction: Diabetes self-management (DSM) refers to the patient's self-

responsibility for dietary choices, exercise habits, insulin therapy, and regular blood

glucose monitoring. Diabetes is a known independent risk factor for stroke and is

associated with greater rates of morbidity and mortality. Diabetic people have worse

stroke outcomes and a lower prognosis for recovery when they are compared to those

without diabetes. To avoid secondary problems and stroke recurrence, stroke

survivors must be continuing to manage their diabetes as independently as possible to

maintain good metabolic control and minimize the complications of diabetes.

2. Aim: The aim of the study is to explore the stroke survivors' perspectives on

diabetes self-management.

3. Methods: Searches were conducted using predetermined keywords on Google

Scholar, PubMed, and Scopus. For the data analysis process, quantitative content

analysis; an analysis based on literature is required. The review of the literature serves

as the foundation for the final report's conclusions.

4. Results: Sixteen stroke patients with presence of diabetes mellitus (11 males, 5

females) took part in the investigation. Participants had been afflicted with their

condition for mean of 9.9 years. It was clear that stroke survivors' perceptions of

diabetes self-management varied significantly. Diabetes self-management was a

concept that majority of stroke survivors were familiar with, but the majority of them

could define it, relate to it, and understand it to mean taking care of oneself by doing

things for oneself and taking care of oneself during diabetes. They did not view

diabetes self-management as a component of their treatment, but they appreciated

x
their therapists as motivating professionals who supported their post-stroke

rehabilitation. With stroke survivors, healthcare professionals should address any such

distinctions and should also discuss the importance of diabetes self-management to

stroke survivors' care, rehabilitation, and early recovery.

5. Conclusion: This fieldwork investigation has found variations in stroke survivors`

understandings and perceptions of diabetes self-management that may prevent

widespread adoption and implementation. The stroke survivors have varying opinions

about the concept of diabetes self-management and its significance in their early

recovery after a stroke, and it can be challenging for health professionals to promote

diabetes self-management in practice.

6. Keywords: Stroke, stroke survivors, diabetes mellitus, diabetes self-management

xi
 CHAPTER I: INTRODUCTION

1.1. Introduction

Globally, the number of stroke deaths has dropped, but during the past few decades,

both the incidence of strokes and their consequences have significantly increased.

Diabetes is a known independent risk factor for stroke and has been associated to

higher morbidity and mortality rates. Because diabetes mellitus is essentially a

lifestyle disease, people with the condition frequently have other risk factors for

stroke include obesity, hypertension, and dyslipidemia. These variables increase the

vascular risk in these individuals (Dutton & Lewis, 2015). To avoid secondary

problems and the recurrence of stroke, stroke survivors must continue managing their

diabetes as independently as possible. Diabetes self-management (DSM) can be quite

tiring on the patient as it is a complex constellation of behaviors that is dynamic and

influenced by changes in social, environmental, and individual factors over the course

of a person's lifetime rather than a single habit, despite the fact that it is essential to

avoid the negative health effects associated with long-term complications of the

condition (Shou et al., 2015). In order to maintain sound metabolic control and

minimize diabetes complications, diabetes self-management (DSM) refers to patients

taking charge of their own dietary choices, exercise routines, insulin therapy, and

glucose monitoring. In order to take their prescriptions, monitor their blood glucose,

follow a diet, and exercise frequently, patients must actively participate in changing

their daily routines and habits. Anyone might find it challenging to make such

significant behavioral changes. For challenging activities like taking medications,

following a diet, and routinely testing blood sugar levels, one must remain motivated

and prepared (Youngson, 2019). A distinct predictor of stroke recurrence was

1
hyperglycemia within 48 hours of the initial stroke. Additionally, diabetes was

demonstrated to be a distinct risk factor for subsequent strokes, particularly in people

who had pure motor strokes frequently accompanied by lacunar infarction (Staaf et al.,

2001). Additionally, this pattern persisted during a two-year period following the

initial stroke, with a recurrence risk of 19.8% in diabetic patients versus 12.3% in

non-diabetic people. In another study, diabetes was linked to a 5.6-fold higher chance

of having another stroke. Diabetes was calculated to be the cause of 9.1% of

recurrences in stroke patients (Hillen et al., 2003).

1.2. Background of Fieldwork

A rise in the prevalence of chronic disorders like stroke has been attributed to factors

including rapid urbanization, altered dietary practices, a lack of physical exercise,

cigarette use, and a drop in communicable diseases (Mamun et al., 2016). One of the

few centers offering stroke therapy is CRP. It should be emphasized that there is little

demographic data available on CRP patients (Ahmed et al., 2015). A total of 103

individuals were chosen for the study of the characteristics of stroke patients treated at

CRP in Bangladesh between December 2015 and May 2016. 77% of people who self-

reported having diabetes before having a stroke (Mamin et al., 2017). The risk for

repeated strokes is considerably increased by improper diabetes management, which

also raises the short- and long-term morbidity and death linked to stroke (Tun et al.,

2017).

The Fieldwork investigator has discussed and investigated the advantages, difficulties,

and other elements of stroke survivors' diabetes self-management both before and

after their stroke.

2
1.3. Rationale of the Investigation

The purpose of the study is to examine the perspectives of stroke survivors on

diabetes self-management(DSM), concentrating on what it entails and its importance

to their care, rehabilitation, and early recovery after stroke in order to determine

implications for occupational therapy practice, and future research. Although there is

little mention of DSM in the occupational therapy literature and in less recent practice,

occupational therapy has a significant untapped potential to help people who struggle

to manage diabetes in the context of everyday living. The study will also help to

determine the necessity of occupational therapy, which can play a role in helping

patients learn the DSM by helping them comprehend the occupational performance

factors. The things I am more concerned about while diabetes is a chronic,

controllable disease, and regardless of whether a patient has a stroke, diabetes self-

care actions should be continued by the patients. If the patient feels burdened by their

modified or altered lifestyle as a result of their diabetes, it may be even more difficult

for them to deal with their functional deficits, cognitive challenges, or other concerns

as a result of their stroke. Because of this, I was interested in learning how stroke

survivors have handled their diabetes both before and after their stroke. What

problems they had been having with their diabetes self-management, how well-

informed they were about it, and how they are handling the difficult management

following their stroke.

3
 CHAPTER II: METHODS

1. Investigation question: From when do you have diabetes mellitus? What do you

know about diabetes self-management? How do you manage your diabetes? What do

you do to manage diabetes? When did you have your stroke? How do you manage

your diabetes after your stroke (ischemic /hemorrhagic)? How much do you manage

your diabetes independently or with assistance? In what ways did occupational

therapists help you to learn to do things for your diabetes self-management in CRP?

What has or has not helped you in diabetes self- management since the stroke?

2. Aim of the investigation: The aim of the study is to explore the perspectives of

stroke survivors about their diabetes self-management.

3. Objectives of the investigation:

 To explore stroke survivors’ views of diabetes self-management before and after

their stroke.

 To address whether diabetes self-management could help address long-term

consequences of stroke.

 To address how important diabetes self-management is for the patients and their

caregivers in the stroke rehabilitation.

4. Inclusion and exclusion criteria of the literature:

Inclusion criteria:

 Article related to the diabetes mellitus, diabetes self- management and stroke

 Studies that published in English

4
 Articles that are published between the year 2013 and 2023

 Full-text articles that are accessible in the journal

Exclusion criteria:

 Articles that are published before 2013

 Journal articles that is not accessible online

5. Literature search strategy and selection: The investigator has conducted a

literature search to include articles released in English between the years 2013 and

2023 using the keywords; “stroke”, “diabetes mellitus” , “stroke and diabetes”,

“stroke survivors” and “diabetes self- management” thorough searches on Google

Scholar, PubMed , Scopus, American Diabetes Association, Bangladesh Diabetes

Association, Diabetes organization.

a) Keywords of the investigation:

‘Stroke’, ‘Stroke survivors’, ‘Diabetes mellitus’,

‘Diabetes self-management’

5
 b) Show the Flowchart of your study selection process:
.

Records identified through database and search engine

searching
(n = 61)

Articles excluded, due to

Title screen for
publish year prior to 2013
relevance
(n = 22)
(n = 44)

Full-text articles
Full-text articles excluded, due to inclusion
assessed for eligibility and exclusion criteria
(n = 22) (n = 12)

Studies included
(n = 10)
.

6. Data analysis process: I have identified records of articles searched through

database and search engine about 61 articles. From the searched articles, title screen

for relevance from 44 articles, articles has been excluded about 22 of the relevant

articles due to published before the year 2013. About 22 full-text articles assessed for

eligibility. Due to inclusion and exclusion criteria about 12 full-text articles has been

excluded and 10 studies has been included for literature review and literature matrix

to get literature findings.

7. Reporting: The investigator follows all the instructions to conduct the fieldwork

investigation.

6
 CHAPTER III: RESULT

3.1. Part A: Findings from literature review

3.1.1. Table 1: Literature Matrix.

Literature Matrix No.- 1
Aim Methods Results

Golden, S. H., Hill-Briggs, F., Williams, K., Stolka, K., & Mayer, R. S. (2005).
Management of Diabetes During Acute Stroke and Inpatient Stroke
Rehabilitation. Archives of Physical Medicine and Rehabilitation, 86(12),
2377–2384. https://doi.org/10.1016/j.apmr.2005.07.306
To summarize evidence on Guidelines for inpatient Two studies evaluating
the impact of management of diabetes interventions by a diabetes
hyperglycemia on stroke were reviewed and team have shown
outcomes and to present extracted from a technical significant reductions in
therapy algorithms for review and length of stay. In 1
inpatient management in recommendations from 2 retrospective study, the
diabetic stroke patients. national diabetes and patients who were seen by
endocrine organizations. the diabetes team had a
Studies were selected that significantly shorter length
specifically addressed the of stay than patients
impact of the following in managed by their internist
stroke patients: alone or by an individual
hyperglycemia and endocrine consultant. In
diabetes on rehabilitation the second study, which
outcomes, management was a clinical trial, patients
strategies for randomized to the diabetes
hyperglycemia and team had a significantly
diabetes, and strategies for shorter length of stay and a
facilitating diabetes self- lower 1-month
management. readmission rate.

7
 Literature Matrix No.- 2
Aim Methods Results

Fukuoka, Y., Hosomi, N., Hyakuta, T., Omori, T., Ito, Y., Uemura, J., Kimura, K.,

Matsumoto, M., & Moriyama, M. (2015). Baseline Feature of a Randomized

Trial Assessing the Effects of Disease Management Programs for the
Prevention of Recurrent Ischemic Stroke. Journal of Stroke and
Cerebrovascular Diseases, 24(3), 610–617.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2014.10.007
The study aimed to This is a randomized A total of 321 eligible subjects,
assess the effects of study conducted with including 21 subjects with transient
DMPs for the ischemic stroke ischemic attack, were enrolled in this
secondary patients within 1 year study. Regarding risk factors for
prevention of stroke. from their onset. stroke, 260 subjects had hypertension,
of the study is Using Subjects in the 249 subjects had dyslipidemia, 102
disease management intervention group subjects had diabetes mellitus, 47
programs (DMPs) received a 6-month subjects had atrial fibrillation, and 98
that were created for DMPs that included subjects had chronic kidney disease.
each of the risk self-management Depending on their recovery status
factor according to education provided by and whether they are in the acute,
clinical practice a nurse along with recovery, or maintenance (living)
guidelines, evaluate support in phase of management, ischemic
their influence on collaboration with the stroke patients often do not stay in the
the prevention of primary care same medical institution where they
stroke recurrence. physician. Those in undergo their initial consultation. For
the usual care group this reason, maintaining continuous
received ordinary support for patient education and
outpatient care. long-term self-management is
difficult.

8
 Literature Matrix no.- 3
Aim Methods Results
Tun, N. N., Arunagirinathan, G., Munshi, S. K., & Pappachan, J. M. (2017).
Diabetes mellitus and stroke: A clinical update. World Journal of Diabetes,
8(6), 235. https://doi.org/10.4239/wjd.v8.i6.235
The aim of the study Individualized care plan Patients with diabetes are
is to outline the for stroke patients particularly at a significantly
evidence base for depending on the clinical higher risk of stroke and have a
the epidemiological scenario should be higher mortality. Initiating good
aspects, tailored with glycaemic control at first
pathophysiology, considerations of disease diagnosis of diabetes,
diagnostic work up co-morbidities including irrespective of type, is essential
and management diabetes. Up to date for sustained cardiovascular
algorithms for scientific evidence should benefits (i.e., metabolic
diabetes and stroke always lead the clinicians memory) and for the reduction
to help clinicians for to optimize such care of hyperglycaemia-induced
a rational approach plan. pathogenic processes implicated
to patients through in atherosclerotic vascular
this comprehensive disease.
article.

9
 Literature Matrix No.- 4
Aim Methods Results
Fritz, H. (2013). The influence of daily routines on engaging in diabetes self-
management. Scandinavian Journal of Occupational Therapy, 21(3), 232-
240. https://doi.org/10.3109/11038128.2013.868033
In contrast to A purposive sampling strategy  Findings reveal that
previous was used to recruit low-income preexisting routines must
research women from an urban location be changed so that they
concerning the in central North Carolina. This may better support
importance of research report presents engagement in DSM, and
routines in selected findings from a larger that such changes are tied
occupational study that studied the influence to underlying habits and
engagement, of daily routines on the process life situations.
most of which by which low-income women  The experiences of study
have largely with type 2 Diabetes Mellitus participants also showed
focused on the integrated diabetes self- that the distribution of daily
routines of management (DSM) into daily occupations through time
children and life. Data in the larger study and across social spheres
families, in this were collected using the can be both supportive of
study a following methods: the and problematic for
qualitative Diabetes Care Profile1, semi- engaging in DSM.
methodology structured interviews,  In addition, the structure
was used to participant-generated and sequence of competing
understand how photography and a photo- daily occupations
routines elicitation interview, and time- influences the available
function in a geographic diaries (TGDs) time and opportunities for
specific along with a follow-up TGD people to further develop
occupation: interview. The TGDs and TGD their skills and become
diabetes self- interviews were used to elicit more adept self-managers.
management the influence of routines on the
(DSM). integration process. The focus
of this research report is the
results from the analysis of the
TGD and TGD interviews.
Sample and recruitment
Approval to conduct the study
was obtained from the
university’s institutional review
board before beginning
recruitment.

10
 Literature Matrix No.- 5

Aim Methods Results

Primožič, S., Tavčar, R., Avbelj, M., Dernovšek, M. Z., & Oblak, M. R. (2012).
Specific cognitive abilities are associated with diabetes self-management
behavior among patients with type 2 diabetes. Diabetes Research and
Clinical Practice, 95(1), 48–54. https://doi.org/10.1016/j.diabres.2011.09.004
Patients with In a cross sectional Specific cognitive functions, namely
diabetes differ in study 98 adults with immediate memory, visuospatial/
compliance to type 2 diabetes attending constructional abilities, attention,
diabetes self- Diabetes Outpatient and specific executive functions
management Clinic were examined (planning and problem solving)
which influences using the measures of were significantly associated with
their long-term diabetes self- diabetes self-management. Among
health. management (Summary cognitive factors, planning and
Psychological of Diabetes Self-Care problem solving abilities were
factors, namely Activities (SDSCA) strongest predictors; furthermore, in
depression and measure), depression a multivariate regression their
cognitive abilities, (Hamilton Depression association was independent from
are associated with Inventory (HDI)), depression.
diabetes self- diabetes distress
management (Problem Areas In
behavior. The aim Diabetes scale (PAID)),
of the study was to and the
identify neuropsychological
independent battery of tests for
association of assessment of cognitive
particular functions. Socio-
cognitive functions demographic and
with diabetes self- diabetes-related data
management. were collected. Uni-
variate and multivariate
regression analyses were
used to identify and
evaluate the predictors
of diabetes self-
management.

11
 Literature Matrix No.- 6
Aim Methods Results
Youngson, B. (2019). Understanding diabetes self-management using the Model of
Human Occupation. British Journal of Occupational Therapy, 82(5), 296-
305. https://doi.org/10.1177/0308022618820010
The aim of the Semi-structured By using MOHO further
study was to to interviews using an explains how the occupational
understand the intuitive inquiry identity of the person; their
experience of methodology were choices, beliefs, values and
diabetes self- conducted with 22 interests; their habits, roles and
management people with diabetes in performance capacities; and the
(DSM), and explore three separate studies. opportunities or demands of the
the role of Analysis of the lived environment impact on that self-
occupational experience of all management.
therapy in relation participants was drawn
to diabetes self- together to explore the
management understanding of diabetes
(DSM). self-management from an
occupational perspective
using the Model of
Human Occupation.

12
 Literature Matrix No.- 7
Aim Methods Results
Sabourin, B. C., & Pursley, S. (2013). Psychosocial Issues in Diabetes Self-
Management: Strategies for Healthcare Providers. Canadian Journal of
Diabetes, 37(1), 36-40. https://doi.org/10.1016/j.jcjd.2013.01.002
The present article  One way to create Diabetes patients' A1C levels
presents an overview and/or identify and mental discomfort have
of psychosocial issues ambivalence is to been proven to reduce with
and approaches that openly discuss health psychosocial therapy. Positive
healthcare providers beliefs. Healthcare outcomes have been linked to
(HCPs) from all providers (HCPs) can shorter therapies with more
disciplines can ask patients about frequent sessions. The
consider in supporting their perceptions of intervention's content covers
patients with the the seriousness of preparation for change,
challenges of diabetes diabetes and its behavior change tactics based
self-management. consequences, and on behavior modification
whether they feel concepts, maintenance of
they have control motivation, emotion
over their behaviours management, including stress
and health outcomes. management and emotional
 Listening to and eating, and relapse prevention
exploring and/or accountability
ambivalence rather maintenance.
than trying to help by Inherent in the management of
fixing or convincing diabetes are psychosocial
is more likely to draw problems. HCPs can assist
out “ change talk ” . patients' efforts at diabetes
This approach is best self-management more
achieved by asking effectively by acknowledging
open-ended questions their presence and fostering an
such as “What open and ongoing discourse
worries you about with patients about issues of
what you are motivation, behavior change,
currently eating?”, or and emotion management.
“How important is
changing your eating
to you?” encourages
patients to speak of
the disadvantages of
staying the same and
their intentions for
change.
.

13
 Literature Matrix No.- 8
Aim Methods Results
Lippa, K. D., & Klein, H. A. (2006). How Patients Understand Diabetes Self-
Care. Proceedings of the Human Factors and Ergonomics Society Annual
Meeting, 50(10), 1083–1087. https://doi.org/10.1177/154193120605001017
The aim of the study Qualitative analyses of interview This study has
is to learn how transcripts were conducted to demonstrated that the
patients understand describe participants’ same cognitive factors
diabetes self-care. understanding of diabetes self- contribute to diabetes
management. This study used self-management. Newly
previous findings concerning skill diagnosed patients must
development in complex domains begin self-care
to understand how people with immediately, with
diabetes learn to manage their minimal supervision.
glucose levels. Twenty people with
type II diabetes (13 male, 7 female)
participated in the study. Semi-
structured interviews were conducted
with all participants. With participant
permission, all interviews were audio
recorded. Participants were asked to
describe their initial diagnosis,
education experiences, and current
self-management regimen.

14
 Literature Matrix No.- 9
Aim Methods Results
Lambrinou, E., Hansen, T. B., & Beulens, J. W. (2019). Lifestyle factors, self-
management and patient empowerment in diabetes care. European Journal of
Preventive Cardiology, 26(2_suppl), 55–63.
https://doi.org/10.1177/2047487319885455
This is a literature review A review was conducted in Diabetes self-management
aiming to overview, order to summarize and education and nutritional
summarize and discuss the discuss central themes for counselling are integral
role and effect of patient prevention. A search of the parts of any therapeutic
empowerment, self- databases PubMed, programme throughout the
management education CINAHL, Cochrane and disease course. This will
and lifestyle modification Google Scholar between ensure that the patient has
in the management of January 2010–May 2019 access to information on
people with DM. was undertaken. The methods to safely monitor
following keywords: and control blood glucose
‘diabetes mellitus’, levels. The IDT focused on
‘cardiovascular diseases’, persons with DM and their
families and how they may
‘empowerment’, ‘self-
have an active role in the
management education’
prevention and
and ‘lifestyle factors’ were
management of DM might
used in different
be the key to deal with the
combinations to identify
rising epidemic of DM.
eligible articles. Important
variables for the
prevention of diabetes
mellitus and its
complications are self-
management

of diabetes mellitus and

the management of risk
factors.

15
.

Literature Matrix No.- 10

Aim Methods Results
Schmitt, A., Gahr, A., Hermanns, N., Kulzer, B., Huber, J., & Haak, T. (2013). The
Diabetes Self-Management Questionnaire (DSMQ): development and
evaluation of an instrument to assess diabetes self-care activities associated
with glycaemic control. Health and Quality of Life Outcomes, 11(1), 138.
https://doi.org/10.1186/1477-7525-11-138
Aim of the study A 16 item questionnaire to The psychometric properties of the
is to assess self- assess self-care activities final 16 item version of the DSMQ
care activities associated with glycemic were assessed in 261 patients. The
which can predict control was developed, SDSCA served as comparison to
glycemic control, based on theoretical assess the quality of our scale. The
and the considerations and a sample was generally well
questionnaire process of empirical matched to the first study’s
was designed to improvements. Four sub- sample, except that 58% of the
assess self-care scales, ‘Glucose patients were diagnosed with type
behaviors which Management’ (GM), 1 diabetes, which is 12% more
can be related to ‘Dietary Control’ (DC), than in the first study. According
the measure of ‘Physical Activity’ (PA), to these results, higher sum scores
HbA1c, so that and ‘Health-Care Use’ as well as subscale scores of the
the data are (HU), as well as a ‘Sum DSMQ allow to infer better self-
suitable for Scale’ (SS) as a global care activities in view of glycemic
mediational measure of self-care were control.
analyses. derived. To evaluate its
psychometric quality, 261
patients with type 1 or 2
diabetes were assessed
with the DSMQ and an
established analogous
scale, the Summary of
Diabetes Self-Care
Activities Measure
(SDSCA). The DSMQ’s
item and scale
characteristics as well as
factorial and convergent
validity were analyzed,
and its convergence with
HbA1c was compared to
the SDSCA.

16
3.1.2. Summary from literature review

3.1.2.1. Literature Review

Diabetes patients' adherence to diabetes self-management varies, which has an impact

on their long-term health. Depression and cognitive capacities are two psychological

variables that are linked to diabetes self-management behavior. The study's objective

was to discover independent relationships between specific cognitive processes and

diabetes self-management. Diabetes self-management was substantially correlated

with a number of specific cognitive abilities, including short-term memory,

visuospatial/constructional skills, attention, and certain executive functions (planning

and problem-solving). The biggest predictors of cognitive characteristics were

planning and problem-solving skills and a multivariate regression showed that their

association with depression was unrelated (Primožič et al., 2012).

In order to investigate how routines work in a specific occupation; diabetes self-

management, this study used a qualitative methodology. Contrary to earlier study on

the topic, this mostly concentrated on family and child routines. The findings indicate

that in order to better encourage engagement in DSM, current routines must be

adjusted, and these modifications are influenced by personal circumstances and

ingrained habits. Additionally, the study participants' experiences showed how the

distribution of regular occupations over time and among social groups can be both

advantageous and problematic for DSM participation (Fritz, 2013).

The purpose of the study is to evaluate self-care behaviors that can be associated to

the measurement of HbA1c, and the questionnaire was created to evaluate self-care

behaviors that can be related to glycemic management, so that the data are appropriate

for medicational analysis. In 261 patients, the psychometric qualities of the Diabetes

17
Self- management Questionnaire (DSMQ)'s final 16 item version were evaluated. To

evaluate the effectiveness of the scale, the Summary of Diabetes Self-Care Activities

Measure (SDSCA) was used as a benchmark. With the exception of 58% of the

patients having type 1 diabetes, which is 12% more than in the previous research, the

sample was generally well matched to the sample from the first trial (Schmitt et al.,

2013).

The study's goal is to provide an overview of two occupational therapy (OT)

programs that use psychosocial techniques and activity-based therapies, respectively,

to improve DSM capacities and quality of life. Evidence suggests that OT

interventions can increase treatment adherence and quality of life in diabetic patients;

hence they should be sustained and expanded to meet the growing demands of

diabetic populations. Therefore, it is imperative that appropriate diabetes management

strategies be developed in order to lower secondary complications and the associated

financial burden (Shen & Shen, 2019).

The study's objectives were to comprehend the DSM experience and investigate the

contribution of occupational therapy to diabetic self-management (DSM). By utilizing

MOHO, it is further explained how a person's occupational identity, choices, beliefs,

values, and interests, as well as their habits, roles, and performance capabilities, as

well as the opportunities and demands of their environment, have an impact on their

ability to manage their own behavior (Youngson, 2019).

18
Through this thorough article, the study hopes to help doctors take a logical approach

to patients by outlining the evidence base for the epidemiological features,

pathophysiology, diagnostic process, and management algorithms for diabetes and

stroke. Patients with diabetes are particularly at a significant increased risk of stroke

and mortality. Regardless of the type of diabetes, starting adequate glycaemic control

at the time of diagnosis is crucial for maintaining cardiovascular advantages (such as

metabolic memory) and lowering the pathogenic processes caused by hyperglycemia

that are linked to atherosclerotic vascular disease (Tun et al., 2017).

The current paper provides a summary of psychosocial concerns and strategies that

healthcare professionals (HCPs) from all fields of study might take into account while

assisting patients with the difficulties of diabetes self-management. Psychosocial

issues are a part of diabetes management. HCPs can better support patients' attempts

to manage their diabetes by recognizing them and encouraging an ongoing, open

dialogue with them about issues related to motivation, behavior modification, and

emotion control (Sabourin & Pursley, 2013).

The prescribed objectives for blood pressure, cholesterol management, glycaemia, and

HbA1c should be closely followed, according to European recommendations. A

manageable amount of challenges can be achieved with the use of patient

empowerment, self-management education, and lifestyle adjustment. Healthcare

professionals who are in charge of carrying out these techniques are used in studies

looking at how they affect DM management and care. The core principle of DM

management is patient and family engagement in care, and it is the responsibility of

the healthcare team to encourage and assist patients in self-management.(Lambrinou

et al., 2019)

19
The study's is Utilizing disease management plans (DMPs) developed for each risk

factor in accordance with clinical practice recommendations; assess their impact on

the prevention of stroke recurrence. The subjects in the intervention group had a 6-

month DMP that included assistance from the primary care physician and self-

management instruction given by a nurse. Because of this, it is challenging to sustain

ongoing support for patient education and long-term self-management. (Fukuoka et al.,

2015)

20
3.2. Part B: Findings from clinical placement

A fieldwork investigation was conducted on stroke patients with diabetes mellitus,

who went to CRP for rehabilitation services had carried out from 1st November to 8th

December, 2022. The investigator had chosen some participants who had a confirmed

stroke diagnosis with diabetes mellitus from the doctor, who would continue to take

rehabilitation services for at least one month, and who had consented to take part in

the investigation. Men and women of any age were welcomed to participate.

Sixteen stroke patients with presence of diabetes mellitus (11 males, 5 females) ages

from 54 years to 70 years had taken part in the investigation.

It was clear that stroke survivors' perceptions of diabetes self-management varied

significantly. Diabetes self-management was a concept that majority of stroke

survivors were familiar with, and the majority of them could define it, relate to it, and

understand it to mean taking care of oneself during diabetes.

They did not view diabetes self-management as a component of their treatment, but

they appreciated their therapists as motivating professionals who supported their post-

stroke rehabilitation.

The clinical Occupational Therapist questioned that whether there was any

intervention related to diabetes self-management available and mentioned that

Occupational Therapists had been working with peripheral neuropathy, pain and

fatigue; secondary complications of diabetes patients.

The investigator also found that majority of the patient had stopped their doctor

visiting, regular glucose monitoring while receiving their post- stroke rehabilitation

services.

21
Table 2: Stroke participants’ characteristics

Participant Age Gender Presence Duration of

of diabetes diabetes before
No.
mellitus stroke

1 59 Female Yes 8 years

2 65 Male Yes 10 years

3 67 Female Yes 11years

4 56 Male Yes 8 years

5 58 Male Yes 10 years

6 54 Female Yes 7 years

7 62 Male Yes 11 years

8 64 Female Yes 8 years

9 70 Male Yes 13 years

10 56 Male Yes 8 years

11 57 Female Yes 6 years

12 54 Male Yes 8 years

13 60 Male Yes 12 years

14 66 Male Yes 13years

15 69 Male Yes 12 years

16 64 Male Yes 13 years

22
The majority of the stroke survivors’ were avoiding appropriate diet for diabetes

management after stroke and did not consult with diabetes specialist or nutritionist for

their diet and they were having excessive fatigue after their therapy.

The majority of stroke patients had a history of having high blood sugar levels prior to

their stroke occurrence; they frequently consume such an irregular diet.

Most stroke patients who had just experienced a stroke were continuing to eat a diet

that consisted primarily of little amounts of less-than-nutritious food. Most of them

were eating according to their beliefs, which often comprised a diet free of sugar, low

in carbs, low in cholesterol, and high in fresh fruits and vegetables.

Majority of the patients and their caregiver reported that the patient were irregular at

their diabetes self -management and avoid appropriate sugar free diet, regular blood

sugar monitoring, doctors’ visit, physical activities and medication taking before

having their stroke.

Some of the patients regretted not enough managing their diabetes before their stroke.

Majority of the patient were also having hypertension alongside with diabetes mellitus

before their stroke and were also irregular at their hypertension medication

consumption. Moreover some stroke patients also had visual problem and kidney

disease alongside with their diabetes.

Majority of the stroke patients with diabetes mellitus were taking their diabetes

medications or insulin time to time and maintain their diet as much as possible after

stroke though some of them ignoring doctor’s appointment with the increasing blood

glucose level (i.e., 15.07 mmol/L fasting blood glucose level).

23
 CHAPTER IV: DISCUSSION

4.1. Discussion

The clinical placement has taken place on the Adult Neurology outdoor unit. To

accomplish the fieldwork investigation goals, which are to explore the views of stroke

survivors about their diabetes self-management the investigator has undertook a

fieldwork investigation placement in the Adult Neurology unit at Centre for the

Rehabilitation of the Paralysed (CRP), Savar. The investigator worked with the stroke

patients with diabetes mellitus throughout the month of November and first week of

December who had come to the CRP, the adult neurology outpatient unit for

Occupational Therapy (OT) services. The patients who have queried about their

experiences said it had been challenging to continue with their self-care practices

including diabetes self-care activities following a stroke. Most of the patients wanted

to get better and be able to live as independently as possible.

Some participants were able to manage their diabetes only by taking oral drugs and/or

insulin. The highest recorded blood sugar levels(i.e., 15.07 mmol/L for fasting blood

glucose level), followed by hyperglycemia in acute ischemic stroke (Villa et al., 2022).

The results of this investigation have found that the perceptions of stroke patients’

influence diabetes self-management. But existing diabetes education does not give

patients the knowledge they require during stroke rehabilitation, as evidenced by the

poor problem-solving skills and limited number of functional strategies discovered.

The stroke survivors’ views of diabetes self-management. The investigator discovered

variations in the stroke patients' understandings and perceptions of diabetes self-

management as self-care behavior. They view occupational therapists as the expert

24
professionals, to take care of them and support them as they recovered from the stroke,

but they did not see diabetes self-management as a component of their rehabilitation

therapy (Sadler et al., 2017).

The results of this investigation have found that the perceptions of stroke patients’

influence diabetes self-management. But existing diabetes education does not give

patients the knowledge they require during stroke rehabilitation, as evidenced by the

poor problem-solving skills and limited number of functional strategies discovered.

Some stroke patients had faced difficulty to blood glucose monitoring, exercises, and

diets. Some patients faced allergic reactions, increased fasting blood glucose level,

irregular blood glucose monitoring, foot care behaviors, doctors’ appointments, and

outcomes with real consequences such as vision problem slow recovery after stroke

(Lippa & Klein, 2006).

Recently diagnosed stroke patients with diabetes had tried taking care of themselves

with or without assistance of their caregivers. Patients had started to practice skills in

a secure setting. These skills aid the patients in creating efficient methods for self-

care. The diagnosis of diabetes differed between the the rehabilitation phases by using

medical history (Piernik-Yoder & Ketchum, 2013), whereas others carried out either

fasting blood glucose(Wang et al., 2015), HbA1c or both (Tang et al., 2016).

In this investigation, several occupational therapists questioned the capacity of stroke

survivors to manage their diabetes on their own and take charge of their early post-

stroke rehabilitation, due to exhaustion and cognitive difficulties brought on by stroke.

Diabetes is a risk factor for stroke with a worse long-term prognosis. Either one week,

one month, or three months after the stroke started, higher mortality in diabetes

25
patients had been seen previously. Diabetes patients had a two-fold greater one-year

death rate than non-diabetic stroke patients. In the investigation, one patient with

diabetes had a recurrence of stroke 2 years following the first stroke and another

patient with diabetes had a stroke recurrence after 28 days following first stroke. Only

20% of diabetics continue to live for more than 2 years following their first stroke.

But one patient with hyperglycemia was on his follow up session after 2 years

following the first stroke, due to shoulder subluxation, and walking difficulty

(Mankovsky & Ziegler, 2004).

Majority of patients were not maintained their diabetes self-management properly.

They were irregular at their blood glucose monitoring, weren't went for the

physician's consultation regularly or avoid doctors’ appointments for their diabetes

checkups, some of them were regular at their blood glucose monitoring, consultation

with the doctors but they weren't very careful about their diet.

Several patients mentioned that they have obtained professional help when their blood

sugar levels were high or low. Only three people said they had independently taken

steps to lower increased glucose levels with moderate support of their carers. Study

finds that elements that are crucial for making decisions regarding cognitive and

behavioural responses by stroke patients with Type I and Type II diabetes.

Participants' levels of compliance and glycemic control were higher when they had a

more in-depth knowledge, and ways of solving problems for diabetes self-care (Lippa

et al., 2008).

26
4.2. Strengths and limitations of the investigation

Strengths of the investigation

 CRP’s staff, supervisor, clinical occupational therapists were very supportive

 The patients were very cooperative

 Opportunity to observe many stroke patient during with variety Occupational

therapy intervention

Limitations of the investigation

 Limited resources of literature related to the investigation

 Some patients had cognitive impairment and speech problem that’s why

investigator discussed with the carer about patients status

27
 CHAPTER V: CONCLUSION

Diabetes self-management skills were more effective in participants who

demonstrated better proficiency in the articulation of problem detection tactics,

functional linkages, and problem solving techniques. Participants were expected to

make better self-care decisions and have lower blood glucose levels if they had shown

more of the cognitive indicators of competence (i.e., greater problem detection

strategies, understanding of functional dynamics, and problem solving strategies). The

investigator looked into diabetes self-management in an effort to understand how

people deal with this complicated issue on a daily basis.

This study has found variations in stroke survivors` understandings and perceptions of

diabetes self-management that may prevent widespread adoption and implementation.

When stroke survivors have varying opinions about the concept of diabetes self-

management and its significance in their early recovery after a stroke, it can be

challenging for health professionals to promote diabetes self-management in practice.

With stroke survivors, healthcare professionals should address any such distinctions

and should also discuss the importance of diabetes self-management to stroke

survivors` care, rehabilitation, and early recovery. If diabetes self-management

support methods are to be implemented, further research must be done to examine the

terminology and tactics experts use to encourage diabetes self-management, as well as

the obstacles that stand in the way of encouraging diabetes self-management at

various stages following a stroke.

28
Addressing simple decision-making requires an understanding of the health

management field. This study finds that elements that distinguish professionals from

beginners are crucial for making decisions regarding healthcare system through an

investigation of cognitive and behavioral responses by type I and type II diabetes

patients. Participants' levels of compliance and glycemic control were higher when

they had a more in-depth knowledge, as evidenced by expected to control indicators,

the utilization of functional linkages, and ways of solving problems. It may be

possible to improve health care and medication compliance by using strategies that

foster skills in other areas.

29
 REFERENCES

Ahmed, S. M., Alam, B. B., Anwar, I., Begum, T., Huque, R., Khan, J. A., Nababan,

H., & Osman, F. A. (2015). Bangladesh Health System Review. W. H.

Organization. https://www.jstor.org/stable/resrep28451.1

Dutton, G. R., & Lewis, C. E. (2015). The Look AHEAD Trial: Implications for

Lifestyle Intervention in Type 2 Diabetes Mellitus. Progress in

Cardiovascular Diseases, 58(1), 69-75.

https://doi.org/10.1016/j.pcad.2015.04.002

Fritz, H. (2013). The influence of daily routines on engaging in diabetes self-

management. Scandinavian Journal of Occupational Therapy, 21(3), 232-240.

https://doi.org/10.3109/11038128.2013.868033

Fukuoka, Y., Hosomi, N., Hyakuta, T., Omori, T., Ito, Y., Uemura, J., Kimura, K.,

Matsumoto, M., & Moriyama, M. (2015). Baseline Feature of a Randomized

Trial Assessing the Effects of Disease Management Programs for the

Prevention of Recurrent Ischemic Stroke. Journal of Stroke and

Cerebrovascular Diseases, 24(3), 610-617.

https://doi.org/http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2014.10.007

Hillen, T., Coshall, C., Tilling, K., G, A., Rudd, McGovern, R., & Wolfe, C. D. A.

(2003). Cause of Stroke Recurrence Is Multifactorial. Stroke, 34(6), 1457-

1463. https://doi.org/10.1161/01.str.0000072985.24967.7f

Lippa, K. D., & Klein, H. A. (2006). How Patients Understand Diabetes Self-Care.

Proceedings of the Human Factors and Ergonomics Society Annual Meeting,

50(10), 1083-1087. https://doi.org/10.1177/154193120605001017

30
Lippa, K. D., Klein, H. A., & Shalin, V. L. (2008). Everyday Expertise: Cognitive

Demands in Diabetes Self-Management. Human Factors: The Journal of the

Human Factors and Ergonomics Society, 50(1), 112-120.

https://doi.org/10.1518/001872008x250601

Lambrinou, E., Hansen, T. B., & Beulens, J. W. (2019). Lifestyle factors, self-

management and patient empowerment in diabetes care. European Journal of

Preventive Cardiology, 26(2), 55-63.

https://doi.org/10.1177/2047487319885455

Mamin, F. A., Islam, M. S., Rumana, F. S., & Faruqui, F. (2017). Profile of stroke

patients treated at a rehabilitation centre in Bangladesh. BMC Research Notes,

10(1), 520. https://doi.org/10.1186/s13104-017-2844-x

Mamun, M. A., Rumana, N., Pervin, K., Azad, M. C., Shahana, N., Choudhury, S. R.,

Zaman, M., & Turin, T. C. (2016). Emerging Burden of Cardiovascular

Diseases in Bangladesh. Journal of Atherosclerosis and Thrombosis, 23(4),

365-375. https://doi.org/10.5551/jat.30445

Mankovsky, B. N., & Ziegler, D. (2004). Stroke in patients with diabetes mellitus.

Diabetes/metabolism research and reviews, 20(4), 268-287.

https://doi.org/10.1002/dmrr.490

Piernik-Yoder, B., & Ketchum, N. (2013). Rehabilitation Outcomes of Stroke Patients

With and Without Diabetes. Archives of Physical Medicine and Rehabilitation,

94(8), 1508-1512. https://doi.org/10.1016/j.apmr.2013.04.014

Primožič, S., Tavčar, R., Avbelj, M., Dernovšek, M. Z., & Oblak, M. R. (2012).

Specific cognitive abilities are associated with diabetes self-management

behavior among patients with type 2 diabetes. Diabetes Research and Clinical

Practice, 95(1), 48-54. https://doi.org/10.1016/j.diabres.2011.09.004

31
Sabourin, B. C., & Pursley, S. (2013). Psychosocial Issues in Diabetes Self-

Management: Strategies for Healthcare Providers. Canadian Journal of

Diabetes, 37(1), 36-40. https://doi.org/10.1016/j.jcjd.2013.01.002

Sadler, E., Wolfe, C. D. A., Jones, F., & McKevitt, C. (2017). Exploring stroke

survivors' and physiotherapists' views of self-management after stroke: a

qualitative study in the UK. BMJ Open, 7(3), e011631.

https://doi.org/10.1136/bmjopen-2016-011631

Schmitt, A., Gahr, A., Hermanns, N., Kulzer, B., Huber, J., & Haak, T. (2013). The

Diabetes Self-Management Questionnaire (DSMQ): development and

evaluation of an instrument to assess diabetes self-care activities associated

with glycaemic control. Health and Quality of Life Outcomes, 11(1), 138.

https://doi.org/10.1186/1477-7525-11-138

Shen, X., & Shen, X. (2019). The Role of Occupational Therapy in Secondary

Prevention of Diabetes. International Journal of Endocrinology, 2019, 1-7.

https://doi.org/10.1155/2019/3424727

Shou, J., Zhou, L., Zhu, S., & Zhang, X. (2015). Diabetes is an Independent Risk

Factor for Stroke Recurrence in Stroke Patients: A Meta-analysis. Journal of

Stroke and Cerebrovascular Diseases, 24(9), 1961-1968.

https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.04.004

Staaf, G., Lindgren, A., & Norrving, B. (2001). Pure motor stroke from presumed

lacunar infarct: long-term prognosis for survival and risk of recurrent stroke.

Stroke, 32(11), 2592-2596. https://doi.org/10.1161/hs1101.098355

Tang, H., Zhang, S., Yan, S., Liebeskind, D. S., Sun, J., Ding, X., Zhang, M., & Lou,

M. (2016). Unfavorable neurological outcome in diabetic patients with acute

ischemic stroke is associated with incomplete recanalization after intravenous

32
 thrombolysis. Journal of neurointerventional surgery, 8(4), 342-346.

https://doi.org/10.1136/neurintsurg-2014-011643

Tun, N. N., Arunagirinathan, G., Munshi, S. K., & Pappachan, J. M. (2017). Diabetes

mellitus and stroke: A clinical update. World Journal of Diabetes, 8(6), 235.

https://doi.org/10.4239/wjd.v8.i6.235

Villa, R. F., Ferrari, F., & Moretti, A. (2022). Hyperglycemia in acute ischemic stroke:

physiopathological and therapeutic complexity. Neural Regeneration

Research, 17(2), 292. https://doi.org/10.4103/1673-5374.317959

Wang, Q., Wang, D., Liu, M., Fang, Y., You, C., Dong, W., Chang, X., Lei, C.,

Zhang, J., & Chen, Y. (2015). Is diabetes a predictor of worse outcome for

spontaneous intracerebral hemorrhage? Clinical neurology and neurosurgery,

134, 67-71. https://doi.org/10.1016/j.clineuro.2015.01.020

Youngson, B. (2019). Undearstnding diabetes self-management using the Model of

Human Occupation. British Journal of Occupational Therapy, 82(5), 296-305.

https://doi.org/10.1177/0308022618820010

33
 APPENDICES

In this appendix section all the articles are attached.

34