PT.

BHAGWAT DAYAL SHARMA UNIVERSITY OF HEALTH

SCIENCES, ROHTAK (HARYANA)

SYNOPSIS

ON

“A STUDY TO ASSESS THE EFFECTIVENESS OF HEALTH

EDUCATION ON KNOWLEDGE AND PRACTICE

REGARDING HYPOGLYCEMIA AND ITS

SELF-CARE MANAGEMENT AMONG DIABETES

MELLITUS CLIENTS IN SELECTED HOSPITALS

AT HISAR, HARYANA.”

GUIDE CO-GUIDE
Dr. Promila Pandey Dr. Shikha

Principal Professor cum HOD

Dept. of Medical Surgical Nursing Dept. of Medical Surgical Nursing

MAMC, Agroha, Hisar. MAMC, Agroha, Hisar.

BY

Pallavi Sharma

1
 PT. BHAGWAT DAYAL SHARMA UNIVERSITY OF HEALTH

SCIENCES, ROHTAK (HARYANA)

PERFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. NAME OF THE CANDIDATE PALLAVI SHARMA

AND ADDRESS FIRST YEAR M.Sc. NURSING

MAHARAJA AGRASEN COLLEGE OF

NURSING, AGROHA, HISAR, HARYANA

2. NAME OF THE INSTITUTION MAHARAJA AGRASEN COLLEGE OF

NURSING, AGROHA, HISAR,

HARYANA

3. COURSE OF THE STUDY AND MASTER OF SCIENCE IN NURSING

SUBJECT (MEDICAL SURGICAL NURSING)

4. DATE OF ADMISSION TO THE

COURSE

“A STUDY TO ASSESS THE

5. TITLE OF THE TOPIC (STUDY
EFFECTIVENESS OF HEALTH
TITLE)
EDUCATION ON KNOWLEDGE AND
PRACTICE REGARDING HYPOGLYCEMIA
AND ITS SELF-CARE MANAGEMENT
AMONG DIABETES MELLITUS CLIENTS
IN SELECTED HOSPITALS AT HISAR,
HARYANA.”

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 BRIEF RESUME OF THE INTENDED WORK

CHAPTER-I

INTRODUCTION

Health is a dynamic condition resulting from the body’s constant adjustment and
adaptation in response to stress and changes in the environment for maintaining an inner
equilibrium. Health is an adaptive state unique to each person. This subjective state must be
distinguished from the objective state of disease. Wellness is first and foremost a choice to
assume responsibility for the quality of our life. It begins with a conscious decision to shape a
healthy life style. Wellness is a mind-set, a pre-disposition to adopt a series of key principles
in varied life areas that lead to high levels of well being and life satisfactions. (Anson, 2012) 1

Diabetes mellitus is a multisystem disease related to abnormal insulin production,

impaired insulin utilization or both. Diabetes mellitus is a serious health problem through out
the world.2

Diabetes mellitus is not modern disease. In 1500 B.C. Papyreus of ancient Egyptians
recorded a number of remedies for passing urine. In 1000 B.C. itself Indian physician
sushurutha diagnosed diabetes. In 1798, J.Jhon, the Greek physician found diabetes is
associated with excess of glucose in blood. Discovery of insulin by Banting and Best in 1921
is a land mark in diabetes history.3

According to the World Health Organization (WHO), approximately 180 million

people worldwide suffer from diabetes. Its incidence is increasing rapidly, and it is estimated
that by the year 2030, this number will almost double.4

Diabetes mellitus may present with characteristics such as thirst, polyuria, blurring of
vision, and weight loss. In its most severe forms, ketoacidosis or non ketotic hyperosmolar
state may develop and lead to stupor and coma. The long term effect of diabetes include
progressive development of the specific complication of retinopathy with potential blindness,
nephropathy that may lead to renal failure and nephropathy with risk of foot ulcer,
amputation, charcot joints, and features of autonomic dysfunction, including sexual

3
dysfunction. Two aspect of diabetes mellitus are hypoglycemia and hyperglycemia.
Hyperglycemia is increase in blood glucose level and hypoglycemia is lower than normal
level of blood glucose level.5

Hypoglycemia is an acute medical situation that occurs when blood sugar falls below
the recommended level. Individuals taking diabetic medications are at increased risk of
experiencing low blood sugar. An estimated 2-4% of people with type 1 diabetes mellitus die
from hypoglycemia each year. It might explain the “dead in bed syndrome” unexplained
death of a person with type 1 diabetes occurring during night time. The symptoms of low
blood sugar vary from person to person, and can change over time. During the early stages a
person with low blood sugar level may have sweating, trembling, feeling hungry and feeling
anxious. The symptoms can become more severe, and can include difficulty of walking,
weakness, visual disturbance; bizarre behavior, personality changes, confusion and
unconsciousness or seizure may be observed.6

Hypoglycemia is the condition, when one’s blood glucose is lower than normal,
usually less than 70mg/dl. It occurs because of a mismatch between insulin dose, food intake
and energy expenditure. The individual fails to become aware of hypoglycaemia and can
result in prolonged hypoglycemia with consequent brain injury, seizure and loss of
consciousness.7

Hypoglycemia may have serious consequence in terms of morbidity and mortality,

occurring in the elderly diabetic patients, but this severe prognosis is less frequently
observed. The rate of severe hypoglycaemia remains low, but increases rapidly in the very
elderly and also with insulin therapy, as well as with unawareness of symptoms.8

Hypoglycemia is an abnormally low plasma glucose concentration that may expose

the individuals to potential harm. It is associated with the treatment of Type 1 and Type 2
diabetes mellitus. Recognizing hypoglycemia and its risk factors and identifying the high-risk
patients can assist with prevention and management. Education of patients and health-care
practitioners is also a key factor in hypoglycemia prevention.9

Hypoglycemia can also lead to major complications in the vital organs such as brain
and kidneys which can lead to permanent neurological and renal damage. Some principles of
prevention of hypoglycemia had been published. These principles include education about
diabetes self-management, self-monitoring of blood glucose levels, flexible and proper

4
insulin and/or other drug regimens, personalized glycemic goals, and consideration of known
risk factors of hypoglycemia.10

Two types of hypoglycemia symptoms are documented. The first one is

neuroglycopenia which causes symptoms such as blurred vision, fatigue, concentrating
disturbance, confusion and behavioral changes, and may lead to loss of consciousness,
seizures, brain damage, and death. The second one is neurogenic symptoms and this occurs
by the hormones and neurotransmitters delivered as a result of low brain glucose levels,
causing symptoms such as tremor, palpitation, anxiety, sweating, hunger, dizziness and
drowsiness.11

Patient’s awareness and knowledge of each hypoglycemia symptoms are very

important to be early recognized and to take measures for treatment and avoid risks that may
even cause death.11

Knowledge about these symptoms is an important step to self-care practice, because

informed people are more likely to have better self-care practice. It is important for patients
with diabetes especially, those receiving insulin to learn about hypoglycemia, and to carry
some form of simple sugar with them at all times. Self-care practice in diabetes management
also includes dietary regulation, medication, physical activity and self-monitoring of blood
glucose (SMBG). Additionally, these patients should always wear an identification bracelet
or tag.12

NEED FOR STUDY

Diabetic Mellitus is a non-communicable heterogeneous group of metabolic disorders

with elevated blood glucose and abnormally shifted carbohydrate, fat and protein metabolism
resulting from defects in insulin secretion and/or insulin action. Both acute and chronic
complications are responsible for the death and hospitalization associated with diabetes.
Hypoglycemia, which is defined as “an abnormally low plasma glucose concentration (<70
mg/dl) that exposes the subject to potential harm”, is one of the acute complications of
diabetes mellitus.13

The number of people with diabetes rose from 108 million in 1980 to 422 million in
2014. Prevalence has been rising more rapidly in low- and middle-income countries than in
high-income countries. Diabetes is a major cause of blindness, kidney failure, heart attacks,

5
stroke and lower limb amputation. Between 2000 and 2019, there was a 3% increase in age-
standardized mortality rates from diabetes. In lower-middle-income countries, the mortality
rate due to diabetes increased 13%.14

According to the IDF in 2019, the top three countries with the highest number of
individuals with diabetes are China (116.4 million), India (77.0 million), and the United
States of America (31.0 million). This trend is expected to continue in 2030 and 2045, with
China (140.5 and 147.2 million) and India (101.0 and 134.2 million) continuing to have the
highest burden of diabetes. This is supported by the Global Burden of Disease Study, which
reported that population growth and ageing in the world's largest countries, such as China and
India, are driving the absolute increase in the number of people with diabetes.15

In India, the burden of diabetes has been increasing steadily since 1990 and leaps and
at a faster pace from the year 2000. The prevalence of diabetes in India has risen from 7.1%
in 2009 to 8.9% in 2019. Currently, 25.2 million adults are estimated to have IGT, which is
estimated to increase to 35.7 million in the year 2045. India ranks second after China in the
global diabetes epidemic with 77 million people with diabetes. Of these, 12.1 million are
aged >65 years, which is estimated to increase to 27.5 million in the year 2045. It is also
estimated that nearly 57% of adults with diabetes are undiagnosed in India, which is
approximately 43.9 million. The mean healthcare expenditure on diabetes per person is 92 US
dollars, and total deaths attributable directly to diabetes account for 1 million.14

Fluctuating blood sugar levels outside the normal ranges tend to be common among
people with T1DM. Hypoglycemia or low blood glucose (BG) is a dangerous condition that
affects people with diabetes when the blood glucose level falls below 70 mg/dL. If the BG
level continues to fall below 54 mg/dL, it may result in severe hypoglycemia. Values below
this level can cause severe cognitive impairment, seizure, loss of consciousness, and, in some
cases, coma. Severe hypoglycemia has also been associated with a higher mortality rate. 16

In one study, 10% of the children surveyed had passed away by the time of follow-
up. Over time, recurrent hypoglycemia can inhibit the associated symptoms, leading the
affected person to lose sensitivity to or become unaware of hypoglycemic symptoms. When
the body is unable to secrete epinephrine that generates hypoglycemic symptoms, the risk of
death could increase by more than 3-fold. This is particularly risky during sleep where
nocturnal hypoglycemia leads to cases of “dead in bed”. Despite evidence suggesting the

6
existence of such self-unawareness and lost sensitivity to hypoglycemic symptoms, little
research exists to document the extent of such a phenomenon among patients with diabetes. 17

Impaired awareness of hypoglycemia (IAH) is an acquired syndrome in people with

insulin-treated diabetes, predominantly T1D, and can be defined as a condition in which
patients experience an attenuation of hypoglycemic symptoms, leading to a diminished or
absent ability to perceive the onset of hypoglycemia. Patients with IAH experience
neuroglycopenic symptoms as the first sign of hypoglycemia and rely on the assistance of
others to manage their episodes of hypoglycemia. The risk of severe hypoglycemia is 6-fold
more common in those with IAH, which, in turn, has been linked to increase in overall
mortality.18

In the absence of identification and immediate treatment for a hypoglycemic episode,

the blood glucose can proceed to drop and causing severe hypoglycemia and other
complexities, such as seizures, coma, emergency room admissions, and possibly death. For
cases with IAH and recurrent severe hypoglycemia, pancreas or islet transplantation can be
taken into account as possible therapy options, however, it is currently limited by graft
availability, expense, and the necessity for dedicated lifelong immunosuppressant use.
Therefore, real-time continuous glucose monitoring (CGM) has become a valuable tool in the
management of diabetic patients by presenting immediate information regarding blood
glucose levels, glycemic trends, and alerts to hypoglycemic events.19

In patients with diabetes, it is not easy to determine a specific plasma glucose

concentration that is diagnostic of hypoglycemia, because the threshold for the appearance of
hypoglycemia symptoms varies among patients. This threshold drops due to recurrent
episodes of hypoglycemia and rises in individuals with uncontrolled diabetes mellitus.20

The incidence of hypoglycemia among patients with DM is high and poor

hypoglycemia awareness can render diabetics prone to severe hypoglycemia. It is important
to identify the association between hypoglycemia and related factors, such as the patient’s
hypoglycemia experience, awareness of glycemic control, and hypoglycemia itself. This
information may help minimize or even eliminate the potential harm to patients with DM
receiving insulin treatment.

As a researcher, I felt that there is lack in knowledge and practice regarding self-care
management of hypoglycemia among diabetic clients. Through the help of structure teaching

7
programme on knowledge and practice regarding hypoglycemia can be improved, which will
help in reduction of complication due to hypoglycemia and also help in early management of
hypoglycemia.

STATEMENT OF THE PROBLEM

“A study to assess the effectiveness of health education on knowledge and practice regarding
hypoglycemia and its self-care management among diabetes mellitus clients in selected
hospitals at Hisar, Haryana.”

OBJECTIVES

1. To assess the knowledge and practice regarding hypoglycemia and its self-care
management among diabetes mellitus clients.
2. To evaluate the effectiveness of health education on knowledge and practice regarding
hypoglycemia and its self-care management among diabetes mellitus clients.
3. To find out the correlation between knowledge and practice regarding hypoglycemia
and its self-care management among diabetes mellitus clients.
4. To find out the association between knowledge and practice regarding hypoglycemia
and its self-care management among diabetes mellitus clients with their selected
demographic variables.

HYPOTHESIS

H0 - There will be no correlation between the knowledge and practice score of diabetes
mellitus clients regarding hypoglycemia and its self-care management.

H1- There is a significant improvement in the knowledge and practice after structured teaching
programme on knowledge and practice regarding hypoglycemia and its self-care management
among diabetes mellitus clients.

H2 - There will be a significant association between level of knowledge and practice score
with the selected demographic variables of diabetes mellitus clients.

OPERATIONAL DEFINITIONS

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Assess- It refers to examine the knowledge and practice regarding hypoglycemia and its self-
care management among diabetes mellitus clients.

Effectiveness- It refers to the improvement of knowledge and practice hypoglycemia and its
self-care management among diabetes mellitus clients

Health education- It refers to the promoting health as well as reducing behavior induced
diseases. Instruction and teaching aids developed and designed for diabetes mellitus clients to
provide information regarding hypoglycemia and its self-care management.

Knowledge- It refers to diabetes mellitus clients awareness regarding hypoglycemia and its
self-care management, which will be assessed through structured knowledge questionnaire.

Practice- It refers to assessment of measures taken by the diabetes mellitus clients for self-
care management of hypoglycemia assessed through checklist.

Hypoglycemia- In this study hypoglycemia refers to blood glucose concentration falls below
70mg/dl.

Self-care Management- In this study, it refers to measures taken by diabetic clients to

prevent hypoglycemia related complications when blood glucose concentration falls below
70mg/dl.

Diabetes mellitus clients- In this study, it refers to the clients who are having the high blood
glucose level above 200mg/dl.

ASSUMPTIONS

 Diabetic clients will have lack of knowledge on management of hypoglycemia.

 Hypoglycemia is a complication of diabetes mellitus.
 Hypoglycemia can result in unconsciousness.
 Self-care management technique can be administered at any time as early as possible
to prevent complications of hypoglycemia.
 Imparting knowledge on the management of hypoglycemia will prevent
complications.

DELIMITATION

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1. Study was delimited to clients with Diabetes mellitus in the outpatient department in
selected hospitals at Hisar during data collection period.
2. Study was delimited to a sample size 60 clients with diabetes mellitus.
3. Study was delimited for duration of four weeks.

Conceptual framework

The conceptual framework for the study is based on Modified Pender’s Health
Promotion Model was developed by Dr. Nola Pender. The health promotion model focuses on
helping people achieve higher level of well-being. It encourages the health professionals to
provide positive resources and help patients to achieve behaviour and specific changes.

This model describes the multi- dimensional talent of persons as they interact within
the environment. It is directed at increasing the health promoting behaviour. Health
promoting behaviour should result in enhanced functional ability of the nurses which will
lead to improved health promoting actions.21

The goal of health promotion model is not just about helping patients prevent illness
through their behaviour but to look at ways in which a person can pursue better health or the
ideal health.

The major concepts of the health promotion model

 Individual characteristics and experiences.

 Health promotional behaviour.

Individual characteristics and experiences: The person has unique personal characteristics
and experiences that affect subsequent actions. In this study, it includes the diabetes mellitus
client’s personal factors such as age, gender, religion, educational status, use of natural herbal
medications and source of information.

Health promotional behaviour: Health promotion behaviour emphasized as endpoint or

action outcome directed toward attaining positive health outcome such as optimal well-being,
personal fulfilment and productive living. In this study, it includes knowledge and practice of
self-care management of hypoglycemia among diabetic mellitus clients. Which include

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Meaning and causes of hypoglycemia, Risk factors for hypoglycemia, Signs and symptoms of
hypoglycemia, Management of hypoglycemia and Complications of hypoglycemia

Health professionals such as nurses and doctors comprise the interpersonal

environment which influences the individual behaviour. The health promotion notes that each
person has unique personal characteristics and experiences that affect subsequent actions
based on the behaviour. These variables can be modified through nursing actions such as
educating regarding the ill effects of hypoglycemia. Health promoting behaviour should
result in improved health, enhanced functional ability, better quality of life and it will reduce
all other consequences related to hypoglycemia. So the structured teaching programme can be
used further to disseminate the knowledge regarding hypoglycemia and self-care
management of hypoglycemia.

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 INDIVIDUAL BEHAVIOUR SPECIFIC HEALTH PROMOTIONAL
CHARACTERSTICS COGNITIVE PERCEPTUAL BEHAVIOUR
FACTORS

Perceived benefits of action

Likelihood of engaging in
Increase in knowledge and practice of knowledge and practice
Personal factors self-care management of regarding hypoglycaemia and its Identifying the diabetes
‘ hypoglycaemia among diabetic mellitus mellitus client’s
self-care management among
 Age clients. diabetic mellitus clients. knowledge and practice
 Gender  Meaning and causes of regarding hypoglycemia
and its self-care
 Religion hypoglycaemia
Perceived efficiency management
 Educational status  Risk factors for
Assessed the knowledge and practice of
 Use of natural hypoglycaemia,
self-care management of
herbal hypoglycaemia among diabetic mellitus  Signs and symptoms of
medications hypoglycaemia,
 Source of  Management of
Activity related affects
information. hypoglycaemia Health Education
Identifying the knowledge about
hypoglycaemia and its self-care  Complications of
management among diabetes mellitus
clients hypoglycaemia

Feedback
Fig-1 Conceptual framework on modified Pender’s Health Promotion Model

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 CHAPTER-II

LITERATURE REVIEW

A Literature review is a critical summary of research on a topic of interest often

prepared to put a research problem in context. A literature review helps to lay the foundation
for a study and can also inspire new research ideas.

A systematic review of literature and appraisal of all the relevant scholarly literature
on the specific topic involves an in-depth study. An extensive review of literature was done
on the related research and non-research literature.

Literatures related to various aspects of the study as follows:

 Literature related to diabetes mellitus.

 Literature related to prevalence and awareness of hypoglycemia.
 Literature regarding knowledge and practice of hypoglycemia.

Literature review related to Diabetes mellitus

Veeresh VG. (2018) a study to assess the effectiveness of planned education

programme on knowledge regarding enhancing quality of life among diabetic patients. An
experimental, one group pretest posttest without control group design was adopted. Total of
100 samples were selected using simple random sampling technique. The study found that the
diabetic patients had inadequate knowledge regarding quality of life; the planned education
programme was effective in bringing the change in the knowledge level regarding enhancing
quality of life among diabetic patients. The mean pretest knowledge score was 12.32±3.28
and posttest knowledge score was 24.67±0.98 (mean±standard deviation) respectively. The
study concluded that the study was effective in imparting the knowledge to enhance quality
of life among diabetic patient which bring confidence in self care of diabetic patients. 22

Faisal K. Alanazi, et al. (2018) conducted a study on Knowledge and awareness of

diabetes mellitus and its risk factors in Saudi Arabia. Nineteen articles are included in our
systematic review. These studies included the following populations: DM patients (n=13),
healthcare workers (n=3), medical students (n=1), secondary school students (n=1), and
general population (n=1). Most studies found a lack of public awareness of the risk factors

13
and complications of DM. Among medical students and healthcare workers, knowledge about
the epidemiology of the disease and angle of insulin injection was deficient. This review
highlights the need for increased knowledge and awareness of DM among the Saudi
population. The means of improving knowledge and awareness of DM needs to be integrated
into existing healthcare systems and processes to better inform patients, families, and
communities about this chronic disease.23

Premkumar (2018) Awareness of diabetes mellitus and its complications among

students in a Malaysian university. Most of the respondents knew that consuming sugar-
containing foods can lead to diabetes and DM is controllable but not curable. The study
revealed only 50% of respondent aware that diabetes can damage kidney, blood flow to heart
is decreased, and DM can cause loss of sensation in hands and feet and blindness. 61.5% of
respondent knew that eating wheat and leafy vegetables are advisable for diabetic patient.
34.5% responded eating potato, banana, and rice is advisable and 4% responded consuming
soft drinks and fruit juices is advisable. The study concluded that the students in AIMST have
good awareness on DM. Awareness about DM among university students will help to play a
crucial role in fight against DM and to prevent complications of DM.24

Kassahun CW, Mekonen AG (2017) Knowledge, attitude, practices and their

associated factors towards diabetes mellitus among non diabetes community members of
Bale Zone administrative towns, South East Ethiopia. A crosssectional study. Data was
collected from 605 non diabetic community members of Bale Zone administrative towns.
Response rate of the study was 98.2%. About 52.5% of participants were knowledgeable,
55.9% and 56.6% had good attitude and practice respectively. The study concluded that
considerable limited knowledge, attitude and practices were seen. A great emphasis on health
education regarding symptoms and risk factors modification for diabetes are necessary.25

Kaur Sumanpreet; & Kaur Harmanpreet; (2017) A Descriptive Study to Assess

the Knowledge Regarding Diabetes Mellitus among the Residents of Selected Rural
Community, Gurdaspur, Punjab. A Non-Experimental, Quantitative Research Approach And
Univariant Descriptive Research design was used in present study to assess the knowledge
regarding diabetes mellitus among selected rural community residents. A self structured
checklist was used to assess the knowledge regarding diabetes mellitus and convenience
sampling was used. The result of present study revealed that out of 100 community people,
90% have average knowledge, 9% have good knowledge and only 1% have poor knowledge.

14
The mean score of good level of knowledge was 21.77 with standard deviation ±0.56, the
mean score of average knowledge was 16.97 with standard deviation ±0.35 and mean score
of poor level of knowledge was 10 with standard deviation 0. The result of present study
revealed that out of 100 community people, 90% have average knowledge, 9% have good
knowledge and only 1% have poor knowledge.26

Sorli Alnamas; et. al. (2017) assessed the knowledge regarding self administration
of insulin injection among diabetes mellitus patients in Diabetic Clinic.20 diabetic mellitus
patients on insulin therapy were selected by convenient sampling method. The study revealed
that 12 participants (60%) are having good knowledge regarding self administration of
Insulin injection. 6 participants (30%) are having average knowledge and 2 participants
(10%) are having poor knowledge regarding self administration of Insulin injection.27

Literature related to prevalence and awareness of hypoglycemia.

Li, XN., et al. (2023) conducted a study on Prevalence and contributing factors of
impaired awareness of hypoglycemia in patients with type 2 diabetes: a meta-analysis. A
reproducible search strategy was used to identify factors affecting IAH in T2DM in PubMed,
MEDLINE, EMBASE, Cochrane, PsycINFO, and CINAHL from inception until 2022. This
meta-analysis result shows that the pooled prevalence of IAH in patients with T2DM was
22% (95%CI:14–29%). Measurement tools included the Gold score, Clarke’s questionnaire,
and the Pedersen-Bjergaard scale. The studyconcluded that a high prevalence of IAH in
T2DM, with an increased risk of severe hypoglycemia, suggesting that medical workers
should take targeted measures to address sociodemographic factors, clinical disease, and
behavior and lifestyle to reduce IAH in T2DM and thus reduce hypoglycemia in patients.28

Ghadeer Hassounah, et. al. (2022) conducted a study on Prevalence of impaired

awareness of hypoglycemia and its risk factors among patients with type 1 diabetes in Saudi
Arabia. A cross-sectional study was conducted on 242 patients with T1D. The study findings
shows that the prevalence of IAH among patients with T1D was 62.8% and the presence of
IAH was significantly associated with the duration of T1D (p = 0.019). Patients with
HbA1c ≥ 7% possess a significantly higher level of drowsiness, dizziness, and hunger.
Dizziness, warmth, difficulty speaking, pounding heart, and blurred vision were significantly
higher among patients with diabetes duration ≥10 yrs. This study concluded that the
prevalence of IAH is high among patients with T1D in Saudi Arabia. Focused and evidence-

15
based interventions are essential to minimize the hypoglycemia risk among patients with
T1D.29

Das M et al. (2022) conducted a study to assess the knowledge on hypoglycemia

among the diabetic patient in selected hospital, Siliguri. A descriptive cross-sectional study,
was carried out in the month of June 2022. A semi-structured questionnaire was used to
interview 100 study participants who were diabetes patients who had been admitted to the
medical ward and who had visited the endocrinology outpatient department. The study
finding shows that 52% of the samples had fair knowledge on hypoglycemia, while
23% of them had poor knowledge. The study's findings highlighted the fact that most
diabetes mellitus patients had a fair understanding of hypoglycemia. The health care
personnel should also take time and efforts to educate patients about the sign of
hypoglycemia. So that hypoglycemic episodes and morbidity could be reduced or prevented
at primordial level.30

Aloriney A.; (2021) Prevalence and characteristics of impaired awareness of

hypoglycemia in King Fahad Medical City, Saudi Arabia. This was an observational cross-
sectional study conducted on diabetic patients attending outpatient clinics of the OEMC of
King Fahd Medical City during a period of 12 months using Clarke questionnaire. Findings
showed a low prevalence of IAH in the region (13.8%) and that IAH patients had experienced
a significantly higher rate of severe hypoglycemia compared to hypoglycemic aware patients.
These findings are consistent with the hypothesis that IAH develops mostly in patients with
type 1 diabetes (T1D) but also presented in type 2 diabetes (T2D). This remains to place them
at risk of experiencing severe hypoglycemia. This study concluded that IAH and severe
hypoglycemia are relatively common among T1D and T2D patients.31

Van Meijel LA, de Vegt F, Abbink EJ, et al. (2019) conducted a study on High
prevalence of impaired awareness of hypoglycemia and severe hypoglycemia among people
with insulin-treated type 2 diabetes. 2350 people with type 2 diabetes on insulin were
included: 59.1% men, mean age 61.1±10.4 years, mean diabetes duration 14.8±9.2 years and
79.5% on basal-bolus therapy. A total of 229 patients (9.7%) were classified as having IAH
and 742 patients (31.6%) reported severe hypoglycemia. Increased odds for IAH were found
with complex insulin regimens and lower odds with having a partner and body mass index
≥30 kg/m2. Severe hypoglycemia was associated with complex insulin regimens, non-
Caucasian ethnicity and use of psychoactive drugs, and inversely with metformin use. This

16
study concluded that in this nationwide cohort, almost one out of ten people with type 2
diabetes on insulin had IAH and >30% had a history of severe hypoglycemia in the past
year.32

Madani, A., et. al. (2019) conducted a study on Assessing Knowledge of

Hypoglycemia Symptoms among Type 2 Diabetic Patients Using Insulin, Khartoum, Sudan.
A single centre, hospital-based, analytical, and cross-sectional study was carried out among
diabetic patients using insulin attended to Ribat University Hospital Diabetes Clinic
(RUHDC), Khartoum State, Sudan during a period of study. A majority of patients (52%) had
poor knowledge of hypoglycemia symptoms and the common symptoms known to patients
were hands tremor (67.2%), blurred vision (52.8%) and sweating (65.6%). No associations
were found among hypoglycemia symptoms knowledge, socio-demographic and diabetes
duration. Only (25.6%) had regular visiting to educating center and physicians were the
major source of diabetes knowledge (74.4%). This study proved low patients hypoglycemia
symptoms knowledge and physician were the main sources of information about diabetes at
RUHDC. Further ideas are required in collaboration and integrated approach to filling the gap
of patients’ awareness and multidisciplinary team in diabetes management.33

Lamounier, R.N., Geloneze, B., Leite, S.O. et al. (2018) Hypoglycemia incidence
and awareness among insulin-treated patients with diabetes: the HAT study in Brazil. This
was a non-interventional, multicenter study, with a 6-month retrospective and a 4-week
prospective evaluation of hypoglycemic events. From 679 included patients, 321 with T1DM
and 293 T2DM, median age of 33.0 and 62.0 years, 59% and 56% were female, and median
diabetes duration was 15.0 and 15.0 years, respectively. Median time of insulin use was 14.0
and 6.0 years. During the prospective period, 91.7% T1DM and 61.8% T2DM patients had at
least one hypoglycemic event. In the same period, 54.0% T1DM and 27.4% T2DM patients
had nocturnal hypoglycemia, 20.6% T1DM and 10.6% T2DM patients had asymptomatic
hypoglycemia, and severe events occurred in 20.0% and 10.3%, respectively. At baseline,
21.4% T1DM and 34.3% T2DM had hypoglycemia unawareness. This study concluded that
referred episodes of hypoglycemia were high, in both T1DM and T2DM insulin users. Patient
attitudes after hypoglycemia, such as reduction in insulin and increase in calorie intake, can
affect diabetes management.34

Zekarias, K., Kumar, A., Moheet, A., & Seaquist, E. (2018) conducted a study on
Real life evidence that impaired awareness of hypoglycemia persists for years in patients with

17
type 1 diabetes. Thirty-six with type 1 diabetes and impaired awareness of hypoglycemia who
participated in studies on impaired awareness of hypoglycemia between 2009 – 2015 were
contacted to complete an online survey. The finding shows that 23 of 36 (63%) subjects
contacted completed the survey. (12 M, 11 F; median age 51 years, median diabetes duration
34 years). One had had an islet cell transplant and was excluded. Persistent impaired
awareness of hypoglycemia was found in 19/22 (86%) using the Cox questionnaire and 18/22
(82%) using the Gold questionnaire. Consistent use of continuous glucose monitoring over
the last six months defined as using a device ≥75% of time over the last 6 months was
reported by 67% (12/18) and 68% (13/19) of participants with persistent impaired awareness
of hypoglycemia as measured by Gold and Cox; respectively. Nineteen of the 22 participants
(86%) reported severe hypoglycemia over the last six months. This survey concluded that the
impaired awareness of hypoglycemia persisted in more than 80% of the subjects with type 1
diabetes we studied between 2009–2015. While the consistent use of continuous glucose
monitoring among our participants was high; it did not translate into restoration of
hypoglycemia awareness in this population. 35

P, Thenmozhi & M, Vijayalakshmi. (2018) conducted a study on Knowledge On

Hypoglycemia Among Patients With Diabetes Mellitus. A cross-sectional research design was
adopted with 60 samples who met the inclusion criteria in the rural community in India.
Structured interview method was used to collect the data. The result shows that out of 60
samples, 38 (63.33%) had inadequate knowledge, 12 (20%) of them had moderately adequate
knowledge, and 10 (16.67%) of them had adequate knowledge. There is a significant
association between the age and type of treatment at the level of p<0.05 with the level of
knowledge on hypoglycemia. The study findings emphasized that majority of the patients
with diabetes mellitus do not have the knowledge on hypoglycemia. The health-care
professional has an important role in educating diabetics on hypoglycemia so that
hypoglycemic episodes and morbidity could be reduced or prevented.36

Hussein Zanariah, et. al. (2017) conducted a study on Hypoglycemia awareness

among insulin-treated patients with diabetes in Malaysia: A cohort subanalysis of the HAT
study. The Hypoglycemia Assessment Tool (HAT) study was a non-interventional, 6-month
retrospective and 4-week prospective analysis of hypoglycemic events in 24 countries. There
were 1153 participants in the Malaysian cohort (114 T1DM; 1039 T2DM). In the prospective
period, 50.4% and 33.4% of patients reported ≥1 hypoglycemic events, with estimated rates

18
of 20.3 and 13.1 events per patient-year of exposure in patients with T1DM and T2DM,
respectively. In the prospective period, 50% of patients with T1DM or T2DM consulted a
doctor or nurse following a hypoglycemia episode. This study concluded that half of patients
with T1DM and a third of patients with T2DM reported ≥1 hypoglycemic event during the
prospective period.37

Shriraam, V., et. al. (2015) conducted a study on Knowledge of hypoglycemia and
its associated factors among type 2 diabetes mellitus patients in a Tertiary Care Hospital in
South India. The study included 366 type 2 diabetic patients, of which 76.5% were females.
The target fasting and postprandial blood glucose levels while on treatment was known to
135 (36.9%) and 126 (34.4%) patients, respectively. The common symptoms of
hypoglycemia known to the study subjects were dizziness (81.4%), weakness (73.8%), and
drowsiness (72.1%). Overall, 242 (66.1%) diabetic patients had good knowledge on
hypoglycemia (knowledge of at least three symptoms of hypoglycemia together with at least
one precipitating factor and at least one remedial measure). This study concluded that
although the knowledge on symptoms of hypoglycemia, precipitating factors, remedial
measures are high in this study, the target blood levels, complications were known to just a
third of them. There is a knowledge gap on important aspects of hypoglycemia among type 2
diabetic patients.38

Literature regarding knowledge and practice of hypoglycemia.

Cecyli, C.; et. al. (2022) conducted a study on Assessment of the Knowledge and
Self-Care Practice on Hypoglycemia among Patients with Diabetic Mellitus Attending
Medical Opd at Smch. A cross sectional descriptive research design was adopted with
hundred samples who met the inclusion criteria in the hospital setting. The study result shows
that out of 100 samples 76(76%) had adequate knowledge and 63(63%)had good self-care
practice on hypoglycemia. Spearman's correlation showed a positive relationship between
knowledge and self-care practice of hypoglycemia (r value = 0.720, p<0.001. This study
result emphasized that the majority of the diabetic patients had adequate knowledge and good
self-care practice on hypoglycemia. Enlightening the patients further with regular self-
monitoring of blood glucose level and obtain medical guidance and support may help the
patients to stay fit.39

19
 Loan Thi Chu; et. al. (2021) conducted a study on "The Effectiveness of Health
Education in Improving Knowledge about Hypoglycemia and Insulin Pen Use among
Outpatients with Type 2 Diabetes Mellitus at a Primary Care Hospital in Vietnam". A pretest–
posttest study was conducted among 80 patients with T2DM at District 11 Hospital in Ho Chi
Minh City, Vietnam. The majority were males (65.0%) and the mean age was 59.6 (standard
deviation 8.1, range 35-75) years. Very few patients had good knowledge and proper insulin
pen use, with percentages ranging from 13.8% to 60%. There was a significant improvement
of knowledge and practice after the intervention. Such improvement remained high one
month and two months after the intervention. The health education intervention is effective in
improving knowledge and practice in this population. There is a pressing need for such
intervention at primary care hospitals to optimize treatment for patients with T2DM, possibly
focusing on those who had characteristics to have the best effectiveness found in this study.40

Shrivastva Anjali; et. al. (2020) conducted a study on knowledge and self-care
practices about Diabetes Mellitus among patients with type 2 Diabetes Mellitus attending
selected tertiary healthcare facilities in coastal Karnataka. Cross-sectional study was
conducted to assess the knowledge and self-care practices about Diabetes among diagnosed
Type 2 Diabetes Mellitus patients attending the out-patient facilities of Medicine Department
at selected tertiary healthcare institutions of Udupi Taluk. A total of 166 participants were
included in the study and they were selected using consecutive sampling. Most of the
participants (>65%) had knowledge about different aspects of Diabetes. The Mean total score
of self-care practices among participants without and with intensive insulin treatment was
6.25 ± 1.25SD and 6.20 ± 1.01SD respectively. This study emphasizes the need to strengthen
the initiatives related to generating awareness about diabetes and improving self-care
practices related to it.41

Muche EA, Mekonen BT; (2020) conducted a study on Hypoglycemia prevention

practice and its associated factors among diabetes patients at university teaching hospital in
Ethiopia: Cross-sectional study. A cross-sectional study was carried out on a total of 422
systematically selected diabetic patients at the University of Gondar Referral and Teaching
Hospital. The study result shows that the majority of respondents had good knowledge of
(77.5%) and practice of (93.1%) hypoglycemia prevention. Only good participant knowledge
about hypoglycemia prevention was strongly associated with the practice of its prevention
(AOR: 2.87 (1.2–6.8), p = 0.01). this study concluded that even though diabetic patients with

20
good knowledge of hypoglycemia and its prevention was strongly associated with good
prevention practice, there exists a gap in knowledge of hypoglycemia prevention. Hence, this
study recommend counseling be offered to patients regarding hypoglycemia during their visit
to the diabetic clinic.42

Sreedevi K. (2020) conducted a study to assess the effectiveness of structured

Teaching Programme on self-care management of patients with type 2 Diabetes mellitus and
Evaluation of prognosis in selected Hospitals. A quasi experimental study was conducted on a
sample of 100 patients with type 2 diabetes mellitus attending diabetic clinic of Rajah
Muthiah Medical College and Hospital as experimental group and 100 patients with type 2
diabetes mellitus attending diabetic clinic of Government Hospital as control group.
Systematic sampling technique was used to select the patients for study. The study result
shows that the mean post-test knowledge score on general information about diabetes, diet,
exercise, medication, urine test for sugar and prevention of complications in the experimental
group was significantly higher than in the control group (P<0.001).There was significant
reduction in post-test BMI level in the experimental group when compared to the control
group (P<0.007).There was significant reduction in post-test HbA1c level in the experimental
group than in the control group (P<0.002).The post-test knowledge score on general
information on diabetes mellitus, medication and prevention of complications was also
influenced by education, which was significant at 0.01, 0.03 and 0.001 respectively. From
this study results and available literatures it is evident that education on self-care
management can improve the health status of diabetic patients and reduce complications. 43

Dinesh, P. V., et. al. (2016) conducted a study on Knowledge and self-care practices
regarding diabetes among patients with Type 2 diabetes in Rural Sullia, Karnataka: A
community-based, cross-sectional study. The sample size was calculated to be 400, and the
sampling method was probability proportionate to sampling size. The result shows majority
of them were married males of Hindu religion and belonged to upper middle class. Only
24.25% of them had good knowledge. Among the self-care practices, foot care was the most
neglected area. This study concluded that only one-fourth of the study population had a good
knowledge toward diabetes. Adherence to some of the self-care practices was also poor.
Government policies may help in creating guidelines on diabetes management, funding
community programs for public awareness, availability of medicines, and diagnostic services
to all sections of the community.45

21
 Varghese, J., & Naidu, S. (2015) conducted a Study to Assess the Effectiveness of
Self Instruction Module on Knowledge, Attitude, and Practice Regarding Prevention of
Complications among Diabetic Patients in Selected Hospitals in Pune. Sample size is 60
samples. Convenient sampling is selected as it is the easiest, fastest, most convenient,
accessible and most proximal to the researcher. Quantitative evaluative Pre-experimental
design with one group pre-test and post-test. The burden of diabetes is increasing globally,
particularly in developing countries. Self instruction module is a simplest technique easy to
understand, which is considered to be appropriate for the diabetic patients and applicable for
them to prevent.46

Gezie GN, et. al. (2015) conducted a study on Knowledge and practice on prevention
of hypoglycemia among diabetic patients in South Gondar, Northwest Ethiopia: Institution
based cross-sectional study. Four hundred sixteen diabetic patients were involved in the
study. From the total study participants 105(25.5%) were found to have good knowledge
about hypoglycemia prevention. Eighty nine (21.4%) had good practice in hypoglycemia
prevention. Educational status and being a member of diabetic association were found to be
positively associated with knowledge and practice. Knowledge and practice on hypoglycemia
prevention are poor. Members of Ethiopian Diabetic Association are very low in this study.
Thus the association should design and provide information tailored to patient education
level.47

22
 CHAPTER-III

RESEARCH METHODOLOGY

RESEARCH APPROACH- Evaluative approach will be used to conduct this study.

RESEARCH DESIGN- Quasi-experimental one group pre-test post-test design will be
adopted to assess the knowledge and practice regarding hypoglycemia and its self-care
management among diabetes mellitus clients.

GROUP PRE-TEST INTERVENTION POST-TEST

KNOWLEDGE

EXPERIMENTA O1 X O2
L GROUP

SETTING OF THE STUDY- The study will be conducted in selected Hospitals at

Hisar. POPULATION- The population selected for this study are diabetes mellitus clients
visiting in selected hospitals at Hisar.

SAMPLE- The diabetes mellitus clients in between the age group of 41-60 years will be
selected as study samples.

SAMPLE SIZE- The sample size comprised of 60 diabetes mellitus clients.

SAMPLING TECHNIQUE- Simple random sampling will be used to select the

samples.

CRITERIA FOR SAMPLE SELECTION

Inclusion Criteria-

23
  Both male and females.
 Diabetes mellitus clients visiting in selected hospitals at Hisar.
 Those who will be available during data collection.

Exclusion criteria

 Diabetes mellitus clients who will not be willing to participate in the study.
 Diabetes mellitus clients who will not came in age group 41-60 years.
 Diabetes mellitus clients who will not read and write Hindi and English

RESEARCH VARIABLES:

 Dependent variable: Knowledge and practice regarding hypoglycemia and its self-care
management
 Independent variable: Health education on hypoglycemia and its management
 Demographic variables: The demographic variables will be age, gender, educational
status, occupation, income, religion, family history, duration of diabetes, past history of
any natural medicines, received information on hypoglycemia.

THE DESCRIPTION OF THE TOOL

PART-I: It consists of demographic variables such as age, gender, educational status,

occupation, income, religion, family history, duration of diabetes, past history of any natural
medicines, received information on hypoglycemia.

PART II: It consists of structured knowledge questionnaire regarding hypoglycemia and its
self-care management. Which consists of 30 multiple choice questions. It has four options
among which, one is the correct response. Scores will be interrupted as follows:

Adequate >75%
Moderately adequate >50% -<75%
Inadequate <50%

PART III: It consist of checklist to assess the practice of the diabetes mellitus clients
regarding self-care management of hypoglycemia.

24
The scale consists of 10 statements to assess the practice of the diabetes mellitus clients
regarding self-care management of hypoglycemia. Each statement has two options Yes or No
and the scores was distributed as 1 for Yes and 0 for No. The maximum score is 10 and the
minimum score is 0.

Scores will be interpreted as follows:

Adequate practice= 67 - 100%

Moderately Adequate practice = 34 - 66 %
Inadequate practice = 0-33 %

PART IV: It consist of health education regarding hypoglycemia and self-care management
of hypoglycemia.

PILOT STUDY- Pilot study will be conducted on 10% diabetes mellitus clients who were
excluded in main study.
ETHICAL CONSIDERATION
 The proposed study will be conducted after the approval of dissertation committee.
 Consent of each subject will be obtained before the data collection.
 Confidentiality will be maintained throughout the study.

DATA ANALYSIS

The collected data will be analysed in terms of descriptive and inferential statistics.

• Organized the collected data in master sheet.

• Demographic data will be analysing by using frequencies and percentage.

• Knowledge score and Practice level will be analysing by computing frequency percentage,
mean and standard deviation of answered question.

• Chi-square test will be used to determine the association between knowledge and practice
scores and selected demographic variables.

• The findings were presented in table and graphs.

DESCRIPTIVE STATISTICS:

25
  Mean, standard Deviation To assess the knowledge and practice of diabetes mellitus
clients on hypoglycemia and its self-care management.
 Karl Pearson correlation formula, to determine the relationship between knowledge and
practice regarding hypoglycemia and its self-care management.

INFERENTIAL STATISTICS

⮚ Chi Square test To Find out the association between knowledge and practice score

regarding hypoglycemia and its self-care management with their demographic

variables.

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Integr Obesity Diabetes . 1: doi: 10.15761/IOD.1000113

SIGNATURE OF THE CANDIDATE

NAME OF THE CANDIDATE Pallavi Sharma (M.sc Nursing)

Dr. Promila Pandey

NAME AND DESIGNATION OF GUIDE
Principal

Dept. of Medical Surgical Nursing

MAMC, Agroha, Hisar

SIGNATURE OF GUIDE

NAME AND DESIGNATION OF CO-GUIDE Dr. Shikha

Professor cum HOD

31
 Dept. of Medical Surgical Nursing

MAMC, Agroha, Hisar

SIGNATURE OF CO-GUIDE

Dr. Shikha
HEAD OF DEPARTMENT

SIGNATURE OF HEAD OF DEPARTMENT

REMARKS OF PRINCIPAL

SIGNATURE

32