OVERVIEW OF SELF-CARE BEHAVIOR IN PATIENTS WITH TYPE II DIABETES MELLITUS : LITERATURE REVIEW

Introduction : Diabetes Mellitus is a chronic disease that requires self-care to improve the quality of life and reduce the occurrence of complications. Self-care behaviors that can be applied by DM patients include physical activity, diet regulation, control of blood glucose levels, treatment, and prevention of complications. The purpose of this literature review is to describe self-care behavior in Type II Diabetes Mellitus patients. Methods : Literature Review using the PICOT framework from several databases (Scopus, Science Direct, Google Scholar, Research Gate and Pubmed). The search results are displayed in the PRISMA. Abstracts and full articles were assessed for eligibility (n = 34), The articles correspond to research feasibility in quantitative studies (n = 12). Results : After collecting data, all data were selected according to the inclusion. Based on a review article, the self-care regimen for type 2 Diabetes Mellitus patients generally includes physical activity, diet, controlling blood glucose levels, monitoring blood glucose and medication. However, most of the respondents' compliance with self-care management behavior in type 2 Diabetes Mellitus (DM) patients has not been carried out optimally. Conclusions : The role of nurses is important in increasing adherence to self-care behavior in Diabetes Mellitus patients.


INTRODUCTION
Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces.Insulin is a hormone that regulates blood sugar.Hyperglycemia, or elevated blood sugar, is a common effect of uncontrolled diabetes and over time causes serious damage to many body systems, especially the nerves and blood vessels (WHO, 2001).
World Health Organization (WHO) predicts Diabetes will be the 7th leading cause of death by 2030.Diabetes is found in every population in the world and in all regions, including rural low-and middle-income countries.The number of people with diabetes continues to increase, WHO estimates that there were 422 million adults with diabetes worldwide in 2018.The prevalence with age in adults rose from 4.7% in 2018, with the largest increase in low populations.and middle-income countries compared to high-income countries (Kementerian Kesehatan RI., 2020) The Southeast Asia region where Indonesia is ranked 3rd with a prevalence of 11.3%.Indonesia is ranked 7th among 10 countries with the highest number of sufferers, which is 10.7 million.The results of the Basic Health Research (Riskesdas) show that the prevalence of diabetes mellitus in Indonesia based on a doctor's diagnosis at the age of > 15 years is 2%.However, the prevalence of diabetes mellitus according to the results of blood sugar examination increased from 6.9% in 2013 to 8.5% in 2018 (Simatupang, 2023).Without interventions to stop the increase in diabetes, there will be at least 629 million people living with diabetes by 2045 (WHO, 2001).Therefore, it is important to control glucose levels in the blood of people with diabetes mellitus.
Metabolic and lipid control in DM patients can be done through increasing self-care behavior (Amelia, 2018).Self-care behaviors that can be applied by DM patients include physical activity (exercise), diet regulation, control of blood glucose levels, treatment, and prevention of complications (Sorato M & C, 2016).The adherence of DM patients to routine and lifelong self-care measures is a big challenge and is not easy to do (Luthfa & Ardian, 2019).The adherence of DM patients in performing self-care such as diet, blood glucose monitoring and foot care is relatively low (Mogre et al., 2017) .
Self-care management behavior in type 2 Diabetes Mellitus (DM) patients has not been carried out optimally (Istiyawanti et al., 2019).The self-care level of Type II DM patients is 52.89% which is included in the moderate category (Fithriani & Istibsaroh, 2019).Showed that patients with type 2 diabetes who received outpatient treatment had 65.4% self-care in the poor category and 48.1% with a poor quality of life (Kusnanto, 2012).According to the American Association of Diabetes (ADA), diabetic patients really need self-care behavior to improve quality of life and reduce the occurrence of complications due to diabetes.
The success of a treatment, both primary and secondary, is strongly influenced by the compliance of Diabetes Mellitus patients in maintaining their health.Primary and secondary treatment can be carried out optimally and the quality of health.Diabetes Mellitus patients who do not have the selfawareness to comply can cause failure in treatment and reduce the patient's health status (Greeson & Chin, 2019).Diabetes Mellitus demands new lifestyle changes for a lifetime and diabetic patients must be able to adapt to undergo life changes.The purpose of this literature review is to describe self-care behavior in Type 2 Diabetes Mellitus patients.

MATERIALS AND METHODS Design and Search Method
This research is a literature review with a narrative method that tries to explore the results of research in Indonesia and internationally (Sukartini et al., 2023).Search journals on several databases, including (Scopus, Science Direct, Google Scholar, Research Gate and Pubmed) with keywords; self-care, self-care behavior, diabetes mellitus, adherence, blood glucose.The search for this journal is limited to the last 5 years from January 2015 to October 2020, fulltext, journals that are appropriate to the topic.The search results are displayed in the PRISMA diagram (Figure 1).

Inclusion and Exclusion Criteria
This literature review begins with a search for articles using the PICOT framework (Problem/Population = diabetes mellitus / type II diabetes mellitus, Intervention = self-care/ self-care behavior, Comparation = self-care behavior, and Outcome = adherence/ blood glucose.

Screening
In the screening process, a selection of journals is carried out which includes the language used (Indonesian or English), selecting the title and the existence of duplicate journals and identifying the abstract.

Data Extraction
The data obtained was extracted in the form of a table by including the author, journal name, year, method and research results.

Critical Review
The critical appraisal process uses the Critical Apprisal Skills Program to assess the quality of research articles.

Data analysis
Data analysis used thematic analysis, with the following steps: 1) understanding the data, identifying the code, 3) identifying the theme of the code, 4) improving the theme, 5) defining the theme   (Polit & Beck, 2013).

DISCUSSION
Self-Care Therapeutic Regimen for Type 2 Diabetes Mellitus Patients Based on a review article, it is said that the selfcare regimen for type 2 Diabetes Mellitus patients generally includes physical activity such as light exercise, diet, controlling blood glucose levels, monitoring blood glucose (SMBG), and medication.However, most of the respondents' compliance with self-care management behavior in type 2 Diabetes Mellitus (DM) patients has not been carried out optimally (Istiyawanti et al., 2019).The overall prevalence of adherence to self-care behaviors is still low.Self-efficacy, home blood glucose test, exercise per week, meal planning, dietary restriction, duration of diabetes, type of medication and description of appetite were significant variables related to adherence to self-care behavior (Oluma et al., 2020).Research by (Mogre et al., 2017) on adherence and factors related to self-care behavior in type 2 Diabetes Mellitus patients in Ghana states that adherence to diet, Self-Monitoring Blood Glucose (SMBG), and foot care very low.Selfcare that is often done by type 2 DM patients is physical activity or light exercise.Only 1 patient did the SMBG routine every day.This low level of adherence is due to the low level of knowledge, in addition it may be that women need additional support to increase adherence to self-care behavior in type 2 DM patients.

Supporting factors
Research by (Chourdakis et al., 2014) stated that the self-care behavior of Diabetes Mellitus patients is closely related to social support.The higher the level of social support, the better the results about self-management.In addition, (Simon-Tuval et al., 2016)states that patients with type 2 diabetes consider the source of coping in diabetes mellitus management as self-acceptance to the disease, adherence to self-care, knowledge of the disease and support from various parties including nurses.

Obstacle factor
The inhibiting factor in the failure of type 2 DM patients to carry out self-care is due to the low level of knowledge (Mogre et al., 2017).Research by (Kassahun et al., 2016) also states that a significant number of DM patients have low levels of knowledge, poor self-care behavior and low levels of adherence to medication.This is also in accordance with research (Chourdakis et al., 2014) that physical exercise is more often done by men who are more educated and diagnosed earlier.Younger patients were less likely to follow their health care professional's recommendations regarding diet, medication intake, blood glucose checks, foot care, and exercise compared to older patients.These results pose a higher risk of complications and morbidity in young patients with type 2 diabetes mellitus, who are likely to require intensive care in the future.
Lack of knowledge about diabetes and self-care is also found in patients with less than optimal blood glucose control (Zhou et al., 2013).In increasing patient awareness of the importance of the self-care domain for type 2 Diabetes Mellitus patients by strengthening the IEC program (Mariye al., 2018).The development of effective educational strategies on understanding the importance of self-care by type 2 DM patients is very necessary (Zhou et al., 2013)

Psychospiritual Self-care Management
Long-term care that type 2 DM patients have to undergo is very difficult to control effectively, so it is necessary to pay attention to psychological and spiritual aspects in addition to physical aspects.(Kusnanto, 2012) research on self-care management-holistic psychospiritual care can improve affective and psychomotor cognitive, DM patients can be more independent in managing their illness.
Psychological aspects are important because beliefs in health, knowledge and behavior will have an effect on patients controlling their illness.The research of (Luthfa & Ardian, 2019) concluded that 2 DM patients undergo a transition process from a healthy condition to an illness.The transition process begins with a cyclic loss response that predisposes the patient to self-control and selfcare decisions.Self-control will make type 2 DM patients adapt and engage with new experiences from new habits.Self-care will facilitate type 2 DM patients in adapting to the internal and external environment and make type 2 DM patients have positive expectations in their lives.
Spiritual care aspects improve patient self-care, expectations, strength and quality of relationships (Gupta & Anandarajah, 2014).Spirituality has a fundamental role in having a positive effect on DM patients.The role of nurses in spiritual care consists of the quality of nurses, nursing interventions and nursing practice scenarios.The quality of nurses as capacity, understanding, calling and commitment to the provisions of spiritual care (Veloza-Gómez et al., 2017).For example, nurses perform wound care by paying attention to spiritual aspects that help type 2 DM patients to understand the patient's sense of honor, experience and value (Frouzandeh et al., 2015).

CONCLUSIONS
There was an influence of physical readiness, psychological readiness, material readiness on the offline learning readiness of the third-level students of the Nursing Study Program, University of Muhammadiyah Klaten.Physical readiness is the most dominant variable which influences the readiness of conducting offline learning.
Notes excluded (n = 812) with reason: 1. P: The population is only in patients with type II diabetes mellitus 2. I: The intervention discusses the problem focused on self-care/ self-care behavior C: Comparison group O: adherence/ blood glucose T: 2015-2020 years Articles identified after duplicate articles have been removed (n = 914) Notes filtered by title (n = 102) Records identified based on literature search Scopus, Sciencedirect, Pubmed, Research Gate dan Google Scholar (n = 4.013).

Table 1 .
Journal Search Results (Babazadeh et al., 2017)D: cross sectional study S: 120 participants V: Self-care behavior, physical health I: self-management of blood glucose control, self-care nutrition A: Multi-variable logistic regression