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Research article Topical Sections

Diabetes education—Cornerstone in management of diabetes mellitus in Jamaica

  • Background 

    Diabetes mellitus (DM) is one of the leading causes of morbidity and mortality among Caribbean populations. Ideal glycemic control can be attained when patients adhere to self-management behaviors such as consistent monitoring of blood glucose (BG) levels, staying physically active, taking medications, and eating a healthy diet.

    Aim 

    The present study has the following aims: (1) to assess knowledge of self-care and the initiative of type 2 diabetic patients in medication compliance, making suitable food choices, regular physical exercise and BG monitoring, (2) to evaluate diabetic patient self-management by adhering to instructions of healthcare provider in attaining outcomes such as medication adherence, appropriate food choices, prescribed physical exercise, and self-monitoring of BG levels and determination of glycated hemoglobin (HbA1c) levels at clinic visits and (3) to determine whether there are associations between BG control (glucose and HbA1 levels) and sociodemographic factors (i.e., age, education, employment status) as well as knowledge of self-care and the number of years persons had type 2 diabetes mellitus (T2DM).

    Method 

    The study is a cross-sectional study that utilized a quantitative methodology. The study population consisted of 101 T2DM patients. The researchers used a 12-point interviewer administered questionnaire to solicit information on socio-demographics, knowledge of self-care, and self-management of T2DM, including physical activity and selecting appropriate food choices, and evidence of glycemic control, such as HbA1c and random blood glucose (RBG) levels. Researchers analyzed the data using SPSS version 17.0 and Microsoft Excel 2007. Authors applied an analytical statistical analysis with a 95% confidence level.

    Results 

    The findings revealed that 90.1% of respondents indicated that they knew how to take their medications. Results also indicated that there was no association of knowledge of self-care with the number of years persons had T2DM. Among the total respondents, 53.5% had poor compliance to prescribed medication, and women were 1.2 times more likely not to comply with medication. In addition, 65.3% of respondents reported poor compliance with physical exercise and 81.2% of respondents indicated poor compliance in self-monitoring BG.

    Conclusion 

    The findings from this study reveal that the majority of patients with T2DM knew how to take their medications. However, compliance with physical exercise and self-monitoring BG were less than satisfactory. Didactic interventions focusing on the acquisition of knowledge and information will empower patients and improve their self-care and management.

    Citation: Paula Barrett-Brown, Donovan McGrowder, Dalip Ragoobirsingh. Diabetes education—Cornerstone in management of diabetes mellitus in Jamaica[J]. AIMS Medical Science, 2021, 8(3): 189-202. doi: 10.3934/medsci.2021017

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  • Background 

    Diabetes mellitus (DM) is one of the leading causes of morbidity and mortality among Caribbean populations. Ideal glycemic control can be attained when patients adhere to self-management behaviors such as consistent monitoring of blood glucose (BG) levels, staying physically active, taking medications, and eating a healthy diet.

    Aim 

    The present study has the following aims: (1) to assess knowledge of self-care and the initiative of type 2 diabetic patients in medication compliance, making suitable food choices, regular physical exercise and BG monitoring, (2) to evaluate diabetic patient self-management by adhering to instructions of healthcare provider in attaining outcomes such as medication adherence, appropriate food choices, prescribed physical exercise, and self-monitoring of BG levels and determination of glycated hemoglobin (HbA1c) levels at clinic visits and (3) to determine whether there are associations between BG control (glucose and HbA1 levels) and sociodemographic factors (i.e., age, education, employment status) as well as knowledge of self-care and the number of years persons had type 2 diabetes mellitus (T2DM).

    Method 

    The study is a cross-sectional study that utilized a quantitative methodology. The study population consisted of 101 T2DM patients. The researchers used a 12-point interviewer administered questionnaire to solicit information on socio-demographics, knowledge of self-care, and self-management of T2DM, including physical activity and selecting appropriate food choices, and evidence of glycemic control, such as HbA1c and random blood glucose (RBG) levels. Researchers analyzed the data using SPSS version 17.0 and Microsoft Excel 2007. Authors applied an analytical statistical analysis with a 95% confidence level.

    Results 

    The findings revealed that 90.1% of respondents indicated that they knew how to take their medications. Results also indicated that there was no association of knowledge of self-care with the number of years persons had T2DM. Among the total respondents, 53.5% had poor compliance to prescribed medication, and women were 1.2 times more likely not to comply with medication. In addition, 65.3% of respondents reported poor compliance with physical exercise and 81.2% of respondents indicated poor compliance in self-monitoring BG.

    Conclusion 

    The findings from this study reveal that the majority of patients with T2DM knew how to take their medications. However, compliance with physical exercise and self-monitoring BG were less than satisfactory. Didactic interventions focusing on the acquisition of knowledge and information will empower patients and improve their self-care and management.


    Abbreviations

    DM:

    Diabetes mellitus; 

    BG:

    Blood glucose; 

    T2DM:

    Type 2 diabetes mellitus; 

    RBG:

    Random blood glucose; 

    DSME/S:

    Diabetes self-management education and support; 

    HbA1c:

    Glycated hemoglobin; 

    SGBM:

    Self glucose blood monitoring

    The interconnection between the dynamical behavior of discrete and continuous systems is referred to as a hybrid class. The concept of hybrid systems can be utilized to study the discrete dynamics of a model whenever the continuous form of the system has a suppressed effect. In networking, hybrid systems maximize the impact of new technology by integrating newly developed techniques with existing ones, thereby enhancing the efficiency of the constructed model. This type of system has gained remarkable attention in various evolving fields, such as networking and communications, industries, and circuit models [1,2,3]. The study of continuous-time models with switches at discrete time instants is referred to as switched systems. By abstracting away the discrete behavior and focusing on the possible switching patterns within a class, it is possible to derive switched systems from hybrid models. In the control design of systems with sub-modules, the switching mechanism plays a crucial role. This mechanism is categorized based on two criteria: time-dependent and state-dependent switches. In the case of switches which are dependent on the state, the space Rn is divided into a set of operating regions by a family of switching sequence. Now each of these regions is interlinked with a sub-module which is continuous. When the trajectory of the system cuts through switching surface, the state response of the system suddenly undergoes a change and jumps to a new region by means of a reset map, whereas, if we consider a switching sequence which is time dependent the system consists of a piecewise constant switching signal δ:[0,]P, where P is a finite positive set of integers. The discontinuities of a function δ at finite time instant is called switching time signals. Here, δ defines the active subsystem at each time instant. Existence of solution and its uniqueness for the uncertain class of the switched fractional model was presented in [4]. Positive solutions of switching models was established by [5]. Switching topologies of the multi-agent model was analyzed in [6].

    The examination of system behavior in the presence of time delay is a crucial aspect while designing physiological and circuit systems. Moreover, analyzation of delay effect has gained even more attention while designing control models. Significant study time-delay control models can be found in [7,8,9]. Controllability is one of the most important and effective aspects of studying and manipulating the designed model according to specific requirements. This approach helps refine differential models. The impact of impulses on a system plays a vital role in designing the control input, as it requires formulating a piecewise control input for each interval. Few methods to study the impulsive control systems and their stability are found in [10,11,12,13]. When it comes to nonlinear controllability, the two vital techniques used are fixed point and differential geometry [14,15,16,17]. Switched system combined with impulsive effects is more efficient to model the discontinuous dynamics. Existing literature provides a great range of solution methods for hybrid systems. [18] et al. discussed the controllability of switch perturbed system with delays. The geometric method to analyze the reachability of the switched linear system was presented in [19]. Controllability of multi-delay switched models was presented in [20]. Some recent results on relative cotrollability of fractional order systems can be found in [21,22]. There are very few works pertaining to the analysis on stability and controllability of the switched fractional system. To mention a few, T. Kaczorek in [23] established the asymptotic behavior of the linear switched positive fractional system. Stability of impulsive switched fractional conformable system was discussed in [24]. Boundedness and stability of switched fractional models over finite time period was discussed in [25]. In [26], the authors discussed the controllability criteria for the Hilfer switched dynamical model. Relative controllability of the switched nonlinear fractional order system was established in [16]. Study on the control results of the nonlocal switching system can be found in [27]. Finite-time stability (FTS) refers to the study of whether a system's state remains within a predefined threshold over a fixed time interval. In other words, FTS ensures that the system's solution does not exceed a certain bound within a given time horizon, regardless of external disturbances or initial conditions. Unlike traditional asymptotic stability, which focuses on long-term behavior, FTS is particularly useful in scenarios where maintaining system constraints over a finite duration is critical, such as in control applications, robotics, and networked systems.

    One of the key criteria for achieving FTS is ensuring that the system variables remain bounded within the specified time frame. This boundedness is essential in many real-world applications where transient behavior plays a crucial role, such as in aerospace systems, power grids, and biological models. Various techniques, including Lyapunov-based methods, comparison principles, and differential inequalities, are commonly employed to establish sufficient conditions for finite-time stability.

    Due to its significance in practical applications, FTS has been a subject of extensive research in recent years. Numerous studies explore different approaches to analyze and enhance FTS, particularly in hybrid and switched systems, where impulsive effects and delays introduce additional complexities. Researchers continue to develop novel methodologies and theoretical frameworks to improve stability guarantees in such systems, making FTS an active and evolving area of study in control theory and applied mathematics. Work presented in [28] analyzes the FTS of neutral fractional system in-terms of fixed point results. Thresholds for impulsive singular systems to admit FTS was studied in [29]. Switching system stability was examined in [15,30]. A lot of informative results on FTS and how essentially it affects the analyzation of differential models are discussed in [2,14,28,29,31,32,33,34]. Comparative studies on stability and controllability of switching systems for various derivatives of fractional order are presented in [15,26,35,36,37,38,39].

    A careful examination of the aforementioned research works reveals that the general form of the solution is not easily deduced when the switched system is subject to time delays that occur at different time instants, particularly when coupled with nonlinear perturbations. This complexity presents a significant challenge in the analysis and control of such systems. In this context, this work investigates the finite-time stability and relative-type control criteria for fractional-order switched impulsive systems with delays occurring at distinct time instants. The aim is to develop effective control strategies that account for the interplay between time delays, nonlinearity, and fractional dynamics.

    (cDγy)(τ)=Hδ(τ)y(τd)+Pδ(τ)w(τρ)+Qδ(τ)(τ,y(τ),τ0g(τ,η,y(η))dη),τ(τl1,τl],Δy(τ)=Eδ(τ)y(τ),τ=τl,y(τ)=ζ1(τ),τ0dττ0,ζ1(τ)C([τ0d,τ0],Rn),w(τ)=ζ2(τ),τ0ρττ0,ζ2(τ)C([τ0ρ,τ0],Rm), (1.1)

    where the derivative order is γ(12,1), the state response vector is y(τ)Rn, and w(τ)Rm. Then, d>0,ρ>0 represents the time delay in the state and control input. δ(τ):[0,]SK1=1,...,K represents the switching function which is left continuous. At the instant δ(τ)=j the jth subsystem (Hj,Pj,Qj) will be active. Jump at the instant τl is denoted by Δy(τl)+y(τl)=y(τ+l). The matrices are HjRn×n,PjRn×m and QjC([τ0,τl]×Rn×Rn,Rn).Eδ(τ):RnRn, represents the impulsive function. Let rl=τlτl1 represent the dwell time. At this point, it is important to note the switching signals and perturbations occur simultaneously and, therefore synchronize at τl. As a first step, we begin by deducing the solution of system (1.1) to analyze the stability and control results. Consider the following system

    (cDγy)(τ)=Hy(τd)+Q(τ),ττ0,y(τ)=ζ1(τ),τ0dττ0,ζ1(τ)C([τ0d,τ0],Rn). (1.2)

    The authors in [40] proposed the solution of (1.2) as

    ˜y(τ)=ZH(ττ0)γdζ1(τd)+τ0τ0dZH(τdν)γdζ1(ν)dν+ττ0ZH(τν)γd,γQ(ν)dν, (1.3)

    where ZH.γd and ZH.γd,γ will be described later. It is more complicated to evaluate the solution of (1.1) as in the form of (1.3); hence, we first establish improvised form of (1.3) to deduce the state response of (1.1).

    While there is significant research on linear models and stability criteria for fractional-order differential equations, the nonlinear analytical methods specific to FTS systems remain less explored. Furthermore, there is a lack of generalization in the thresholds for FTS across different models. The study of generalized models and their identifiability or invertibility in the context of fractional delays has not been thoroughly established in previous works, especially concerning systems with nonlinear dynamics. The paper addresses identifiability and invertibility of generalized fractional models, which is not commonly explored in the literature. This contributes to the practical application of these models, particularly in fields involving parameter estimation and system identification. This integrated approach offers a more robust validation of the theoretical findings, providing a clear pathway from mathematical derivations to practical implementation. This was largely missing from earlier research where either theoretical or numerical methods were treated separately. We try to propose a piecewise continuous solution in the form of the delayed matrix Mittag Leffler function. Then, we deduce the require bound for (1.1) to admit finite time period stability. Further, analytical and fixed point techniques will be used to analyze the relative control results of (1.1). The framework of the article is outlined as follows:

    In Section 2, we discuss the basic results, integral inequalities, and definitions which are required for theoretical study. The thresholds required for FTS are deduced in Section 3. In Section 4, we provide a nonlinear analytical study using theorems, such as the fixed point for (1.1), to be relatively controllable. In Section 5, we substantiate our study with concrete numerical simulations.

    Let us take into account the vector space Rn with H=λmax(HTH) as the matrix norm, where λmax(H) is the largest eigenvalue of the matrix H. Then, J=P.C.([τ0d,τN],Rn) denoted the piecewise continuous Banach space function. Let y=sup{y(τ),τJ}. Moreover, let yL2[τ0,τN]=(τNτ0y(ν)2dν)12 be the square functions which are integrable. The important assumption that we need to consider is rl>max{d,ρ}.

    Definition 2.1. [16] Let {τl}N1 be a sequence of time periods. Then, δ:[τ0,τN]SK1 is defined as an admissible switch if δ(τ)=δ(τ+l)=δ(τl+1),τ(τl1,τl], and δ(τ0)=δ(τ+0).

    Definition 2.2. [16] For any given initial functions ζ1(τ) and ζ2(τ), the relative type controllability of (1.1) with respect to the {τl}Nl=1 is guaranteed if for the admissible signal δ(τ) and the input wL2([τ0,τNρ],Rm) in such a way that y(τN)=yf.

    Definition 2.3. [7] The differential operator in the sense of Riemann-Liouville with order γ(0,1) of a function y:[0,)R is given as (RLDγy)(τ)=1Γ(1γ)ddττ0y(ν)(τν)γdν.

    Definition 2.4. [30] The differential operator in the sense of Caputo with order γ(0,1) of a function y:[0,)R is given as (CDγy)(τ)=(RLDγy)(τ)y(0)Γ(1γ)τγ.

    Definition 2.5. [7] The Mittag-Leffler (ML) functions Eγ and Eγ,ν are given as

    Eγ(τ)=l=0τlΓ(lγ+1),γ>0,Eγ,ν(τ)=l=0τlΓ(lγ+ν),(γ,ν)>0.

    Moreover, we have the integral identity

    ba(τν)γ1Eγ,γ(λ(τν)γ)dν=1λ[Eγ(λ(τa)γ)Eγ(λ(τb)γ)].

    Definition 2.6. [16] The classical form of delayed type ML matrix is defined as ZHτγd:RRn×n with

    ZHτγd={Θ,<τ<d,I,dτ0,I+HτγΓ(γ+1)+H2(τd)2γΓ(2γ+1)+...+Hm(τ(m1)d)mγΓ(γm+1),(m1)d<τmd,mS1,

    where the notion Θ denoted the matrix with all entries zero and I is the identity matrix.

    Definition 2.7. [16] The delayed type ML matrix of two parameters ZHτγd,ν:RRn×n is of the type

    ZHτγd,ν={Θ,<τ<d,I(d+τ)γ1Γ(ν),dτ0,I(d+τ)γ1Γ(ν)+Hτ2γ1Γ(γ+ν)+H2(τd)3γ1Γ(2γ+ν)+...+Hm(τ(m1)d)(m+1)γ1Γ(mγ+ν),(m1)d<τmd,mS1.

    Definition 2.8. [16] System (1.1) admits FTS with respect to , whenever and for all Moreover are positive constants.

    Lemma 2.1. [16] For then

    Lemma 2.2. If , then the solution of (1.2) is formulated as

    (2.1)

    Proof. By following Theorem 3 [34], we get that

    is a solution of with as initial value.

    Moreover, if , then as any solution of (1.2) has the form and Eq (2.1) follows.

    As a direct consequence of the above lemma we present Lemma 2.3 without proof.

    Lemma 2.3. Whenever and , for an admissible , the state response of (1.1) can be formulated as

    (2.2)

    with and

    H1: For the continuous function , there exists so that

    Therefore we get

    where

    In order to make the paper in an easily readable manner, we consider the below given notions

    where

    The primary focus of this section is to avoid the Lyapnouv method and to reduce the conservative criterias to establish the stability over the bounded interval. Let

    Then,

    Theorem 3.1. FTS of system (1.1) is guarenteed if the following inequality holds:

    where

    Proof. Taking norm of Eq (2.2) on the interval , we get

    where Now, let and , then we have

    Then, while comparing the above inequality with the GI theorem [41], we formulate

    As an initial step to analyze the relatively controllable criteria of (1.1), we begin by formulating the following Grammian matrix.

    where is a switching signal.

    where

    As a next step, we construct the operator

    The technique of the fixed point argument will be utilized for our theoretical analyzation.

    Lemma 4.1. [42] If is a closed convex subset of a banach space and if is an operator which is completely continuous, then there exists at least one fixed point for in

    H2: Let be a switching signal which is admissible and satisfies the condition Rank

    Theorem 4.1. If the condition

    (4.1)

    holds then relative controllability of (1.1) is well-established.

    Proof. We need to prove that has a fixed point

    To show in such a way that , we use the contradiction method to establish this result. Let there exist a possibility to find in such a way then we have the following estimations.

    When

    for ,

    for ,

    where

    As we have

    where

    Therefore, we obtain

    which conflicts our assumed fact hence

    Now we proceed to prove that is completely continuous.

    The operator is continuous.

    If converges to in , then continuity of follows from the fact

    Therefore

    where

    Then, it is straightforward to view when from which we get as ; hence, is continuous.

    The operator is compact.

    Consider to be a subset of , which is bounded. Then, it is easy to view that is bounded uniformly on .

    Then, for and , we get

    where As, we know that and are continuous functions and as .

    Further, for and , we get

    Analogous to the previous method, we get whenever Moreover, we can conclude the equi-continuous of on . Then, is relatively compact by the application Ascoli theorem. Then, from the above argument, we conclude that is compact. Hence, is relatively controllable.

    Example 5.1. Let us consider the system (1.1) with the below given choice of system parameters

    Moreover, Let

    It is straightforward to note that

    Now, let us fix

    Then, on calculation we get

    Moreover,

    Then, by substituting the above values in (4.1), we get Thus, our considered form of switching system (1.1) is controllable relatively.

    The FTS of (1.1) for the above choice of system parameters is shown in Table 1. Furthermore, the norm of the solution for the system in (1.1) is presented in Figure 1.

    Table 1.  FTS of system (1.1) for the chosen parameters as in Example 5.1.
    Theorem r (FTS)
    3.1 0.1 0.6 0.4 0.1 0.2 2.35 2.36 yes

     | Show Table
    DownLoad: CSV
    Figure 1.  Norm of the solution of system (1.1) for chosen and .

    In the presented work, we have considered a class of switching impulsive fractional control systems. An explicit form of the solution for (1.1) was derived using the delayed parameters ML function. Stability of the system was then analyzed by constructing appropriate thresholds with Gronwall's inequality. Furthermore, for an admissible switching signal we constructed an appropriate control input that is piecewise continuous over the given interval to determine the relatively controllable criteria of (1.1) with nonlinear arguments and impulses. Finally, a concrete numerical simulation is provided to substantiate the theoretical results. One of the challenging problems arising from this study is when the impulses are of the non-instantaneous type, which will be addressed in our future work. Moreover, the study of this problem will remain an interesting and active research field for future studies.

    P. K. Lakshmi Priya, K. Kaliraj and Panumart Sawangtong: Conceptualization, methodology, formal analysis, software, writing – original draft and writing – review & editing. All authors of this article have been contributed equally. All authors have read and approved the final version of the manuscript for publication.

    The authors declare that they have not used Artificial Intelligence (AI) tools in the creation of this article.

    This research was funded by National Science, Research and Innovation Fund (NSRF), and King Mongkut's University of Technology North Bangkok with Contract no. KMUTNB-FF-68-B-33.

    All authors declare no conflicts of interest in this paper


    Acknowledgments



    The authors are most grateful to the Western Regional Health Authority Public Health Services, Montego Bay, St. James, Jamaica for the financial and other support that facilitated this study.

    Conflict of interest



    All the authors declare that there are not biomedical financial interests or potential conflicts of interest in writing this manuscript.

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    [21] Hennis AJ, Fraser HS, Jonnalagadda R, et al. (2004) Explanations for the high risk of diabetes-related amputation in a Caribbean population of black African descent and potential for prevention. Diabetes Care 27: 2636-2641. doi: 10.2337/diacare.27.11.2636
    [22] Gulliford MC, Mahabir D (2002) Diabetic foot disease and foot care in a Caribbean community. Diabetes Res Clin Prac 56: 35-40. doi: 10.1016/S0168-8227(01)00343-6
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