Factors of Influence on Diabetes Awareness in Older People With Chronic Obstructive Pulmonary Disease Comorbid With Type 2 Diabetes Mellitus

ABSTRACT Background Type 2 diabetes mellitus (T2DM) is a common comorbidity in patients with chronic obstructive pulmonary disease (COPD) and has been associated with an increased risk of mortality in this population. Purpose This study was designed to investigate the predictive factors of diabetes awareness (DA), including diabetes knowledge (DK), and diabetes care behaviors (DCB) among older people with both COPD and T2DM. Methods This was a cross-sectional descriptive correlation study. One hundred thirty-three older-age patients with COPD comorbid with T2DM receiving treatment at a chest hospital were enrolled as participants. Both DK and DCB were utilized to measure DA. The Diabetes Knowledge Questionnaire was utilized to measure DK, and the Summary of Diabetes Self-Care Activities was used to evaluate DCB. Results The average glycated hemoglobin (HbA1c) was 7.68% (SD = 1.55%), with 74 (55.6%) participants having a level > 7%. The average DA was 46.46% (SD = 13.34%), the average DK was 53.42% (SD = 18.91%), and the average DCB was 39.50% (SD = 16.66%). In terms of demographic variables, age, diabetes education, diabetes shared care, and HbA1c were all significantly associated with DA, DK, and DCB (all ps < .05). The overall variance in DA was significantly explained by diabetes education and HbA1c (all ps < .05). The overall variance in DK was significantly explained by age, diabetes education, and HbA1c. The overall variance in DCB was significantly explained by diabetes education and HbA1c (all ps < .05). Conclusions/Implications for Practice Our study findings indicate that older adult patients with COPD comorbid with T2DM are at elevated risks of poor glycemic control and low DA. Healthcare professionals should be aware of these issues and develop appropriate DA plans to prevent poor glycemic control in this population. Providing accurate information on diabetes to older adults with COPD comorbid with T2DM is important to improving their DK and promoting better DCB.


Background
Chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM) are prevalent chronic conditions that impact life expectancy and quality of life significantly.Type 2 DM (T2DM), accounting for most diabetes diagnoses, not only is influenced by environmental, genetic, and lifestyle factors but also commonly coexists as a comorbidity among patients with COPD (Gayle et al., 2019).The results of prior research indicate patients with COPD have a 1.17 (Rasmussen et al., 2018) to 1.26 (Gayle et al., 2019) times higher risk of developing T2DM than the general population.Glycated hemoglobin (HbA1c) is a commonly used measure for identifying DM (Ho et al., 2017).Individuals with diabetes and an HbA1c level of 6.9% are 1.69 times more likely to experience debilitation compared with those without diabetes.That study also revealed a correlation between the concentration of HbA1c and the rate of decline in physical function (Zaslavsky et al., 2016).Poor glycemic control (HbA1c > 7.0%) among patients with COPD has been associated with higher mortality rates compared with patients with COPD alone (Ho et al., 2017).This is primarily because high blood glucose levels can worsen COPD progression and increase the risks of delayed recovery or reoccurrence of COPD, hospitalization, and even death (Gayle et al., 2019;Li et al., 2020).Furthermore, a 10-year longitudinal study revealed older individuals with COPD comorbid with DM to be at a higher risk of various microvascular and macrovascular complications such as hypertension, cerebrovascular diseases, and coronary artery diseases (Ho et al., 2017).Hence, COPD comorbid with T2DM in older adults should be detected as early as possible through regular sugar level monitoring and treated.In addition, early referrals of cases should be made to DM centers for management and follow-up.
Having knowledge and awareness of the various aspects of DM is crucial for its prevention, effective management, and control.According to a report by Foma et al. (2013), awareness of DM is quite low, with 53% having no awareness of DM (Safari-Faramani et al., 2019).Poor awareness of DM can influence treatment compliance (Alhammadi et al., 2022).According to Wang et al. (2018), only 40.3% of elderly individuals with diabetes understood their condition, 62.9% were accepting treatment, and only 16.9% achieved good control over their diabetes.Little research on COPD comorbid with T2DM has been done on older people, with most prior related research focused on chronic kidney disease (CKD) comorbid with T2DM (51.5% unaware; Chu et al., 2022).Diabetes awareness (DA) refers to educating people about diabetes, a chronic disease that affects the body's ability to regulate blood sugar levels.Making conscious efforts to improve awareness includes implementing DM-related health education programs (Foma et al., 2013) and promoting related self-care behaviors (Marciano et al., 2019).Factors such as age, educational level, health status, support system, physical and psychological abilities (Hu et al., 2013;Weinger et al., 2014), nutritional status, duration of participation in diabetes shared care (Huang et al., 2017), and unhealthy lifestyle habits (e.g., alcohol consumption and smoking) can also impact behaviors (Nyberg et al., 2014) in older patients with T2DM.
According to Park et al. (2022), health-related quality of life in older patients with diabetes presents different patterns of change in various subgroups, and diabetes control status will affect their quality-of-life patterns.Blood sugar levels can influence COPD symptom control and health status (Ho et al., 2017).Tang et al. (2022) used the patient activation measure to assess self-health management knowledge, skills, and confidence in 170 patients with COPD.The maximum score for this measurement is 100 points, and the results showed an average score of only 55.6 points, with only 0.6% of the participants showing an ability to actively and proactively manage their health.Most of the participants exhibited a passive approach.Therefore, it is important for healthcare professionals to proactively assess and monitor levels of DM knowledge and behaviors in their patients with COPD comorbid with DM, particularly in those using inhaled steroids.
DM presents an additional burden on patients with COPD and can significantly impact COPD assessments, management efficacy, and management strategies.The treatment plan for patients with both COPD and DM should include a physical exercise program, oral corticosteroid treatment, and regular blood sugar level monitoring (Singh et al., 2019).The results of previous studies indicate individuals with CKD and other chronic conditions often have low awareness of diabetes (Chu et al., 2022;Foma et al., 2013;Safari-Faramani et al., 2019).The COPD care plan is focused primarily on disease management, and blood-related issues are often neglected (Korpershoek et al., 2017).Despite the fact that diabetes is a common comorbidity of COPD (Kastner et al., 2018;Putcha et al., 2015), current nursing guidelines for managing COPD comorbid with diabetes do not include recommendations for managing blood sugar levels.There are differences in awareness, including health education and self-care behavior management, between patients with COPD only and those with COPD comorbid with diabetes.For example, the factors affecting self-care behavior factors in patients with COPD only include age, marital status, body mass index (BMI), and educational level (Bos-Touwen et al., 2015;Yang et al., 2019), whereas these factors in patients with DM include age, duration of diabetes diagnosis, type of medication, HbA1c control status, and lifestyle (D'Souza et al., 2017).Moreover, factors affecting the perceived importance of DA include knowledge of diabetes, healthy behaviors, risk factors, and management of complications (Chu et al., 2022;Foma et al., 2013;Safari-Faramani et al., 2019).COPD care guidelines emphasize the importance of managing comorbidities to effectively control and prevent the worsening of COPD symptoms (Negewo et al., 2015).The prevalence of individuals with multiple chronic diseases is increasing.This phenomenon is attributed not only to the aging of the global population but also to factors such as educational level and socioeconomic status, as indicated by previous systematic literature research reports (Pathirana & Jackson, 2018).Hence, exploring awareness of comorbidities among patients with chronic diseases is an important strategy.Diabetes is a common comorbidity of COPD (Gayle et al., 2019).Studies have shown poor blood sugar control in individuals with diabetes or CKD coupled with comorbid diabetes to be associated with lower DA (Alhammadi et al., 2022;Chu et al., 2022).However, limited research into blood sugar control and awareness of diabetes among patients with COPD and comorbid T2DM has been conducted.Therefore, this study was designed to investigate DA, including diabetes knowledge (DK) and diabetes care behaviors (DCB), and related predictive factors among older adult patients with COPD and comorbid DM.

Study Design
This cross-sectional descriptive correlation study with purposive sampling was conducted at a chest hospital in southern Taiwan between September 2019 and September 2020.

Participants
The inclusion criteria were patients with clinically diagnosed COPD with (a) physician-diagnosed T2DM and (b) clear consciousness and the ability to communicate in Mandarin The Journal of Nursing Research Lin-Yu LIAO et al.
or Taiwanese.The exclusion criteria were patients with clinically diagnosed COPD who (a) were using ventilators, had biphasic positive airway pressure, or had severe wheezing or (b) were experiencing DM complications such as hemodialysis or unstable conditions like falling blood pressure.
The sample size calculation was performed using G*Power with an alpha level of .05, a power of 0.80, and linear multiple regression: fixed model with R 2 deviation from zero.Following the study of Bos-Touwen et al. (2015) on COPD patient self-care behaviors, an R 2 value of .16 was used.The required sample size was estimated at 109, and considering an attrition rate of 20%, the target sample size in this study was set at 131-137.

Ethical Considerations
The study was approved by the Jianan Psychiatric Center, Ministry of Health and Welfare, Taiwan .The principal investigator informed potential participants of the study objectives and procedures and informed them that they could withdraw from the study at any time.Written informed consent forms were gathered from the participants before data collection.The collected data were deidentified by the researchers before data coding and analysis.

Demographics
The demographic and clinical data collected from the participants included age, gender, marital status, educational level, BMI, duration of DM diagnosis (years), smoking status, alcohol consumption status, diabetes education (hours), diabetes shared care, and the forced expiratory volume in 1 second (FEV1) value.Diabetes education covered various topics such as diabetes knowledge and skills, oral hypoglycemic drugs, insulin injection, managing high and low blood sugar levels, self-monitoring of blood glucose, chronic complications, foot care and oral care, travel and sports recommendations, quitting smoking and alcohol, and social psychological support.The diabetes shared care program refers to an integrated care team composed of physicians, diabetes health education case managers, and dietitians.The participants' HbA1c values over the past 3 months, retrieved from their medical records, were used as the measure of glycemic control efficacy.

Diabetes awareness
Effective management of diabetes requires adequate awareness of diabetes, which encompasses both knowledge and behavior.The calculation method involves adding the average ratio of DK to the average ratio of DCB to obtain a total score, which is then divided by 2. Higher total scores indicate greater DA.

Diabetes knowledge
The Diabetes Knowledge Questionnaire (DKQ) was used in this study to assess the level of cognitive understanding of DK.The DKQ is a validated instrument used to assess individuals' knowledge of various aspects of diabetes, including etiology, physiology, symptoms, and management (i.e., blood sugar control; Hu et al., 2013).The DKQ comprises 24 items, with three response options: "yes," "no," and "I don't know."Each correct answer is awarded 1 point, whereas an incorrect option receives 0 points.The scoring method involves summing the scores for each question to obtain a total score, which is divided by 24.Higher ratio values indicate greater awareness of DK.The Cronbach's alpha for the DKQ was .89 in Hu et al. (2013) and was .82 in this study.

Diabetes care behaviors
The Summary of Diabetes Self-Care Activities (SDSCA) was used in this study to measure the participants' DCB related to blood glucose management.This measure assesses various aspects of diabetes self-care activities, including diet, exercise, blood glucose testing, medication adherence, and foot care, to provide an overall measure of the extent to which individuals are engaging in these activities.Each domain of the SDSCA includes two questions, resulting in 10 items.The participants were asked to circle a number ranging from 0 to 7 to reflect the frequency of the particular activity performed during the past 7 days, with a total possible score of 70 points.The scoring method involves adding up the scores for each question to obtain a total score, which is then divided by 70.Higher ratio values indicate greater awareness of DCB.The Cronbach's alpha for the SDSCA was .81 in Hu et al. (2013) and was .70 in this study.

Data Collection Procedure
After obtaining approval from the human experiment committee, data collection was conducted in the thoracic medicine ward of a regional hospital in southern Taiwan using an intentional sampling method.Suitable subjects were selected based on the inclusion and exclusion criteria.The purpose of the research was explained by the project host to potential participants, and consent was obtained before participation.Before enrollment as participants, the research consent form was provided to potential participants for review.Data collection was carried out by nursing therapists with 10 years of work experience.Participants who were able to read completed the questionnaire independently, with any unclear sections explained by the researchers.For those with visual impairments or who were illiterate, the researchers verbally asked the questions, explained the topics, and recorded their responses accordingly.After completing the questionnaire, participants were informed of their answers, and any mistakes or uncertainties were addressed immediately.

Statistical Analysis
The data were analyzed using IBM SPSS Statistics 22.0 (IBM Inc., Armonk, NY, USA).Descriptive statistics were used, with continuous variables presented in terms of mean and standard deviation values and categorical variables presented in terms of frequencies and proportions.The Pearson correlation coefficient was used to examine the associations among DA, DK and DCB, as well as demographic and clinical variables such as age, BMI, duration of DM, diabetes education, FEV1, and HbA1c.The independent sample t test was used to compare differences in DA, DK, and DCB by demographic variables, including gender, marital status, educational level, smoking status, alcohol consumption status, and participation in diabetes shared care.Multiple regression analysis was applied to identify predictors of DA, with DK and DCB.The p values below .05were considered statistically significant.

Predictors of Diabetes Awareness, Diabetes Knowledge, and Diabetes Care Behaviors
Variables that were significantly correlated with DA, DK, and DCB, including age, diabetes education, HbA1c, and diabetes shared care program, were further analyzed using stepwise multiple regression analysis.Two models were presented in the prediction of DA.The second model accounted for the highest explained variance of 21% (F = 10.94,p < .001), in which diabetes education (β = 2.95, p < .001)and HbA1c (β = 2.23, p = .001)were the significant

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Discussion
In this study, the participants had generally poor control of their blood sugar level, indicating a need for improvement in disease management.The average HbA1c among the participants of 7.68% indicates suboptimal blood glucose management during the past 3 months.This finding is consistent with the results of previous studies involving patients with DM, suggesting poor daily glycemic control in individuals with diabetes (D'Souza et al., 2017;Khosla et al., 2021).Another study found that patients with CKD comorbid with diabetes had an HbA1c level above 7.0% (61.5%), indicating poor blood sugar control (Chu et al., 2022).Nephropathy care has been incorporated into regular follow-up and management (Lipsky et al., 2020).However, it is worth considering that there are currently no suggested treatment modes for COPD patients with diabetes in the guidelines for diabetes treatment, highlighting a gap in clinical care.The findings of this study showed that a large proportion (55.6%) of the research subjects had HbA1C levels above 7.0, yet only 53.4% participated in diabetes shared care.Past research has shown that participation in diabetes shared care can impact HbA1C management positively.For instance, Wollny et al. (2021) studied patients with T2DM with HbA1C levels ≥ 8.0% and found that participation in diabetes shared care for 6 months significantly improved HbA1C levels.Notably, this study also revealed a significant positive correlation between HbA1C levels and DA, including DK and DCB, which are essential factors contributing to poor diabetes control.
This study provides a clearer understanding of the factors contributing to poor diabetes control than Wollny et al.
In addition, this study found DA to be low (46.64%) and lower than the levels reported by Alhammadi et al. (2022), which surveyed 466 diabetic patients and reported a level of 53.2%, and Chu et al. (2022), which studied 169 CKD patients with T2DM and found 51.5% of the patients were unaware of their diabetes.These findings suggest patients with COPD pay less attention to diabetes compared with diabetic and chronic kidney patients.This may be because of the characteristic symptoms of these diseases.Diabetes and CKD are both silent diseases, and changes in blood sugar levels do not cause immediate discomfort to patients (Chu et al., 2022;Landgraf et al., 2019).In contrast, COPD exacerbation symptoms include wheezing, dyspnea, and thick and large quantities of sputum that can directly affect patients' mood and daily routines.Furthermore, acute COPD symptoms can be life-threatening, often requiring hospitalization (Dury, 2016;Negewo et al., 2015).As a result, changes in blood glucose levels may not be easily noticed, making it easy for patients and their families to neglect diabetes care.Moreover, to prevent frequent emergency visits, hospitalization, and readmission in patients with COPD, self-care behaviors for COPD such as lung rehabilitation exercises, medication adherence, the use of inhalers, and smoking cessation are usually emphasized to improve breathing quality (Jolly et al., 2016).Finally, care for comorbidities such as diabetes is often neglected by clinicians and healthcare professionals, which may lead to negative attitudes toward diabetes management among patients with COPD (Bos-Touwen et al., 2015).
In the subgroup analysis of DA, this study found diabetes education (frequency), DCB, and DK to be significantly associated with DA, with diabetes education (frequency) acting as a predictor.This study provides insight into the factors and predictors of DA.However, Chu et al. (2022) did not explore the associated factors and predictors of DA in patients with both CKD and T2DM.Furthermore, the level DCB in this study (39.50%) was significantly lower than the level of DK (53.42%).These results suggest that DCB may be relatively overlooked compared with DK (D'Souza et al., 2017;Huang et al., 2017).Managing chronic diseases such as diabetes and COPD requires proper disease self-care behaviors, which are often challenging for patients.Diabetic patients tend to be more passive and less willing to comply with self-care behaviors, but patients with COPD are also faced with similar challenges.Pathirana and Jackson (2018) highlighted that educational level plays a significant role as an influencing factor among chronic patients with multiple comorbidities.Therefore, it is crucial to increase patient awareness of their diseases and comorbidities and to provide sufficient knowledge and health education to improve disease self-care behaviors.
Furthermore, this study found age, participation in diabetes shared care, and diabetes education to be significantly correlated with DCB.Age and diabetes education were also shown to be predictive factors.This is consistent with the findings of Wollny et al. (2021), who noted that longer participation in diabetes shared care and increased frequency of diabetes education positively impacted stable blood sugar control.It is important to recognize self-care behaviors as an evolutionary learning process that takes time and professional support.Therefore, healthcare providers should prioritize patient education and support to improve patient self-care behaviors and effectively manage chronic diseases.Therefore, encouraging COPD patients with comorbid T2DM to participate in shared care is crucial.The Taiwan National Health Service currently promotes several chronic individual care programs.Although patients with COPD may participate in the COPD and Smoking Cessation Individual Management Plan, if they also have diabetes, they must participate in diabetes shared care, which may make it more challenging for patients and their families to seek medical treatment and manage the disease and may result in lower participation rates in diabetes shared care.However, further clinical studies are needed to verify the effectiveness of this approach.

Limitations
The data on DCB were self-reported by the participants and thus may be influenced by recall bias.In addition, patients using steroids, which may affect changes in blood glucose levels, were not excluded from participation.Moreover, the duration of participation in diabetes shared care was not investigated.These limitations should be taken into consideration when interpreting the findings and indicate areas for improvement in future studies.Finally, the results of crosssectional studies are subject to influence from factors such as sample size, quality of data collection, and the potential for bias.To mitigate the impact of these factors on the results, this study estimated the minimum sample size required, used reliable data collection tools, implemented a standardized data collection process, and ensured data collectors had sufficient (> 10 years) work experience and strong communication skills.These measures were taken to minimize potential design-related influences that could affect the outcomes.

Conclusions
The results indicate poor glycemic control and deficits in DA among older adult patients with COPD comorbid with T2DM.Interestingly, our findings differ from previous studies, as we found DA deficits to be characterized by both low DK and DCB.Moreover, DA was identified as a significant predictor of blood sugar control in this population.Age, diabetes education, diabetes duration, participation in diabetes shared care, DK, and DCB were identified as factors that influence DA.These predictive factors may be used to identify COPD patients with comorbid T2DM who are at a higher risk of poor glycemic control and enable targeted prevention or treatment strategies to be implemented.In conclusion, improving DA specifically in COPD patients with comorbid T2DM may help improve glycemic control and prevent long-term disease progression.

Implications for Research and Practice
The findings of this study contribute to raising awareness among healthcare professionals regarding diabetes in older adults with COPD comorbid with T2DM.These results provide a foundation for developing strategies to enhance disease knowledge about COPD comorbid with T2DM as well as evidence-based intervention measures and policies.In addition, they provide valuable insights for future research on the management of comorbid conditions and disease prevention, with the aim of improving the quality of care provided to individuals with COPD comorbid with T2DM.

Table 1
Characteristics of the Participants (N = 133) HbA1c) was used to determine blood glucose, and the level of 6.5% and over indicates poor control of blood glucose.d Diabetes awareness = (diabetes knowledge scoring rate + diabetes care behaviors scoring rate) / 2. e Diabetes knowledge was measured by the Diabetes Knowledge Questionnaire, and a higher score indicates better diabetes knowledge.f Diabetes care behaviors were measured by the Summary of Diabetes Self-Care Activities, and it included five subscales: dietary control, exercise, medication adherence, blood glucose monitoring, and foot care; a higher score indicates better self-care management.

Table 3
Correlations Among Demographic and Clinical Characteristics With Diabetes Knowledge, Diabetes Care Behaviors, and Diabetes Awareness (N = 133)