A Cross-Sectional Evaluation of Knowledge of Medicine Safety and Frequency of Reading Medication Leaflets and Its Predictors - Insights from Saudi Adults in Riyadh, Saudi Arabia.

Background and Aim: On the other hand, patient safety, is of the utmost importance, in addition to health care providers' counseling and advice, patient information leaflets (PILs) also have a significant impact on health outcomes. This study aimed to assess the Knowledge of medicine safety and Frequency of reading medication Leaflets and their predictors among the Saudi population in Riyadh Saudi Arabia. Methods and Materials: This cross-sectional study was conducted over three months in 2023 using online structured self-administered questionnaires, on the adults of Saudi Arabia, admitted to provide informed consent, aged ≥18 years, able to complete the questionnaires, being Saudi nationals, and currently living in the country. The data analysis was performed using the Statistical Package for Social Science (SPSS) version 27. Results: In this study, 23.6% (n=123) of respondents always read the PILs, while 14.6% (n=76) of them never read the PILs. In addition, 22.6% (n=118) of them find it difficult to understand the PILs. In this study, 53.9% of them revealed that ADRs are unexpected reactions after taking the normal dose and 15.4% of them do not know what ADRs are. The respondents gender (B= 0.164; SE=0.075; 95CI = 0.017-0.310; p = 0.029), Social status (B = 0.251; SE = 0.079; 95CI = 0.096-0.406; p = 0.002) and monthly income (B= 0.136; SE = 0.021; 95CI = 0.095-0.178; p < 0.001) was the predictor of reading PILs. Conclusion: In this study, two-thirds of participants took medication and knew why they were taking it. However, only a few of them took the medicine after seeing a doctor, suggesting self-medication practice. In addition, 22.1% of them find it difficult to understand the PILS, and a small number of them would rather read it. Highlighting the significance of seeking medical advice from healthcare professionals before using a medication.

Navigating the Knowledge of Risk Factors, Warning Signs, of Stroke - A Community-Based Cross-Sectional Study Among Saudi Adults in Riyadh Saudi Arabia.

Background: The incidence of stroke is increasing in everyday life as a result of modifiable cerebrovascular risk factors and aging. Therefore, the goal of this study was to assess knowledge of the risk factors, and warning signs, of stroke and to determine associated demographic factors among individuals living in Riyadh, Saudi Arabia. Methods and Materials: A cross-sectional online study using a convenience sampling of general population living in Riyadh was carried out over three months in 2023 using a series of questionnaires that was adopted from the previous study. Before data collection, the study tool was subjected to pilot testing among a small sample of individuals to validate for consistency and reliability. The data was collected using social media platforms. A statistical package for the social science (SPSS version 27) was used. Results: Four hundred and sixty-two individuals completed the survey. Among those 69.5%, identified hypertension as a risk factor for stroke followed by hyperlipidemia (42.9%), heart disease (44.8%). In addition, most of the respondents (n = 332, 71.9%) knew that numbness or weakness of the face and/or limbs of the body was a warning sign of stroke. In this, 73.5% (n=249) of the respondents agreed that if they saw an individual suffering from a stroke, they would like to take the patient to the hospital immediately. However, there was a significant association between the knowledge of the respondents about the risk factor of stroke and educational degree (p=0.011), and parents working in healthcare settings (p =0.015). Conclusion: In conclusion it was observed that a significant respondents had an adequate knowledge of stroke risk factors, while most were unaware of the early warning signs of a stroke. To promote primary prevention and early management/outcomes, we advise that future regional campaigns focus on raising knowledge and recognition of stroke symptoms.

Societal vulnerability in the context of population aging-Perceptions of healthcare students' in Saudi Arabia.

Background and objective: Healthcare professionals have an important role in increasing awareness and protecting populations from natural disasters. This study aimed to assess the perception of healthcare students toward societal vulnerability in the context of population aging. Methods: This is a cross-sectional questionnaire-based study conducted among students from two different health colleges over 4 months from February to May 2021. Descriptive analysis was used to assess the perception, and inferential testing was used to assess the various association of knowledge toward societal vulnerability using SPSS. Results: The majority of respondents were male (69.2%), between 20 and 24 years of age (91.2%), and studying for a nursing degree (76.6%). Only 4.7% had previously completed a previous degree. The mean score of perceptions on the Aging and Disaster Vulnerability Scale among nursing students was 42.5 ± 10.3 (0-65) while for paramedicine 48.1 ± 9.7 (0-65). Similarly, the mean score among male students was 44.1 ±10.5. The mean PADVS total score for the cohort was 43.8 (SD = 10.5). The mean PADVS total score for nursing students was significantly lower than paramedic students (42.5 vs. 48.1; p < 0.001). There was no correlation between PADVS total score and gender, age, area of residence, or previous degree. Conclusion: Our results indicate that Saudi healthcare students perceive older adults are somewhat vulnerable to disasters with significant differences between nursing and paramedic students. Furthermore, we suggest informing emergency services disaster response planning processes about educational intervention to overcome disasters in Saudi Arabia and other countries.

Evaluation of clinical knowledge and perceptions about the development of thyroid cancer-An observational study of healthcare undergraduates in Saudi Arabia.

Background and objective: In the healthcare context, healthcare personnel are available to help patients according to their requirements. However, having sufficient knowledge of many elements of diseases before graduation may have a good impact on clinical practices later in one's career. As a result, the purpose of this study was to assess the clinical knowledge and perceptions of healthcare students in Saudi Arabia about thyroid cancer (TC). Methods: A cross-sectional study was conducted in King Saud University from August 2021 to November 2021, using a validated self-reporting online survey. The data collection was carried out among senior healthcare students, including pharmacy, nursing, and medical students of both genders, who were Arabic speakers. The data were analyzed using the Statistical Package for the Social Sciences version 26 for Windows (SPSS). Results: There were 141 healthcare students who responded, with 46.8% (n = 66) being pharmacy students, 28.4% (n = 40) being nursing students, and 24.8% (n = 35) being medical students. Male participants made up the majority of them (52.5%). Lump or swelling in the neck was described as the most common early indicator of TC by 54.6% (n = 77), followed by difficulty in swallowing by 34.04% (n = 48), and pain in the neck by 24.8% (n = 35). Female participants accounted for 44.7% (n = 63) of those with thyroid dysfunction, according to the study. About 55.3% of the participants (n = 78), reported that they had sufficient knowledge about TC. The knowledge score differed significantly by gender; female participants (60.3%) (n = 47) were more knowledgeable than male participants (30.7%) (n = 31) (p = 0.049). Conclusion: This study depicts that half of the healthcare students thatwere knowledgeable about TC had positive perceptions about the causes of diseases. Furthermore, we also recommend arranging awareness programs for the students by the university officials to overcome the knowledge gap.

Evaluation of Knowledge, Awareness, and Factors Associated with Diabetes: A Cross-Sectional Community-Based Study.

Methods: A cross-sectional study was carried out for over 4 months from May to August 2020 using a self-administered, anonymous online questionnaire. All adults of both genders were invited to participate in the study. Individuals who are able to read and understand the English language were included in the study. Data were descriptively analyzed using a statistical package for social science version 26 (SPSS). Results: A total of 427 subjects responded to the questionnaires. More than half of them were male 253 (59.3%), while 174 (40.7%) were female, approximately 49% had a university degree, and 196 (45.9%) were postgraduates. The mean age of the participants was 25.7 ± 6.2 (mean ± SD). Most of them were single 230 (53.9%). The majority of the respondents 367 (85.9%) had heard of hyperglycemia, while a comparable number of 366 (85.7%) were aware of it being a lifelong disease. About 305 (71.4%) of participants knew that genetic factors were associated with hyperglycemia, and more than half of 250 (58.5%) knew that diabetes causes foot problems. There was a significant association between the cause of diabetes with income and educational status (p < 0.05) and diabetic complications with age, education, and family income (p < 0.05). Conclusion: In conclusion, there is a need for greater awareness and additional education regarding hyperglycemia among the general community in the state of Telangana, India, to reduce the incidence of diabetes and associated risk factors. Public health campaigns that encourage healthier lifestyles might help achieve this aim.

Prevalence of Physical Activity Among Healthcare Students in King Saud University, Riyadh, Saudi Arabia. An Observational Study.

BACKGROUND AND OBJECTIVE: Physical inactivity is 1 of the most important cardiovascular risk factors causing higher morbidity and mortality rate worldwide. Thus, the promotion of physical activity (PA) is 1 of the fundamental pillars in the primary prevention of heart disease. Therefore, this study aimed to assess the prevalence of Physical Activity among healthcare Students in the Riyadh region, Saudi Arabia. METHODS: An observational, descriptive, cross-sectional study using paper-based printed questionnaires was conducted among Emergency medical students (EMS) from the Prince Sultan College for Emergency Medical Services King Saud University. To evaluate the physical activity, Global Physical Activity Questionnaire (16-items) developed by the World health organization was used. The questionnaires talk about activity at work (6 items), travel to and from places (3-items), recreational activities (6- items), and sedentary behavior (1-item). Both binary answers (Yes\No) and continuous scales were used to collect the data. Data were descriptively analyzed using a statistical package for social science version 26 (SPSS). RESULTS: The prevalence of PA among students was 69.9% (n = 123). The most common type of physical activity was walking, accounted for 51.7% (n = 91), followed by Gym/bodybuilding 25% (n = 44), running 24.4% (n = 43). A total of 7.16 mean hours (SD = 11.23) were spent by students doing vigorous-intensity activities on a typical day, while 4.93(SD = 8.84) of mean hours were spent on moderate-intensity activities. Additionally, more than half of the students 55.7% (n = 98) performed vigorous-intensity sports, fitness, or recreational activities that cause large increases in breathing or heart rate (for at least 10 minutes continuously). The mean time spent by the students in this study performing vigorous-intensity sports, and fitness activity were 4.60(SD = 10.22) mean hours per day. The sedentary behavior, like constant sitting, was reported to be 7.33 (SD = 4.24) mean hours per day. CONCLUSION: In conclusion, about 3 in ten EMS students are physically inactive, which could be due to study-related actions. Future research among undergraduates should focus on approaches to increase PA is needed.

Prevalence, Beliefs, and the Practice of the Use of Herbal and Dietary Supplements Among Adults in Saudi Arabia: An Observational Study.

Background and Aim: Alternative treatments for respiratory disorders attempt to prevent or relieve symptoms and enhance functions. Furthermore, substantial evidence shows that several herbal medicines have been clinically effective against respiratory disorders. Thus this study assesses the Saudi students' use, beliefs, and practices related to herbal and dietary supplements for the possible prevention of respiratory infections. Methods: A cross-sectional web-based survey was designed using Google Forms to collect the data from the healthcare and non-healthcare students currently pursuing their courses at King Saud University, Riyadh, Saudi Arabia. The data was collected over 4 months, from November 2021 to February 2022, using convenience sampling with a 25-item questionnaire. A statistical package for social sciences, SPSS 26, was used to analyze the data. Results: A total of 274 participants responded to the study. The mean age of the respondents was 21.9 ± 3.08 (mean (SD)). The prevalence of herbal medicine (HM) was found to be 62.7% (n = 172). Around 48.5% (n = 133) of the respondents occasionally used some form of HM during the period of an illness associated with a respiratory infection. About 66% of the respondents agreed that using HMs prevents or controls respiratory symptoms and strengthens immunity. A majority (75.2%) of the respondents agreed that ginger extract possesses antiviral and immunity-boosting properties, followed by garlic extract (59.5%), cinnamon (39.4%), and lemongrass (38.3%). In addition, between 37% and 45.6% of the respondents agreed that vitamin C and vitamin D intake helps in boosting immunity and reducing the likelihood of developing respiratory infections. The overall mean of the positive beliefs and practice score was 9.6 (range 0-14). The mean positive beliefs and practice scores were significantly higher for males (11.4 ± 3.2) compared to females (8.6 ± 3.6) (P < .001). The numbers were not significantly different regardless of the source of information (9.6 ± 3.5), respondents being in health colleges (8.9 ± 4.1) or non-health colleges (9.8 ± 3.7), them being previously or currently infected (9.7 ± 3.8), the absence of infection (9.7 ± 3.8), or the respondents possessing a history of chronic diseases (10.5 ± 3.9) or not (9.5 ± 3.7) (P > .05). Conclusions: This study found a relatively high prevalence of herbal and dietary supplements' use, positive beliefs, and practices to strengthen one's immunity against respiratory symptoms.

Psychometric appraisal of the Readiness for Interprofessional Learning Scale (RIPLS) Arabic-version.

Interprofessional education within healthcare has been shown to have many benefits, however, it is a relatively new educational concept within the Arabic setting. Although the Readiness for Interprofessional Learning Scale is a commonly utilised tool to examine student attitudes, there is a lack of evidence for use of an Arabic translated version. The aim of this study was to develop and psychometrically evaluate an Arabic language version of the Readiness for Interprofessional Learning Scale with Saudi nurses. Two independent translators, proficient in both English and Arabic languages, completed a forward-backward translation of the original English version of the Readiness for Interprofessional Learning Scale. Subsequently, this Readiness for Interprofessional Learning Scale-Arabic version was used to collect data from undergraduate nursing students enrolled at a number of Saudi Arabian universities. Exploratory and Confirmatory Factor Analyses were then performed on the scale. Six hundred and fifty-two participants were recruited. Exploratory Factor Analysis of the Readiness for Interprofessional Learning Scale-Arabic version resulted in a 15-item, three-factor model. Subsequent analysis with Confirmatory Factor Analysis and the resultant final 13-item model demonstrated a poor fit between the hypothesized model and the data. Although our three-factor model is supported by previous studies, the proposed model did not perform well on Confirmatory Factor Analysis assessment. This suggests that there may be issues of applicability of the Readiness for Interprofessional Learning Scale-Arabic version within the current cohort. The present study of the Readiness for Interprofessional Learning Scale-Arabic version has demonstrated some psychometric inadequacies and thus it is possible that this scale may not be appropriate for use with Saudi nurses. However further research with different professional groups is suggested to fully explore its utility within the Saudi setting.

The factors affecting nurses' assessments toward pain management in Saudi Arabia.

BACKGROUND AND AIMS: Pain assessment requires an extensive practice in diagnosis coupled with proficiency in recognizing health factors that lead to its occurrence. Nurses' education and training could be the main factor influencing pain perception and diagnosis. This study aims at comparing nurses' academic qualifications and relevant training courses that may impact their assessment skills toward patients in pain. METHODS: A descriptive cross-sectional design using a Knowledge and Attitudes Survey Regarding Pain questionnaire was administered to a total of 247 nurses. In this survey, the nurses were asked to answer specific questions related to correctly diagnosing and assessing patients' pain, as well as answer questions about their previous training in pain assessment. RESULTS: A total of 247 nurses answered the questionnaire, with an overall response rate of 82%. Questionnaires revealed that more than half (50.6%) of the nurses involved in this study have not received any pain education related to pain management in the 5 years following their initial nursing licensure or supervision under a nurse supervisor. CONCLUSIONS: The results of the paper show that nurses' experiential level has the highest impact on their knowledge of pain relief management and medications necessary for treating it. Also, nurses' pain education following their initial licensure and during their professional practice has the second highest impact on their pain relief management knowledge, whereas their primary nursing education had the lowest.

Knowledge and Attitudes Toward Cancer Pain Management Among Nurses at Oncology Units.

Nurses have major responsibilities to treat cancer pain in an optimal way. Their knowledge and attitudes are the key to success cancer pain management (CPM) process and impact the outcomes of pain treatment. This study aimed to evaluate the knowledge and attitudes toward CPM among Jordanian nurses working at oncology units. A cross-sectional descriptive design was used to collect data from 135 nurses who were working at four oncology units using Knowledge and Attitudes Survey Regarding Pain. The percentage of correct answers was 51.5% indicating that participants had fair knowledge and attitudes toward CPM. Nurses appeared knowledgeable about CPM guidelines but were unfamiliar regarding pharmacological management and had negative attitudes toward opioids addiction and pain assessment. Significantly, knowledge and attitudes were higher among nurses who had previous education programs (P < .001) and worked in a pain team (P < .001). Therefore, including CPM topics in nursing curricula and postgraduate educational programs is needed. Additionally, initiating pain management teams and using CPM guidelines will contribute to effective treatment of cancer pain.

Emergency department visits for paroxysmal supraventricular tachycardia in Saudi Arabia.

PURPOSE: The present study aimed to compare the demographic, medical history, clinical features, and treatment management of paroxysmal supraventricular tachycardia (PSVT) in the emergency department of a teaching hospital in Riyadh, Saudi Arabia. A secondary purpose was to evaluate Adenosine response among numerous variables that might be used as predictors of the conversion. METHODS: All PSVT cases presented to the Department of Emergency Medicine at King Khalid University Hospital, during the period from January 1, 2016, until December 31, 2016, were included in the study. Patients were assigned into two groups: adenosine sensitive (AS-group) and adenosine resistant (AR-group) according to adenosine conversion response. RESULTS: A total of 38 patients were admitted during the study period. Fisher's exact test results showed that there were no significant (P > 0.05) differences among the AS-group and AR-group in the demographics, past medical history and clinical features, and post-ablation condition, except for the previous usage of the other anti-arrhythmic drugs to convert the last PSVT in the AR-group. The first bolus of adenosine had higher sensitivity and specificity, compared to the second bolus. Further, the second bolus of adenosine was not specific for short-term treatment of PSVT. CONCLUSIONS: Differences in adenosine sensitivity among PSVT patients were independent of demographic, past medical history, and clinical features of PSVT patients. Thus, the difference in adenosine response among groups may be attributed to the heterozygosity in conducting pathways. The first bolus of adenosine had high sensitivity and specificity, compared to the second bolus, and their optimal levels were predictable by HR deceleration.

Research utilization barriers for emergency medical technicians in Saudi Arabia.

INTRODUCTION: Translation of research findings into clinical practice has potential to improve health care procedures, increase patient safety, and improve patient outcomes. However, low levels of evidence utilization in clinical practice have been widely reported. Anecdotal evidence suggests that this is also the case for emergency medical technicians (EMTs) in Saudi Arabia. This study aimed to examine the barriers to the utilization of research findings within this cohort. METHODS: The BARRIERS scale was used to gather data from a convenience sample of EMTs in Saudi Arabia. RESULTS: The barriers most commonly rated as "great" or "moderate" were "Implications for practice are not made clear", "The relevant literature is not compiled in one place", and "The EMT feels the benefits of changing practice will be minimal". However, when responses were examined at a subscale level, reliability, as measured by Cronbach's α, was suboptimal (range 0.20-0.62). DISCUSSION: No similar study has been conducted within paramedicine to enable direct comparison of our results; however, the top barriers identified in the present study are also highly rated in some previous studies of nurse cohorts. The low reliability measures of the subscales may demonstrate the importance of context specificity when utilizing this scale and that further research is required to develop a reliable and valid tool for use within this cohort. CONCLUSION: The top 2 barriers identified indicate that there may be a need for improvement regarding communication of research evidence to Saudi EMTs. For future studies, translation of the BARRIERS scale may be useful. However, as these EMT courses are taught in English, careful consideration of cultural suitability and more subtle interpretation issues could also be appropriate. Once context-specific barriers are identified and examined, they may inform the development of effective strategies to increase the uptake of research evidence into Saudi EMT practice.

ICU Nurses' Perceived Barriers to Effective Enteral Nutrition Practices: A Multicenter Survey Study.

BACKGROUND: Critically ill patients are hypermetabolic and have increased energy requirements, making nutritional support a vital intervention. In the Intensive Care Units, enteral nutrition is based on opinions rather than evidence-based practices. Therefore, there is a need to identify the barriers to evidence based practice protocols for enteral feeding of patients in Jordanian ICUs. AIMS: To explore Jordanian ICU nurses' perceived barriers for enteral nutrition that hinders them from utilizing the recommended EN guidelines. METHODS: A descriptive cross-sectional design was utilized using self-administered questionnaire. A total of 131 nurses participated from different hospitals representing different healthcare sectors in Jordan. RESULTS: The five barriers subscales' means were almost equal ranging from 4.04 (Delivery of EN to the Patient) to 4.33 (ICU Resources) (out of 7). The most important barrier was "Not enough nursing staff to deliver adequate nutrition" (M=4.80, SD=1.81, 60%), followed by "Fear of adverse events due to aggressively feeding patients" (M= 4.59, SD=1.50, 56%). Although no significant differences in the mean barrier score were revealed, minimal significant differences were revealed that were distributed among different barrier subscales. CONCLUSION: Participants moderately perceived barriers with more focus on insufficient resources in ICU and among healthcare providers. Such barriers are modifiable and manageable, making their identification and management crucial for optimal patient care. This study confirms that enteral nutrition is a multidisciplinary responsibility.

Exercise Self-Efficacy Scale: Validation of the Arabic Version Among Jordanians With Chronic Diseases.

This study assessed the psychometric properties of the Arabic version of Exercise Self-Efficacy scale (ESE-A) among Jordanian outpatients with a variety of chronic diseases using descriptive cross-sectional design. Participants' scores of ESE-A significantly correlated with their reported weekly exercise frequency ( r = .23, p< .001), duration ( r = .31, p< .001), and evaluation of their physical exercise ( r = .39, p< .001). The construct validity was tested using exploratory factor analysis, which retained all items, and the scree plot showed one meaningful factor with an eigenvalue of 10.38 and an explained variance of 57.7%. Furthermore, Cronbach's alpha was .89 and split-half coefficient was .83 indicating that the ESE-A is a reliable scale. The ESE-A was found to be a robust measure to evaluate exercise self-efficacy among Arabic patients with chronic diseases. Arabic researchers interested in exercise self-efficacy are invited to utilize the ESE-A in their studies to confirm its psychometric properties.

The pulmonary consequences of sandstorms in Saudi Arabia: A comprehensive review and update.

Sandstorms represent a major natural hazard in the Arabian Peninsula. Their pulmonary consequences can be life-threatening, especially to those with a history of allergies, asthma, and chronic obstructive pulmonary diseases. Novel presentations of respiratory diseases caused by sandstorms can now be traced to specific chemical and organic components of sandstorms. We present an update of the pathophysiology of pulmonary conditions based on the results of clinical and epidemiologic research as well as from greater knowledge of the complex chemical composition of sandstorms. This has led to more precise therapeutic approaches to severe respiratory illnesses and a greater understanding of risk factors for morbidity and mortality due to Arabian sandstorms.

Evaluating the Psychometric Properties of the Arabic Version of the Diabetes Distress Scale.

The current study evaluated the psychometric properties of the Arabic version of the Diabetes Distress Scale (DDS-A) among Arab patients with diabetes mellitus (DM) using a descriptive cross-sectional design. Participants' DDS-A total scores significantly correlated with depressive symptoms (r = 0.288, p = 0.000) as well as two subscales, emotional burden (r = 0.276, p = 0.000) and regimen distress (r = 0.265, p = 0.000). Participants' DDS-A scores had significant negative correlations with income, DM self-management, and knowledge (r = -0.184, p = 0.008; r = -0.310, p = 0.000; r = -0.174, p = 0.003, respectively) and a positive correlation with HbA1c level (r = 0.153, p = 0.018). Factor analysis revealed a four-factor solution that retained all items and explained a variance of 65.59%. Cronbach's alpha was 0.822 for the total scale and 0.778 to 0.881 for the subscales, indicating a high internal consistency. The DDS-A was found to be a psychometrically sound measure to evaluate DM-related distress among Arab patients. [Journal of Psychosocial Nursing and Mental Health Services, 55(9), 43-51.].

Psychosocial Correlates of Diabetes Self-management Practices.

BACKGROUND: Self-Management is a crucial regimen for patients with diabetes mellitus. Many factors have affected patients' self-management practice including psychosocial factors. Literature revealed contradictory results concerning the psychosocial correlates of patients' self-management practices. Therefore, this study assessed the psychosocial correlates of diabetes self-management practices among Jordanian diabetic patients. METHODS: A descriptive, cross-sectional, correlational design was utilized to collect data (conducted in the middle region of Jordan in 2015) from 341 Jordanian outpatients with diabetes using self-reported questionnaires (Social Support Scale, CES-D, and Summary of Diabetes Self-Care Activities) and chart review. RESULTS: Participants reported practice rate of 2.85/ 7 (SD=1.3), with diet practice the most (M=3.66, SD=1.5) and exercise the least (M=1.53, SD=2.1). Participants reported receiving social support (M=3.23, SD=1.3) less than needed (M=3.39, SD=1.3). High levels of depressive symptoms were reported (M=17.1, SD= 11.4). Diet practices had significant positive correlation with family support attitude (r= .266, P= .000) and negative correlation with depressive symptoms (r= - .114, P= .037). Testing blood sugar significantly correlated with both support needed (r= .144, P= .008) and support received (r= .166, P= .002). CONCLUSION: Jordanian DM patients were found to practice less than optimum DM self-management practices, and to consider diet practices than exercise practices. This study confirmed that the subcategories of DM self-care management should be considered rather than considering the general plan.