Effectiveness of medication review services on diabetes self-care in primary care patients-A randomised controlled study

Abstract

Background

Though self-care is a critical component of diabetes management, it is unknown whether pharmacist-run medication review service (MRS) can be an additional intervention to enhance self-care in diabetic patients.

Objectives

Hence, this study aims to determine the effectiveness of MRS in addition to existing care protocol in improving self-care in diabetic patients.

Methods

This randomised controlled study was conducted in five polyclinics from December 2014 to October 2016. Participants were 40 to 80 years of age and had been diagnosed with type 2 diabetes. These participants were prescribed with five or more chronic medications, of which at least one was an antidiabetic medication, by the primary healthcare centres’ doctors. The participants were randomly recruited into the intervention or control arm. A self-developed questionnaire which incorporated the validated Diabetes Self-Management Questionnaire (DSMQ) was administered face-to-face by the study team to the participants prior to and after MRS. MRS was not administered to participants in the control group.

Results

A total of 221 participants completed the follow up. There were 105 participants in the control arm and 116 in the intervention arm. The DSMQ Sum Scale score of the control group improved by 0.16 ± 1.11 (p = 0.136) while the intervention group improved by 0.40 ± 0.99 (p = 0.000). Participants in the intervention group reported a better improvement in their self-care of diabetes, specifically in glucose management (p = 0.003), dietary control (p = 0.096) and physical activity (p = 0.003).

Conclusions

Pharmacist-run MRS can be included in addition to existing care to improve self-care in patients with diabetes.

Keywords

Medication review service pharmacist diabetes self-care primary care

Introduction

Despite concerted efforts and much money spent on preventing type 2 diabetes such as promoting active lifestyles and educating the public on healthier food choices,¹ the prevalence of diabetes and deaths associated with it worldwide is increasing over the years and is projected to keep rising.^2,3 The management of diabetes to prevent both acute and chronic complications associated with the metabolic condition is a long and often costly process.^4–6 This translates to a huge economic burden to the society.^7,8 In US alone, the total estimated cost of diagnosed diabetes in 2017 is $327 billion, including $237 billion in direct medical costs and $90 billion in reduced productivity.⁷ The amount spent by each patient with diabetes is approximately 2.3 times more than those without the disease.⁷

Diabetes is one of the top 3 chronic medical conditions managed at Singapore’s public primary healthcare institutions, also known as polyclinics.⁹ Diabetes alone accounted for 10.3% of the total polyclinics attendance which was about 6.19 million in 2021.⁹ The prevalence of diabetes in Singapore amongst adults aged 18 to 69 years have increased from 8.3% in 2010 to 8.6% in 2017.¹⁰ As with the rest of the world, Singapore currently faces a greying population, which has a higher incidence of chronic diseases such as diabetes.¹¹ The disease burden caused by diabetes will thus increase astronomically⁸ if no effective interventions are put in place.

Pharmacists in primary care settings run medication review service (MRS), managing patients with a wide spectrum of medical conditions. As diabetes is one of the top three medical conditions referred to these pharmacists, MRS provides a valuable platform to resolve medication-related issues faced by patients with diabetes and educate these patients on medications, medical conditions, management and complications associated with the disease. In addition, through MRS services, pharmacists help to review these patients’ medications and optimise them, identifying any medication-related issues and providing appropriate solutions to resolve them, with the intention to improve their diabetic control. Despite these efforts, the effectiveness of MRS on diabetes self-care, which is a critical component of diabetes management advocated by both American Diabetes Association (ADA) and the Association of Diabetes Care and Education Specialists (ADCES) and is incorporated as part of U.S. national standards for Diabetes Self-Management Education and Support (DSMES),¹² has not been assessed locally. Hence, this study aims to determine whether MRS can be an effective tool in the management of diabetes by testing the following hypothesis, and thereby providing an additional intervention to enhance diabetes care.

Hypothesis: “MRS is effective in improving patients’ participation in self-care of diabetes”.

Methods

Study design

This randomised controlled study was conducted in five SingHealth Polyclinics, which are primary healthcare centres in Singapore, from December 2014 to October 2016. These five polyclinics are mainly located in the eastern, north-eastern and southern regions of the island-state.

Study participants

The target participants of this study were patients who visited the five polyclinics’ in-house pharmacies to refill their prescriptions. These participants were 40 to 80 years of age and had been diagnosed with type 2 diabetes. They had been prescribed with five or more chronic medications, of which at least one was an antidiabetic medication, by the polyclinics’ doctors. The participants’ HbA1c readings were above 7.0% and they would be followed up at the polyclinic within the next 2 to 6 months. Participants who could not understand or converse in the most commonly used languages locally, namely English, Mandarin, Chinese dialects or Malay were excluded.

The participants were randomised into the control and intervention arms. A randomisation table was set up using a random number generator to allocate the participants into either the control or intervention arm. In the control group, the participants would receive care as per existing protocols. In the intervention group, the participants would receive care as per existing protocols plus MRS.

Using an assumed effect size of 50%, it was estimated that at least 64 participants in each of the intervention and control groups were required to test whether MRS was effective in improving the diabetic participants’ HbA1c at 5% significance level with 80% statistical power.

Study instrument

A questionnaire was administered face-to-face by the study team in a standardised manner to the participant, and in a language that the participant can understand. The English language questionnaire had been designed and validated internally by the study team members who were pharmacists in the polyclinics. Each participant in the intervention group completed the questionnaire by filling up the responses to the questions himself/herself prior to (during the first visit) and after MRS (during the second visit). For participants in the control group, they were also completed the questionnaire twice, at 2 visits corresponding to the 2 visit dates by the intervention group participants. Participant who had difficulties in completing the responses himself/herself will have the questions read by the investigator to the participant in the language that the participant was conversant in. The questionnaire consisted of 2 parts, namely (i) participants’ demographics and (ii) Diabetes Self-Management Questionnaire (DSMQ).¹³ The participants’ demographic information that was collected using the questionnaire included age, gender, race, education level, smoking status and working status (Table 1).

Table 1.

Participants’ characteristics.

Baseline characteristics of study participants (N = 221)
Variable	N (%)
Age (median ± SD)	64.0 ± 8.8 years
Duration between participants’ first and follow up visit	11.7 ± 3.4 weeks
Study group
Control	105 (47.5%)
Intervention	116 (52.5%)
Gender
Male	101 (45.7%)
Female	120 (54.3%)
Ethnicity
Chinese	162 (73.3%)
Malays	39 (17.7%)
Indian	18 (8.1%)
Others	2 (0.9%)
Working status
Not working	117 (52.9%)
Working	104 (47.1%)
Smoking status
Smoke	25 (11.3%)
Does not smoke	196 (88.7%)
Education level
At least primary level and above	181 (81.9%)
No formal education	40 (18.1%)

DSMQ was selected for use in this study over the commonly used 11-item research tool Summary of Diabetes Self-care Activities Measure (SDSCA). DSMQ’s self-management behaviours have been found to have strong negative association with levels of glycaemic control as reflected by HbA1c and is significantly better in this regards when compared with SDSCA (an equivalent scale also designed to assess diabetes self-management).¹⁴ This helps one to better understand the causes of hyperglycaemia in patients by evaluating their self-management behaviours.¹⁴

The DSMQ, designed and validated by Schall S and team, is a 16-item questionnaire.¹³ It consists of 7 positively and 9 negatively worded statements on diabetic self-care. The questionnaire consists of 4 subscales of ratings (see below) and assesses the following aspects of diabetic self-care, with an overall rating which is also known as the Sum Scale (SS) score of self-care. The Sum Scale is a global measure of the quality of diabetes self-care and it comprises all 16 items in the DSMQ (15 items of which are distributed into 4 subscales and there is one additional solitary item). A Sum Scale score of 6 or below indicates suboptimal self-care.

• Glucose Management (GM) subscale: Self-monitoring of blood glucose and medication intake

• Dietary Control (DC) subscale: Diabetes-related diet

• Health-Care Use (HU) subscale: Appointment adherence

• Physical Activity (PA) subscale: Physical activity

Each question in the DSMQ is scored using the 4-point Likert scale and a score is associated with each of the option. For statements in DSMQ where the participant indicates that the treatment or management option is not part of the medical care, the item would not be scored. For statements that are negatively-worded, the scores would be in reverse such that higher values would indicate more effective self-care.

Each subscale score is then calculated by summing up the scores associated with the relevant statements in the questionnaire in accordance to the DSMQ scoring guide and computed using the following formula.

Subscale Score = (Actual Sum of Item Scores/Maximum Possible Item Scores) × 10

The Sum Scale is computed as follows:

Sum Scale Score = [(Sum of all 4 Subscale Scores + Score for the additional solitary item)/Maximum Possible Item Scores] × 10

Statistical methods

Descriptive analyses were used to describe demographic characteristics of the study participants. Student paired t-test was used to determine whether pharmacist-run MRS was an effective intervention tool to improve participants’ participation in self-care of diabetes. All the statistical analyses were performed using SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. p-values of less than 0.05 were considered statistically significant.

Results

Participants’ characteristics

A total of 221 participants completed the follow up. There were 105 participants enrolled in the control arm and 116 enrolled in the intervention arm (Figure 1). The number of male and female participants involved in the study were 101 (45.7%) and 120 (54.3%) respectively. The median age of the participants was 64.0 ± 8.8 years. (Table 1). Please refer to other details in Table 1.

Figure 1.

Flow chart of the inclusion process.

Impact of pharmacist-run MRS on diabetic self-care

The control arm had an average DSMQ Sum Scale score of 6.46 ± 1.39 and 6.62 ± 1.29 at the first and second visits respectively. The intervention arm scored an average of 6.36 ± 1.60 and 6.75 ± 1.24 prior to and after MRS respectively. Both the control and intervention arms had optimal self-care, where a Sum Scale score of 6.00 or below indicated suboptimal self-care. The improvement in average DSMQ Sum Scale score in the intervention arm was 0.40 ± 0.99 (p = .000) while that in the control arm was 0.16 ± 1.11 (p = .136). The intervention arm showed more improvement across all the 4 subscales, except healthcare use (HU), compared to the control group. (Table 2).

Table 2.

Impact of Pharmacist-run MRS on Diabetes Self-care using the DSMQ Sum Scale Score.

DSMQ scale	Pre-/Post- intervention	Control group					Intervention group
		DSMQ scores	Difference between pre- and post-intervention			Sig.	DSMQ scores	Difference between pre- and post-intervention following MRS			Sig
		DSMQ scores	Avg ± SD	Lower 95% CI	Upper 95% CI	Sig.	DSMQ scores	Avg ± SD	Lower 95% CI	Upper 95% CI	Sig
Physical activity	Pre-intervention	6.17 ± 2.69	0.31 ± 2.40	−0.16	0.77	0.194	5.99 ± 3.02	0.67 ± 2.36	0.24	1.10	0.003
Physical activity	Post-intervention	6.48 ± 2.95	0.31 ± 2.40	−0.16	0.77	0.194	6.66 ± 2.88	0.67 ± 2.36	0.24	1.10	0.003
Glucose Management	Pre-intervention	5.73 ± 2.48	0.23 ± 1.59	−0.08	0.53	0.146	5.76 ± 2.44	0.38 ± 1.35	0.13	0.63	0.003
Glucose Management	Post-intervention	5.95 ± 2.35	0.23 ± 1.59	−0.08	0.53	0.146	6.14 ± 2.32	0.38 ± 1.35	0.13	0.63	0.003
Dietary control	Pre-intervention	6.02 ± 2.06	0.15 ± 1.85	−0.21	0.51	0.406	6.16 ± 2.29	0.26 ± 1.66	−0.05	0.56	0.096
Dietary control	Post-intervention	6.17 ± 2.13	0.15 ± 1.85	−0.21	0.51	0.406	6.42 ± 2.42	0.26 ± 1.66	−0.05	0.56	0.096
Health-care use	Pre-intervention	8.72 ± 1.61	0.50 ± 1.48	0.21	0.78	0.001	8.50 ± 1.94	0.49 ± 1.83	0.15	0.83	0.005
Health-care use	Post-intervention	9.22 ± 1.32	0.50 ± 1.48	0.21	0.78	0.001	8.98 ± 1.38	0.49 ± 1.83	0.15	0.83	0.005
Sum scale score	Pre-intervention	6.46 ± 1.39	0.16 ± 1.11	−0.05	0.38	0.136	6.36 ± 1.60	0.40 ± 0.99	0.21	0.58	0.000
Sum scale score	Post-intervention	6.62 ± 1.29	0.16 ± 1.11	−0.05	0.38	0.136	6.75 ± 1.24	0.40 ± 0.99	0.21	0.58	0.000

Physical activity subscale

The study found that the intervention group reported a bigger improvement in the physical activity subscale at 0.67 ± 2.36 (p = .003) while the control group reported an improvement of 0.31 ± 2.40 (p = .194). (Table 2).

The percentage of participants who would tend to skip planned physical activity increased by 1.9% (an increment from 46.7% to 48.6%) in the control group while the intervention group decreased by 6.9% (a reduction from 48.3% to 41.4%).

The number of participants who would do regular physical activity to achieve optimal blood sugar levels increased in both the control and intervention groups, with the former reporting slightly higher increase of 4.8% (an increment from 73.3% to 78.1%) compared to the latter reporting an improvement of 3.4% (an increment from 71.6% to 75.0%). (Table 3).

Table 3.

Impact of pharmacist-run MRS on diabetes self-care on each DSMQ subscales.

Types of DSMQ subscale	DSMQ statements	Control/Intervention group	Pre-/Post- intervention	“Apply to me” (%)	Difference between pre-/post- intervention in “apply to me” (%)	“Does not apply to me” (%)
Physical activity	I do regular physical activity to achieve optimal blood sugar levels	Control	Pre-intervention	73.3	4.8	26.7
		Control	Post-intervention	78.1	4.8	21.9
		Intervention	Pre-intervention	71.6	3.4	28.4
		Intervention	Post-intervention	75	3.4	25
	I avoid physical activity, although it would improve my diabetes.	Control	Pre-intervention	57.2	−10.6	42.8
		Control	Post-intervention	46.6	−10.6	53.4
		Intervention	Pre-intervention	50.9	−7.8	49.1
		Intervention	Post-intervention	43.1	−7.8	56.9
	I tend to skip planned physical activity	Control	Pre-intervention	46.7	1.9	53.3
		Control	Post-intervention	48.6	1.9	51.4
		Intervention	Pre-intervention	48.3	−6.9	51.7
		Intervention	Post-intervention	41.4	−6.9	58.6
Glucose Management	I check my blood sugar levels with care and attention.	Control	Pre-intervention	33.4	−0.7	66.6
		Control	Post-intervention	32.7	−0.7	67.3
		Intervention	Pre-intervention	39.4	5.8	60.6
		Intervention	Post-intervention	45.2	5.8	54.8
	I take my diabetes medication (e.g., insulin, tablets) as prescribed.	Control	Pre-intervention	97.1	1.0	2.9
		Control	Post-intervention	98.1	1.0	1.9
		Intervention	Pre-intervention	96.6	1.7	3.4
		Intervention	Post-intervention	98.3	1.7	1.7
	I record my blood sugar levels regularly (or analyse the value chart with my blood glucose meter)	Control	Pre-intervention	38.6	−5	61.4
		Control	Post-intervention	33.6	−5	66.4
		Intervention	Pre-intervention	45.2	1.5	54.8
		Intervention	Post-intervention	46.7	1.5	53.3
	I do not check my blood sugar levels frequently enough as would be required for achieving good blood glucose control.	Control	Pre-intervention	58.3	−0.2	41.7
		Control	Post-intervention	58.1	−0.2	41.9
		Intervention	Pre-intervention	63.5	1.2	36.5
		Intervention	Post-intervention	64.7	1.2	35.3
	I tend to forget to take or skip my diabetes medication (e.g., insulin, tablets).	Control	Pre-intervention	34.3	−8.6	65.7
		Control	Post-intervention	25.7	−8.6	74.3
		Intervention	Pre-intervention	38.7	−10.2	61.3
		Intervention	Post-intervention	28.5	−10.2	71.5
Dietary control	The food I choose to eat makes it easy to achieve optimal blood sugar levels	Control	Pre-intervention	90.5	2.8	9.5
		Control	Post-intervention	93.3	2.8	6.7
		Intervention	Pre-intervention	90.5	−0.8	9.5
		Intervention	Post-intervention	89.7	−0.8	10.3
	Occasionally, I eat lots of sweets or other foods rich in carbohydrates.	Control	Pre-intervention	83.8	1.9	16.2
		Control	Post-intervention	85.7	1.9	14.3
		Intervention	Pre-intervention	77.6	0.8	22.4
		Intervention	Post-intervention	78.4	0.8	21.6
	I strictly follow the dietary recommendations given by my doctor or diabetes specialist.	Control	Pre-intervention	87.6	0.0	12.4
		Control	Post-intervention	87.6	0.0	12.4
		Intervention	Pre-intervention	86.2	3.5	13.8
		Intervention	Post-intervention	89.7	3.5	10.3
	Sometimes I have real ‘food binges’ (not triggered by hypoglycaemia).	Control	Pre-intervention	51.5	3.7	48.5
		Control	Post-intervention	55.2	3.7	44.8
		Intervention	Pre-intervention	46.5	0.9	53.5
		Intervention	Post-intervention	47.4	0.9	52.6
Health-care use	I keep all doctors’ appointments recommended for my diabetes treatment	Control	Pre-intervention	98.1	0.0	1.9
		Control	Post-intervention	98.1	0.0	1.9
		Intervention	Pre-intervention	97.4	1.7	2.6
		Intervention	Post-intervention	99.1	1.7	0.9
	I tend to avoid diabetes-related doctors’ appointments	Control	Pre-intervention	17.1	−13.2	82.9
		Control	Post-intervention	3.9	−13.2	96.1
		Intervention	Pre-intervention	18.2	−9.6	81.8
		Intervention	Post-intervention	8.6	−9.6	91.4
	Regarding my diabetes care, I should see my medical practitioner(s) more often.	Control	Pre-intervention	32.4	−6.7	67.6
		Control	Post-intervention	25.7	−6.7	74.3
		Intervention	Pre-intervention	38.8	−7.0	61.2
		Intervention	Post-intervention	31.8	−7.0	68.2

Glucose management subscale

The study found that the intervention group reported a bigger improvement in the glucose management subscale at 0.38 ± 1.35 (p = .003) while the control group reported an improvement of 0.23 ± 1.59 (p = .146).

There were more participants in the intervention group who would check their blood sugar levels with care and attention, and record their blood sugar levels regularly compared to the control group. The percentage of participants in the intervention group who would check their blood sugar levels with care and attention increased by 5.8% (an increment from 39.4% to 45.2%) while that in the control group decreased by 0.7% (a reduction from 33.4% to 32.7%). There was an increase from 45.2% to 46.7% (an increment of 1.5%) of participants in the intervention group who would record their blood sugar levels regularly versus a decrease from 38.6% to 33.6% (a reduction of 5%) in the control group.

The percentage of participants in the control arm who took their diabetes medications as prescribed increased by 1.0% (an increment from 97.1% to 98.1%), while that in the intervention arm increased by 1.7% (an increment from 96.6% to 98.3%). Both groups of participants improved in terms of not forgetting or skipping their diabetes medications. The percentage of participants in the control group who tended to forget to take or skip their diabetes medications decreased by 8.6% (a reduction from 34.3% to 25.7%) while that in the intervention group decreased by a higher percentage of 10.2% (a reduction from 38.7% to 28.5%). (Table 3).

Dietary control subscale

The intervention group reported a bigger improvement in the dietary control subscale with an improvement of 0.26 ± 1.66 (p = .096) than that for the control group (0.15 ± 1.85, p = .406).

Both groups’ scores deteriorated in terms of avoiding sweets or carbohydrate-rich food. The percentage of participants who would occasionally eat a lot of sweets or food rich in carbohydrates increased by 1.9% (an increment from 83.8% to 85.7%) in the control group while the intervention group reported an increase of 0.8% (an increment from 77.6% to 78.4%).

For following dietary recommendations, the percentage of participants in the control arm who strictly followed the dietary recommendations given by their doctor or diabetes specialist remained unchanged at 87.6%, while that in the intervention arm increased by 3.5% (an increment from 86.2% to 89.7%). (Table 3).

Health-care use subscale

The intervention arm had a smaller improvement in the health-care use subscale at 0.49 ± 1.83 (p = .005) while the control group reported an improvement of 0.50 ± 1.48 (p = .001).

The percentage of participants in the control arm who would keep to all their doctors’ appointments recommended for their diabetes treatment remained unchanged at 98.1%, while that in the intervention arm improved by 1.7% (an increment from 97.4%% to 99.1%).

There were fewer participants who would avoid diabetes-related doctor’s appointment in both control and intervention groups, with the former reporting a reduction of 13.2% (a decrease from 17.1% to 3.9%) while the latter reported 9.6% reduction (a decrease from 18.2% to 8.6%). (Table 3).

Discussions

This study found that patients who had received MRS in addition to care as per existing protocol reported better self-care than those who only received care as per existing protocol (without MRS). Patients who received MRS also reported higher scores for all DSMQ subscales, except the health-care use subscale.

The value of a pharmacist goes beyond supplying medications to patients and providing them with advice on their medications.^15–19 The pharmacist-run MRS was introduced to help patients optimise the benefits they can derive from their medications in achieving their therapeutic goals for management of their disease conditions, and to address patients’ medication-related issues and needs.

Feedback from patients has revealed that a significant number of them have medication-related issues.^20,21 This finding is corroborated by our study, which found that close to 5% of the study population did not take their diabetic medications and almost 1 in 3 patients tended to skip, or forget to take their diabetic medications. If focus on medication adherence is narrowed to include only adherence to diabetic medications, the findings in our study are also fairly consistent with the 75.0% adherence rate to oral hypoglycaemic agents reported by WHO in 2003.²²

Evaluating patients’ adherence during MRS, educating them on their medications and medical conditions, as well as addressing the concerns that the patients have with their medications will encourage and empower patients to take on a more active role in the management of their diabetic condition, in partnership with their healthcare professionals.²³ The study results provide support for this observation, with the percentage of patients who took their diabetic medications as prescribed increased from 96.6% to 98.3% through MRS and the percentage of patients who tended to forget to take or skip their diabetic medications decreased from 38.7% to 28.5% after MRS.

The impact of MRS is not only limited to enhancing patients’ adherence to their prescribed medication regimen. This study also found that MRS increased the percentage of patients who kept to their doctors’ appointments for diabetes review from 97.4% to 99.1%. The patients were also less likely to skip planned physical activity. The percentage of patients in this study who would tend to skip planned physical activity decreased from 48.3% to 41.4%. Patients who have undergone MRS tend to check their blood sugar level more frequently and record their blood sugar levels regularly with care and attention. The percentage of patients who would check their blood sugar regularly increased from 45.2% to 46.7% after MRS. Further, the percentage of patients who would check their blood sugar levels with care and attention also increased from 39.4% to 45.2% after MRS. Patients are also more likely to strictly follow the dietary recommendations given by their doctors or diabetes specialists to control their diabetes after MRS. As observed in this study, the percentage of patients in the intervention arm who adhered to dietary recommendations by doctors/diabetes specialists increased from 86.2% to 89.7% after MRS. These observations in our study resonate with the findings of the study conducted by Helen Jones and team.²⁴

Strengths and limitations

Over the years, healthcare systems in the world have evolved from one that is physician-driven to one that is patient-centric.²⁵ For patients to benefit most from this new healthcare model, a supportive healthcare ecosystem must be put in place to engage patients in self-care in partnership with their healthcare professionals.²⁶ Empowering patients for self-care in partnership with their healthcare professionals presents an opportunity for healthcare systems to achieve optimal healthcare outcomes with limited resources.²⁷ Our study has shown the promise of MRS in contributing to patients’ empowerment for self-care for diabetes management, particularly in the area of optimising pharmacotherapeutic outcomes.

The English version of the DSMQ questionnaire was internally validated by the study team members as DSMQ has not been validated in Singapore population. Participants who were not English-literate were administered the questionnaire face-to-face in a language that they were conversant in. It would be ideal if the questionnaire had been translated into other languages and the translated questionnaires had been validated as well. Another limitation of this study was that the point measurement of the effectiveness of MRS on diabetes self-care was conducted over an average period of about 3 months. Researchers could, in future, look into the sustainability of the effectiveness of the pharmacist-run MRS on diabetes self-care over a longer time frame and to identify factors that may affect patients’ self-care of diabetes. Future studies could also measure the impact of diabetes self-care arising from MRS on glycaemic control and disease complications which will be able to shed light on the potential impact of MRS on the clinical outcomes of the diabetic population.

Conclusions

This study has found that receiving pharmacist-run MRS, in addition to care as per usual protocol, helped patients to achieve better diabetes self-care. Hence, our study has shown the promise of MRS in improving patient self-care, and by extension, in improving care of patients with diabetes.

Footnotes

Acknowledgements

We acknowledge Dr Andreas Schmitt and his team for granting us the use of the validated Diabetes Self-Management Questionnaire (DSMQ). We would also like to thank Mrs Lo Fei Ling for granting her approval for the team to proceed with this study, and all the participants involved in the study.

Author contributions

STS- Conception, methodology, project administration, acquisition of data, drafted and revised manuscript, and final approval. DTS, MTS, CJY and OWL - acquisition of data, revised manuscript and final approval. CLJ- Conception, methodology, supervision, drafted and revised manuscript, and final approval. BGQ - Conception, methodology, project administration, data curation, data analysis, drafted and revised manuscript, and final approval. GBK, KSY and TWP- Supervision, drafted and revised manuscript, and final approval.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

SingHealth Centralised Institutional Review Board’s approval (IRB number: 2014/2059) was sought prior to the commencement of the study.

Informed consent

Written informed consent was obtained from all subjects before the study. Participants’ informed consent was obtained prior to their participation in the study.

ORCID iD

Bandy Qiuling Goh

Data Availability Statement

The generated and/or analysed are available from the corresponding author.

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